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Lai X, Wang A. Clinical Study on Prevention of Irinotecan-Induced Delayed-Onset Diarrhea by Hot Ironing with Moxa Salt Packet on Tianshu and Shangjuxu. Emerg Med Int 2022; 2022:6587884. [PMID: 35912389 PMCID: PMC9334062 DOI: 10.1155/2022/6587884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To study the clinical efficacy of hot ironing of the Tianshu and Shangjuxu with moxa salt packet to prevent irinotecan (CPT-11)-induced delayed-onset diarrhea (IIDD). Methods A randomized controlled study was conducted on a sample of 120 patients with advanced colorectal cancer who were hospitalized in our oncology department and treated with FOLFIRI chemotherapy regimen from February 2018 to July 2021. They were equally divided into study group (n = 60) and control group (n = 60) according to whether they were treated with hot ironing with moxa salt packs or not. The general conditions, occurrence of IIDD, occurrence of delayed chemotherapy due to IIDD, time of occurrence and duration of IIDD, Karnofsky performance score (KPS) score, occurrence of leukopenia, and myelosuppression were compared between the two groups. Result The incidence of grade 1, 2, 3, and 4 diarrhea in the study group was 11.67% (7/60), 5.00% (3/60), 3.33% (2/60), and 0.00% (0/60), respectively, while the incidence of grade 1, 2, 3, and 4 diarrhea in the control group was 21.67% (13/60), 8.33% (5/60), 10.00% (6/60), and 3.33% (2/60). The incidence of severe diarrhea and total diarrhea in the study group was (3.33% and 20.00%) lower than that in the control group (13.33% and 43.33%) (P < 0.05). The incidence of delayed chemotherapy was lower in the study group (8.33%) (1/12) than in the control group (23.08%) (6/26) but the difference between the groups was not statistically significant (P > 0.05). The time to onset of IIDD in the study group (6.45 ± 1.53) days was comparable to that in the control group (6.40 ± 1.77 days) (P > 0.05), but the duration of IIDD in the study group (3.25 ± 1.05 days) was shorter than that in the control group (5.70 ± 1.72 days) (P < 0.05). After treatment, the incidence of KPS improvement, stabilization, and reduction in the study group was 38.33% (23/60), 51.67% (31/60), and 10.00% (6/60), respectively, the incidence of KPS improvement, stabilization, and reduction in the control group was 23.33% (14/60), 50.00% (30/60), and 26.67% (16/60), respectively, and the percentage of KPS reduction in the study group was less than that in the control group (P < 0.05). During the observation period after treatment, the total incidence of leucopenia in the study group was 11.67% (7/60) which is lower than 31.67% (19/60) in the control group (P < 0.05). During the observation period after treatment, the incidence of III°+°IV myelosuppression in the study group was 5.00% (3/60) which is lower than 25.00% (15/60) in the control group (P < 0.05). Conclusion The hot ironing with moxa salt packet on Tianshu and Shangjuxu was more effective in preventing IIDD, which could reduce the incidence and severity of IIDD, shorten the duration of diarrhea and significantly increase the quality of life of patients with no significant adverse effects.
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Affiliation(s)
- Xianghong Lai
- Department of Integrated Chinese and Western Medicine Oncology, Hangzhou Cancer Hospital, Hangzhou, Zhejiang 310002, China
| | - Anmei Wang
- Department of Integrated Chinese and Western Medicine Oncology, Hangzhou Cancer Hospital, Hangzhou, Zhejiang 310002, China
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Caramanti R, Aprígio RM, D`Aglio Rocha CE, Morais DF, Góes MJ, Chaddad-Neto F, Tognola WA. Is Edema Zone Volume Associated With Ki-67 Index in Glioblastoma Patients? Cureus 2022; 14:e24246. [PMID: 35602791 PMCID: PMC9116516 DOI: 10.7759/cureus.24246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 11/05/2022] Open
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Treatment of Older Adult Patients with Glioblastoma: Moving towards the Inclusion of a Comprehensive Geriatric Assessment for Guiding Management. Curr Oncol 2022; 29:360-376. [PMID: 35049706 PMCID: PMC8774312 DOI: 10.3390/curroncol29010032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults, and over half of patients with newly diagnosed GBM are over the age of 65. Management of glioblastoma in older patients includes maximal safe resection followed by either radiation, chemotherapy, or combined modality treatment. Despite recent advances in the treatment of older patients with GBM, survival is still only approximately 9 months compared to approximately 15 months for the general adult population, suggesting that further research is required to optimize management in the older population. The Comprehensive Geriatric Assessment (CGA) has been shown to have a prognostic and predictive role in the management of older patients with other cancers, and domains of the CGA have demonstrated an association with outcomes in GBM in retrospective studies. Furthermore, the CGA and other geriatric assessment tools are now starting to be prospectively investigated in older GBM populations. This review aims to outline current treatment strategies for older patients with GBM, explore the rationale for inclusion of geriatric assessment in GBM management, and highlight recent data investigating its implementation into practice.
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Gómez Vecchio T, Corell A, Buvarp D, Rydén I, Smits A, Jakola AS. Classification of Adverse Events Following Surgery in Patients With Diffuse Lower-Grade Gliomas. Front Oncol 2022; 11:792878. [PMID: 34993147 PMCID: PMC8724913 DOI: 10.3389/fonc.2021.792878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/25/2021] [Indexed: 12/21/2022] Open
Abstract
Background Recently, the Therapy-Disability-Neurology (TDN) was introduced as a multidimensional reporting system to detect adverse events in neurosurgery. The aim of this study was to compare the novel TDN score with the Landriel–Ibanez classification (LIC) grade in a large cohort of patients with diffuse lower-grade glioma (dLGG). Since the TDN score lacks validation against patient-reported outcomes, we described health-related quality of life (HRQoL) change in relation to TDN scores in a subset of patients. Methods We screened adult patients with a surgically treated dLGG World Health Organization (WHO) grade 2 and 3 between 2010 and 2020. Up until 2017, it consists of a retrospective cohort (n = 158). From 2017 and onwards, HRQoL was registered using EuroQoL-5-dimension, three levels of response (EQ-5D 3L) questionnaire at baseline and 3 months follow-up, in a prospectively recruited cohort (n = 102). Both the LIC grade and TDN score were used to classify adverse events. Results In total, 231 patients were included. In 110/231 (47.6%) of the surgical procedures, a postoperative complication was registered. When comparing the TDN score to LIC grades, only a minor shift towards complications of higher order could be observed. EQ-5D 3L was reported for 45 patients. Patients with complications related to surgery had pre- to postoperative changes in EQ-5D 3L index values (n = 27; mean 0.03, 95% CI −0.06 to 0.11) that were comparable to patients without complications (n = 18; mean −0.06, 95% CI −0.21 to 0.08). In contrast, patients with new-onset neurological deficit had a deterioration in HRQoL at follow-up, with a mean change in the EQ-5D 3L index value of 0.11 (n = 13, 95% CI 0.0 to 0.22) compared to −0.06 (n = 32, 95% CI −0.15 to 0.03) for all other patients. Conclusions In patients with dLGG, TDN scores compared to the standard LIC tend to capture more adverse events of higher order. There was no clear relation between TDN severity and HRQoL. However, new-onset neurological deficit caused impairment in HRQoL. For the TDN score to better align with patient-reported outcomes, more emphasis on neurological deficit and function should be considered.
