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Mazarakis NK, Robinson SD, Sinha P, Koutsarnakis C, Komaitis S, Stranjalis G, Short SC, Chumas P, Giamas G. Management of glioblastoma in elderly patients: A review of the literature. Clin Transl Radiat Oncol 2024; 46:100761. [PMID: 38500668 PMCID: PMC10945210 DOI: 10.1016/j.ctro.2024.100761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.
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Affiliation(s)
- Nektarios K. Mazarakis
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
- School of Medicine RCSI, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland
| | - Stephen D. Robinson
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
- Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton BN1 9QG, UK
| | - Priyank Sinha
- Department of Neurosurgery, Leeds General Infirmary, Great George Street, LS1 3EX, UK
| | | | - Spyridon Komaitis
- Department of Neurosurgery, Evaggelismos Hospital, Ipsilantou 45-47, Athens, Greece
| | - George Stranjalis
- Department of Neurosurgery, Evaggelismos Hospital, Ipsilantou 45-47, Athens, Greece
| | - Susan C. Short
- Leeds Institute of Medical Research at St James’s Wellcome Trust Brenner Building St James’s University Hospital Leeds, LS9 7TF, UK
| | - Paul Chumas
- School of Medicine RCSI, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland
| | - Georgios Giamas
- Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton BN1 9QG, UK
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2
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Refined Efficacy and Outcome Estimates of Surgical Treatment in Oldest-Old Patients with Glioblastomas Based on Competing Risk Model and Conditional Survival Analysis: A Surveillance, Epidemiology, and End Results Population-Based Study. Clin Neurol Neurosurg 2022; 221:107391. [DOI: 10.1016/j.clineuro.2022.107391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022]
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3
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Abstract
Purpose of Review Elderly patients with newly diagnosed glioblastoma (eGBM) carry a worse prognosis compared with their younger counterparts. eGBM garners special attention due to the unique challenges, including increased treatment-associated toxicity, less relative benefit from aggressive therapy, medical comorbidities, and immunosuppression. The pivotal GBM trials excluded patients > 70 years old and the optimal treatment approach remains unsettled for eGBM. In this review, we analyze the historical evidence-based data for treating eGBM and discuss the future direction for managing this vulnerable population. Recent Findings Treatment for eGBM continues to evolve. Therapy choice is guided by performance status and presence of O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation. For eGBM with good performance status, combinatorial hypofractionated radiation therapy (hRT) and temozolomide should be recommended. For those with poor performance status, further stratification based on MGMT promoter methylation test result is recommended. Single-agent temozolomide is a viable treatment option for MGMT methylated tumors (mMGMT); in particular, those classified with receptor tyrosine kinase II methylation. hRT alone can be considered in MGMT unmethylated (uMGMT) eGBM patients. As precision oncology continues to advance, effective targeted and immunotherapy may emerge as new treatment options for eGBM. Summary Management of elderly patients with newly diagnosed GBM carries a unique set of challenges. Progress has been made in defining the optimal therapeutic approach for these patients, but many questions remain to be answered.
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Affiliation(s)
- Carlen A. Yuen
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
| | - Marissa Barbaro
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
- Present Address: Perlmutter Cancer Center at NYU Langone Hematology Oncology Associates – Mineola, NYU Long Island School of Medicine, NYU Langone Health, Mineola, NY USA
| | - Aya Haggiagi
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY USA
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4
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Vaugier L, Ah-Thiane L, Aumont M, Jouglar E, Campone M, Colliard C, Doucet L, Frenel JS, Gourmelon C, Robert M, Martin SA, Riem T, Roualdes V, Campion L, Mervoyer A. Standard 6-week chemoradiation for elderly patients with newly diagnosed glioblastoma. Sci Rep 2021; 11:22057. [PMID: 34764361 PMCID: PMC8586368 DOI: 10.1038/s41598-021-01537-3] [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: 05/04/2021] [Accepted: 10/29/2021] [Indexed: 11/09/2022] Open
Abstract
Glioblastoma (GBM) is frequent in elderly patients, but their frailty provokes debate regarding optimal treatment in general, and the standard 6-week chemoradiation (CRT) in particular, although this is the mainstay for younger patients. All patients with newly diagnosed GBM and age ≥ 70 who were referred to our institution for 6-week CRT were reviewed from 2004 to 2018. MGMT status was not available for treatment decision at that time. The primary endpoint was overall survival (OS). Secondary outcomes were progression-free survival (PFS), early adverse neurological events without neurological progression ≤ 1 month after CRT and temozolomide hematologic toxicity assessed by CTCAE v5. 128 patients were included. The median age was 74.1 (IQR: 72-77). 15% of patients were ≥ 80 years. 62.5% and 37.5% of patients fulfilled the criteria for RPA class I-II and III-IV, respectively. 81% of patients received the entire CRT and 28% completed the maintenance temozolomide. With median follow-up of 11.7 months (IQR: 6.5-17.5), median OS was 11.7 months (CI 95%: 10-13 months). Median PFS was 9.5 months (CI 95%: 9-10.5 months). 8% of patients experienced grade ≥ 3 hematologic events. 52.5% of patients without neurological progression had early adverse neurological events. Post-operative neurological disabilities and age ≥ 80 were not associated with worsened outcomes. 6-week chemoradiation was feasible for "real-life" elderly patients diagnosed with glioblastoma, even in the case of post-operative neurological disabilities. Old does not necessarily mean worse.
