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Wong LS, St George J, Agyemang K, Grivas A, Houston D, Foo SY, Mullan T. Outcomes of Fluorescence-Guided vs White Light Resection of Glioblastoma in a Single Institution. Cureus 2023; 15:e42695. [PMID: 37649945 PMCID: PMC10465263 DOI: 10.7759/cureus.42695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
Background Glioblastoma (GBM) is the most common malignant primary brain tumour and confers a very poor prognosis. Maximal safe resection of tumour is the goal of neurosurgical intervention and may be more easily achieved through the use of surgical adjuncts such as fluorescence-guided surgery (FGS). 5-Aminolevulinic acid (5-ALA) accumulates in GBM tissue and fluoresce red, distinguishing tumour cells from the surrounding tissue and therefore making resection easier. 5-ALA-guided resection in GBM has been shown to increase resection rates and prolong progression-free survival without impacting post-operative morbidity. Radiotherapy and concomitant chemotherapy also improve survival in GBM. Other factors such as patient age and molecular status of the tumour also impact prognosis. Aims The aim of this study was to compare the outcomes of 5-ALA vs white light-guided resection for glioblastoma in the west of Scotland. Methods This was a retrospective analysis of baseline characteristics (age, sex, tumour molecular markers, radiotherapy, chemotherapy, anatomical location of tumour and treatment group) and outcomes (mortality, survival, degree of resection and performance status) of 239 patients who underwent primary resection of glioblastoma over a four-year period (2017-2020). A variety of statistical methods were used to analyse the relationship between each variable and surgical technique; multivariate Cox regression and the Kaplan-Meier method were used in survival analysis. Results 5-ALA-guided resection substantially improved resection rates (74.0% vs 40.2%). Mortality at 15 months was 5.1% lower in the 5-ALA group (52.0% vs 57.1%, p = 0.53), and patients lived an average of 68 days longer compared to the white light group (444 days vs 376 days, p = 0.21). There were negligible differences between treatment groups in terms of post-operative performance status (PS) and post-operative complications. In our multivariate Cox regression model, six factors were statistically significant at a level of p ≤ 0.05: age, radiotherapy, chemotherapy, O(6)-methylguanine-DNA methyltransferase (MGMT) methylation, anatomical location and >90% resection. Receiving chemotherapy and radiotherapy, MGMT methylation and undergoing >90% resection conferred a survival benefit at 15 months. Older age and multi-focal disease were related to a worsened mortality rate. Undergoing radiotherapy and maximal resection were the two greatest predictors of improved survival, reducing mortality risk by 58% and 51%, respectively. Conclusion 5-ALA-guided resection improved resection rates without impacting post-operative morbidity. 5-ALA-guided resection was associated with improved survival and lower mortality rate, but this was not statistically significant. Receiving chemoradiotherapy, MGMT methylation and undergoing maximal resection conferred a survival benefit, whilst older age and multi-focal disease were associated with a poorer prognosis.
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Affiliation(s)
- Li Siang Wong
- General Medicine, Royal Alexandra Hospital, Paisley, GBR
| | | | - Kevin Agyemang
- Neurosurgery, Queen Elizabeth University Hospital, Glasgow, GBR
| | | | - Deborah Houston
- Neurosurgery, Queen Elizabeth University Hospital, Glasgow, GBR
| | - Sin Yee Foo
- Radiology, Queen Elizabeth University Hospital, Glasgow, GBR
| | - Thomas Mullan
- General Medicine, Royal Alexandra Hospital, Paisley, GBR
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Paiva ALC, Vitorino-Araujo JL, Lovato RM, Costa GHFD, Veiga JCE. An economic study of neuro-oncological patients in a large developing country: a cost analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1149-1158. [PMID: 36577414 PMCID: PMC9797276 DOI: 10.1055/s-0042-1758649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation. OBJECTIVE The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America. METHODS The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. RESULTS Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures. CONCLUSIONS Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.
