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Habibi MA, Ghorbani M, Esmaeilian S, Tajvidi F, Nekutalaban P, Boskabadi AR, Alemi F, Zafari R, Mirjani MS, Eazi S, Minaee P. Stereotactic radiosurgery versus combined stereotactic radiosurgery and bevacizumab for recurrent glioblastoma; a systematic review and meta-analysis of survival. Neurosurg Rev 2024; 47:323. [PMID: 39002028 DOI: 10.1007/s10143-024-02585-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/21/2024] [Accepted: 07/08/2024] [Indexed: 07/15/2024]
Abstract
Recurrent glioblastoma (rGBM) is a brain tumor that is resistant to standard treatments. Although stereotactic radiosurgery (SRS) is a non-invasive radiation technique, it cannot fully prevent tumor recurrence and progression. Bevacizumab blocks tumor blood supply and has been approved for rGBM. However, the best way to combine SRS and bevacizumab is still unclear. We did a systematic review and meta-analysis of studies comparing SRS alone and SRS plus bevacizumab for rGBM. We searched three databases for articles published until June 2023. All statistical analysis was performed by STATA v.17. Our meta-analysis included 20 studies with 926 patients. We found that the combination therapy had a significantly lower rate of overall survival (OS) than SRS alone at 6-month 0.77[95%CI:0.74-0.85] for SRS alone and (100%) for SRS plus bevacizumab. At 1-year OS, 0.39 [95%CI: 0.32-0.47] for SRS alone and 0.61 [95%CI:0.44-0.77] for SRS plus bevacizumab (P-value:0.02). However, this advantage was not seen in the long term (18 months and two years). Additionally, the combination therapy had lower chances of progression-free survival (PFS) than SRS alone at the 6-month and 1-year time points, but the differences were insignificant. Our study indicates that incorporating bevacizumab with SRS may lead to a short-term increase in OS for rGBM patients but not long-term. Additionally, the PFS rate did not show significant improvement in the group receiving combination therapy. Further clinical trials are necessary to validate the enhanced overall survival with combination therapy for rGBM.
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Affiliation(s)
- Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Ghorbani
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeid Esmaeilian
- General Radiologist, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Forouhar Tajvidi
- Student Research Committee, Abadan University of Medical Sciences, Abadan, Iran
| | - Parham Nekutalaban
- Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran
| | | | - Fakhroddin Alemi
- Faculty of Medicine, Mazandaran University of Medical Science, Mazandaran, Iran
| | - Rasa Zafari
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sina Mirjani
- Student Research Committee, Faculty of Medicine, Qom University of Medical Sciences, Qom, Iran
| | - SeyedMohammad Eazi
- Student Research Committee, Faculty of Medicine, Qom University of Medical Sciences, Qom, Iran
| | - Poriya Minaee
- Student Research Committee, Faculty of Medicine, Qom University of Medical Sciences, Qom, Iran
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Cuccia F, Jafari F, D’Alessandro S, Carruba G, Craparo G, Tringali G, Blasi L, Ferrera G. Preferred Imaging for Target Volume Delineation for Radiotherapy of Recurrent Glioblastoma: A Literature Review of the Available Evidence. J Pers Med 2024; 14:538. [PMID: 38793120 PMCID: PMC11122491 DOI: 10.3390/jpm14050538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Recurrence in glioblastoma lacks a standardized treatment, prompting an exploration of re-irradiation's efficacy. METHODS A comprehensive systematic review from January 2005 to May 2023 assessed the role of MRI sequences in recurrent glioblastoma re-irradiation. The search criteria, employing MeSH terms, targeted English-language, peer-reviewed articles. The inclusion criteria comprised both retrospective and prospective studies, excluding certain types and populations for specificity. The PICO methodology guided data extraction, and the statistical analysis employed Chi-squared tests via MedCalc v22.009. RESULTS Out of the 355 identified studies, 81 met the criteria, involving 3280 patients across 65 retrospective and 16 prospective studies. The key findings indicate diverse treatment modalities, with linac-based photons predominating. The median age at re-irradiation was 54 years, and the median time interval between radiation courses was 15.5 months. Contrast-enhanced T1-weighted sequences were favored for target delineation, with PET-imaging used in fewer studies. Re-irradiation was generally well tolerated (median G3 adverse events: 3.5%). The clinical outcomes varied, with a median 1-year local control rate of 61% and a median overall survival of 11 months. No significant differences were noted in the G3 toxicity and clinical outcomes based on the MRI sequence preference or PET-based delineation. CONCLUSIONS In the setting of recurrent glioblastoma, contrast-enhanced T1-weighted sequences were preferred for target delineation, allowing clinicians to deliver a safe and effective therapeutic option; amino acid PET imaging may represent a useful device to discriminate radionecrosis from recurrent disease. Future investigations, including the ongoing GLIAA, NOA-10, ARO 2013/1 trial, will aim to refine approaches and standardize methodologies for improved outcomes in recurrent glioblastoma re-irradiation.
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Affiliation(s)
- Francesco Cuccia
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy (G.F.)
| | - Fatemeh Jafari
- Radiation Oncology Department, Imam-Khomeini Hospital Complex, Teheran University of Medical Sciences, Teheran 1416634793, Iran
| | | | - Giuseppe Carruba
- Division of Internationalization and Health Research (SIRS), ARNAS Civico Hospital, 90100 Palermo, Italy
| | | | | | - Livio Blasi
- Medical Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy;
| | - Giuseppe Ferrera
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy (G.F.)
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Yilmaz MT, Kahvecioglu A, Yazici G, Mohammadipour S, Kertmen N, Cifci GC, Zorlu F. Hypofractionated stereotactic re-irradiation for progressive glioblastoma: twelve years' experience of a single center. J Neurooncol 2024; 167:295-303. [PMID: 38383875 PMCID: PMC11023988 DOI: 10.1007/s11060-024-04607-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/14/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE We aimed to evaluate the prognostic factors and the role of stereotactic radiotherapy (SRT) as a re-irradiation technique in the management of progressive glioblastoma. METHODS The records of 77 previously irradiated glioblastoma patients who progressed and received second course hypofractionated SRT (1-5 fractions) between 2009 and 2022 in our department were evaluated retrospectively. Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM, Armonk, NY, USA) was utilized for all statistical analyses. RESULTS The median time to progression from the end of initial radiotherapy was 14 months (range, 6-68 months). The most common SRT schedule was 30 Gy (range, 18-50 Gy) in 5 fractions (range, 1-5 fractions). The median follow-up after SRT was 9 months (range, 3-80 months). One-year overall (OS) and progression-free survival (PFS) rates after SRT were 46% and 35%, respectively. Re-irradiation dose and the presence of pseudoprogression were both significant independent positive prognostic factors for both OS (p = 0.009 and p = 0.04, respectively) and PFS (p = 0.008 and p = 0.04, respectively). For PFS, progression-free interval > 14 months was also a prognostic factor (p = 0.04). The treatment was well tolerated without significant acute toxicity. During follow-up, radiation necrosis was observed in 17 patients (22%), and 14 (82%) of them were asymptomatic. CONCLUSION Hypofractionated SRT is an effective treatment approach for patients with progressive glioblastoma. Younger patients who progressed later than 14 months, received higher SRT doses, and experienced pseudoprogression following SRT had improved survival rates.