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Affiliation(s)
- Loïg Vaugier
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest (ICO), Boulevard J. Monod, 44805, Nantes-Saint-Herblain, France.
| | - Loïc Ah-Thiane
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest (ICO), Boulevard J. Monod, 44805, Nantes-Saint-Herblain, France
| | - Maud Aumont
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest (ICO), Boulevard J. Monod, 44805, Nantes-Saint-Herblain, France
| | - Emmanuel Jouglar
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest (ICO), Boulevard J. Monod, 44805, Nantes-Saint-Herblain, France
| | - Mario Campone
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest (ICO), Nantes-Saint-Herblain, France
| | - Camille Colliard
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest (ICO), Nantes-Saint-Herblain, France
| | - Ludovic Doucet
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest (ICO), Nantes-Saint-Herblain, France
| | - Jean-Sébastien Frenel
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest (ICO), Nantes-Saint-Herblain, France
| | - Carole Gourmelon
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest (ICO), Nantes-Saint-Herblain, France
| | - Marie Robert
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest (ICO), Nantes-Saint-Herblain, France
| | - Stéphane-André Martin
- Department of Neurosurgery, Centre Hospitalo-Universitaire (CHU), Nantes-Saint Herblain, France
| | - Tanguy Riem
- Department of Neurosurgery, Centre Hospitalo-Universitaire (CHU), Nantes-Saint Herblain, France
| | - Vincent Roualdes
- Department of Neurosurgery, Centre Hospitalo-Universitaire (CHU), Nantes-Saint Herblain, France
| | - Loïc Campion
- Department of Biostatistics, Institut de Cancérologie de l'Ouest, St-Herblain, France.,Centre de Recherche en Cancérologie Nantes-Angers (CRCNA), UMR 1232 Inserm-6299 CNRS, Institut de Recherche en Santé de l'Université de Nantes, Nantes, France
| | - Augustin Mervoyer
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest (ICO), Boulevard J. Monod, 44805, Nantes-Saint-Herblain, France
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Gregucci F, Surgo A, Bonaparte I, Laera L, Ciliberti MP, Carbonara R, Gentile MA, Giraldi D, Calbi R, Caliandro M, Sasso N, D’Oria S, Somma C, Martinelli G, Surico G, Lombardi G, Fiorentino A. Poor-Prognosis Patients Affected by Glioblastoma: Retrospective Study of Hypofractionated Radiotherapy with Simultaneous Integrated Boost and Concurrent/Adjuvant Temozolomide. J Pers Med 2021; 11:jpm11111145. [PMID: 34834497 PMCID: PMC8619413 DOI: 10.3390/jpm11111145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/23/2021] [Accepted: 10/30/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Glioblastoma (GBM) is a very poor-prognosis brain tumor. To date, maximal excision followed by radiochemotherapy, in 30 fractions, is the standard approach. Limited data are present in the literature about hypofractionated radiotherapy (hypo-RT) in GBM poor prognosis patients. Thus, this retrospective study was conducted to evaluate efficacy and toxicity of hypo-RT with simultaneous integrated boost (SIB) in association with temozolomide (TMZ) in this patient setting. METHODS Poor-prognosis GBM patients underwent surgery (complete, subtotal or biopsy) followed by SIB-hypo-RT and concomitant/adjuvant TMZ. The prescription dose was 40.05 Gy (15 fractions) with a SIB of 52.5 Gy (3.5 Gy/fraction) on surgical cavity/residual/macroscopic disease. Volumetric modulated arc therapy was performed. RESULTS From July 2019 to July 2021, 30 poor-prognosis patients affected by GBM were treated by SIB-hypo-RT; 25 were evaluated in the present analysis due to a minimum follow up of 6 months. The median age and KPS were 65 years and 60%, respectively. At the median follow-up time of 15 months (range 7-24), median and 1-year overall survival and progression-free survival were 13 months and 54%, and 8.4 months and 23%, respectively. No acute or late neurological side effects of grade ≥ 2 were reported. Grade 3-4 hematologic toxicity occurred in three cases. CONCLUSION SIB-hypo-RT associated with TMZ in poor-prognosis patients affected by GBM is an effective and safe treatment. Prospective studies could be warranted.
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Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Letizia Laera
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (L.L.); (N.S.); (G.S.)
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Maria Annunziata Gentile
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (M.A.G.); (R.C.); (G.M.)
| | - David Giraldi
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (D.G.); (S.D.); (C.S.)
| | - Roberto Calbi
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (M.A.G.); (R.C.); (G.M.)
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Nicola Sasso
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (L.L.); (N.S.); (G.S.)
| | - Salvatore D’Oria
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (D.G.); (S.D.); (C.S.)
| | - Carlo Somma
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (D.G.); (S.D.); (C.S.)
| | - Gaetano Martinelli
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (M.A.G.); (R.C.); (G.M.)
| | - Giammarco Surico
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (L.L.); (N.S.); (G.S.)
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Padova, Italy;
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
- Correspondence: ; Tel.: +39-0803054608
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6
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Liu H, Sun Q, Chen S, Chen L, Jia W, Zhao J, Sun X. DYRK1A activates NFATC1 to increase glioblastoma migration. Cancer Med 2021; 10:6416-6427. [PMID: 34309232 PMCID: PMC8446559 DOI: 10.1002/cam4.4159] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 07/02/2021] [Accepted: 07/09/2021] [Indexed: 12/27/2022] Open
Abstract
Glioblastoma (GBM) is the most aggressive glioma, and is prone to develop resistance to chemotherapy and radiotherapy; hence, patients with glioblastoma have a high recurrence rate and a low 1-year survival rate. In addition, the pathogenesis of glioblastoma is complex and largely unknown, and the available treatments are limited. Here, we uncovered a fundamental role of DYRK1A in regulating NFATC1 in GBMs. We found that DYRK1A was highly expressed in glioma and glioblastoma cells, and its expression was positively correlated with that of NFATC1. Moreover, inhibition of DYRK1A promoted NFATC1 degradation in GBM cells and sharply reduced the transactivation of NFATC1, not only by decreasing the expression of NFATC1-targeted genes, but also by reducing the luciferase activity, and vice versa. However, DYRK1A had the opposite effect on NFATC2. Most importantly, our data suggest that DYRK1A inhibition reduces glioblastoma migration. Polypeptides derived from the DYRK1A-targeted motif of NFATC1, by competitively blocking DYRK1A kinase activity on NFATC1, clearly destabilized NFATC1 protein and impaired glioblastoma migration. We propose that the recovery of NFATC1 stability is a key oncogenic event in a large proportion of gliomas, and pharmacological inhibition of DYRK1A by polypeptides could represent a promising therapeutic intervention for GBM.