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Affiliation(s)
- Aline Lariessy Campos Paiva
- Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo SP, Brazil.,Hospital do Coração, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Neurosurgery Department, São Paulo SP, Brazil.,Address for correspondence Aline Lariessy Campos Paiva
| | - João Luiz Vitorino-Araujo
- Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo SP, Brazil.,Hospital do Coração, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Neurosurgery Department, São Paulo SP, Brazil.
| | - Renan Maximilian Lovato
- Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo SP, Brazil.,Hospital do Coração, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Neurosurgery Department, São Paulo SP, Brazil.
| | | | - José Carlos Esteves Veiga
- Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Neurosurgery Department, São Paulo SP, Brazil.
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Goel NJ, Bird CE, Hicks WH, Abdullah KG. Economic implications of the modern treatment paradigm of glioblastoma: an analysis of global cost estimates and their utility for cost assessment. J Med Econ 2021; 24:1018-1024. [PMID: 34353213 DOI: 10.1080/13696998.2021.1964775] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Glioblastoma is the most common primary brain tumor in adults. Standard of care includes maximal surgical resection of the tumor followed by concurrent chemotherapy and radiation. The treatment of glioblastoma must account for an increased disease severity and treatment intensity compared to other cancers which place a significant cost burden on the patient and health system. Cost assessments of glioblastoma treatment have been sparse in comparison to other solid cancer subtypes. This study evaluates all currently available cost literature with an emphasis on the modern treatment paradigm to properly assess the economic implications of this disease. METHODS A critical review of 21 studies from 13 different countries measuring direct costs related to glioblastoma management was performed. Evaluated data included itemized costs, total costs of treatment regimens from diagnosis until death, the cost of second-line care after recurrence, and the incremental costs and cost-effectiveness of emerging therapies. RESULTS The average cost of a craniotomy was $10,042 across studies. Imaging for the duration of glioblastoma care had a mean cost of $2,788 ± 3,719. Studies examined different combinations of treatment modalities. Utilization of the modern treatment paradigm led to survival of 16.3 months across studies and had a mean cost of $62,602. Surgery for the recurrent disease had an average cost of $27,442 ± 18,992. LIMITATIONS AND CONCLUSIONS Direct cost estimates for glioblastoma varied substantially between institutions and countries and often failed to uniformly describe direct cost estimates associated with care for glioblastoma. The limitations of these studies make a true economic assessment of standards of care, costs of recurrence, and incremental costs associated with adjunctive therapy uncertain.
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Affiliation(s)
- Nicholas J Goel
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cylaina E Bird
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William H Hicks
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kalil G Abdullah
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Warsi NM, Zewude R, Karmur B, Pirouzmand N, Hachem L, Mansouri A. The Cost-Effectiveness of 5-ALA in High-Grade Glioma Surgery: A Quality-Based Systematic Review. Can J Neurol Sci 2020; 47:793-799. [PMID: 32329422 DOI: 10.1017/cjn.2020.78] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND High-grade gliomas (HGGs) are aggressive tumors that inevitably recur due to their diffusely infiltrative nature. Intraoperative adjuncts such as 5-aminolevulinic acid (5-ALA) have shown promise in increasing extent of resection. As the prospect of increased use of 5-ALA rises, a systematic overview of the health economics of this adjunct is critical. METHODS Medline, EMBASE, Centre for Reviews and Dissemination, EconPapers, and Cochrane databases were searched for keywords relating to glioma, cost-effectiveness, and 5-ALA. Primary studies reporting on the health economics or cost-effectiveness of 5-ALA compared to white light surgery in HGG were included. Quality was assessed using the British Medical Journal guidelines. RESULTS Three studies were identified. All were European and conducted from the perspective of national healthcare systems. Two studies demonstrated the cost-utility of 5-ALA compared to white light (C$12,817 and C$13,508/quality-adjusted life-years (QALYs)). One assessed the cost-utility per gross total resection (C$6,813). Both these values were below the national cost-effectiveness thresholds for each respective study. The third study demonstrated no significant difference in cost of 5-ALA in glioblastoma resection (C$14,732) compared to prior to its routine use (C$15,936). The quality of these studies ranged from moderate to average. None of these studies considered patient perspective or indirect costs in their analysis. CONCLUSIONS Growing evidence exists examining the health economic benefit of 5-ALA as an intraoperative adjunct for HGG resection. Additional studies within the Canadian context using 5-ALA, specifically incorporating patient and societal perspectives into the cost-utility analyses, are necessary to solidify this line of evidence.