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Affiliation(s)
- Melek Tugce Yilmaz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alper Kahvecioglu
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gozde Yazici
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Sepideh Mohammadipour
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Neyran Kertmen
- Department of Medical Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gokcen Coban Cifci
- Radiology Department, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Faruk Zorlu
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Marwah R, Xing D, Squire T, Soon YY, Gan HK, Ng SP. Reirradiation versus systemic therapy versus combination therapy for recurrent high-grade glioma: a systematic review and meta-analysis of survival and toxicity. J Neurooncol 2023; 164:505-524. [PMID: 37733174 PMCID: PMC10589175 DOI: 10.1007/s11060-023-04441-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE This review compares reirradiation (reRT), systemic therapy and combination therapy (reRT & systemic therapy) with regards to overall survival (OS), progression-free survival (PFS), adverse effects (AEs) and quality of life (QoL) in patients with recurrent high-grade glioma (rHGG). METHODS A search was performed on PubMed, Scopus, Embase and CENTRAL. Studies reporting OS, PFS, AEs and/or QoL and encompassing the following groups were included; reirradiation vs systemic therapy, combination therapy vs systemic therapy, combination therapy vs reRT, and bevacizumab-based combination therapy vs reRT with/without non-bevacizumab-based systemic therapy. Meta-analyses were performed utilising a random effects model. Certainty of evidence was assessed using GRADE. RESULTS Thirty-one studies (three randomised, twenty-eight non-randomised) comprising 2084 participants were included. In the combination therapy vs systemic therapy group, combination therapy improved PFS (HR 0.57 (95% CI 0.41-0.79); low certainty) and OS (HR 0.73 (95% CI 0.56-0.95); low certainty) and there was no difference in grade 3 + AEs (RR 1.03 (95% CI 0.57-1.86); very low certainty). In the combination therapy vs reRT group, combination therapy improved PFS (HR 0.52 (95% CI 0.38-0.72); low certainty) and OS (HR 0.69 (95% CI 0.52-0.93); low certainty). In the bevacizumab-based combination therapy vs reRT with/without non-bevacizumab-based systemic therapy group, adding bevacizumab improved PFS (HR 0.46 (95% CI 0.27-0.77); low certainty) and OS (HR 0.42 (95% CI 0.24-0.72; low certainty) and reduced radionecrosis (RR 0.17 (95% CI 0.06-0.48); low certainty). CONCLUSIONS Combination therapy may improve OS and PFS with acceptable toxicities in patients with rHGG compared to reRT or systemic therapy alone. Particularly, combining bevacizumab with reRT prophylactically reduces radionecrosis. REGISTRATION CRD42022291741.
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Affiliation(s)
- Ravi Marwah
- Department of Radiation Oncology, Townsville University Hospital, 100 Angus Smith Drive, Douglas, Townsville, QLD, 4814, Australia.
- College of Medicine and Dentistry, James Cook University, Townsville, Australia.
| | - Daniel Xing
- Department of Radiation Oncology, Townsville University Hospital, 100 Angus Smith Drive, Douglas, Townsville, QLD, 4814, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Timothy Squire
- Department of Radiation Oncology, Townsville University Hospital, 100 Angus Smith Drive, Douglas, Townsville, QLD, 4814, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore
| | - Hui K Gan
- Department of Medical Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Melbourne, Australia
- Cancer Therapies and Biology Group, Centre of Research Excellence in Brain Tumours, Olivia Newton-John Cancer Wellness & Research Centre, Austin Hospital, Melbourne, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Melbourne, Australia
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De Pietro R, Zaccaro L, Marampon F, Tini P, De Felice F, Minniti G. The evolving role of reirradiation in the management of recurrent brain tumors. J Neurooncol 2023; 164:271-286. [PMID: 37624529 PMCID: PMC10522742 DOI: 10.1007/s11060-023-04407-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023]
Abstract
Despite aggressive management consisting of surgery, radiation therapy (RT), and systemic therapy given alone or in combination, a significant proportion of patients with brain tumors will experience tumor recurrence. For these patients, no standard of care exists and management of either primary or metastatic recurrent tumors remains challenging.Advances in imaging and RT technology have enabled more precise tumor localization and dose delivery, leading to a reduction in the volume of health brain tissue exposed to high radiation doses. Radiation techniques have evolved from three-dimensional (3-D) conformal RT to the development of sophisticated techniques, including intensity modulated radiation therapy (IMRT), volumetric arc therapy (VMAT), and stereotactic techniques, either stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT). Several studies have suggested that a second course of RT is a feasible treatment option in patients with a recurrent tumor; however, survival benefit and treatment related toxicity of reirradiation, given alone or in combination with other focal or systemic therapies, remain a controversial issue.We provide a critical overview of the current clinical status and technical challenges of reirradiation in patients with both recurrent primary brain tumors, such as gliomas, ependymomas, medulloblastomas, and meningiomas, and brain metastases. Relevant clinical questions such as the appropriate radiation technique and patient selection, the optimal radiation dose and fractionation, tolerance of the brain to a second course of RT, and the risk of adverse radiation effects have been critically discussed.
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Affiliation(s)
- Raffaella De Pietro
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucy Zaccaro
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Marampon
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Paolo Tini
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Francesca De Felice
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giuseppe Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.
- IRCCS Neuromed, Pozzilli (IS), Isernia, Italy.