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Affiliation(s)
- Heng Liu
- NHC Key Laboratory of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Department of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Qian Sun
- NHC Key Laboratory of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Department of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Immunology InstituteSchool of Basic Medical SciencesCheeloo College of MedicineShandong UniversityJinanShandongChina
| | - Shuai Chen
- NHC Key Laboratory of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Department of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Immunology InstituteSchool of Basic Medical SciencesCheeloo College of MedicineShandong UniversityJinanShandongChina
| | - Long Chen
- NHC Key Laboratory of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Department of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Wenming Jia
- NHC Key Laboratory of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Department of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Juan Zhao
- NHC Key Laboratory of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
- Department of OtorhinolaryngologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Xiulian Sun
- Brain Research InstituteQilu Hospital of Shandong UniversityJinanShandongChina
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7
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Ius T, Pignotti F, Della Pepa GM, Bagatto D, Isola M, Battistella C, Gaudino S, Pegolo E, Chiesa S, Arcicasa M, La Rocca G, Olivi A, Skrap M, Sabatino G. Glioblastoma: from volumetric analysis to molecular predictors. J Neurosurg Sci 2020; 66:173-186. [PMID: 32031360 DOI: 10.23736/s0390-5616.20.04850-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite decades of therapeutic and molecular refinements, the prognosis of patients with glioblastoma (GBM) still remains unfavorable. Integrative clinical studies allow a better understanding of the natural evolution of GBM. To assess independent predictors of overall survival (OS) and progression free survival (PFS) clinical, surgical, molecular and radiological variables were evaluated. A novel preoperative volumetric magnetic resonance imaging (MRI) index for tumor prognosis in GBM patients was investigated. METHODS A cohort of 195 cases of patients operated for newly GBM were analyzed. Extent of tumoral resection (EOR), tumor growth pattern, expressed by preoperative volumetric ΔT1-T2 MRI index, molecular markers such as O6-methylguanine-DNA methyltransferase (MGMT) methylation and isocitrate dehydrogenase 1/2 (IDH1/2) mutation, were analyzed. Analysis of survival was done using Cox-proportional hazard models. RESULTS The 1-, 2- years estimated OS and PFS rate for the whole population were 61% and 27%, 38% and 17%, respectively. A better survival rate, both in terms of survival and tumor progression, was observed in patient with higher EOR (p=0.000), younger age (p=0.000), MGMT methylation status (p=0.001) and lower preoperative ΔT1-T2 MRI index (p=0.004). Regarding the tumor growth pattern a cut-off value of 0.75 was found to discriminate patient with different prognosis. Patients with a preoperative ΔT1-T2 MRI index <0.75 had a 1-year estimated OS of 67%, otherwise patients with a preoperative ΔT1-T2 MRI index >0.75 hada 1-year estimated OS of 34%. CONCLUSIONS In this investigation longer survival is associated with younger age, EOR, promoter methylation of MGMT and preoperative tumor volumetric features expressed by ΔT1-T2 MRI index. The preoperative ΔT1-T2 MRI index could be a promising prognostic factor potentially useful in GBM management. Future investigations based on multiparametric MRI data and next generation sequences analysis, may better clarify this result.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy -
| | | | | | - Daniele Bagatto
- Neuroradiology Unit, Department of Diagnostic Imaging ASUIUD Udine, Italy
| | - Miriam Isola
- Department of Medicine, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Claudio Battistella
- Department of Medicine, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Simona Gaudino
- Institute of Radiology, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Enrico Pegolo
- Institute of Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Silvia Chiesa
- Institute of Radiotherapy, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | | | | | | | - Miran Skrap
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
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8
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Kamińska K, Nalejska E, Kubiak M, Wojtysiak J, Żołna Ł, Kowalewski J, Lewandowska MA. Prognostic and Predictive Epigenetic Biomarkers in Oncology. Mol Diagn Ther 2019; 23:83-95. [PMID: 30523565 PMCID: PMC6394434 DOI: 10.1007/s40291-018-0371-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Epigenetic patterns, such as DNA methylation, histone modifications, and non-coding RNAs, can be both driver factors and characteristic features of certain malignancies. Aberrant DNA methylation can lead to silencing of crucial tumor suppressor genes or upregulation of oncogene expression. Histone modifications and chromatin spatial organization, which affect transcription, regulation of gene expression, DNA repair, and replication, have been associated with multiple tumors. Certain microRNAs (miRNAs), mainly those that silence tumor suppressor genes and occur in a greater number of copies, have also been shown to promote oncogenesis. Multiple patterns of these epigenetic factors occur specifically in certain malignancies, which allows their potential use as biomarkers. This review presents examples of tests for each group of epigenetic factors that are currently available or in development for use in early cancer detection, prediction, prognosis, and response to treatment. The availability of blood-based biomarkers is noted, as they allow sampling invasiveness to be reduced and the sampling procedure to be simplified. The article stresses the role of epigenetics as a crucial element of future cancer diagnostics and therapy.
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Affiliation(s)
- Katarzyna Kamińska
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, Bydgoszcz, Poland
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Ewelina Nalejska
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, Bydgoszcz, Poland
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Marta Kubiak
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, Bydgoszcz, Poland
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Joanna Wojtysiak
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, Bydgoszcz, Poland
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Łukasz Żołna
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Janusz Kowalewski
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Marzena Anna Lewandowska
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, Bydgoszcz, Poland.