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Affiliation(s)
- Tomás Gómez Vecchio
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alba Corell
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dongni Buvarp
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Isabelle Rydén
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anja Smits
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Asgeir S Jakola
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Barz M, Gerhardt J, Bette S, Aftahy AK, Huber T, Combs SE, Ryang YM, Wiestler B, Skardelly M, Gepfner-Tuma I, Behling F, Schmidt-Graf F, Meyer B, Gempt J. Prognostic value of tumour volume in patients with a poor Karnofsky performance status scale - a bicentric retrospective study. BMC Neurol 2021; 21:446. [PMID: 34781889 PMCID: PMC8591917 DOI: 10.1186/s12883-021-02424-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 09/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKROUND Median overall survival (OS) after diagnosis of glioblastoma (GBM) remains 15 months amongst patients receiving aggressive surgical resection, chemotherapy and irradiation. Treatment of patients with a poor preoperative Karnofsky Performance Status Scale (KPSS) is still controversial. Therefore, we retrospectively assessed the outcome after surgical treatment in patients with a KPSS of ≤60%. METHODS We retrospectively included patients with a de-novo glioblastoma WHO °IV and preoperative KPSS ≤60%, who underwent surgery at two neurosurgical centres between September 2006 and March 2016. We recorded pre- and postoperative tumour volume, pre- and postoperative KPSS, OS, age and MGMT promoter status. RESULTS One hundred twenty-three patients (58 females/65 males, mean age 67.4 ± 13.4 years) met the inclusion criteria. Seventy-five of the 123 patients (61%) underwent surgical resection. 48/123 patients (39%) received a biopsy. The median preoperative and postoperative tumour volume of all patients was 33.0 ± 31.3 cm3 (IR 15.0-56.5cm3) and 3.1 ± 23.8 cm3 (IR 0.2-15.0 cm3), respectively. The median KPSS was 60% (range 20-60%) preoperatively and 50% (range 0-80%) postoperatively. Patients who received a biopsy showed a median OS for patients who received a biopsy only was 3.0 months (95% CI 2.0-4.0 months), compared to patients who had a resection and had a median OS of 8 months (95% CI 3.1-12.9 months). Age (p < 0.001, HR: 1.045 [95% CI 1.022-1.068]), postoperative tumour volume (p = 0.02, HR: 1.016 [95% CI 1.002-1.029]) and MGMT promotor status (p = 0.016, HR: 0.473 [95% CI 0.257-0.871]) were statistically significant in multivariate analysis. In subgroup analyses only age was shown as a significant prognostic factor in multivariate analyses for patients receiving surgery (p < 0.001, HR: 1.046 [95% CI 1.022-1.072]). In the biopsy group no significant prognostic factors were shown in multivariate analysis. CONCLUSION GBM patients with a preoperative KPSS of ≤60% might profit from surgical reduction of tumour burden.
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Affiliation(s)
- Melanie Barz
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Julia Gerhardt
- Department of Neurosurgery, Helios Klinikum Berlin Buch, Berlin, Germany
| | - Stefanie Bette
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Augsburg, Augsburg, Germany.,Department of Neuroradiology, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - A Kaywan Aftahy
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Huber
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stephanie E Combs
- Helmholtz Zentrum Munich (HMGU), Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK) (German Cancer Consortium), Partner Site Munich, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Helios Klinikum Berlin Buch, Berlin, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Marco Skardelly
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | | | - Felix Behling
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
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Fan W, Yu X, Li K, Zhu M. The alerting expression of microRNA-411 predicts clinical prognosis and regulates tumor progression of glioblastoma. Bioengineered 2021; 12:8650-8657. [PMID: 34606414 PMCID: PMC8806974 DOI: 10.1080/21655979.2021.1988365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Glioblastoma is a malignant intracranial tumor with indispensable growth. Identification of biomarkers associated with the progression of tumors could benefit the clinical therapy of and improve patient’s survival. miR-411 has been reported to play a role in other cancers, while its function in glioblastoma has been explored in the present study. The expression of miR-411 was evaluated in glioblastoma tissues (collected from 108 glioblastoma patients) and cells by polymerase chain reaction. The clinical significance of miR-411 was estimated with a series of statistical analyses. The biological function of miR-411 in the cellular processes of glioblastoma was assessed by cell counting kit 8 and Transwell assay. The expression of miR-411 was significantly reduced in glioblastoma, which was associated with the Karnofsky Performance Score (KPS) and Isocitrate dehydrogenase 1 (IDH1) status of patients. miR-411 was identified as an independent prognostic indicator that correlated with the poor prognosis of patients. miR-411 suppressed the growth, migration, and invasion of glioblastoma cells via modulating signal transducer and activator of transcription 3 (STAT3). miR-411 participated in the development of glioblastoma and function as a prognostic biomarker. miR-411 functions as a tumor suppressor, which provides a novel potential therapeutic target for glioblastoma.
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Affiliation(s)
- Weihua Fan
- Department of Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xia Yu
- Department of Anesthesia and Perioperative Medicine, Dongying Hospital of Traditional Chinese Medicine, Dongying, Shandong, China
| | - Kunrong Li
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Mingtao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
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Moriconi C, Civita P, Neto C, Pilkington GJ, Gumbleton M. Caveolin-1, a Key Mediator Across Multiple Pathways in Glioblastoma and an Independent Negative Biomarker of Patient Survival. Front Oncol 2021; 11:701933. [PMID: 34490102 PMCID: PMC8417742 DOI: 10.3389/fonc.2021.701933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
Glioblastoma (GB) remains an aggressive malignancy with an extremely poor prognosis. Discovering new candidate drug targets for GB remains an unmet medical need. Caveolin-1 (Cav-1) has been shown to act variously as both a tumour suppressor and tumour promoter in many cancers. The implications of Cav-1 expression in GB remains poorly understood. Using clinical and genomic databases we examined the relationship between tumour Cav-1 gene expression (including its spatial distribution) and clinical pathological parameters of the GB tumour and survival probability in a TCGA cohort (n=155) and CGGA cohort (n=220) of GB patients. High expression of Cav-1 represented a significant independent predictor of shortened survival (HR = 2.985, 5.1 vs 14.9 months) with a greater statistically significant impact in female patients and in the Proneural and Mesenchymal GB subtypes. High Cav-1 expression correlated with other factors associated with poor prognosis: IDH w/t status, high histological tumour grade and low KPS score. A total of 4879 differentially expressed genes (DEGs) in the GB tumour were found to correlate with Cav-1 expression (either positively or negatively). Pathway enrichment analysis highlighted an over-representation of these DEGs to certain biological pathways. Focusing on those that lie within a framework of epithelial to mesenchymal transition and tumour cell migration and invasion we identified 27 of these DEGs. We then examined the prognostic value of Cav-1 when used in combination with any of these 27 genes and identified a subset of combinations (with Cav-1) indicative of co-operative synergistic mechanisms of action. Overall, the work has confirmed Cav-1 can serve as an independent prognostic marker in GB, but also augment prognosis when used in combination with a panel of biomarkers or clinicopathologic parameters. Moreover, Cav-1 appears to be linked to many signalling entities within the GB tumour and as such this work begins to substantiate Cav-1 or its associated signalling partners as candidate target for GB new drug discovery.
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Affiliation(s)
- Chiara Moriconi
- School of Pharmacy and Pharmaceutical Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
- Department of Pathology and Cell Biology, Columbia University, New York Presbyterian Hospital, New York, NY, United States
| | - Prospero Civita
- School of Pharmacy and Pharmaceutical Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
- Brain Tumour Research Centre, School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, United Kingdom
| | - Catia Neto
- School of Pharmacy and Pharmaceutical Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Geoffrey J. Pilkington
- School of Pharmacy and Pharmaceutical Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
- Brain Tumour Research Centre, School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, United Kingdom
- Department of Basic and Clinical Neuroscience, Division of Neuroscience, Institute of Psychiatry & Neurology, King’s College London, London, United Kingdom
| | - Mark Gumbleton
- School of Pharmacy and Pharmaceutical Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
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Dono A, Mitra S, Shah M, Takayasu T, Zhu JJ, Tandon N, Patel CB, Esquenazi Y, Ballester LY. PTEN mutations predict benefit from tumor treating fields (TTFields) therapy in patients with recurrent glioblastoma. J Neurooncol 2021; 153:153-160. [PMID: 33881725 PMCID: PMC8363068 DOI: 10.1007/s11060-021-03755-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Optimal treatment for recurrent glioblastoma isocitrate dehydrogenase 1 and 2 wild-type (rGBM IDH-WT) is not standardized, resulting in multiple therapeutic approaches. A phase III clinical trial showed that tumor treating fields (TTFields) monotherapy provided comparable survival benefits to physician's chemotherapy choice in rGBM. However, patients did not equally benefit from TTFields, highlighting the importance of identifying predictive biomarkers of TTFields efficacy. METHODS A retrospective review of an institutional database with 530 patients with infiltrating gliomas was performed. Patients with IDH-WT rGBM receiving TTFields at first recurrence were included. Tumors were evaluated by next-generation sequencing for mutations in 205 cancer-related genes. Post-progression survival (PPS) was examined using the log-rank test and multivariate Cox-regression analysis. RESULTS 149 rGBM patients were identified of which 29 (19%) were treated with TTFields. No significant difference in median PPS was observed between rGBM patients who received versus did not receive TTFields (13.9 versus 10.9 months, p = 0.068). However, within the TTFields-treated group (n = 29), PPS was improved in PTEN-mutant (n = 14) versus PTEN-WT (n = 15) rGBM, (22.2 versus 11.6 months, p = 0.017). Within the PTEN-mutant group (n = 70, 47%), patients treated with TTFields (n = 14) had longer median PPS (22.2 versus 9.3 months, p = 0.005). No PPS benefit was observed in PTEN-WT patients receiving TTFields (n = 79, 53%). CONCLUSIONS TTFields therapy conferred a significant PPS benefit in PTEN-mutant rGBM. Understanding the molecular mechanisms underpinning the differences in response to TTFields therapy could help elucidate the mechanism of action of TTFields and identify the rGBM patients most likely to benefit from this therapeutic option.