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Gregucci F, Surgo A, Carbonara R, Laera L, Ciliberti MP, Gentile MA, Caliandro M, Sasso N, Bonaparte I, Fanelli V, Tortora R, Paulicelli E, Surico G, Lombardi G, Signorelli F, Fiorentino A. Radiosurgery and Stereotactic Brain Radiotherapy with Systemic Therapy in Recurrent High-Grade Gliomas: Is It Feasible? Therapeutic Strategies in Recurrent High-Grade Gliomas. J Pers Med 2022; 12:1336. [PMID: 36013284 PMCID: PMC9410141 DOI: 10.3390/jpm12081336] [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: 08/01/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE For recurrent high-grade gliomas (HGG), no standard therapeutic approach has been reported; thus, surgery, chemotherapy, and re-irradiation (re-RT) may all be proposed. The aim of the study was to evaluate safety and efficacy of re-RT by radiosurgery or fractionated stereotactic radiotherapy (SRS/FSRT) in association to chemotherapy in patients with recurrent HGG. MATERIAL/METHODS All patients with histological diagnosis of HGG that suffered by recurrent disease diagnosed by magnetic resonance imaging (MRI), according to Response Assessment in Neuro-Oncology (RANO) criteria, after primary/adjuvant chemo-radiotherapy treatment and underwent to re-RT by SRS/FSRT were included in the analysis. Second-line chemotherapy was administered. Outcomes were evaluated by neurological examination and brain MRI performed 1 month after re-RT and then every 2-3 months. RESULTS From November 2019 to September 2021, 30 patients presenting recurrent HGG underwent re-RT. Median dose was 24 Gy (range 15-36 Gy), and median fractions was 5 (range 1-6). Twenty-one patients (70%) had RPA class ≤ IV. One patient had a histological diagnosis of anaplastic oligodendroglioma, 24 patients (80%) were affected by glioblastoma (GBM) including 3 cases of multifocal form, and 5 patients (17%) by anaplastic astrocytoma. Median time between primary/adjuvant RT and disease recurrence was 8 months. In six cases (20%) re-operation was performed, and in most cases (87%), a second line of systemic therapy was administrated. At a median follow-up time from recurrence of 13 months (range 6-56 months), 10 patients (33%) were alive: 2 patients with partial response disease, 7 patients with stable disease, and 1 patient with out-field progression disease. Of the 20 patients who died (67%), 15 (75%) died for progression disease and 5 (25%) for other causes (3 due to septic event, 1 due to thrombo-embolic event, and 1 due to car accident). Median OS and PFS after recurrence were 12.1 and 11.2 months. Six-month and one-year OS were, respectively, 81% and 51%. No acute or late neurological side effects grade ≥ 2 and no case of radio-necrosis were reported. One patient experienced, after reintervention and during Regorafenib treatment (administered 40 days after surgery), dehiscence of the surgical wound. In three cases, grade 2 distal paresthesia was reported. Grade 3-4 hematologic toxicity occurred in seven cases. Three case of grade 5 toxicities during chemotherapy were reported: three septic events and one thrombo-embolic event. CONCLUSION Re-RT with SRT/FSRT in association with second-line systemic therapy is a safe and feasible treatment for patients with HGG recurrence. Validation of these results by prospective studies is needed.
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Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Letizia Laera
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Maria Annunziata Gentile
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Nicola Sasso
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Vincenzo Fanelli
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Romina Tortora
- Centro Orientamento Oncologico, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Eleonora Paulicelli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Giammarco Surico
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Giuseppe Lombardi
- Department of Medical Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, Division of Neurosurgery, University “Aldo Moro”, 70124 Bari, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
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A phase II open label, single arm study of hypofractionated stereotactic radiotherapy with chemoradiotherapy using intensity-modulated radiotherapy for newly diagnosed glioblastoma after surgery: the HSCK-010 trial protocol. BMC Cancer 2022; 22:827. [PMID: 35906549 PMCID: PMC9335974 DOI: 10.1186/s12885-022-09914-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background The most frequently diagnosed primary brain tumor is glioblastoma (GBM). Nearly all patients experience tumor recurrence and up to 90% of which is local recurrence. Thus, increasing the therapeutic ratio of radiotherapy using hypofractionated stereotactic radiotherapy (HSRT) can reduce treatment time and may increase tumor control and improve survival. To evaluate the efficacy and toxicity of the combination of HSRT and intensity-modulated radiotherapy (IMRT) with temozolomide after surgery in GBM patients and provide evidence for further randomized controlled trials. Methods/design HSCK-010 is an open-label, single-arm phase II trial (NCT04547621) which includes newly diagnosed GBM patients who underwent gross total resection. Patients will receive the combination of 30 Gy/5fx HSRT, and 20 Gy/10fx IMRT adjuvant therapy with concurrent temozolomide and adjuvant chemotherapy. The primary endpoint is overall survival (OS). Secondary outcomes include progression-free survival (PFS) rate, objective-response rate (ORR), quality of life (Qol) before and after the treatment, cognitive function before and after the treatment, and rate of treatment-related adverse events (AE). The combination of HSRT and IMRT with temozolomide can benefit the patients after surgery with good survival, acceptable toxicity, and reduced treatment time. Trial registration NCT04547621. Registered on 14 September 2020.
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Lovo EE, Moreira A, Barahona KC, Ramirez J, Campos F, Tobar C, Caceros V, Sallabanda M, Sallabanda K. Stereotactic Radiosurgery for Recurrent Glioblastoma Multiforme: A Retrospective Multi-Institutional Experience. Cureus 2021; 13:e18480. [PMID: 34754642 PMCID: PMC8569687 DOI: 10.7759/cureus.18480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Glioblastoma multiforme (GBM) is the most common and lethal primary malignancy of the central nervous system. Despite standard therapy protocols, such as aggressive surgical resection, radiotherapy, and chemotherapy, GBM's aggressive nature produces low survival rates. Tumor recurrence and progression are nearly universal. Stereotactic radiosurgery (SRS) has been studied as an alternative treatment for recurrent GBM as a minimally invasive option that might prolong survival. The objective of this retrospective study was to evaluate the efficacy of SRS as a treatment modality considering overall survival (OS) in patients with GBM who had tumor recurrence and were treated with SRS in three different institutions. Materials and methods We retrospectively reviewed patients who received SRS for recurrent GBM between 1992 and 2020. A total of 46 patients were included in this study. We recorded age at diagnosis, the extent of surgical resection, radiation treatment, chemotherapy regimen, Karnofsky Performance Status at the time of SRS and at last follow-up, use of adjuvant chemotherapy after SRS, and response evaluation criteria in solid tumors. Primary endpoints were OS after initial diagnosis and OS from the date of the SRS procedure. Results Patients received SRS at a median of 10 months (range, 1 to 94 months) after their initial diagnoses. Median follow-up was seven months from the time of SRS and 22.8 months since diagnosis. The estimated median OS for all patients was nine months (range, 1 to 42 months) after SRS and 23.8 months (range, 4 to 102 months) after diagnosis. Median OS after SRS was seven months for patients treated from 1992 to 2011 and nine months for those treated from 2012 to 2020 (p = 0.008; X2 = 7.008). Median OS for younger patients (i.e., those aged <50 years) was 37.1 months compared to 18.6 months for older patients (i.e., those aged >50 years; p = 0.04; X2 = 3.870). Patients who received SRS after 10 months since diagnosis had a median OS of 36.2 months versus those who received SRS sooner than 10 months, who had an OS of 15 months (p = 0.004; X2 = 8.145). Radiosurgery doses larger than 15 Gy correlated with a median survival of nine months versus seven months in those treated with doses <15 Gy (p = 0.01; X2 = 6.756). Lastly, patients who received adjuvant bevacizumab (BEV) and or chemotherapy after SRS had a median survival of 12 months versus seven months for patients who did not receive any additional therapy after SRS (p = 0.04; X2 = 4.196). Conclusion SRS focal recurrent GBM in selected patients may improve OS, especially when combined with adjuvant therapy such as BEV and chemotherapy. Other prognostic variables proved relevant such as patients' age, the dose delivered, and surgery-to-SRS time that translates to the time of recurrence. Our results were consistent with the published literature and added to the accumulating evidence regarding SRS in recurrent GBM; however, extensive, multi-center studies are required to make definitive recommendations on this treatment approach.