- Department of Thoracic Surgery and Tumors, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
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9
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Fiorentino A, Gregucci F, Mazzola R, Figlia V, Ricchetti F, Sicignano G, Giajlevra N, Ruggieri R, Fersino S, Naccarato S, Massocco A, Corradini S, Alongi F. Intensity-modulated radiotherapy and hypofractionated volumetric modulated arc therapy for elderly patients with breast cancer: comparison of acute and late toxicities. LA RADIOLOGIA MEDICA 2018; 124:309-314. [PMID: 30547358 DOI: 10.1007/s11547-018-0976-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the differences between conventional fractionated intensity-modulated radiotherapy (IMRT) and hypofractionated (HypoRT) volumetric modulated arc therapy (VMAT) in elderly women affected by early-stage breast cancer (BC) in terms of RT-related acute/late side effect. MATERIALS AND METHODS Between October 2011 and July 2015, 80 consecutive elderly BC patients were treated with IMRT for 5 weeks (40 patients) or HypoRT-VMAT for 3 weeks (40 patients). Inclusion criteria were: age ≥ 70 years, early BC (pT1-2 pN0-1), no prior neoadjuvant chemotherapy and non-metastatic disease. For patients receiving IMRT or HypoRT-VMAT, a total dose of 50 Gy (25 fractions) or 40.5 Gy (15 fractions) was prescribed to the whole ipsilateral breast, respectively. All patients received a simultaneously integrated boost up to a total dose of 60 Gy for IMRT and 48 Gy for HypoRT-VMAT. Acute and late side effects were evaluated using the RTOG/EORTC radiation morbidity scoring system. RESULTS With a median follow-up of 45 months, acute skin toxicity was overall very low, with grade 1 in 25 cases (62.5%) of the IMRT group and 21 cases (52.5%) of the HypoRT-VMAT group, while grade 2 toxicity was reported in 10 IMRT patients (25%) and 1 HypoRT-VMAT patient (2.5%) (p = 0.001). Regarding late adverse events, only grade 1 skin toxicity was recorded. CONCLUSION The present study showed that whole breast IMRT and HypoRT-VMAT are feasible and well tolerated in early-stage BC elderly patients and that HypoRT-VMAT is affected by lower risk of acute and late RT-related side effects.
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Affiliation(s)
- Alba Fiorentino
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Fabiana Gregucci
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - Rosario Mazzola
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Vanessa Figlia
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Francesco Ricchetti
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Gianluisa Sicignano
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Niccolo Giajlevra
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Ruggero Ruggieri
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Sergio Fersino
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Stefania Naccarato
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Alberto Massocco
- Breast Unit, Cancer Care Center, Ospedale Sacro Cuore don Calabria, Negrar, Verona, Italy
| | - Stefanie Corradini
- Radiation Oncology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Filippo Alongi
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
- University of Brescia, Brescia, Italy
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10
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Linac-based radiosurgery or fractionated stereotactic radiotherapy with flattening filter-free volumetric modulated arc therapy in elderly patients : A mono-institutional experience on 110 brain metastases. Strahlenther Onkol 2018; 195:218-225. [PMID: 30478669 DOI: 10.1007/s00066-018-1405-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/15/2018] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to analyze the feasibility and clinical results of linear accelerator (linac-)based stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SFRT) with flattening filter-free (FFF) volumetric modulated arc therapy (VMAT) in elderly patients affected by brain metastases (BMs). PATIENTS AND METHODS Patients selected for the present analysis were ≥65 years old with a life expectancy of >3 months, a controlled or synchronous primary tumor, and <10 BMs with a diameter <3 cm. All patients were treated with FFF linac-based SRS/SFRT. The prescribed total dose (15-30 Gy/1-5 fractions) was based on BM size and proximity to organs at risk (OAR). Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. MedCalc v18.2 (MedCalc Software, Ostend, Belgium) was used for statistical analysis. RESULTS From April 2014 to December 2017, 40 elderly patients with 110 BMs were treated by FFF linac-based SRS/SFRT. With a median follow-up of 28 months (range 6-50 months), median and 1‑year overall survival were 9 months and 39%, respectively; median intracranial progression-free survival was 6 months. At the time of the analysis, local control was reported in 109/110 BMs (99.1%): 12 BMs had a complete response; 51 a partial response; 46 showed stable disease. One BM (0.9%) progressed after 2 months. BM volume (<1 cc) and higher SRS/SFRT dose correlated to treatment response (p = 0.01 and p = 0.0017, respectively). No adverse events higher than grade 2 were observed. CONCLUSION The present findings highlight the feasibility, safety, and effectiveness of FFF linac-based SRS/SFRT in elderly patients with BMs.
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11
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Asmaa A, Dixit S, Rowland-Hill C, Achawal S, Rajaraman C, O'Reilly G, Highley R, Hussain M, Baker L, Gill L, Morris H, Hingorani M. Management of elderly patients with glioblastoma-multiforme-a systematic review. Br J Radiol 2018; 91:20170271. [PMID: 29376741 DOI: 10.1259/bjr.20170271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The management of elderly patients with glioblastoma-multiforme (GBM) remains poorly defined with many experts in the past advocating best supportive care, in view of limited evidence on efficacy of more aggressive treatment protocols. There is randomised evidence (NORDIC and NA-O8 studies) to support the use of surgery followed by adjuvant monotherapy with either radiotherapy (RT) using hypofractionated regimes (e.g. 36 Gy in 6 fractions OR 40 Gy in 15 fractions) or chemotherapy with temozolomide (TMZ) in patients expressing methylation of promoter for O6-methylguanine-DNA methyltransferase enzyme. However, the role of combined-modality therapy involving the use of combined RT and TMZ protocols has remained controversial with data from the EORTC (European Organisation for Research and Treatment of Cancer)-NCIC (National Cancer Institute of Canada) studies indicating that patients more than 65 years of age may not benefit significantly from combining standard RT fractionation using 60 Gy in 30 fractions with concurrent and adjuvant TMZ. More recently, randomised data has emerged on combining hypofractionated RT with concurrent and adjuvant TMZ. We provide a comprehensive review of literature with the aim of defining an evidence-based algorithm for management of elderly glioblastoma-multiforme population.