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Affiliation(s)
- Nebras M Warsi
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Rahel Zewude
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brij Karmur
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Neda Pirouzmand
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Laureen Hachem
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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Improved 3-year survival rates for glioblastoma multiforme are associated with trends in treatment: analysis of the national cancer database from 2004 to 2013. J Neurooncol 2020; 148:69-79. [DOI: 10.1007/s11060-020-03469-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/23/2020] [Indexed: 12/22/2022]
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Hanna C, Lawrie TA, Rogozińska E, Kernohan A, Jefferies S, Bulbeck H, Ali UM, Robinson T, Grant R. Treatment of newly diagnosed glioblastoma in the elderly: a network meta-analysis. Cochrane Database Syst Rev 2020; 3:CD013261. [PMID: 32202316 PMCID: PMC7086476 DOI: 10.1002/14651858.cd013261.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND A glioblastoma is a fatal type of brain tumour for which the standard of care is maximum surgical resection followed by chemoradiotherapy, when possible. Age is an important consideration in this disease, as older age is associated with shorter survival and a higher risk of treatment-related toxicity. OBJECTIVES To determine the most effective and best-tolerated approaches for the treatment of elderly people with newly diagnosed glioblastoma. To summarise current evidence for the incremental resource use, utilities, costs and cost-effectiveness associated with these approaches. SEARCH METHODS We searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase to 3 April 2019, and the NHS Economic Evaluation Database (EED) up to database closure. We handsearched clinical trial registries and selected neuro-oncology society conference proceedings from the past five years. SELECTION CRITERIA Randomised trials (RCTs) of treatments for glioblastoma in elderly people. We defined 'elderly' as 70+ years but included studies defining 'elderly' as over 65+ years if so reported. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for study selection and data extraction. Where sufficient data were available, treatment options were compared in a network meta-analysis (NMA) using Stata software (version 15.1). For outcomes with insufficient data for NMA, pairwise meta-analysis were conducted in RevMan. The GRADE approach was used to grade the evidence. MAIN RESULTS We included 12 RCTs involving approximately 1818 participants. Six were conducted exclusively among elderly people (either defined as 65 years or older or 70 years or older) with newly diagnosed glioblastoma, the other six reported data for an elderly subgroup among a broader age range of participants. Most participants were capable of self-care. Study quality was commonly undermined by lack of outcome assessor blinding and attrition. NMA was only possible for overall survival; other analyses were pair-wise meta-analyses or narrative syntheses. Seven trials contributed to the NMA for overall survival, with interventions including supportive care only (one trial arm); hypofractionated radiotherapy (RT40; four trial arms); standard radiotherapy (RT60; five trial arms); temozolomide (TMZ; three trial arms); chemoradiotherapy (CRT; three trial arms); bevacizumab with chemoradiotherapy (BEV_CRT; one trial arm); and bevacizumab with radiotherapy (BEV_RT). Compared with supportive care only, NMA evidence suggested that all treatments apart from BEV_RT prolonged survival to some extent. Overall survival High-certainty evidence shows that CRT prolongs overall survival (OS) compared with RT40 (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.56 to 0.80) and low-certainty evidence suggests that CRT may prolong overall survival compared with TMZ (TMZ versus CRT: HR 1.42, 95% CI 1.01 to 1.98). Low-certainty evidence also suggests that adding BEV to CRT may make little or no difference (BEV_CRT versus CRT: HR 0.83, 95% CrI 0.48 to 1.44). We could not compare the survival effects of CRT with different radiotherapy fractionation schedules (60 Gy/30 fractions and 40 Gy/15 fractions) due to a lack of data. When treatments were ranked according to their effects on OS, CRT ranked higher than