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Affiliation(s)
- Eduardo E Lovo
- Radiosurgery/Neurosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Alejandra Moreira
- Neurosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Kaory C Barahona
- Radiation Oncology, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | | | - Fidel Campos
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Carlos Tobar
- Radiation Oncology, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Victor Caceros
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | | | - Kita Sallabanda
- Radiosurgery/Neurosurgery, Hospital Clinico Universitario San Carlos, Madrid, ESP
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García-Cabezas S, Rivin del Campo E, Solivera-Vela J, Palacios-Eito A. Re-irradiation for high-grade gliomas: Has anything changed? World J Clin Oncol 2021; 12:767-786. [PMID: 34631441 PMCID: PMC8479348 DOI: 10.5306/wjco.v12.i9.767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Optimal management after recurrence or progression of high-grade gliomas is still undefined and remains a challenge for neuro-oncology multidisciplinary teams. Improved radiation therapy techniques, new imaging methods, published experience, and a better radiobiological knowledge of brain tissue have positioned re-irradiation (re-RT) as an option for many of these patients. Decisions must be individualized, taking into account the pattern of relapse, previous treatment, and functional status, as well as the patient’s preferences and expected quality of life. Many questions remain unanswered with respect to re-RT: Who is the most appropriate candidate, which dose and fractionation are most effective, how to define the target volume, which imaging technique is best for planning, and what is the optimal timing? This review will focus on describing the most relevant studies that include re-RT as salvage therapy, with the aim of simplifying decision-making and designing the best available therapeutic strategy.
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Affiliation(s)
- Sonia García-Cabezas
- Department of Radiation Oncology, Reina Sofia University Hospital, Cordoba 14004, Spain
| | | | - Juan Solivera-Vela
- Department of Neurosurgery, Reina Sofia University Hospital, Cordoba 14004, Spain
| | - Amalia Palacios-Eito
- Department of Radiation Oncology, Reina Sofia University Hospital, Cordoba 14004, Spain
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Radiotherapy versus combination radiotherapy-bevacizumab for the treatment of recurrent high-grade glioma: a systematic review. Acta Neurochir (Wien) 2021; 163:1921-1934. [PMID: 33796887 PMCID: PMC8195900 DOI: 10.1007/s00701-021-04794-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
Background High-grade gliomas (HGG) comprise the most common primary adult brain cancers and universally recur. Combination of re-irradiation therapy (reRT) and bevacizumab (BVZ) therapy for recurrent HGG is common, but its reported efficacy is mixed. Objective To assess clinical outcomes after reRT ± BVZ in recurrent HGG patients receiving stereotactic radiosurgery (SRS), hypofractionated radiosurgery (HFSRT), or fully fractionated radiotherapy (FFRT). Methods We performed a systematic review of PubMed, Web of Science, Scopus, Embase, and Cochrane databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified studies reporting outcomes for patients with recurrent HGG treated via reRT ± BVZ. Cohorts were stratified by BVZ treatment status and re-irradiation modality (SRS, HFSRT, and FFRT). Outcome variables were overall survival (OS), progression-free survival (PFS), and radiation necrosis (RN). Results Data on 1399 patients was analyzed, with 954 patients receiving reRT alone and 445 patients receiving reRT + BVZ. All patients initially underwent standard-of-care therapy for their primary HGG. In a multivariate analysis that adjusted for median patient age, WHO grade, RT dosing, reRT fractionation regimen, time between primary and re-irradiation, and re-irradiation target volume, BVZ therapy was associated with significantly improved OS (2.51, 95% CI [0.11, 4.92] months, P = .041) but no significant improvement in PFS (1.40, 95% CI [− 0.36, 3.18] months, P = .099). Patients receiving BVZ also had significantly lower rates of RN (2.2% vs 6.5%, P < .001). Conclusions Combination of reRT + BVZ may improve OS and reduce RN rates in recurrent HGG, but further controlled studies are needed to confirm these effects. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-04794-3.
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11
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De Maria L, Terzi di Bergamo L, Conti A, Hayashi K, Pinzi V, Murai T, Lanciano R, Burneikiene S, Buglione di Monale M, Magrini SM, Fontanella MM. CyberKnife for Recurrent Malignant Gliomas: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:652646. [PMID: 33854978 PMCID: PMC8039376 DOI: 10.3389/fonc.2021.652646] [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: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Possible treatment strategies for recurrent malignant gliomas include surgery, chemotherapy, radiotherapy, and combined treatments. Among different reirradiation modalities, the CyberKnife System has shown promising results. We conducted a systematic review of the literature and a meta-analysis to establish the efficacy and safety of CyberKnife treatment for recurrent malignant gliomas. METHODS We searched PubMed, MEDLINE, and EMBASE from 2000 to 2021 for studies evaluating the safety and efficacy of CyberKnife treatment for recurrent WHO grade III and grade IV gliomas of the brain. Two independent reviewers selected studies and abstracted data. Missing information was requested from the authors via email correspondence. The primary outcomes were median Overall Survival, median Time To Progression, and median Progression-Free Survival. We performed subgroup analyses regarding WHO grade and chemotherapy. Besides, we analyzed the relationship between median Time To Recurrence and median Overall Survival from CyberKnife treatment. The secondary outcomes were complications, local response, and recurrence. Data were analyzed using random-effects meta-analysis. RESULTS Thirteen studies reporting on 398 patients were included. Median Overall Survival from initial diagnosis and CyberKnife treatment was 22.6 months and 8.6 months. Median Time To Progression and median Progression-Free Survival from CyberKnife treatment were 6.7 months and 7.1 months. Median Overall Survival from CyberKnife treatment was 8.4 months for WHO grade IV gliomas, compared to 11 months for WHO grade III gliomas. Median Overall Survival from CyberKnife treatment was 4.4 months for patients who underwent CyberKnife treatment alone, compared to 9.5 months for patients who underwent CyberKnife treatment plus chemotherapy. We did not observe a correlation between median Time To Recurrence and median Overall Survival from CyberKnife. Rates of acute neurological and acute non-neurological side effects were 3.6% and 13%. Rates of corticosteroid dependency and radiation necrosis were 18.8% and 4.3%. CONCLUSIONS Reirradiation of recurrent malignant gliomas with the CyberKnife System provides encouraging survival rates. There is a better survival trend for WHO grade III gliomas and for patients who undergo combined treatment with CyberKnife plus chemotherapy. Rates of complications are low. Larger prospective studies are warranted to provide more accurate results.