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Affiliation(s)
- Antonio Dono
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
| | - Sonali Mitra
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
- Rice University, Houston, TX, 77030, USA
| | - Mauli Shah
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
| | - Takeshi Takayasu
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
| | - Jay-Jiguang Zhu
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
- Memorial Hermann Hospital-TMC, Houston, TX, 77030, USA
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
- Memorial Hermann Hospital-TMC, Houston, TX, 77030, USA
| | - Chirag B Patel
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA.
- Memorial Hermann Hospital-TMC, Houston, TX, 77030, USA.
- Center for Precision Health, The University of Texas Health Science Center at Houston - McGovern Medical School, 6400 Fannin Street, Suite # 2800, Houston, TX, 77030, USA.
| | - Leomar Y Ballester
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA.
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center At Houston, Houston, TX, 77030, USA.
- Memorial Hermann Hospital-TMC, Houston, TX, 77030, USA.
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Wasilewski A, Alam A, Mohile N. Chemotherapy toxicities and geriatric syndromes in older patients with malignant gliomas. J Geriatr Oncol 2020; 12:134-138. [PMID: 32674977 DOI: 10.1016/j.jgo.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe treatment toxicities and polypharmacy in older patients with malignant gliomas (MG). BACKGROUND Advanced age in cancer patients is associated with increased treatment-related toxicities, acute care utilization and functional decline. Most patients with MG are over age 65, yet treatment patterns and toxicities are poorly defined. METHODS A retrospective chart review of 125 patients with MG age 65 or older at the University of Rochester from January 2012 to December 2018. RESULTS 115 patients with glioblastoma and 10 with anaplastic astrocytoma had a median age of 71 (range 65-89) at diagnosis and median overall survival (OS) of 10.3 months. Radiotherapy (RT) was offered and completed in 79% (fractionated, n = 69, hypofractionated, n = 30). 24% of the 98 patients treated with concurrent temozolomide (TMZ) experienced treatment delays (n = 24). Median of 4 cycles of adjuvant TMZ were taken by 61% (n = 76). Delays and dose reductions occurred in 55% during treatment with adjuvant TMZ, most commonly due to thrombocytopenia (n = 29) and fatigue (n = 15). 16/98 patients required transfusions during treatment with concurrent or adjuvant TMZ. At baseline, patients were prescribed a median of 11 medications. OS was longer in patients prescribed less than 8 medications vs. 8 or more (14 vs. 8.6 months, p = .0738). 96% experienced a non-elective hospital admission and 64% reported at least one fall. CONCLUSION Older patients with MG experience significant polypharmacy, treatment toxicities and falls. Studies incorporating geriatric assessment tools may better determine associations between geriatric syndromes and survival. Clinical trials in older patients should also include non-survival outcomes.
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Butterbrod E, Synhaeve N, Rutten GJ, Schwabe I, Gehring K, Sitskoorn M. Cognitive impairment three months after surgery is an independent predictor of survival time in glioblastoma patients. J Neurooncol 2020; 149:103-111. [PMID: 32643066 PMCID: PMC7452884 DOI: 10.1007/s11060-020-03577-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/25/2020] [Indexed: 12/31/2022]
Abstract
Purpose Cognitive functioning is increasingly investigated for its prognostic value in glioblastoma (GBM) patients, but the association of cognitive status during early adjuvant treatment with survival time is unclear. The aim of this study was to determine whether cognitive performance three months after surgical resection predicted survival time, while using a clinically intuitive time ratio (TR) statistic. Methods Newly diagnosed patients with GBM undergoing resection between November 2010 and February 2018 completed computerized cognitive assessment 3 months after surgery with the CNS Vital Signs battery (8 measures). The association of cognitive performance (continuous Z scores and dichotomous impairment status; impaired vs. unimpaired) with survival time was assessed with multivariate Accelerated Failure Time (AFT) models that also included clinical prognostic factors and covariates related to cognitive performances. Results 114 patients were included in the analyses (median survival time 16.4 months). Of the clinical factors, postoperative Karnofsky Performance Status (TR 1.51), surgical (TR 2.20) and non-surgical (TR 1.94) salvage treatment, and pre-surgical tumor volume (cm3, TR 1.003) were significant independent predictors of survival time. Independently of the base model factors and covariates, impairment on Stroop test I and Stroop test III estimated 23% and 26% reduction of survival time (TR 0.77, TR 0.74) respectively, as compared to unimpaired performance. Conclusion These findings suggest that impaired performances on tests of executive control and processing speed in the early phase of adjuvant treatment can reflect a worse prognostic outlook rather than an early treatment effect, and their assessment might allow for early refinement of current prognostic stratification. Electronic supplementary material The online version of this article (10.1007/s11060-020-03577-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elke Butterbrod
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
| | - Nathalie Synhaeve
- Department of Neurology, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Geert-Jan Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Inga Schwabe
- Department of Methodology and Statistics, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.,Translational Neurogenomics Laboratory, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Brisbane, Australia
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Margriet Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
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11
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Alan O, Telli TA, Tuylu TB, Arikan R, Demircan NC, Ercelep O, Kaya S, Babacan NA, Atasoy BM, Bozkurt S, Bayri Y, Gul D, Ekinci G, Ziyal I, Dane F, Yumuk PF. Prognostic factors in progressive high-grade glial tumors treated with systemic approach: A single center experience. J Oncol Pharm Pract 2020; 27:329-339. [PMID: 32349641 DOI: 10.1177/1078155220920684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Malignant high-grade gliomas are the most common and aggressive type of primary brain tumor, and the prognosis is generally extremely poor. In this retrospective study, we analyzed the outcome of systemic treatment in recurrent high-grade glioma patients and the impact of prognostic factors on survivals. METHODS Data from 114 patients with recurrent high-grade glioma who received systemic treatment and followed in our clinic between 2012 and 2018 were retrospectively analyzed. Eastern Cooperative Oncology Group (ECOG) performance status, age, gender, histology, type of surgical resection, side effects after systemic treatment (deep vein thrombosis, hypertension, proteinuria), IDH1 and alpha thalassemia/mental retardation syndrome X-linked (ATRX) mutation status were investigated as prognostic factors for progression-free survival and overall survival. RESULTS At the time of diagnosis, the median age was 48 (17-77) and 68% of the patients were male. Most common pathologic subtype was glioblastoma multiforme (68%). Median follow-up duration was 9.1 months (1-68 months). Median progression-free survival and overall survival were 6.2 months and 8 months, respectively. In multivariate analysis, ECOG PS, deep venous thrombosis and the presence of ATRX and IDH1 mutation were found to be independent prognostic factors for progression-free survival (p < 0.05) and, ECOG PS, the presence of ATRX and IDH1 mutation for overall survival (p < 0.05). CONCLUSION Our study is real life data and the median progression-free survival and overall survival rates are similar to the literature. We have found ECOG PS, presence of ATRX and IDH1 mutation to be independent prognostic factors for both progression-free survival and overall survival.