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Affiliation(s)
- Almadani Asmaa
- 1 Faculty of Health Sciences, University of Hull , Hull , UK
| | - Sanjay Dixit
- 2 Queen centre of Oncology, Castle Hill hospital , Cottingham , UK
| | | | | | | | - Gerry O'Reilly
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Robin Highley
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Masood Hussain
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Louise Baker
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Lynne Gill
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Holly Morris
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Mohan Hingorani
- 4 Leeds Institue of Oncology, Leeds Teaching Hospitals NHS Trust , Leeds , UK
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12
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Shin JY, Yoon JK, Diaz AZ. Gliosarcoma in septuagenarians and octogenarians: What is the impact of adjuvant chemoradiation? J Clin Neurosci 2017; 45:77-82. [DOI: 10.1016/j.jocn.2017.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
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13
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A Model to Predict the Feasibility of Concurrent Chemoradiotherapy With Temozolomide in Glioblastoma Multiforme Patients Over Age 65. Am J Clin Oncol 2017; 40:523-529. [PMID: 26017481 DOI: 10.1097/coc.0000000000000198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES It is controversial whether concurrent chemoradiotherapy (CRT) with temozolomide is feasible and beneficial in elderly patients with glioblastoma. MATERIALS AND METHODS Retrospective analysis of 74 elderly glioblastoma patients (65 y and above) treated with concurrent CRT with temozolomide. Factors influencing prognosis and feasibility of CRT were investigated. RESULTS The median overall survival was 11.3 months. Univariate analysis showed a significant difference in median overall survival for cumulative dose of concurrent temozolomide (optimal cutoff, 2655 mg/m; 13.9 mo for >2655 mg/m vs. 4.9 mo for ≤2655 mg/m; P=0.0216, adjusted for multiple testing). Furthermore, cumulative dose of concurrent temozolomide >2655 mg/m was a significant independent prognostic parameter in multivariate analysis (hazard ratio, 0.33; P=0.002). Hematotoxicity was the most common cause of treatment interruption or discontinuation in patients with an insufficient cumulative temozolomide dose. Prognostic factors for successful performance of CRT with a cumulative dose of concurrent temozolomide >2655 mg/m were female sex (odds ratio [OR], 0.174; P=0.006), age (OR, 0.826 per year; P=0.017), and pretreatment platelet count (OR, 1.013 per 1000 platelets/µL; P=0.001). For easy clinical application of the model an online calculator was developed, which is available at http://www.OldTMZ.com. CONCLUSIONS The probability of successful performance of concurrent CRT with temozolomide can be estimated based on the patient's age, sex, and pretreatment platelet count using the model developed in this study. Thus, a subgroup of elderly glioblastoma patients suitable for chemoradiation with temozolomide can be identified.
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14
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Binabaj MM, Bahrami A, ShahidSales S, Joodi M, Joudi Mashhad M, Hassanian SM, Anvari K, Avan A. The prognostic value of MGMT promoter methylation in glioblastoma: A meta-analysis of clinical trials. J Cell Physiol 2017; 233:378-386. [PMID: 28266716 DOI: 10.1002/jcp.25896] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 03/06/2017] [Indexed: 01/16/2023]
Abstract
The DNA repair protein O6-Methylguanine-DNA methyltransferase (MGMT) is suggested to be associated with resistance to alkylating agents such as Temozolomide which is being used in treatment of patients with glioblastoma (GBM). Therefore, we evaluated the associations between MGMT promoter methylation and prognosis of patients with glioblastoma (GBM). Data were extracted from publications in Embase, PubMed, and the Cochrane Library. Data on overall survival (OS), progression-free survival (PFS), and MGMT methylation status were obtained and 4,097 subjects were enrolled. Data from 34 studies showed that MGMT methylated patients had better OS, compared to GBM unmethylated patients (pooled HRs, 0.494; 95%CI 0.412-0.591; p = 0.001). Meta-analysis of 10 eligible studies reporting on PFS, demonstrated that MGMT promoter methylation was not significantly associated with better PFS (pooled HRs, 0.653; 95%CI 0.414-1.030; p = 0.067). GBM patients with MGMT methylation were associated with longer overall survival, although this effect was not detected for PFS. Moreover, we performed further analysis in patients underwent a comprehensive imaging evaluation. This data showed a significant association with better OS and PFS, although further studies are warranted to assess the value of emerging marker in prospective setting in patients with glioblastoma as a risk stratification biomarker in clinical management of the patients.
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Affiliation(s)
- Maryam Moradi Binabaj
- Department of Medical Biochemistry, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afsane Bahrami
- Department of Modern Sciences and Technology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soodabeh ShahidSales
- Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Marjan Joodi
- Department of Pediatric Surgery, School of Medicine, Mashhad University of Medical Sciences, Sarvar Children's Hospital, Endoscopic and Minimally Invasive Surgery Research Center, Mashhad, Iran
| | - Mona Joudi Mashhad
- Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mahdi Hassanian
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kazem Anvari
- Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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15
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Halani SH, Babu R, Adamson DC. Management of Glioblastoma Multiforme in Elderly Patients: A Review of the Literature. World Neurosurg 2017; 105:53-62. [PMID: 28465276 DOI: 10.1016/j.wneu.2017.04.153] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 04/21/2017] [Accepted: 04/22/2017] [Indexed: 12/11/2022]
Abstract
Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor in adults, occurs most commonly in individuals older than 65 years of age, and is universally fatal. Increasing age compounds the poor prognosis of GBM, as elderly patients have markedly worse outcomes than younger patients. However, many of the studies previously investigating optimal treatment regimens exclude patients older than the age of 65 years and thus may not represent the best approaches to ensuring prolonged survival with preserved quality of life. This review aims to highlight the current literature on surgical and medical management, including our own experience, for GBM in the elderly patients, and to provide rational treatment approaches for a vulnerable, often-overlooked, patient population.
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Affiliation(s)
- Sameer H Halani
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ranjith Babu
- Division of Neurosurgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - D Cory Adamson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA; Neurosurgery Section, Atlanta VA Medical Center, Decatur, Georgia, USA.
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16
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Cihoric N, Tsikkinis A, Minniti G, Lagerwaard FJ, Herrlinger U, Mathier E, Soldatovic I, Jeremic B, Ghadjar P, Elicin O, Lössl K, Aebersold DM, Belka C, Herrmann E, Niyazi M. Current status and perspectives of interventional clinical trials for glioblastoma - analysis of ClinicalTrials.gov. Radiat Oncol 2017; 12:1. [PMID: 28049492 PMCID: PMC5210306 DOI: 10.1186/s13014-016-0740-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/08/2016] [Indexed: 01/09/2023] Open
Abstract
The records of 208.777 (100%) clinical trials registered at ClinicalTrials.gov were downloaded on the 19th of February 2016. Phase II and III trials including patients with glioblastoma were selected for further classification and analysis. Based on the disease settings, trials were classified into three groups: newly diagnosed glioblastoma, recurrent disease and trials with no differentiation according to disease setting. Furthermore, we categorized trials according to the experimental interventions, the primary sponsor, the source of financial support and trial design elements. Trends were evaluated using the autoregressive integrated moving average model. Two hundred sixteen (0.1%) trials were selected for further analysis. Academic centers (investigator initiated trials) were recorded as primary sponsors in 56.9% of trials, followed by industry 25.9%. Industry was the leading source of monetary support for the selected trials in 44.4%, followed by 25% of trials with primarily academic financial support. The number of newly initiated trials between 2005 and 2015 shows a positive trend, mainly through an increase in phase II trials, whereas phase III trials show a negative trend. The vast majority of trials evaluate forms of different systemic treatments (91.2%). In total, one hundred different molecular entities or biologicals were identified. Of those, 60% were involving drugs specifically designed for central nervous system malignancies. Trials that specifically address radiotherapy, surgery, imaging and other therapeutic or diagnostic methods appear to be rare. Current research in glioblastoma is mainly driven or sponsored by industry, academic medical oncologists and neuro-oncologists, with the majority of trials evaluating forms of systemic therapies. Few trials reach phase III. Imaging, radiation therapy and surgical procedures are underrepresented in current trials portfolios. Optimization in research portfolio for glioblastoma is needed.