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Affiliation(s)
- Lucio De Maria
- Unit of Neurosurgery, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | | | - Alfredo Conti
- Unit of Neurosurgery, Alma Mater Studiorum University of Bologna and IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Kazuhiko Hayashi
- Unit of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Valentina Pinzi
- Unit of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Taro Murai
- Unit of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | | | | | - Stefano Maria Magrini
- Unit of Radiation Oncology, University of Brescia and ASST Spedali Civili, Brescia, Italy
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12
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Minniti G, Niyazi M, Alongi F, Navarria P, Belka C. Current status and recent advances in reirradiation of glioblastoma. Radiat Oncol 2021; 16:36. [PMID: 33602305 PMCID: PMC7890828 DOI: 10.1186/s13014-021-01767-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/11/2021] [Indexed: 12/12/2022] Open
Abstract
Despite aggressive management consisting of maximal safe surgical resection followed by external beam radiation therapy (60 Gy/30 fractions) with concomitant and adjuvant temozolomide, approximately 90% of WHO grade IV gliomas (glioblastomas, GBM) will recur locally within 2 years. For patients with recurrent GBM, no standard of care exists. Thanks to the continuous improvement in radiation science and technology, reirradiation has emerged as feasible approach for patients with brain tumors. Using stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT), either hypofractionated or conventionally fractionated schedules, several studies have suggested survival benefits following reirradiation of patients with recurrent GBM; however, there are still questions to be answered about the efficacy and toxicity associated with a second course of radiation. We provide a clinical overview on current status and recent advances in reirradiation of GBM, addressing relevant clinical questions such as the appropriate patient selection and radiation technique, optimal dose fractionation, reirradiation tolerance of the brain and the risk of radiation necrosis.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, VR, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano, MI, Italy
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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13
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Guan Y, Xiong J, Pan M, Shi W, Li J, Zhu H, Gong X, Li C, Mei G, Liu X, Pan L, Dai J, Wang Y, Wang E, Wang X. Safety and efficacy of Hypofractionated stereotactic radiosurgery for high-grade Gliomas at first recurrence: a single-center experience. BMC Cancer 2021; 21:123. [PMID: 33546642 PMCID: PMC7863415 DOI: 10.1186/s12885-021-07856-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/11/2021] [Indexed: 12/20/2022] Open
Abstract
Background The optimal treatment for recurrent high-grade gliomas (rHGGs) remains uncertain. This study aimed to investigate the efficacy and safety of hypofractionated stereotactic radiosurgery (HSRS) as a first-line salvage treatment for in-field recurrence of high-grade gliomas. Methods Between January 2016 and October 2019, 70 patients with rHGG who underwent HSRS were retrospectively analysed. The primary endpoint was overall survival (OS), and secondary endpoints included both progression-free survival (PFS) and adverse events, which were assessed according to Common Toxicity Criteria Adverse Events (CTCAE) version 5. The prognostic value of key clinical features (age, performance status, planning target volume, dose, use of bevacizumab) was evaluated. Results A total of 70 patients were included in the study. Forty patients were male and 30 were female. Forty-nine had an initial diagnosis of glioblastoma (GBM), and the rest (21) were confirmed to be WHO grade 3 gliomas. The median planning target volume (PTV) was 16.68 cm3 (0.81–121.96 cm3). The median prescribed dose was 24 Gy (12–30 Gy) in 4 fractions (2–6 fractions). The median baseline of Karnofsky Performance Status (KPS) was 70 (40–90). With a median follow-up of 12.1 months, the median overall survival after salvage treatment was 17.6 months (19.5 and 14.6 months for grade 3 and 4 gliomas, respectively; p = .039). No grade 3 or higher toxicities was recorded. Multivariate analysis showed that concurrent bevacizumab with radiosurgery and KPS > 70 were favourable prognostic factors for grade 4 patients with HGG. Conclusions Salvage HSRS showed a favourable outcome and acceptable toxicity for rHGG. A prospective phase II study (NCT04197492) is ongoing to further investigate the value of hypofractionated stereotactic radiosurgery (HSRS) in rHGG. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-07856-y.
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Affiliation(s)
- Yun Guan
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Ji Xiong
- Department of pathology, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Mingyuan Pan
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jing Li
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Huaguang Zhu
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Xiu Gong
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Chao Li
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Guanghai Mei
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Xiaoxia Liu
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Li Pan
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Jiazhong Dai
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Yang Wang
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Enmin Wang
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China.
| | - Xin Wang
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China.
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14
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Scoccianti S, Perna M, Olmetto E, Delli Paoli C, Terziani F, Ciccone LP, Detti B, Greto D, Simontacchi G, Grassi R, Scoccimarro E, Bonomo P, Mangoni M, Desideri I, Di Cataldo V, Vernaleone M, Casati M, Pallotta S, Livi L. Local treatment for relapsing glioblastoma: A decision-making tree for choosing between reirradiation and second surgery. Crit Rev Oncol Hematol 2020; 157:103184. [PMID: 33307416 DOI: 10.1016/j.critrevonc.2020.103184] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/21/2020] [Accepted: 11/23/2020] [Indexed: 12/22/2022] Open
Abstract
In case of circumscribed recurrent glioblastoma (rec-GBM), a second surgery (Re-S) and reirradiation (Re-RT) are local strategies to consider. The aim is to provide an algorithm to use in the daily clinical practice. The first step is to consider the life expectancy in order to establish whether the patient should be a candidate for active treatment. In case of a relatively good life expectancy (>3 months) and a confirmed circumscribed disease(i.e. without multiple lesions that are in different lobes/hemispheres), the next step is the assessment of the prognostic factors for local treatments. Based on the existing prognostic score systems, patients who should be excluded from local treatments may be identified; based on the validated prognostic factors, one or the other local treatment may be preferred. The last point is the estimation of expected toxicity, considering patient-related, tumor-related and treatment-related factors impacting on side effects. Lastly, patients with very good prognostic factors may be considered for receiving a combined treatment.
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Affiliation(s)
- Silvia Scoccianti
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy.
| | - Marco Perna
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Emanuela Olmetto
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Camilla Delli Paoli
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Francesca Terziani
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Lucia Pia Ciccone
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Beatrice Detti
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Daniela Greto
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Gabriele Simontacchi
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Roberta Grassi
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Erika Scoccimarro
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Pierluigi Bonomo
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Monica Mangoni
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Isacco Desideri
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Vanessa Di Cataldo
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Marco Vernaleone
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Marta Casati
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Medical Physics Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Stefania Pallotta
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Medical Physics Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
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15
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Kim MS, Lim J, Shin HS, Cho KG. Re-Irradiation and Its Contribution to Good Prognosis in Recurrent Glioblastoma Patients. Brain Tumor Res Treat 2020; 8:29-35. [PMID: 32390351 PMCID: PMC7221471 DOI: 10.14791/btrt.2020.8.e10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/11/2020] [Accepted: 03/17/2020] [Indexed: 01/02/2023] Open
Abstract
Background Radiation therapy, one of the strongest anti-cancer treatments, is already performed to treat primary glioblastoma; however, the effect of repeated radiation therapy for recurrent tumors has not been fully explored. The aim of this study was to determine the efficacy of re-irradiation in treating recurrent glioblastoma. Methods The study included 36 patients with recurrent glioblastoma treated with repeated radiation therapy between 2002 and 2016. Stereotactic radiosurgery (SRS) and hypo-fractionated stereotactic radiotherapy (HSRT) were performed in these patients. Results Fourteen patients received SRS with a median dose of 25 Gy (range, 20–32 Gy) in 1–5 fractions. Twenty-two patients received HSRT with a median dose of 40 Gy (range, 31.5–52 Gy) in 6–20 fractions. There were six treatment-related grade 3 adverse events. Survival analysis showed that re-irradiation significantly prolonged overall survival (OS) and progression-free survival (PFS). The median OS and one-year OS rate after re-irradiation were 17.2 months and 60.4%, respectively. The median PFS and 6-month PFS rate after re-irradiation were 4.4 months and 41.9%, respectively. Of the 36 patients, three survived without any progression in their condition. Conclusion Re-irradiation for recurrent glioblastoma showed favorable outcomes. Radiation dose and fractionation should be carefully considered to minimize radiation necrosis.