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Affiliation(s)
- Ozkan Alan
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Tugba Akin Telli
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Tugba Basoglu Tuylu
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Rukiye Arikan
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Nazım Can Demircan
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Ozlem Ercelep
- Marmara University Pendik Education and Research Hospital, Medical Oncology Clinic, Istanbul, Turkey
| | - Serap Kaya
- Marmara University Pendik Education and Research Hospital, Medical Oncology Clinic, Istanbul, Turkey
| | - Nalan Akgul Babacan
- Marmara University Pendik Education and Research Hospital, Medical Oncology Clinic, Istanbul, Turkey
| | - Beste M Atasoy
- Department of Radiation Oncology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Suheyla Bozkurt
- Department of Pathology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Yasar Bayri
- Department of Neurosurgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Dilek Gul
- Marmara University Pendik Education and Research Hospital, Radiation Oncology Clinic, Istanbul, Turkey
| | - Gazanfer Ekinci
- Department of Radiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Ibrahim Ziyal
- Department of Neurosurgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Faysal Dane
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - P Fulden Yumuk
- Division of Medical Oncology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
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12
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Effect of Physical Condition on Outcomes in Transplant Patients: A Retrospective Data Analysis. REHABILITATION ONCOLOGY 2020. [DOI: 10.1097/01.reo.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Shao J, Radakovich NR, Grabowski M, Borghei-Razavi H, Knusel K, Joshi KC, Muhsen BA, Hwang L, Barnett GH, Mohammadi AM. Lessons Learned in Using Laser Interstitial Thermal Therapy for Treatment of Brain Tumors: A Case Series of 238 Patients from a Single Institution. World Neurosurg 2020; 139:e345-e354. [PMID: 32298824 DOI: 10.1016/j.wneu.2020.03.213] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) is a novel, minimally invasive alternative to craniotomy, and as with any new technology, comes with a learning curve. OBJECTIVE We present our experience detailing the evolution of this technology in our practice in one of the largest patient cohorts to date regarding LITT in neuro-oncology. METHODS We reviewed 238 consecutive patients with brain tumor treated with LITT at our institution. Data on patient, surgery and tumor characteristics, and follow-up were collected. Patients were categorized into 2 cohorts: early (<2014, 100 patients) and recent (>2015, 138 patients). Median follow-up for the entire cohort was 8.4 months. RESULTS The indications for LITT included gliomas (70.2%), radiation necrosis (21.0%), and metastasis (8.8%). Patient demographics stayed consistent between the 2 cohorts, with the exception of age (early, 54.3; recent, 58.4; P = 0.04). Operative time (6.6 vs. 3.5; P < 0.001) and number of trajectories (53.1% vs. 77.9% with 1 trajectory; P < 0.001) also decreased in the recent cohort. There was a significant decrease in permanent motor deficits over time (15.5 vs. 4.4%; P = 0.005) and 30-day mortality (4.1% vs. 1.5%) also decreased (not statistically significant) in the recent cohort. In terms of clinical outcomes, poor preoperative Karnofsky Performance Status (≤70) were significantly correlated with increased permanent deficits (P = 0.001) and decreased overall survival (P < 0.001 for all time points). CONCLUSIONS We observed improvement in operative efficiency and permanent deficits over time and also patients with poor preoperative Karnofsky Performance Status achieved suboptimal outcomes with LITT. As many other treatment modalities, patient selection is important in this procedure.
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Affiliation(s)
- Jianning Shao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA; Case Western School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nathan R Radakovich
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA; Case Western School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Matthew Grabowski
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hamid Borghei-Razavi
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Konrad Knusel
- Case Western School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Krishna C Joshi
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Baha'eddin A Muhsen
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lee Hwang
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.
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14
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Clinical characteristics and risk factors of perioperative outcomes in elderly patients with intracranial tumors. Neurosurg Rev 2019; 44:389-400. [PMID: 31848767 DOI: 10.1007/s10143-019-01217-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/13/2019] [Accepted: 11/21/2019] [Indexed: 01/21/2023]
Abstract
We aimed to study the clinical and radiological characteristics of intracranial tumors and explore the possible predictive value of these characteristics in relation to perioperative outcomes in elderly patients. We retrospectively identified 1535 elderly patients (aged 65 years and older) with intracranial tumors who underwent surgical resection between 2014 and 2018 in Beijing Tiantan Hospital. Factors associated with an increased risk of unfavorable perioperative performance and complications were investigated. Meningiomas were the most common tumors in the cohort (43.26%). The overall risk of perioperative death was 0.59%, and 42.80% of patients were discharged with unfavorable performance (Karnofsky Performance Scale [KPS] score ≤ 70). Of all patients, 39.22% had one or more complications after surgical resection. Aggressive surgery significantly lowered the rate of unfavorable perioperative outcomes (P = 0.000) with no increase in postoperative complications (P = 0.153), but it failed to be an independent predictor for perioperative outcomes in the multivariate analysis. Low performance status at admission (KPS ≤ 70) was independently associated with both unfavorable perioperative performance (P = 0.000) and complications (P = 0.000). In addition to the histopathological patterns of tumors, low performance status at admission is an independent predictor for both unfavorable perioperative performance and the occurrence of complications in elderly patients with intracranial tumors who have undergone surgical resections. However, age is not associated with perioperative outcomes in elderly patients.
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15
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Gempt J, Bette S, Albertshauser J, Cammardella JH, Gradtke C, Wiestler B, Schirmer L, Ryang YM, Meyer B, Ringel F. Personality Traits in Patients with Neuroepithelial Tumors - A Prospective Study. Sci Rep 2018; 8:17055. [PMID: 30451871 PMCID: PMC6243000 DOI: 10.1038/s41598-018-34980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/28/2018] [Indexed: 11/09/2022] Open
Abstract
Aim of this study was to analyze personality traits in patients with neuroepithelial brain tumors. Personality alteration is a common feature in brain tumor patients, but not much is known about associations between specific personality changes and brain tumors. We assessed potential factors influencing personality such as tumor location, tumor grade and tumor volume. Mini-mental state examination (MMSE), Beck's Depression Inventory II (BDI-II), and the NEO Five-Factor Inventory (NEO-FFI) for the five factors of personality were acquired. Patients had lower scores regarding the factor openness and higher scores regarding the BDI-II compared to the norm population. No significant influencing factors (tumor entity, location) were found regarding personality traits. Neuroticism was associated with depression, whereas extraversion showed an opposed association. Patients with intrinsic brain tumors have differences in personality traits compared to the control population, with an emphasis on the factor openness. No significant confounding factors like tumor grade, entity, or location were found for personality traits.
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Affiliation(s)
- Jens Gempt
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany.
| | - Stefanie Bette
- Abteilung für Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Jennifer Albertshauser
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Jasmin Hernandez Cammardella
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Corinna Gradtke
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Benedikt Wiestler
- Abteilung für Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Lucas Schirmer
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Neurology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, 68167, Germany
| | - Yu-Mi Ryang
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Bernhard Meyer
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Florian Ringel
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
- Neurochirurgische Klinik und Poliklinik, Johannes Gutenberg-Universität Mainz, Langenbeckstraße, Mainz, 155131, Germany
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16
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Deluche E, Leobon S, Lamarche F, Tubiana-Mathieu N. First validation of the G-8 geriatric screening tool in older patients with glioblastoma. J Geriatr Oncol 2018; 10:159-163. [PMID: 30037767 DOI: 10.1016/j.jgo.2018.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/25/2018] [Accepted: 07/09/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Management of glioblastoma, with a very poor prognosis, remains a challenge in older patients because of coexisting comorbidities and the increased risk of toxic treatment effects. The use of screening tools to identify vulnerable patients is essential. This study was performed to establish whether the G8 scale can be used for screening older patients with glioblastoma. METHODS We retrospectively reviewed the files of patients assessed by the G8 scale and diagnosed with glioblastoma at a single center from January 2010 to July 2017. Patients aged 65 years or older were classified into three groups (more efficiently than two groups) according to their G8 score to identify those with a poor prognosis: high score group, G8 score 14.5-17; intermediate score group, G8 score 10.5-14; and low score group, G8 score < 10.5. RESULTS Of 89 patients, 19% were classified into the high score group, 43% into the intermediate score group, and 38% into the low score group. Median overall survival was four months in the low score group, 15 months in the intermediate score group, and 42 months in the high score group (p < .0001). On multivariate analysis, G8 score was a significant independent predictor of overall survival (hazard ratio: 55.46; 99.5% confidence interval: 13.42-229.13; p < .0001). CONCLUSIONS Here, we highlighted the possibility of using the G8 score, with possibly three cut-offs, in the management of older patients with glioblastoma and determined the prognostic role of this quick and easy screening tool.
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Affiliation(s)
- Elise Deluche
- Department of Medical Oncology, University Hospital, Limoges 87042, France.
| | - Sophie Leobon
- Department of Medical Oncology, University Hospital, Limoges 87042, France
| | - Francois Lamarche
- Department of Medical Oncology, University Hospital, Limoges 87042, France
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17
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Infarct volume after glioblastoma surgery as an independent prognostic factor. Oncotarget 2018; 7:61945-61954. [PMID: 27566556 PMCID: PMC5308702 DOI: 10.18632/oncotarget.11482] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 07/29/2016] [Indexed: 11/25/2022] Open
Abstract
Postoperative ischemia is associated with reduced functional independence measured by karnofsky performance score (KPS), which correlates well with overall survival. Other studies suggest that postoperative hypoxia might initiate infiltrative tumor growth. Therefore, aim of this study was to analyze the impact of infarct volume on overall survival and progression free survival (PFS) of glioblastoma patients. 251 patients with surgery for a newly diagnosed glioblastoma (WHO IV) were retrospectively assessed. Pre- and postoperative KPS, date of death/last follow-up and histopathological markers were recorded. Pre- and postoperative tumor volume and the volume of postoperative infarction were manually segmented. A significant correlation of infarct volume with postoperative KPS decrease (P = 0.001) was observed. Infarct volume showed a significant impact on overall survival (P = 0.014), but not on PFS (P = 0.112) in univariate analysis. This effect increased in the subgroup of patients with near-total tumor resection (> 90%) (overall survival: P = 0.006, PFS: P = 0.066). Infarct volume remained as an independent prognostic factor for overall survival in multivariate analysis (HR 1.013 [1.000–1.026], P = 0.042) including other prognostic factors (age, extent of resection, postoperative KPS). Postoperative infarct volume significantly correlates as an independent factor with overall survival after glioblastoma surgery. Besides the influence of perioperative infarction on postoperative KPS, postoperative hypoxia might also have an effect on tumor biology initiating infiltrative growth and therefore impaired survival.