TMZ, RT and supportive care only, with the latter ranked last. BEV plus RT was the only treatment for which there was no clear benefit in OS over supportive care only. One trial comparing tumour treating fields (TTF) plus adjuvant chemotherapy (TTF_AC) with adjuvant chemotherapy alone could not be included in the NMA as participants were randomised after receiving concomitant chemoradiotherapy, not before. Findings from the trial suggest that the intervention probably improves overall survival in this selected patient population. We were unable to perform NMA for other outcomes due to insufficient data. Pairwise analyses were conducted for the following. Quality of life Moderate-certainty narrative evidence suggests that overall, there may be little difference in QoL between TMZ and RT, except for discomfort from communication deficits, which are probably more common with RT (1 study, 306 participants, P = 0.002). Data on QoL for other comparisons were sparse, partly due to high dropout rates, and the certainty of the evidence tended to be low or very low. Progression-free survival High-certainty evidence shows that CRT increases time to disease progression compared with RT40 (HR 0.50, 95% CI 0.41 to 0.61); moderate-certainty evidence suggests that RT60 probably increases time to disease progression compared with supportive care only (HR 0.28, 95% CI 0.17 to 0.46), and that BEV_RT probably increases time to disease progression compared with RT40 alone (HR 0.46, 95% CI 0.27 to 0.78). Evidence for other treatment comparisons was of low- or very low-certainty. Severe adverse events Moderate-certainty evidence suggests that TMZ probably increases the risk of grade 3+ thromboembolic events compared with RT60 (risk ratio (RR) 2.74, 95% CI 1.26 to 5.94; participants = 373; studies = 1) and also the risk of grade 3+ neutropenia, lymphopenia, and thrombocytopenia. Moderate-certainty evidence also suggests that CRT probably increases the risk of grade 3+ neutropenia, leucopenia and thrombocytopenia compared with hypofractionated RT alone. Adding BEV to CRT probably increases the risk of thromboembolism (RR 16.63, 95% CI 1.00 to 275.42; moderate-certainty evidence). Economic evidence There is a paucity of economic evidence regarding the management of newly diagnosed glioblastoma in the elderly. Only one economic evaluation on two short course radiotherapy regimen (25 Gy versus 40 Gy) was identified and its findings were considered unreliable. AUTHORS' CONCLUSIONS For elderly people with glioblastoma who are self-caring, evidence suggests that CRT prolongs survival compared with RT and may prolong overall survival compared with TMZ alone. For those undergoing RT or TMZ therapy, there is probably little difference in QoL overall. Systemic anti-cancer treatments TMZ and BEV carry a higher risk of severe haematological and thromboembolic events and CRT is probably associated with a higher risk of these events. Current evidence provides little justification for using BEV in elderly patients outside a clinical trial setting. Whilst the novel TTF device appears promising, evidence on QoL and tolerability is needed in an elderly population. QoL and economic assessments of CRT versus TMZ and RT are needed. More high-quality economic evaluations are needed, in which a broader scope of costs (both direct and indirect) and outcomes should be included.
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Affiliation(s)
- Catherine Hanna
- University of GlasgowDepartment of OncologyBeatson West of Scotland Cancer CentreGreat Western RoadGlasgowScotlandUKG4 9DL
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ewelina Rogozińska
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Sarah Jefferies
- Addenbrooke's HospitalDepartment of OncologyHills RoadCambridgeUKCB2 0QQ
| | - Helen Bulbeck
- brainstrustDirector of Services4 Yvery CourtCastle RoadCowesIsle of WightUKPO31 7QG
| | - Usama M Ali
- University of OxfordNuffield Department of Population HealthRoosevelt DriveOld Road CampusOxfordOxfordshireUKOX3 7LF
| | - Tomos Robinson
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghScotlandUKEH4 2XU
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Picart T, Berhouma M, Dumot C, Pallud J, Metellus P, Armoiry X, Guyotat J. Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2019; 65:164-177. [PMID: 31125558 DOI: 10.1016/j.neuchi.2019.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.