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Affiliation(s)
- Mi Sun Kim
- Department of Radiation Oncology, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Jaejoon Lim
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Hyun Soo Shin
- Department of Radiation Oncology, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Kyung Gi Cho
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, Korea.
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16
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Yaprak G, Isık N, Gemici C, Pekyurek M, Ceylaner Bıcakcı B, Demircioglu F, Tatarlı N. Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option. Stereotact Funct Neurosurg 2020; 98:167-175. [PMID: 32248188 DOI: 10.1159/000505706] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Glioblastoma (GBM) is a dismal disease. Recurrence is inevitable despite initial surgery and postoperative temozolomide (TMZ) and radiotherapy. Salvage surgery is the standard treatment in selected patients. Chemotherapy, biological agents, and re-irradiation are other treatment approaches available. Stereotactic radiotherapy (SRT) is nowadays a common treatment as a salvage treatment option. MATERIALS AND METHODS We reviewed the files of 132 GBM cases treated between 2010 and 2018. All patients received TMZ and radiotherapy after surgery or biopsy. Among the patients who had recurrence, we identified 42 cases treated with salvage SRT. The CyberKnife robotic system was used to administer SRT. RESULTS While the median follow-up time for all patients was 16 months (range 1-123), the median follow-up time for patients treated with SRT after initial diagnosis was 26.5 months (range 9-123). The median follow-up time after SRT was 10 months (range 2-107). SRT was performed in a median of 3 fractions (range 2-5). The median prescription dose was 20 Gy (range 18-30). While the median actuarial survival after initial diagnosis for patients treated with salvage SRT was 30 months (range 9-123), it was only 14 months (range 1-111) for patients who could not be treated with salvage SRT (p = 0.001). The median survival time after SRT was 12 months, and 1- and 2-year survival rates were 48 and 9%, respectively. The time to progression after SRT was 5 months (range 1-62), and 6-month and 1-year progression-free survival rates were 50 and 22%, respectively. Patients with longer time to recurrence >12 months had longer overall survival with respect to the ones having recurrence <12 months (p < 0.001). Salvage surgery had been performed in 7 out of 42 patients before SRT. These reoperated patients had significantly worse survival after SRT when compared to the patients who underwent SRT alone (p = 0.02). SRT was well tolerated and there was no grade III/IV toxicity. CONCLUSIONS SRT is a viable salvage treatment option for recurrent GBM. SRT provides acceptable local control and survival benefit for recurrent GBM cases. SRT can be considered especially in patients with long time to recurrence.
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Affiliation(s)
- Gokhan Yaprak
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey,
| | - Naciye Isık
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Gemici
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Melike Pekyurek
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Beyhan Ceylaner Bıcakcı
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Fatih Demircioglu
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Necati Tatarlı
- Department of Neurosurgery, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
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17
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Morris SAL, Zhu P, Rao M, Martir M, Zhu JJ, Hsu S, Ballester LY, Day AL, Tandon N, Kim DH, Shepard S, Blanco A, Esquenazi Y. Gamma Knife Stereotactic Radiosurgery in Combination with Bevacizumab for Recurrent Glioblastoma. World Neurosurg 2019; 127:e523-e533. [DOI: 10.1016/j.wneu.2019.03.193] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 01/17/2023]
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18
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Efficacy and Safety of Hypofractionated Stereotactic Radiotherapy for Recurrent Malignant Gliomas: A Systematic Review and Meta-analysis. World Neurosurg 2019; 127:176-185. [DOI: 10.1016/j.wneu.2019.03.297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/29/2019] [Accepted: 03/30/2019] [Indexed: 02/07/2023]
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19
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Chapman CH, Hara JH, Molinaro AM, Clarke JL, Oberheim Bush NA, Taylor JW, Butowski NA, Chang SM, Fogh SE, Sneed PK, Nakamura JL, Raleigh DR, Braunstein SE. Reirradiation of recurrent high-grade glioma and development of prognostic scores for progression and survival. Neurooncol Pract 2019; 6:364-374. [PMID: 31555451 DOI: 10.1093/nop/npz017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/25/2019] [Accepted: 03/04/2019] [Indexed: 12/17/2022] Open
Abstract
Background Optimal techniques and patient selection for salvage reirradiation of high-grade glioma (HGG) are unclear. In this study, we identify prognostic factors for freedom from progression (FFP) and overall survival (OS) after reirradiation, risk factors for high-grade toxicity, and validate clinical prognostic scores. Methods A total of 116 patients evaluated between 2000 and 2018 received reirradiation for HGG (99 WHO grade IV, 17 WHO grade III). Median time to first progression after initial therapy was 10.6 months. Salvage therapies before reirradiation included surgery (31%) and systemic therapy (41%). Sixty-five patients (56%) received single-fraction stereotactic radiosurgery (SRS) as reirradiation. The median biologically effective dose (BED) was 47.25 Gy, and the median planning target volume (PTV) was 4.8 cc for SRS and 95.0 cc for non-SRS treatments. Systemic therapy was given concurrently to 52% and adjuvantly to 74% of patients. Results Median FFP was 4.9 months, and median OS was 11.0 months. Significant multivariable prognostic factors for FFP were performance status, time to initial progression, and BED; for OS they were age, time to initial progression, and PTV volume at recurrence. High-grade toxicity was correlated to PTV size at recurrence. Three-level prognostic scores were generated for FFP and OS, with cross-validated receiver operating characteristic area under the curve (AUC) of 0.640 and 0.687, respectively. Conclusions Clinical variables at the time of reirradiation for HGG can be used to prognosticate FFP and OS.