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18
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Bette S, Barz M, Huber T, Straube C, Schmidt-Graf F, Combs SE, Delbridge C, Gerhardt J, Zimmer C, Meyer B, Kirschke JS, Boeckh-Behrens T, Wiestler B, Gempt J. Retrospective Analysis of Radiological Recurrence Patterns in Glioblastoma, Their Prognostic Value And Association to Postoperative Infarct Volume. Sci Rep 2018. [PMID: 29540809 PMCID: PMC5852150 DOI: 10.1038/s41598-018-22697-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Recent studies suggested that postoperative hypoxia might trigger invasive tumor growth, resulting in diffuse/multifocal recurrence patterns. Aim of this study was to analyze distinct recurrence patterns and their association to postoperative infarct volume and outcome. 526 consecutive glioblastoma patients were analyzed, of which 129 met our inclusion criteria: initial tumor diagnosis, surgery, postoperative diffusion-weighted imaging and tumor recurrence during follow-up. Distinct patterns of contrast-enhancement at initial diagnosis and at first tumor recurrence (multifocal growth/progression, contact to dura/ventricle, ependymal spread, local/distant recurrence) were recorded by two blinded neuroradiologists. The association of radiological patterns to survival and postoperative infarct volume was analyzed by uni-/multivariate survival analyses and binary logistic regression analysis. With increasing postoperative infarct volume, patients were significantly more likely to develop multifocal recurrence, recurrence with contact to ventricle and contact to dura. Patients with multifocal recurrence (Hazard Ratio (HR) 1.99, P = 0.010) had significantly shorter OS, patients with recurrent tumor with contact to ventricle (HR 1.85, P = 0.036), ependymal spread (HR 2.97, P = 0.004) and distant recurrence (HR 1.75, P = 0.019) significantly shorter post-progression survival in multivariate analyses including well-established prognostic factors like age, Karnofsky Performance Score (KPS), therapy, extent of resection and patterns of primary tumors. Postoperative infarct volume might initiate hypoxia-mediated aggressive tumor growth resulting in multifocal and diffuse recurrence patterns and impaired survival.
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Affiliation(s)
- Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Thomas Huber
- Department of Radiology, University Hospital, LMU, Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Institute of Innovativ Radiotherapy (iRt), Department of Radiation Sciences (DRS) Helmholtz Zentrum München, Ingolstädter Landstraße Neuherberg, Munich, Germany.,Deutsches Konsortium für Transnationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Institute of Innovativ Radiotherapy (iRt), Department of Radiation Sciences (DRS) Helmholtz Zentrum München, Ingolstädter Landstraße Neuherberg, Munich, Germany.,Deutsches Konsortium für Transnationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Julia Gerhardt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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19
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Bette S, Barz M, Wiestler B, Huber T, Gerhardt J, Buchmann N, Combs SE, Schmidt-Graf F, Delbridge C, Zimmer C, Kirschke JS, Meyer B, Ryang YM, Ringel F, Gempt J. Prognostic Value of Tumor Volume in Glioblastoma Patients: Size Also Matters for Patients with Incomplete Resection. Ann Surg Oncol 2017; 25:558-564. [PMID: 29159745 DOI: 10.1245/s10434-017-6253-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Incomplete resection of glioblastoma is discussed controversially in the era of combined radiochemotherapy. OBJECTIVE The aim of this study was to analyze the benefit of subtotal tumor resection for glioblastoma patients as this was recently questioned in the era of radiochemotherapy. METHODS Overall, 209 patients undergoing surgery for newly diagnosed WHO grade IV gliomas were retrospectively analyzed, and pre- and postoperative tumor volumes were manually segmented (cm3). Survival analyses were performed, including prognostic factors such as age, Karnofsky performance score (KPS), O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation status, and adjuvant treatment regimen. RESULTS Pre- and postoperative tumor volume is significantly associated with pre- and postoperative KPS, as well as age (p < 0.001). Postoperative tumor volume remained a significant prognostic factor in a multivariate analysis, independent of other prognostic factors (hazard ratio 1.0365, 95% confidence interval 1.0235-1.0497, p < 0.001). CONCLUSIONS In the era of molecularly-driven radiochemotherapy, glioblastoma surgery remains a major prognostic factor. Even in situations in which a gross total resection cannot be achieved, maximum safe reduction of tumor burden should be attempted.
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Affiliation(s)
- Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Thomas Huber
- Department of Radiology, Ludwig-Maximilians-University, Munich, Germany
| | - Julia Gerhardt
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Niels Buchmann
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, 85764, Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Florian Ringel
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany.
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20
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Dehkordi ANV, Kamali-Asl A, Wen N, Mikkelsen T, Chetty IJ, Bagher-Ebadian H. DCE-MRI prediction of survival time for patients with glioblastoma multiforme: using an adaptive neuro-fuzzy-based model and nested model selection technique. NMR IN BIOMEDICINE 2017; 30:e3739. [PMID: 28543885 DOI: 10.1002/nbm.3739] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/28/2017] [Accepted: 03/30/2017] [Indexed: 06/07/2023]
Abstract
This pilot study investigates the construction of an Adaptive Neuro-Fuzzy Inference System (ANFIS) for the prediction of the survival time of patients with glioblastoma multiforme (GBM). ANFIS is trained by the pharmacokinetic (PK) parameters estimated by the model selection (MS) technique in dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data analysis, and patient age. DCE-MRI investigations of 33 treatment-naïve patients with GBM were studied. Using the modified Tofts model and MS technique, the following physiologically nested models were constructed: Model 1, no vascular leakage (normal tissue); Model 2, leakage without efflux; Model 3, leakage with bidirectional exchange (influx and efflux). For each patient, the PK parameters of the three models were estimated as follows: blood plasma volume (vp ) for Model 1; vp and volume transfer constant (Ktrans ) for Model 2; vp , Ktrans and rate constant (kep ) for Model 3. Using Cox regression analysis, the best combination of the estimated PK parameters, together with patient age, was identified for the design and training of ANFIS. A K-fold cross-validation (K = 33) technique was employed for training, testing and optimization of ANFIS. Given the survival time distribution, three classes of survival were determined and a confusion matrix for the correct classification fraction (CCF) of the trained ANFIS was estimated as an accuracy index of ANFIS's performance. Patient age, kep and ve (Ktrans /kep ) of Model 3, and Ktrans of Model 2, were found to be the most effective parameters for training ANFIS. The CCF of the trained ANFIS was 84.8%. High diagonal elements of the confusion matrix (81.8%, 90.1% and 81.8% for Class 1, Class 2 and Class 3, respectively), with low off-diagonal elements, strongly confirmed the robustness and high performance of the trained ANFIS for predicting the three survival classes. This study confirms that DCE-MRI PK analysis, combined with the MS technique and ANFIS, allows the construction of a DCE-MRI-based fuzzy integrated predictor for the prediction of the survival of patients with GBM.