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Affiliation(s)
- T Picart
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; Inserm 1052, UMR 5286,Team ATIP/AVENIR Transcriptomic diversity of stem cells, centre de cancérologie de Lyon, centre Léon-Bérard, 69008 Lyon, France.
| | - M Berhouma
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - C Dumot
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - J Pallud
- Département de neurochirurgie, hôpital Sainte-Anne, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; IMA-Brain, Inserm U894, institut de psychiatrie et neurosciences de Paris, 7013 Paris, France
| | - P Metellus
- Hôpital Privé Clairval, Ramsay général de santé, 13009 Marseille, France; UMR 7051, institut de neurophysiopathologie, université d'Aix-Marseille, 13344 Marseille, France
| | - X Armoiry
- MATEIS (Team I2B), University of Lyon, Lyon school of pharmacy, 69008 Lyon, France; Édouard-Herriot Hospital, Pharmacy Department, 69008 Lyon, France; University of Warwick, Warwick Medical School, Coventry, UK
| | - J Guyotat
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France
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Wilde H, Azab MA, Abunimer AM, Abou-Al-Shaar H, Karsy M, Guan J, Menacho ST, Jensen RL. Evaluation of cost and survival in intracranial gliomas using the Value Driven Outcomes database: a retrospective cohort analysis. J Neurosurg 2019; 132:1006-1016. [PMID: 30925470 DOI: 10.3171/2018.12.jns183109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gliomas occur in 3-4 individuals per 100,000 individuals and are one of the most common primary brain tumors. Treatment options are limited for gliomas despite the progressive nature of the disease. The authors used the Value Driven Outcomes (VDO) database to identify cost drivers and subgroups that are involved in the surgical treatment of gliomas. METHODS A retrospective cohort of patients with gliomas treated at the authors' institution from August 2011 to February 2018 was evaluated using medical records and the VDO database. RESULTS A total of 263 patients with intracranial gliomas met the authors' inclusion criteria and were included in the analysis (WHO grade I: 2.0%; grade II: 18.5%; grade III: 18.1%; and grade IV: 61.4%). Facility costs were the major (64.4%) cost driver followed by supplies (16.2%), pharmacy (10.1%), imaging (4.5%), and laboratory (4.7%). Univariate analysis of cost contributors demonstrated that American Society of Anesthesiologists physical status (p = 0.002), tumor recurrence (p = 0.06), Karnofsky Performance Scale score (p = 0.002), length of stay (LOS) (p = 0.0001), and maximal tumor size (p = 0.03) contributed significantly to the total costs. However, on multivariate analysis, only LOS (p = 0.0001) contributed significantly to total costs. More extensive tumor resection in WHO grade III and IV tumors was associated with significant improvement in survival (p = 0.004 and p = 0.02, respectively). CONCLUSIONS Understanding care costs is challenging because of the highly complex, fragmented, and variable nature of healthcare delivery. Adopting effective strategies that would reduce facility costs and limit LOS is likely the most important aspect in reducing intracranial glioma treatment costs.