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Affiliation(s)
| | - Jared H Hara
- John A. Burns School of Medicine, University of Hawaii, Honolulu
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco
| | - Jennifer L Clarke
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Jennie W Taylor
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Nicholas A Butowski
- Department of Neurological Surgery, University of California San Francisco, USA
| | - Susan M Chang
- Department of Neurological Surgery, University of California San Francisco, USA
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California San Francisco
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco
| | - Jean L Nakamura
- Department of Neurology, University of California San Francisco
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco
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20
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Qie S, Yuan L, Shi HY, Zhang X, Li Y. Conventionally fractionated stereotactic radiotherapy (CFRT) in combination with dose-dense temozolomide (TMZ) in relapsed malignant glioma: A case report. Medicine (Baltimore) 2019; 98:e13869. [PMID: 30608405 PMCID: PMC6344191 DOI: 10.1097/md.0000000000013869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE At present, there is no uniform consensus on the treatment of recurrent glioblastoma, especially the re-irradiation dose and temozolomide (TMZ) dose. The literature on the treatment of recurrent glioblastoma (GBM) by conventionally fractionated stereotactic radiotherapy (CFRT) is even rarer. PATIENT CONCERNS A 44-year-old woman was admitted to our hospital for residual tumor after reoperation. DIAGNOSES Postoperative pathological diagnosis was GBM, WHO grade IV. The brain magnetic resonance imaging re-examination showed abnormal enhancement around the local operative region after resection of the left frontal lobe tumor, and there was presence of residual tumor. INTERVENTIONS The patient was treated with reoperation followed by re-irradiation plus dose-dense TMZ to achieve complete remission. OUTCOMES Complete remission was observed at the end of radiotherapy and at the 1 month follow-up after radiotherapy. LESSONS This study suggests that CFRT plus dose-dense TMZ might be a feasible option for the treatment in relapsed malignant glioma patients with good general condition.
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21
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Re-irradiation for recurrent glioblastoma (GBM): a systematic review and meta-analysis. J Neurooncol 2018; 142:79-90. [PMID: 30523605 DOI: 10.1007/s11060-018-03064-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/24/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE To determine the efficacy and toxicity of re-irradiation for patients with recurrent GBM. MATERIALS AND METHODS We searched various biomedical databases from 1998 to 2018, for eligible studies where patients were treated with re-irradiation for recurrent GBM. Outcomes of interest were 6 and 12-month overall survival (OS-6, OS-12), 6 and 12-month progression free survival (PFS-6, PFS-12) and serious (Grade 3 +) adverse events (AE). We used the random effects model to pool outcomes across studies and compared pre-defined subgroups using interaction test. Methodological quality of each study was assessed using the Newcastle-Ottawa scoring system. RESULTS We found 50 eligible non-comparative studies including 2095 patients. Of these, 42% were of good or fair quality. The pooled results were as follows: OS-6 rate 73% (95% confidence interval (CI) 69-77%), OS-12 rate 36% (95% CI 32-40%), PFS-6 rate 43% (95% CI 35-50%), PFS-12 rate 17% (95% CI 13-20%), and Grade 3 + AE rate 7% (95% CI 4-10%). Subgroup analysis showed that prospective studies reported higher toxicity rates, and studies which utilized brachytherapy to have a longer OS-12. Within the external beam radiotherapy group, there was no dose-response [above or below 36 Gy in 2 Gy equivalent doses (EQD2)]. However, a short fractionation regimen (≤ 5 fractions) seemed to provide superior PFS-6. CONCLUSION The available evidence, albeit mostly level III, suggests that re-irradiation provides encouraging disease control and survival rates. Toxicity was not uniformly reported, but seemed to be low from the included studies. Randomized controlled trials (RCT) are needed to establish the optimal management strategy for recurrent GBM.
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22
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Patterns of re-irradiation for recurrent gliomas and validation of a prognostic score. Radiother Oncol 2018; 130:156-163. [PMID: 30446315 DOI: 10.1016/j.radonc.2018.10.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE OR OBJECTIVE Re-irradiation is a generally accepted method for salvage treatment in patients with recurrent glioma. However, no standard radiation regimen has been defined. This study aims to compare the efficacy and safety of different treatment regimens and to independently externally validate a recently published reirradiation risk score. MATERIAL AND METHODS We retrospectively analyzed a cohort of patients with recurrent malignant glioma treated with salvage conventionally fractionated (CFRT), hypofractionated (HFRT) or stereotactic radiotherapy (SRT) between 2007 and 2017 at the University Medical Centers in Utrecht and Groningen. RESULTS Of the 121 patients included, 60 patients (50%) underwent CFRT, 22 (18%) HFRT and 39 (32%) SRT. The primary tumor was grade II-III in 52 patients and grade IV in 69 patients with median Overall Survival (mOS) since first surgery of 113 [Interquartile range: 53.2-137] and 39.7 [24.6-64.9] months respectively (p < 0.01). Overall, mOS from the first day of re-irradiation was 9.7 months [6.5-14.6]. No significant difference in mOS was found between the treatment groups. In multivariate analysis, the Karnofsky performance scale ≥70% (p < 0.01), re-irradiation for first recurrence (p = 0.02), longer time interval between RT start dates (p < 0.01) and smaller planning target volume (p < 0.05) were significant favorable prognostic factors. The reirradiation risk score was validated. CONCLUSION In our series, mOS after reirradiation was sufficient to justify use of this modality. Until a reliable treatment decision tool is developed based on larger retrospective research, the decision for re-irradiation schedule should remain personalized and based on a multidisciplinary evaluation of each patient.
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23
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Gigliotti MJ, Hasan S, Karlovits SM, Ranjan T, Wegner RE. Re-Irradiation with Stereotactic Radiosurgery/Radiotherapy for Recurrent High-Grade Gliomas: Improved Survival in the Modern Era. Stereotact Funct Neurosurg 2018; 96:289-295. [PMID: 30404102 DOI: 10.1159/000493545] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/05/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) as salvage therapy for recurrent high-grade glioma and to look at the overall efficacy of treatment with linear accelerator (LINAC)-based radiosurgery and fractionated radiotherapy. METHODS From 2010 to 2017, a total of 25 patients aged 23-74 years were re-irradiated with LINAC-based SRS and fSRT. Patients were treated to a median dose of 25 Gy in 5 fractions. RESULTS The median overall survival (OS) after (initial) diagnosis was 39 months with an actuarial 1-, 3-, and 5-year OS rate of 88, 56, and 30%, respectively. After treatment with SRS or fSRT, the median OS was 9 months with an actuarial 1-year OS rate of 29%. Local control, assessed for 28 tumors, after 6 months was 57%, while local control after 1 year was 39%. Three patients experienced local failure. There was no evidence of toxicity noted after SRS or fSRT throughout the follow-up period. CONCLUSION SRS and fSRT remain a safe, reasonable, effective treatment option for re-irradiation following recurrent glioblastoma. Additionally, treatment volume may predict local control in the salvage setting.