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Affiliation(s)
- Azimeh N V Dehkordi
- Department of Radiation Medicine Engineering, Shahid Beheshti University, Tehran, Iran
| | - Alireza Kamali-Asl
- Department of Radiation Medicine Engineering, Shahid Beheshti University, Tehran, Iran
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Tom Mikkelsen
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
- Ontario Brain Institute, Toronto, Ontario, Canada
| | - Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hassan Bagher-Ebadian
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan, USA
- Department of Physics, Oakland University, Rochester, Michigan, USA
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Liau CT, Chou WC, Wei KC, Chang CN, Toh CH, Jung SM. Female sex, good performance status, and bevacizumab-induced hypertension associated with survival benefit in Asian patients with recurrent glioblastoma treated with bevacizumab. Asia Pac J Clin Oncol 2017; 14:e8-e14. [PMID: 28792121 DOI: 10.1111/ajco.12747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 06/05/2017] [Indexed: 11/30/2022]
Abstract
AIM The goals of this study were to assess the activity and safety profile of bevacizumab in Taiwan Chinese patients with recurrent glioblastoma, to determine whether their response differed from that reported in other clinical trials, and to examine potential prognostic factors for survival. METHODS We retrospectively assessed patients who received bevacizumab for recurrent glioblastoma between 2012 and 2015. Twelve predefined variables and the outcomes of our cohort were analyzed. RESULTS In total, 76 patients with recurrent glioblastoma were analyzed. The overall response rate was 59.2%, including 19 patients (25.0%) with complete response and 26 patients (34.2%) with partial response. The median progression-free survival and overall survival were 5.2 months (95% confidence interval [CI], 4.6-5.8 months) and 7.8 months (95% CI, 5.8-9.8 months), respectively. Multivariate analysis identified sex and grade 3 posttreatment hypertension (systolic ≥ 160 mmHg or diastolic ≥ 100 mmHg) as the only independent predictive factors for progression-free survival and overall survival. Eastern Cooperative Oncology Group performance status was also found to be independently predictive of improved overall survival. CONCLUSION We showed good responses using bevacizumab and the progression-free survival and overall survival were comparable with those previously reported. The adverse events of bevacizumab in our study were generally acceptable and manageable. Female sex, good performance status, and grade 3 posttreatment hypertension were suggested to be associated with survival benefits.
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Affiliation(s)
- Chi-Ting Liau
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Chen-Nen Chang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Cheng-Hong Toh
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Shih-Ming Jung
- Department of Pathology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
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Zhang P, Liu Q, Yan S, Yuan G, Shen J, Li G. Homeobox‑containing protein 1 loss is associated with clinicopathological performance in glioma. Mol Med Rep 2017; 16:4101-4106. [PMID: 28731165 DOI: 10.3892/mmr.2017.7050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 02/24/2017] [Indexed: 12/17/2022] Open
Abstract
Homeobox-containing protein 1 (HMBOX1) is a novel member of the homeobox family, and abnormal expression of HMBOX1 has been observed in several types of carcinoma. A total of 144 cases of confirmed glioma diagnoses were included in the present study. Grading was performed according to the World Health Organization (WHO) grading system for central nervous system neoplasm. Immunohistochemical staining of HMBOX1, proliferation marker protein Ki‑67 (Ki‑67) and microvessel density (MVD) was performed, and scores were calculated. HMBOX1 mRNA levels were detected using the reverse transcription quantitative polymerase chain reaction. It was identified that the expression of HMBOX1 was reduced in glioma tissue compared with normal brain tissue (P<0.05). The expression of HMBOX1 was downregulated significantly in WHO grade IV tumors compared with WHO grades II and III (P<0.05). HMBOX1 expression was significantly correlated with WHO grade, Karnofsky Performance Score, MVD and Ki‑67 expression; however, not associated with age or gender. Log‑rank testing did not demonstrate that HMBOX1 expression was associated with prognosis. In conclusion, HMBOX1 may be a potential diagnostic marker in glioma.
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Affiliation(s)
- Ping Zhang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Qinglin Liu
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Shaofeng Yan
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Guang Yuan
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Jie Shen
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Gang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
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Huber T, Bette S, Wiestler B, Gempt J, Gerhardt J, Delbridge C, Barz M, Meyer B, Zimmer C, Kirschke JS. Fractional Anisotropy Correlates with Overall Survival in Glioblastoma. World Neurosurg 2016; 95:525-534.e1. [PMID: 27565465 DOI: 10.1016/j.wneu.2016.08.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Glioblastoma (GB) is an infiltrative disease that results in microstructural damage on a cellular level. Fractional anisotropy (FA) is an important estimate of diffusion tensor imaging (DTI) that can be used to assess microstructural integrity. The aim of this study was to examine the correlation between FA values and overall survival (OS) in patients with GB. METHODS This retrospective single-center study included 122 consecutive patients with GB (50 women; median age, 63 years) with preoperative MRI including fluid attenuated inversion recovery (FLAIR), contrast-enhanced T1-weighted sequences, and DTI. FA and apparent diffusion coefficient (ADC) values in contrast-enhancing lesions (FA-CEL, FA-ADC), nonenhancing lesions, and central tumor regions were correlated to histopathologic and clinical parameters. Univariate and multivariate survival analyses were performed. RESULTS Patients with low FA-CEL (median <0.31) showed significantly improved OS in univariate analysis (P = 0.028). FA-CEL also showed a positive correlation with Ki-67 proliferation index (P = 0.003). However, in a multivariate survival model, FA values could not be identified as independent prognostic parameters beside established factors such as age and Karnofsky performance scale score. FA values in nonenhancing lesions and central tumor regions and mean ADC values had no distinct influence on OS. CONCLUSIONS FA values can provide prognostic information regarding OS in patients with GB. There is a correlation between FA-CEL values and Ki-67 proliferation index, a marker for malignancy. Noninvasive identification of more aggressive GB growth patterns might be beneficial for preoperative risk evaluation and estimation of prognosis.
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Affiliation(s)
- Thomas Huber
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Gerhardt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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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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Blakeley JO, Coons SJ, Corboy JR, Kline Leidy N, Mendoza TR, Wefel JS. Clinical outcome assessment in malignant glioma trials: measuring signs, symptoms, and functional limitations. Neuro Oncol 2016; 18 Suppl 2:ii13-ii20. [PMID: 26989128 PMCID: PMC4795998 DOI: 10.1093/neuonc/nov291] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 10/25/2015] [Indexed: 11/12/2022] Open
Abstract
The shared goal of all parties developing therapeutics against malignant gliomas is to positively impact the lives of people affected by these cancers. Clinical outcome assessment (COA) tools, including measures of patient-reported outcome, performance outcome, clinician-reported outcome, and observer-reported outcome, allow patient-focused assessments to complement traditional efficacy measures such as overall survival and radiographic endpoints. This review examines the properties of various COA measures used in malignant glioma clinical trials to date and cross references their content to the priority signs, symptoms, and functional limitations defined through a community survey conducted by the National Brain Tumor Society. The overarching goal of this initiative is to identify COA measures that are feasible and have appropriate psychometric properties for use in this patient population as well as highlight where further development is needed.
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Affiliation(s)
- Jaishri O Blakeley
- Johns Hopkins University, Departments of Neurology, Neurosurgery and Oncology, Baltimore, Maryland (J.O.B.); Critical Path Institute, 1730 E. River Road, Tucson, Arizona (S.J.C.); University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, 12631 East 17th Avenue B185, Aurora, Colorado (J.R.C.); Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, Maryland (N.K.L.); University of Texas MD Anderson Cancer Center, 1515 Holcombe Bld., Houston, Texas (T.R.M., J.S.W.)
| | - Stephen Joel Coons
- Johns Hopkins University, Departments of Neurology, Neurosurgery and Oncology, Baltimore, Maryland (J.O.B.); Critical Path Institute, 1730 E. River Road, Tucson, Arizona (S.J.C.); University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, 12631 East 17th Avenue B185, Aurora, Colorado (J.R.C.); Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, Maryland (N.K.L.); University of Texas MD Anderson Cancer Center, 1515 Holcombe Bld., Houston, Texas (T.R.M., J.S.W.)
| | - John R Corboy
- Johns Hopkins University, Departments of Neurology, Neurosurgery and Oncology, Baltimore, Maryland (J.O.B.); Critical Path Institute, 1730 E. River Road, Tucson, Arizona (S.J.C.); University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, 12631 East 17th Avenue B185, Aurora, Colorado (J.R.C.); Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, Maryland (N.K.L.); University of Texas MD Anderson Cancer Center, 1515 Holcombe Bld., Houston, Texas (T.R.M., J.S.W.)
| | - Nancy Kline Leidy
- Johns Hopkins University, Departments of Neurology, Neurosurgery and Oncology, Baltimore, Maryland (J.O.B.); Critical Path Institute, 1730 E. River Road, Tucson, Arizona (S.J.C.); University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, 12631 East 17th Avenue B185, Aurora, Colorado (J.R.C.); Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, Maryland (N.K.L.); University of Texas MD Anderson Cancer Center, 1515 Holcombe Bld., Houston, Texas (T.R.M., J.S.W.)
| | - Tito R Mendoza
- Johns Hopkins University, Departments of Neurology, Neurosurgery and Oncology, Baltimore, Maryland (J.O.B.); Critical Path Institute, 1730 E. River Road, Tucson, Arizona (S.J.C.); University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, 12631 East 17th Avenue B185, Aurora, Colorado (J.R.C.); Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, Maryland (N.K.L.); University of Texas MD Anderson Cancer Center, 1515 Holcombe Bld., Houston, Texas (T.R.M., J.S.W.)
| | - Jeffrey S Wefel
- Johns Hopkins University, Departments of Neurology, Neurosurgery and Oncology, Baltimore, Maryland (J.O.B.); Critical Path Institute, 1730 E. River Road, Tucson, Arizona (S.J.C.); University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, 12631 East 17th Avenue B185, Aurora, Colorado (J.R.C.); Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, Maryland (N.K.L.); University of Texas MD Anderson Cancer Center, 1515 Holcombe Bld., Houston, Texas (T.R.M., J.S.W.)