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Affiliation(s)
- Nikola Cihoric
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Alexandros Tsikkinis
- Department of Genitourinary Oncology, David H. Koch Center for Applied Research of Genitourinary Cancers, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Giuseppe Minniti
- Unit of Radiation Oncology, Sant' Andrea Hospital, University Sapienza, and IRCCS Neuromed, Pozzilli (IS), Italy
| | - Frank J Lagerwaard
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Ulrich Herrlinger
- Department of Neurology, Division of Clinical Neurooncology, University of Bonn Medical Center, Bonn, Germany
| | - Etienne Mathier
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branislav Jeremic
- Institute of Lung Diseases, Sremska Kamenica, Serbia and BioIRC Center for Biomedical Research, Kragujevac, Serbia
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Kristina Lössl
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Claus Belka
- Department of Radiation Oncology, LMU Munich, München, Germany.,German Cancer Consortium (DKTK) & German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Evelyn Herrmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Maximilian Niyazi
- Department of Radiation Oncology, LMU Munich, München, Germany.,German Cancer Consortium (DKTK) & German Cancer Research Center (DKFZ), Heidelberg, Germany
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17
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Radiotherapy with or without temozolomide in elderly patients aged ≥ 70 years with glioblastoma. Contemp Oncol (Pozn) 2016; 20:251-5. [PMID: 27647990 PMCID: PMC5013689 DOI: 10.5114/wo.2016.61569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 07/20/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Although the recommended optimal treatment of glioblastoma multiforme (GBM) is adjuvant chemoradiotherapy, trials in GBM have excluded patients older than 70 years. In this study, we aimed to assess overall survival (OS) and prognostic factors in elderly patients (≥ 70 years) with newly diagnosed GBM treated with radiotherapy (RT) ± concurrent/adjuvant temozolomide (TMZ). Material and methods Inclusion criteria were patients ≥ 70 years, pre-RT Karnofsky performance status (KPS) ≥ 60, and time between diagnosis and start of RT ≤ 2 months. A total of 40 patients aged ≥ 70 years, 12 female and 28 male, treated between January 2004 and December 2012, were evaluated. Median age was 73.5 years (range, 70–83 years). The median RT dose was 60 Gy (range, 30–62 Gy). Twenty-one (52.5%) received concurrent TMZ, and of those 12 (30%) went on to receive adjuvant TMZ. Results The median OS was 7 months (95% CI: 5.45–8.54). One- and two-year OS for the whole cohort was 38% and 16%, respectively. Sex, type of surgery, tumor size, and RT dose did not significantly affect the OS. Presence of concurrent TMZ (p < 0.005) and presence of adjuvant TMZ (p < 0.001) were associated with longer OS in our cohort. Conclusions RT ± TMZ seems to be a well-tolerated treatment in patients ≥ 70 years with GBM. Even though no superiority was found between conventional or hypofractionated RT regimens (p = 0.405), the addition of concurrent and adjuvant TMZ to RT increased the OS in our study.
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18
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Abdullah KG, Ramayya A, Thawani JP, Macyszyn L, Martinez-Lage M, O’Rourke DM, Brem S. Factors associated with increased survival after surgical resection of glioblastoma in octogenarians. PLoS One 2015; 10:e0127202. [PMID: 25978638 PMCID: PMC4433248 DOI: 10.1371/journal.pone.0127202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/13/2015] [Indexed: 11/18/2022] Open
Abstract
Elderly patients with glioblastoma represent a clinical challenge for neurosurgeons and oncologists. The data available on outcomes of patients greater than 80 undergoing resection is limited. In this study, factors linked to increased survival in patients over the age of 80 were analyzed. A retrospective chart review of all patients over the age of 80 with a new diagnosis of glioblastoma and who underwent surgical resection with intent for maximal resection were examined. Patients who had only stereotactic biopsies were excluded. Immunohistochemical expression of oncogenic drivers (p53, EGFR, IDH-1) and a marker of cell proliferation (Ki-67 index) performed upon routine neuropathological examination were recorded. Stepwise logistic regression and Kaplan Meier survival curves were plotted to determine correlations to overall survival. Fifty-eight patients fit inclusion criteria with a mean age of 83 (range 80–93 years). The overall median survival was 4.2 months. There was a statistically significant correlation between Karnofsky Performance Status (KPS) and overall survival (P < 0.05). There was a significantly longer survival among patients undergoing either radiation alone or radiation and chemotherapy compared to those who underwent no postoperative adjuvant therapy (p < 0.05). There was also an association between overall survival and lack of p53 expression (p < 0.001) and lack of EGFR expression (p <0.05). In this very elderly population, overall survival advantage was conferred to those with higher preoperative KPS, postoperative adjuvant therapy, and lack of protein expression of EGFR and p53. These findings may be useful in clinical decision analysis for management of patients with glioblastoma who are octogenarians, and also validate the critical role of EGFR and p53 expression in oncogenesis, particularly with advancing age.