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Affiliation(s)
- Herschel Wilde
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Mohammed A Azab
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Abdullah M Abunimer
- 2Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Hussam Abou-Al-Shaar
- 3Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Michael Karsy
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Jian Guan
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Sarah T Menacho
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Randy L Jensen
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Esquenazi Y, Friedman E, Liu Z, Zhu JJ, Hsu S, Tandon N. The Survival Advantage of "Supratotal" Resection of Glioblastoma Using Selective Cortical Mapping and the Subpial Technique. Neurosurgery 2018; 81:275-288. [PMID: 28368547 DOI: 10.1093/neuros/nyw174] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 08/12/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A substantial body of evidence suggests that cytoreductive surgery is a prerequisite to prolonging survival in patients with glioblastoma (GBM). OBJECTIVE To evaluate the safety and impact of "supratotal" resections beyond the zone of enhancement seen on magnetic resonance imaging scans, using a subpial technique. METHODS We retrospectively evaluated 86 consecutive patients with primary GBM, managed by the senior author, using a subpial resection technique with or without carmustine (BCNU) wafer implantation. Multivariate Cox proportional hazards regression was used to analyze clinical, radiological, and outcome variables. Overall impacts of extent of resection (EOR) and BCNU wafer placement were compared using Kaplan-Meier survival analysis. RESULTS Mean patient age was 56 years. The median OS for the group was 18.1 months. Median OS for patients undergoing gross total, near-total, and subtotal resection were 54, 16.5, and 13.2 months, respectively. Patients undergoing near-total resection ( P = .05) or gross total resection ( P < .01) experienced statistically significant longer survival time than patients undergoing subtotal resection as well as patients undergoing ≥95% EOR ( P < .01) when compared to <95% EOR. The addition of BCNU wafers had no survival advantage. CONCLUSIONS The subpial technique extends the resection beyond the contrast enhancement and is associated with an overall survival beyond that seen in similar series where resection of the enhancement portion is performed. The effect of supratotal resection on survival exceeded the effects of age, Karnofsky performance score, and tumor volume. A prospective study would help to quantify the impact of the subpial technique on quality of life and survival as compared to a traditional resection limited to the enhancing tumor.
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Affiliation(s)
- Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas
| | - Elliott Friedman
- Department of Radiology, Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Zheyu Liu
- Department of Biostatistics, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Jay-Jiguang Zhu
- Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas
| | - Sigmund Hsu
- Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas
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Jiang S, Hill K, Patel D, Waldeck AR, Botteman M, Aly A, Norden AD. Direct medical costs of treatment in newly-diagnosed high-grade glioma among commercially insured US patients. J Med Econ 2017; 20:1237-1243. [PMID: 28777020 DOI: 10.1080/13696998.2017.1364258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM This analysis assessed the direct medical costs of newly-diagnosed, temozolomide (TMZ)-treated glioblastoma (GBM) from the perspective of a US commercial setting. MATERIALS AND METHODS The analysis included subjects identified from the IMS PharMetrics LifeLink Plus™ claims database from January 1, 2008 to August 31, 2014 who were ≥18 years of age, had ≥1 malignant brain cancer diagnosis, had brain surgery ≤90 days prior to TMZ initiation, had TMZ treatment, and were continuously enrolled for ≥12 months pre-diagnosis and ≥1 month post-diagnosis. Per-patient per-month (PPPM) and cumulative costs from 3 months pre-diagnosis to various post-diagnosis follow-up time points were calculated. Multivariable analyses were used to estimate adjusted mean cost and identify contributors of cost. RESULTS The study included 2,921 subjects (median age = 56 years; 60% male). After diagnosis, the median (interquartile range, IQR) number of inpatient, emergency department, and outpatient visits were 2 (1-4), 1 (1-3), and 19 (13-27); median (IQR) length of stay per hospitalization was 5 (3-9) days. Mean total cumulative costs per patient from 3 months pre-diagnosis to 12 months and to 5 years post-diagnosis were $201,749 (197,490-206,024) and $268,031 (262,877-274,416). Mean (SD) PPPM costs were $818 (1,128) and $7,394 (8,676) pre- and post-GBM diagnosis, respectively. The variables most predictive of cumulative costs included radiation therapy (+$81,732), ≥2 weeks of hospitalization (+$49,629), and ≥7 MRI scans (+$40,105). CONCLUSIONS The direct medical costs of newly-diagnosed, TMZ-treated GBM in commercially insured patients are substantial, with estimated total cumulative costs of $268,031.