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Choi YS, Kim DW, Lee SK, Chang JH, Kang SG, Kim EH, Kim SH, Rim TH, Ahn SS. The Added Prognostic Value of Preoperative Dynamic Contrast-Enhanced MRI Histogram Analysis in Patients with Glioblastoma: Analysis of Overall and Progression-Free Survival. AJNR Am J Neuroradiol 2015; 36:2235-41. [PMID: 26338911 DOI: 10.3174/ajnr.a4449] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE The prognostic value of dynamic contrast-enhanced MR imaging in patients with glioblastoma is controversial. We investigated the added prognostic value of dynamic contrast-enhanced MR imaging to clinical parameters and molecular biomarkers in patients with glioblastoma by using histogram analysis. MATERIALS AND METHODS This retrospective study consisted of 61 patients who underwent preoperative dynamic contrast-enhanced MR imaging for glioblastoma. The histogram parameters of dynamic contrast-enhanced MR imaging, including volume transfer constant, extravascular extracellular volume fraction, and plasma volume fraction, were calculated from entire enhancing tumors. Univariate analyses for overall survival and progression-free survival were performed with preoperative clinical and dynamic contrast-enhanced MR imaging parameters and postoperative molecular biomarkers. Multivariate Cox regression was performed to build pre- and postoperative models for overall survival and progression-free survival. The performance of models was assessed by calculating the Harrell concordance index. RESULTS In univariate analysis, patients with higher volume transfer constant and extravascular extracellular volume fraction values showed worse overall survival and progression-free survival, whereas plasma volume fraction showed no significant correlation. In multivariate analyses for overall survival, the fifth percentile value of volume transfer constant and kurtosis of extravascular extracellular volume fraction were independently prognostic in the preoperative model, and kurtosis of volume transfer constant and extravascular extracellular volume fraction were independently prognostic in the postoperative model. For progression-free survival, independent prognostic factors were minimum and fifth percentile values of volume transfer constant and kurtosis of extravascular extracellular volume fraction in the preoperative model and kurtosis of extravascular extracellular volume fraction in the postoperative model. The performance of preoperative models for progression-free survival was significantly improved when minimum or fifth percentile values of volume transfer constant and kurtosis of extravascular extracellular volume fraction were added. CONCLUSIONS Higher volume transfer constant and extravascular extracellular volume fraction values are associated with worse prognosis, and dynamic contrast-enhanced MR imaging may have added prognostic value in combination with preoperative clinical parameters, especially in predicting progression-free survival.
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Affiliation(s)
- Y S Choi
- From the Departments of Radiology and Research Institute of Radiological Science (Y.S.C., S.-K.L., S.S.A.)
| | - D W Kim
- Department of Policy Research Affairs (D.W.K.), National Health Insurance Service Ilsan Hospital, Goyang, Gyeonggi-do, Korea
| | - S-K Lee
- From the Departments of Radiology and Research Institute of Radiological Science (Y.S.C., S.-K.L., S.S.A.)
| | - J H Chang
- Neurosurgery (J.H.C., S.-G.K., E.H.K.)
| | - S-G Kang
- Neurosurgery (J.H.C., S.-G.K., E.H.K.)
| | - E H Kim
- Neurosurgery (J.H.C., S.-G.K., E.H.K.)
| | | | - T H Rim
- Ophthalmology (T.H.R.), Yonsei University College of Medicine, Seoul, Korea
| | - S S Ahn
- From the Departments of Radiology and Research Institute of Radiological Science (Y.S.C., S.-K.L., S.S.A.)
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Endovascular versus Non-Interventional Therapy for Cervicocranial Artery Dissection in East Asian and Non-East Asian Patients: a Systematic Review and Meta-analysis. Sci Rep 2015; 5:10474. [PMID: 25990610 PMCID: PMC4438427 DOI: 10.1038/srep10474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/16/2015] [Indexed: 01/11/2023] Open
Abstract
Endovascular methods have been increasingly applied in treating cervicocranial artery dissection (CCAD). Anti-thrombotic therapy, which is used in non-interventional care of CCAD patients, has differential effects in East Asian patients. Therefore, we aimed to compare the clinical outcomes of endovascular versus non-interventional therapy for CCAD in East Asians and non-East Asians. A search was performed for studies comparing endovascular and non-interventional approaches to CCAD patients. Rates of recovery, disability, and mortality were used to assess these approaches in East Asian and non-East Asian patients. Subgroup analyses were conducted for CCAD patients with ruptured dissections. Eleven East Asian studies and five non-East Asian studies were included. The subgroup analyses for CCAD patients with ruptured dissections on mortality (East Asian odds ratio [OR] [95% confidence interval [CI]]: 0.24 [0.08-0.71], P = 0.01; I2 = 34%) and good recovery (East Asian OR [95% CI]: 3.79 [1.14-12.60], P = 0.03; I2 = 54%) revealed that endovascular therapy is significantly superior to non-interventional therapy for East Asians. No differences in treatment effect upon mortality, disability, or good recovery outcomes were found for the CCAD populations-at-large nor for non-East Asian CCAD patients with ruptured dissections. Endovascular therapy appears to be superior to non-interventional therapy for East Asian CCAD patients with ruptured dissections.
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Buglione M, Borghetti P, Pedretti S, Triggiani L, Fontanella MM, Spena G, Grisanti S, Liserre R, Poliani LP, Gipponi S, Spiazzi L, Magrini SM. Post-surgical therapeutic approaches to glioblastoma patients submitted to biopsy (BA) or "partial" resection (PR): the possibilities to treat also them without renunciations. Study from the Brescia Neuro-Oncology Group. Radiol Med 2015; 120:975-81. [PMID: 25773653 DOI: 10.1007/s11547-015-0528-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
Abstract
The extent of surgery predicts overall survival (OS) in patients treated for glioblastoma (GBM). The therapeutic approach after partial resection (PR) or biopsy alone (BA) is not clearly defined. This retrospective analysis was therefore planned to analyse clinical features, treatment and survival of patients undergoing PR or BA. We analysed the clinical/therapeutic features and the outcome of 232 patients submitted to BA/PR and treated with radiotherapy (RT) with/without chemotherapy. Two subgroups (pre- and post-Temozolomide-era) were identified. The BA/PR ratio did not change with the accrual periods. In the TMZ-era, 50 % of the patients had chemotherapy; "small" volume, hypo-fractionated and "low" dose RT (<54 Gy) were delivered to 93, 38 and 44 % of the patients; corresponding values for the previous period were 4, 28, 11 and 2 % (P < 0.001). Better two-year OS was evident in the TMZ-era (18 vs 7 %); PR and chemotherapy affected OS in patients treated with hypo-fractionated, low doses RT (P = 0.02, 0.04). Limited volume, more often MRI-based, and "short" RT treatments were given mostly to unfavourably selected patients, without compromising the results of the whole group. This strategy, combined with an increased use of chemotherapy, resulted in reduced treatment burden, in an improved 2-year OS rate and prospectively in better quality of life, even in this prognostically worse subset of glioma patients.