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Affiliation(s)
- Kalil G. Abdullah
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Ashwin Ramayya
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jayesh P. Thawani
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lukasz Macyszyn
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Maria Martinez-Lage
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Donald M. O’Rourke
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Steven Brem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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19
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Azoulay M, Santos F, Souhami L, Panet-Raymond V, Petrecca K, Owen S, Guiot MC, Patyka M, Sabri S, Shenouda G, Abdulkarim B. Comparison of radiation regimens in the treatment of Glioblastoma multiforme: results from a single institution. Radiat Oncol 2015; 10:106. [PMID: 25927334 PMCID: PMC4422039 DOI: 10.1186/s13014-015-0396-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/27/2015] [Indexed: 02/25/2023] Open
Abstract
Background The optimal fractionation schedule of radiotherapy (RT) for Glioblastoma multiforme (GBM) is yet to be determined. We aim to compare different fractionation regimens and identify prognostic factors to better tailor RT for newly diagnosed GBM patients. Methods All data for patients who underwent surgery for GBM between January 2005 and December 2012 were compiled. Clinical information was collected using patient charts and government registry. Cox analysis was used to identify variables affecting survival and treatment outcome. Results The median follow-up time was 13.2 months. Two hundred and seventy-six patients met the inclusion criteria, including 147 patients in the 60 Gy in 30 fractions (ConvRT) group, 86 patients in the 60 Gy in 20 fractions (HF60) group, and 43 patients in the 40 Gy in 15 fractions (HF40) group. Median survival (MS) was 16.0 months with a median progression-free survival (PFS) of 9.23 months in the ConvRT group. This was comparable to outcome in the HF60 group with MS 15.0 months and a median PFS of 9.1 months. Patients in the HF40 group had MS of 8 months, with a median PFS 5.4 months. Cox analysis showed no significant difference in OS between the ConvRT and HF60 groups but worse outcome in the HF40 group (HR 2.22, P = 0.04). MGMT methylation, extent of resection, use of chemotherapy, and repeat surgery were found to be significant independent prognostic factors for survival. Conclusions HF60 constitutes a safe RT approach that shows survival comparable to standard RT while allowing for a shorter treatment time.
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Affiliation(s)
- Melissa Azoulay
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal General Hospital, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada.
| | - Fabiano Santos
- Department of Oncology, Division of Cancer Epidemiology, McGill University, 546 Pine Avenue West, H2W1S6, Montreal, QC, Canada.
| | - Luis Souhami
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal General Hospital, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada.
| | - Valerie Panet-Raymond
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal General Hospital, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada.
| | - Kevin Petrecca
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital, McGill University, 3801 University Avenue, H2W1S6, Montreal, QC, Canada.
| | - Scott Owen
- Division of Medical oncology, Department of Oncology, Montreal General Hospital, McGill University, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada.
| | - Marie-Christine Guiot
- Department of Pathology, Montreal Neurological Hospital, McGill University, 3801 University Avenue, H3A 2B4, Montreal, QC, Canada.
| | - Mariia Patyka
- Research Institute of the McGill University Health Center, Montreal General Hospital, 1625 Pine Avenue West, H3G 1A4, Montreal, QC, Canada.
| | - Siham Sabri
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal General Hospital, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada. .,Research Institute of the McGill University Health Center, Montreal General Hospital, 1625 Pine Avenue West, H3G 1A4, Montreal, QC, Canada.
| | - George Shenouda
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal General Hospital, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada.
| | - Bassam Abdulkarim
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal General Hospital, 1650 Avenue Cedar, H3G 1A4, Montréal, QC, Canada.
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Bauchet L, Zouaoui S, Darlix A, Menjot de Champfleur N, Ferreira E, Fabbro M, Kerr C, Taillandier L. Assessment and treatment relevance in elderly glioblastoma patients. Neuro Oncol 2014; 16:1459-68. [PMID: 24792440 DOI: 10.1093/neuonc/nou063] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Glioblastoma (GBM) is the most common malignant primary brain tumor. Its incidence continues to increase in the elderly because the older segment of the population is growing faster than any other age group. Most clinical studies exclude elderly patients, and "standards of care" do not exist for GBM patients aged >70 years. We review epidemiology, tumor biology/molecular factors, prognostic factors (clinical, imaging data, therapeutics), and their assessments as well as classic and specific endpoints plus recent and ongoing clinical trials for elderly GBM patients. This work includes perspectives and personal opinions on this topic. Although there are no standards of care for elderly GBM patients, we can hypothesize that (i) Karnofsky performance status (KPS), probably after steroid treatment, is one of the most important clinical factors for determining our oncological strategy; (ii) resection is superior to biopsy, at least in selected patients (depending on location of the tumor and associated comorbidities); (iii) specific schedules of radiotherapy yield a modest but significant improvement; (iv) temozolomide has an acceptable tolerance, even when KPS <70, and could be proposed for methylated elderly GBM patients; and (v) the addition of concomitant temozolomide to radiotherapy has not yet been validated but shows promising results in some studies, yet the optimal schedule of radiotherapy remains to be determined. In the future, specific assessments (geriatric, imaging, biology) and use of new endpoints (quality of life and toxicity measures) will aid clinicians in determining the balance of potential benefits and risks of each oncological strategy.