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Affiliation(s)
- Shan Jiang
- a Pharmerit International , Bethesda , MD , USA
| | - Kala Hill
- b Celldex Therapeutics Inc. , Hampton , NJ , USA
| | - Dipen Patel
- a Pharmerit International , Bethesda , MD , USA
| | | | | | - Abdalla Aly
- a Pharmerit International , Bethesda , MD , USA
| | - Andrew D Norden
- c Dana-Farber/Brigham and Women's Cancer Center , Boston , MA , USA
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11
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Sage W, Guilfoyle M, Luney C, Young A, Sinha R, Sgubin D, McAbee JH, Ma R, Jefferies S, Jena R, Harris F, Allinson K, Matys T, Qian W, Santarius T, Price S, Watts C. Local alkylating chemotherapy applied immediately after 5-ALA guided resection of glioblastoma does not provide additional benefit. J Neurooncol 2017; 136:273-280. [PMID: 29139095 PMCID: PMC5770495 DOI: 10.1007/s11060-017-2649-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/22/2017] [Indexed: 11/12/2022]
Abstract
Grade IV glioma is the most common and aggressive primary brain tumour. Gross total resection with 5-aminolevulinic acid (5-ALA) guided surgery combined with local chemotherapy (carmustine wafers) is an attractive treatment strategy in these patients. No previous studies have examined the benefit carmustine wafers in a treatment programme of 5-ALA guided resection followed by a temozolomide-based chemoradiotherapy protocol. The objective of this study was to examine the benefit of carmustine wafers on survival in patients undergoing 5-ALA guided resection. A retrospective cohort study of 260 patients who underwent 5-ALA resection of confirmed WHO 2007 Grade IV glioma between July 2009 and December 2014. Survival curves were calculated using the Kaplan–Meier method from surgery. The log-rank test was used to compare survival curves between groups. Cox regression was performed to identify variables predicting survival. A propensity score matched analysis was used to compare survival between patients who did and did not receive carmustine wafers while controlling for baseline characteristics. Propensity matched analysis showed no significant survival benefit of insertion of carmustine wafers over 5-ALA resection alone (HR 0.97 [0.68–1.26], p = 0.836). There was a trend to higher incidence of wound infection in those who received carmustine wafers (15.4 vs. 7.1%, p = 0.064). The Cox regression analysis showed that intraoperative residual fluorescent tumour and residual enhancing tumour on post-operative MRI were significantly predictive of reduced survival. Carmustine wafers have no added benefit following 5-ALA guided resection. Residual fluorescence and residual enhancing disease following resection have a negative impact on survival.
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Affiliation(s)
- William Sage
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Mathew Guilfoyle
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Catriona Luney
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Adam Young
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Rohitashwa Sinha
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Donatella Sgubin
- Division of Neurosurgery, Azienda Ospedaliera Nazionale SS, Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Joseph H McAbee
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - Ruichong Ma
- Department of Neurosurgery, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Rajesh Jena
- Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Fiona Harris
- Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Kieren Allinson
- Department of Histopathology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Tomasz Matys
- Department of Radiology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Wendi Qian
- Cambridge Cancer Trial Centre, Cambridge Clinical Trials Unit - Cancer Theme, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Thomas Santarius
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Stephen Price
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Colin Watts
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK.
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Hills Road, Box 167, Cambridge, CB2 0QQ, UK.