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Affiliation(s)
- Michela Buglione
- Department of Radiation Oncology, University of Brescia, P.le Spedali Civili, 1, 25123, Brescia, BS, Italy.
| | - Paolo Borghetti
- Department of Radiation Oncology, University of Brescia, P.le Spedali Civili, 1, 25123, Brescia, BS, Italy
| | - Sara Pedretti
- Department of Radiation Oncology, University of Brescia, P.le Spedali Civili, 1, 25123, Brescia, BS, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, University of Brescia, P.le Spedali Civili, 1, 25123, Brescia, BS, Italy
| | | | | | | | - Roberto Liserre
- Department of Neuroradiology, University of Brescia, Brescia, Italy
| | | | - Stefano Gipponi
- Department of Neurology, University of Brescia, Brescia, Italy
| | - Luigi Spiazzi
- Department of Medical Physics, Spedali Civili Brescia, Brescia, Italy
| | - Stefano Maria Magrini
- Department of Radiation Oncology, University of Brescia, P.le Spedali Civili, 1, 25123, Brescia, BS, Italy
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Sacko A, Hou MM, Temgoua M, Alkhafaji A, Marantidou A, Belin C, Mandonnet E, Ursu R, Doridam J, Coman I, Levy-Piedbois C, Carpentier AF. Evolution of the Karnosky Performance Status throughout life in glioblastoma patients. J Neurooncol 2015; 122:567-73. [DOI: 10.1007/s11060-015-1749-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 02/16/2015] [Indexed: 11/28/2022]
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Retrospective analysis of bevacizumab in combination with fotemustine in chinese patients with recurrent glioblastoma multiforme. BIOMED RESEARCH INTERNATIONAL 2015; 2015:723612. [PMID: 25789324 PMCID: PMC4348597 DOI: 10.1155/2015/723612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/22/2015] [Accepted: 01/29/2015] [Indexed: 11/21/2022]
Abstract
The aim of this study was to assess the activity and safety of bevacizumab (BEV) and fotemustine (FTM) for the treatment of recurrent glioblastoma multiforme (GBM) patients and explore the potential prognostic parameters on survival. This study retrospectively analyzed all patients with GBM who were treated with at least one cycle of BEV and FTM from July 2010 to October 2012. A total of 176 patients with recurrent GBM were enrolled. The response rate and disease control rate were 46.6% and 90.9%, respectively. A 6-month PFS rate of 33.3% (95% CI: 26.5%–40.3%) and a median PFS of 5.0 (95% CI: 2.4–7.5) months were observed. The median OS was 8.0 (95% CI: 6.7–9.2) months. Multivariate analysis showed that risk factors with a significant influence on the PFS of all patients were Karnofsky Performance Status (KPS) (≥70 versus <70, HR = 0.53, 95% CI: 0.39–0.73, and P = 0.01) and MGMT status (methylated versus unmethylated, HR = 0.69, 95% CI: 0.52–0.97, and P = 0.04). The most common treatment-related adverse events were fatigue, proteinuria, hypophonia, hypertension, thrombocytopenia, anemia, and neutropenia. In conclusion, combination of BEV with FTM is well tolerated and may derive some clinical benefits in recurrent GBM patients. Higher KPS and MGMT promoter hypermethylation were suggested to be associated with prolonged survival.
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Chambless LB, Kistka HM, Parker SL, Hassam-Malani L, McGirt MJ, Thompson RC. The relative value of postoperative versus preoperative Karnofsky Performance Scale scores as a predictor of survival after surgical resection of glioblastoma multiforme. J Neurooncol 2014; 121:359-64. [DOI: 10.1007/s11060-014-1640-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/18/2014] [Indexed: 10/24/2022]
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Abstract
Malignant astrocytomas constitute the most aggressive and common primary tumors of the central nervous system. The standard treatment protocol for these tumors involves maximum safe surgical resection with adjuvant chemoradiotherapy. Despite numerous advances in surgical techniques and adjuncts, as well as the ongoing renaissance in the genetic and molecular characterization of these tumors, malignant astrocytomas continue to be associated with poor prognosis, with median overall survival averaging 15 months for grade IV astrocytomas after standard-of-care treatment. In this article, the goals, principles, techniques, prognostic factors, and modern outcomes of malignant astrocytoma surgery are reviewed. Particular attention is paid to contemporary methods of neuronavigation and functional mapping, the prognostic significance of the extent of resection, surgically delivered adjunctive therapies, and future avenues of research.
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Affiliation(s)
- Eli T Sayegh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Taemin Oh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shayan Fakurnejad
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Daniel E Oyon
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Orin Bloch
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew T Parsa
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Eyüpoglu IY, Buchfelder M, Savaskan NE. Surgical resection of malignant gliomas-role in optimizing patient outcome. Nat Rev Neurol 2013; 9:141-51. [PMID: 23358480 DOI: 10.1038/nrneurol.2012.279] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malignant gliomas represent one of the most devastating human diseases. Primary treatment of these tumours involves surgery to achieve tumour debulking, followed by a multimodal regimen of radiotherapy and chemotherapy. Survival time in patients with malignant glioma has modestly increased in recent years owing to advances in surgical and intraoperative imaging techniques, as well as the systematic implementation of randomized trial-based protocols and biomarker-based stratification of patients. The role and importance of several clinical and molecular factors-such as age, Karnofsky score, and genetic and epigenetic status-that have predictive value with regard to postsurgical outcome has also been identified. By contrast, the effect of the extent of glioma resection on patient outcome has received little attention, with an 'all or nothing' approach to tumour removal still taken in surgical practice. Recent studies, however, reveal that maximal possible cytoreduction without incurring neurological deficits has critical prognostic value for patient outcome and survival. Here, we evaluate state-of-the-art surgical procedures that are used in management of malignant glioma, with a focus on assessment criteria and value of tumour reduction. We highlight key surgical factors that enable optimization of adjuvant treatment to enhance patient quality of life and improve life expectancy.
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Affiliation(s)
- Ilker Y Eyüpoglu
- Department of Neurosurgery, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
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Diffusion tensor and dynamic susceptibility contrast MRI in glioblastoma. Clin Neurol Neurosurg 2012; 114:607-12. [DOI: 10.1016/j.clineuro.2011.12.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 12/06/2011] [Accepted: 12/13/2011] [Indexed: 11/19/2022]
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Link TW, Woodworth GF, Chaichana KL, Grossman SA, Mayer RS, Brem H, Weingart JD, Quinones-Hinojosa A. Hyperglycemia is independently associated with post-operative function loss in patients with primary eloquent glioblastoma. J Clin Neurosci 2012; 19:996-1000. [PMID: 22595358 DOI: 10.1016/j.jocn.2011.09.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Revised: 09/17/2011] [Accepted: 09/30/2011] [Indexed: 01/04/2023]
Abstract
The poor prognosis for patients with glioblastoma (GB) heightens the importance of maintaining function throughout treatment. Hyperglycemia has been linked to poor neurological outcomes following stroke, traumatic brain and spinal cord injury. We hypothesized this may also be true following the resection of GB. We assessed associations with post-operative function with the goal of identifying modifiable factors in the peri-operative period with a particular focus on blood glucose levels. Independent associations with worse post-operative function included: patient age, pre-operative motor deficit, deep tumor location, post-operative motor deficit, and elevated mean peri-operative glucose. Interestingly, controlling for associated factors including dexamethasone dosing, patients with elevated peri-operative glucose levels were nearly twice as likely to have new post-operative neurological deficits. These results suggest, together with the broad literature supporting a role for hyperglycemia in neurological injury, that this may represent a modifiable factor in the peri-operative care of these patients.
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Affiliation(s)
- Thomas W Link
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Johnson DR, Sawyer AM, Meyers CA, O'Neill BP, Wefel JS. Early measures of cognitive function predict survival in patients with newly diagnosed glioblastoma. Neuro Oncol 2012; 14:808-16. [PMID: 22508762 DOI: 10.1093/neuonc/nos082] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Cognitive dysfunction is a common manifestation of primary brain tumors. We evaluated the association between early cognitive dysfunction and prognosis in a cohort of patients with newly diagnosed glioblastoma. Ninety-one patients who completed neuropsychological assessment after tumor resection but before further treatment were identified in the MD Anderson Neuropsychology database. The relationship between performance on cognitive testing and survival was evaluated using not only Cox proportional hazards models that included clinical factors such as age and KPS but also the Kaplan-Meier method. Median survival time from surgery was 20.7 months. Rates of impairment on cognitive testing ranged from 7.1% for Similarities, to 60.0% for Hopkins Verbal Learning Test-Revised Total Recall. As continuous variables, the Clinical Trial Battery Composite, Trail Making Test Part B, and Controlled Oral Word Association test were associated with survival. Impairment on the Trail Making Test Part B, Controlled Oral Word Association, Similarities, and Digit Span were associated with mortality. Kaplan-Meier analysis demonstrated the survival impact of these tests on the group as a whole and in select patient subgroups defined by classification by the Radiation Therapy Oncology Group (RTOG) Recursive Partitioning Analysis (RPA). Cognitive impairment as measured by specific neuropsychological tests is independently associated with poor prognosis in patients with newly diagnosed glioblastoma, and this effect remains significant even within patient subgroups defined by RTOG RPA class. Executive function and attention are the cognitive domains most closely associated with prognosis in this analysis.
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Affiliation(s)
- Derek R Johnson
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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