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Affiliation(s)
- Luc Bauchet
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Sonia Zouaoui
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Amélie Darlix
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Nicolas Menjot de Champfleur
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Ernestine Ferreira
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Michel Fabbro
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Christine Kerr
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Luc Taillandier
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
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21
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Yin AA, Zhang LH, Cheng JX, Dong Y, Liu BL, Han N, Zhang X. The predictive but not prognostic value of MGMT promoter methylation status in elderly glioblastoma patients: a meta-analysis. PLoS One 2014; 9:e85102. [PMID: 24454798 PMCID: PMC3890309 DOI: 10.1371/journal.pone.0085102] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/22/2013] [Indexed: 12/24/2022] Open
Abstract
Background The clinical implication of O6-methylguanine-DNA methyltransferase (MGMT) promoter status is ill-defined in elderly glioblastoma patients. Here we report a meta-analysis to seek valid evidence for its clinical relevance in this subpopulation. Methods Literature were searched and reviewed in a systematic manner using the PubMed, EMBASE and Cochrane databases. Studies investigating the association between MGMT promoter status and survival data of elderly patients (≥65 years) were eligible for inclusion. Results Totally 16 studies were identified, with 13 studies included in the final analyses. The aggregate proportion of MGMT promoter methylation in elderly patients was 47% (95% confidence interval [CI]: 42–52%), which was similar to the value for younger patients. The analyses showed differential effects of MGMT status on overall survival (OS) of elderly patients according to assigned treatments: methylated vs. unmethylated: (1) temozolomide (TMZ)-containing therapies: hazard ratio [HR] 0.49, 95% CI 0.41–0.58; (2) TMZ-free therapies: HR 0.97, 95% CI 0.77–1.21. More importantly, a useful predictive value was observed by an interaction analysis: TMZ-containing therapies vs. RT alone: (1) methylated tumors: HR 0.48, 95% CI 0.36–0.65; (2) unmethylated tumors: HR 1.14; 95% CI 0.90–1.44. Conclusion The meta-analysis reports an age-independent presence of MGMT promoter methylation. More importantly, the study encouraged routine testing of MGMT promoter status especially in elderly glioblastoma patients by indicating a direct linkage between biomarker test and individual treatment decision. Future studies are needed to justify the mandatory testing in younger patients.
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Affiliation(s)
- An-an Yin
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
| | - Lu-hua Zhang
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
| | - Jin-xiang Cheng
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
| | - Yu Dong
- Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
| | - Bo-lin Liu
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
| | - Ning Han
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
| | - Xiang Zhang
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, The People's Republic of China
- * E-mail:
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Tabouret E, Tassy L, Chinot O, Crétel E, Retornaz F, Rousseau F. High-grade glioma in elderly patients: can the oncogeriatrician help? Clin Interv Aging 2013; 8:1617-24. [PMID: 24353408 PMCID: PMC3861296 DOI: 10.2147/cia.s35941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Gliomas are the most frequent primary brain tumors in adults. As the population ages in Western countries, the number of people being diagnosed with glioblastoma is expected to increase. Clinical management of elderly patients with primary brain tumors is difficult, owing to multiple comorbidities, polypharmacy, decreased tolerance to chemotherapy, and an increased risk of radiation-induced neurotoxicity. A few specific randomized studies have shown a benefit for radiotherapy in elderly patients with good performance status. For patients with poor performance status, chemotherapy (temozolomide) has been shown to be associated with prolonged duration of response. Patients with methylated O6-alkylguanine deoxyribonucleic acid alkyltransferase promoter seem to have better outcomes. Oncogeriatrics proposes the geriatric evaluation of elderly patients to improve therapeutic choices and optimize the management of treatment toxicities and comorbidities.
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Affiliation(s)
- Emeline Tabouret
- Department of Neuro-oncology, Timone Hospital, Marseille, France
| | - Louis Tassy
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Olivier Chinot
- Department of Neuro-oncology, Timone Hospital, Marseille, France
| | - Elodie Crétel
- Transveral Oncogeriatric Unit, University Hospital Timone, Marseille, France
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Thon N, Kreth S, Kreth FW. Personalized treatment strategies in glioblastoma: MGMT promoter methylation status. Onco Targets Ther 2013; 6:1363-72. [PMID: 24109190 PMCID: PMC3792931 DOI: 10.2147/ott.s50208] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The identification of molecular genetic biomarkers considerably increased our current understanding of glioma genesis, prognostic evaluation, and treatment planning. In glioblastoma, the most malignant intrinsic brain tumor entity in adults, the promoter methylation status of the gene encoding for the repair enzyme O6-methylguanine-DNA methyltransferase (MGMT) indicates increased efficacy of current standard of care, which is concomitant and adjuvant chemoradiotherapy with the alkylating agent temozolomide. In the elderly, MGMT promoter methylation status has recently been introduced to be a predictive biomarker that can be used for stratification of treatment regimes. This review gives a short summery of epidemiological, clinical, diagnostic, and treatment aspects of patients who are currently diagnosed with glioblastoma. The most important molecular genetic markers and epigenetic alterations in glioblastoma are summarized. Special focus is given to the physiological function of DNA methylation-in particular, of the MGMT gene promoter, its clinical relevance, technical aspects of status assessment, its correlation with MGMT mRNA and protein expressions, and its place within the management cascade of glioblastoma patients.
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Affiliation(s)
- Niklas Thon
- Department of Neurosurgery, Hospital of the University of Munich, Campus Grosshadern, Munich, Germany
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Radiotherapy plus concurrent or sequential temozolomide for glioblastoma in the elderly: a meta-analysis. PLoS One 2013; 8:e74242. [PMID: 24086323 PMCID: PMC3782499 DOI: 10.1371/journal.pone.0074242] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/31/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Many physicians are reluctant to treat elderly glioblastoma (GBM) patients as aggressively as younger patients, which is not evidence based due to the absence of validated data from primary studies. We conducted a meta-analysis to provide valid evidence for the use of the aggressive combination of radiotherapy (RT) and temozolomide (TMZ) in elderly GBM patients. METHODS A systematic literature search was conducted using the PubMed, EMBASE and Cochrane databases. Studies comparing combined RT/TMZ with RT alone in elderly patients (≥65 years) with newly diagnosed GBM were eligible for inclusion. RESULTS No eligible randomized trials were identified. Alternatively, a meta-analysis of nonrandomized studies (NRSs) was performed, with 16 studies eligible for overall survival (OS) analysis and nine for progression-free survival (PFS) analysis. Combined RT/TMZ was shown to reduce the risk of death and progression in elderly GBM patients compared with RT alone (OS hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.48-0.72; PFS: HR 0.58, 95% CI 0.41-0.84). Evaluable patients were reported to tolerate combined treatment but certain toxicities, and especially hematological toxicities, were more frequently observed. Limited data on O6-methylguanine-DNA methyltransferase (MGMT) promoter status and quality of life were reported. CONCLUSION The meta-analysis of NRSs provided level 2a evidence (Oxford Centre for Evidence-Based Medicine) that combined RT/TMZ conferred a clear survival benefit on a selection of elderly GBM patients who had a favorable prognosis (e.g., extensive resection, favorable KPS). Toxicities were more frequent but acceptable. Future randomized trials are warranted to justify a definitive conclusion.
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