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12
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Belykh E, Martirosyan NL, Yagmurlu K, Miller EJ, Eschbacher JM, Izadyyazdanabadi M, Bardonova LA, Byvaltsev VA, Nakaji P, Preul MC. Intraoperative Fluorescence Imaging for Personalized Brain Tumor Resection: Current State and Future Directions. Front Surg 2016; 3:55. [PMID: 27800481 PMCID: PMC5066076 DOI: 10.3389/fsurg.2016.00055] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/12/2016] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Fluorescence-guided surgery is one of the rapidly emerging methods of surgical "theranostics." In this review, we summarize current fluorescence techniques used in neurosurgical practice for brain tumor patients as well as future applications of recent laboratory and translational studies. METHODS Review of the literature. RESULTS A wide spectrum of fluorophores that have been tested for brain surgery is reviewed. Beginning with a fluorescein sodium application in 1948 by Moore, fluorescence-guided brain tumor surgery is either routinely applied in some centers or is under active study in clinical trials. Besides the trinity of commonly used drugs (fluorescein sodium, 5-aminolevulinic acid, and indocyanine green), less studied fluorescent stains, such as tetracyclines, cancer-selective alkylphosphocholine analogs, cresyl violet, acridine orange, and acriflavine, can be used for rapid tumor detection and pathological tissue examination. Other emerging agents, such as activity-based probes and targeted molecular probes that can provide biomolecular specificity for surgical visualization and treatment, are reviewed. Furthermore, we review available engineering and optical solutions for fluorescent surgical visualization. Instruments for fluorescent-guided surgery are divided into wide-field imaging systems and hand-held probes. Recent advancements in quantitative fluorescence-guided surgery are discussed. CONCLUSION We are standing on the threshold of the era of marker-assisted tumor management. Innovations in the fields of surgical optics, computer image analysis, and molecular bioengineering are advancing fluorescence-guided tumor resection paradigms, leading to cell-level approaches to visualization and resection of brain tumors.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- School of Life Sciences, Arizona State University, Tempe, AZ, USA
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Irkutsk State Medical University, Irkutsk, Russia
| | - Nikolay L. Martirosyan
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- School of Life Sciences, Arizona State University, Tempe, AZ, USA
| | - Kaan Yagmurlu
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Eric J. Miller
- University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA
| | - Jennifer M. Eschbacher
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mohammadhassan Izadyyazdanabadi
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- School of Life Sciences, Arizona State University, Tempe, AZ, USA
| | - Liudmila A. Bardonova
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Irkutsk State Medical University, Irkutsk, Russia
| | - Vadim A. Byvaltsev
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Irkutsk State Medical University, Irkutsk, Russia
| | - Peter Nakaji
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mark C. Preul
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
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13
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Bernard-Arnoux F, Lamure M, Ducray F, Aulagner G, Honnorat J, Armoiry X. The cost-effectiveness of tumor-treating fields therapy in patients with newly diagnosed glioblastoma. Neuro Oncol 2016; 18:1129-36. [PMID: 27177573 PMCID: PMC4933490 DOI: 10.1093/neuonc/now102] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND There is strong concern about the costs associated with adding tumor-treating fields (TTF) therapy to standard first-line treatment for glioblastoma (GBM). Hence, we aimed to determine the cost-effectiveness of TTF therapy for the treatment of newly diagnosed patients with GBM. METHODS We developed a 3-health-state Markov model. The perspective was that of the French Health Insurance, and the horizon was lifetime. We calculated the transition probabilities from the survival parameters reported in the EF-14 trial. The main outcome measure was incremental effectiveness expressed as life-years gained (LYG). Input costs were derived from the literature. We calculated the incremental cost-effectiveness ratio (ICER) expressed as cost/LYG. We used 1-way deterministic and probabilistic sensitivity analysis to evaluate the model uncertainty. RESULTS In the base-case analysis, adding TTF therapy to standard of care resulted in increases of life expectancy of 4.08 months (0.34 LYG) and €185 476 per patient. The ICER was €549 909/LYG. The discounted ICER was €596 411/LYG. Parameters with the most influence on ICER were the cost of TTF therapy, followed equally by overall survival and progression-free survival in both arms. The probabilistic sensitivity analysis showed a 95% confidence interval of the ICER of €447 017/LYG to €745 805/LYG with 0% chance to be cost-effective at a threshold of €100 000/LYG. CONCLUSION The ICER of TTF therapy at first-line treatment is far beyond conventional thresholds due to the prohibitive announced cost of the device. Strong price regulation by health authorities could make this technology more affordable and consequently accessible to patients.
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Affiliation(s)
- F Bernard-Arnoux
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - M Lamure
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - F Ducray
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - G Aulagner
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - J Honnorat
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - X Armoiry
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
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