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Affiliation(s)
- Michael J Gigliotti
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Stephen M Karlovits
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Tulika Ranjan
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA,
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24
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Shanker M, Chua B, Bettington C, Foote MC, Pinkham MB. Re-irradiation for recurrent high-grade gliomas: a systematic review and analysis of treatment technique with respect to survival and risk of radionecrosis. Neurooncol Pract 2018; 6:144-155. [PMID: 31386038 DOI: 10.1093/nop/npy019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Re-irradiation may be considered for select patients with recurrent high-grade glioma. Treatment techniques include conformal radiotherapy employing conventional fractionation, hypofractionated stereotactic radiotherapy (FSRT), and single-fraction stereotactic radiosurgery (SRS). Methods A pooled, population-weighted, multiple linear regression analysis of publications from 1992 to 2016 was performed to evaluate the relationships between re-irradiation technique and median overall survival (OS) and radionecrosis outcomes. Results Seventy published articles were analyzed, yielding a total of 3302 patients. Across all studies, initial treatment was external beam radiotherapy to a median dose of 60 Gy in 30 fractions, with or without concurrent chemotherapy. On multivariate analysis, there was a significant correlation between OS and radiotherapy technique after adjusting for age, re-irradiation biologically equivalent dose (EQD2), interval between initial and repeat radiotherapy, and treatment volume (P < .0001). Adjusted mean OS was 12.2 months (95% CI, 11.8-12.5) after SRS, 10.1 months (95% CI, 9.7-10.5) after FSRT, and 8.9 months (95% CI, 8.4-9.4) after conventional fractionation. There was also a significant association between radionecrosis and treatment technique after adjusting for age, re-irradiation EQD2, interval, and volume (P < .0001). Radionecrosis rate was 7.1% (95% CI, 6.6-7.7) after FSRT, 6.1% (95% CI, 5.6-6.6) after SRS, and 1.1% (95% CI, 0.5-1.7) after conventional fractionation. Conclusions The published literature suggests that OS is highest after re-irradiation using SRS, followed by FSRT and conventionally fractionated radiotherapy. Whether this represents superiority of the treatment technique or an uncontrolled selection bias is uncertain. The risk of radionecrosis was low for all modalities overall. Re-irradiation is a feasible option in appropriately selected patients.
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Affiliation(s)
- Mihir Shanker
- The University of Queensland, Faculty of Medicine, Australia.,Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Benjamin Chua
- Department of Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Catherine Bettington
- The University of Queensland, Faculty of Medicine, Australia.,Department of Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Matthew C Foote
- The University of Queensland, Faculty of Medicine, Australia.,Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Mark B Pinkham
- The University of Queensland, Faculty of Medicine, Australia.,Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Australia
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25
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Re-irradiation as salvage treatment in recurrent glioblastoma: A comprehensive literature review to provide practical answers to frequently asked questions. Crit Rev Oncol Hematol 2018; 126:80-91. [PMID: 29759570 DOI: 10.1016/j.critrevonc.2018.03.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 02/11/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
The primary aim of this review is to provide practical recommendations in terms of fractionation, dose, constraints and selection criteria to be used in the daily clinical routine. Based on the analysis of the literature reviewed, in order to keep the risk of severe side effects ≤3,5%, patients should be stratified according to the target volume. Thus, patients should be treated with different fractionation and total EQD2 (<12.5 ml: EQD2 < 65 Gy with radiosurgery; >12.5 ml and <35 ml: EQD2 < 50 Gy with hypofractionated stereotactic radiotherapy; >35 ml and <50 ml: EQD2 < 36 Gy with conventionally fractionated radiotherapy). Concurrent approaches with temozolomide or bevacizumab do not seem to improve the outcomes of reirradiation and may lead to a higher risk of toxicity but these findings need to be confirmed in prospective series.
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26
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Ho A, Jena R. Re-irradiation in the Brain: Primary Gliomas. Clin Oncol (R Coll Radiol) 2018; 30:124-136. [DOI: 10.1016/j.clon.2017.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
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27
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Attal J, Chaltiel L, Lubrano V, Sol JC, Lanaspeze C, Vieillevigne L, Latorzeff I, Cohen-Jonathan Moyal E. Subventricular zone involvement at recurrence is a strong predictive factor of outcome following high grade glioma reirradiation. J Neurooncol 2017; 136:413-419. [PMID: 29273890 DOI: 10.1007/s11060-017-2669-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/11/2017] [Indexed: 11/26/2022]
Abstract
We aimed to assess the efficacy of stereotactic irradiation for patients with recurrent high-grade glioma (HGG) and identify predictive factors of progression-free survival (PFS) and overall survival (OS) following reirradiation. We identified 32 patients with recurrent brain HGG who had been treated with either single-dose (stereotactic radiosurgery) or fractionated stereotactic radiotherapy between April 2008 and October 2015. Median follow up was 21.4 months (range 12.9-23.2) and median PFS was and 3.3 months (95% CI [2.3-4.7]), respectively. OS was 90.40% (95% CI [73.09-96.80]) at 6 months and 79.55% (95% CI [59.9-90.29]) at 12 months. Univariate analysis showed that biological effective dose at isocenter ≤ 76 Gy was a poor prognostic factor for both OS (83.33 vs. 100% at 6 months, p = 0.032) and median PFS (2.7 vs. 4.7 months, p = 0.025), as was gross tumor volume (GTV) above 1 cm3 for OS (86.15 vs. 94.12% at 6 months, p = 0.043). Contact with the subventricular zone (SVZ) was also a poor prognostic factor for median PFS (2.3 vs. 4.7 months, p = 0.002). Multivariate analysis showed that SVZ contact remained a poor prognostic factor for PFS (hazard ratio = 3.44, 95% CI [1.21-9.82], p = 0.021). Results suggest that reirradiation is a safe and effective treatment option for recurrent HGG in patients with a good Karnosfsky Performance Scale score, a long progression-free interval since first radiation and limited GTV, and that contact to SVZ is a strong prognostic factor for PFS.
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Affiliation(s)
- J Attal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France.
| | - L Chaltiel
- Department of Biostatistics, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - V Lubrano
- Regional Center for Stereotactic Radiosurgery, CHU Rangueil, Avenue Jean-Poulhès, 31052, Toulouse, France
- Department of Neurosurgery, CHU de Toulouse, Université Paul-Sabatier, 31059, Toulouse, France
| | - J C Sol
- Department of Neurosurgery, CHU de Toulouse, Université Paul-Sabatier, 31059, Toulouse, France
| | - C Lanaspeze
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - L Vieillevigne
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - I Latorzeff
- Regional Center for Stereotactic Radiosurgery, CHU Rangueil, Avenue Jean-Poulhès, 31052, Toulouse, France
- Department of Oncology-Radiotherapy, Groupe ONCORAD Garonne, Clinique Pasteur, 31300, Toulouse, France
| | - E Cohen-Jonathan Moyal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
- INSERM U1037, Cancer Research Center of Toulouse (CRCT), 31000, Toulouse, France
- Université Toulouse III Paul Sabatier, 31300, Toulouse, France
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28
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Imber BS, Kanungo I, Braunstein S, Barani IJ, Fogh SE, Nakamura JL, Berger MS, Chang EF, Molinaro AM, Cabrera JR, McDermott MW, Sneed PK, Aghi MK. Indications and Efficacy of Gamma Knife Stereotactic Radiosurgery for Recurrent Glioblastoma: 2 Decades of Institutional Experience. Neurosurgery 2017; 80:129-139. [PMID: 27428784 DOI: 10.1227/neu.0000000000001344] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 05/23/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The role of stereotactic radiosurgery (SRS) for recurrent glioblastoma and the radionecrosis risk in this setting remain unclear. OBJECTIVE To perform a large retrospective study to help inform proper indications, efficacy, and anticipated complications of SRS for recurrent glioblastoma. METHODS We retrospectively analyzed patients who underwent Gamma Knife SRS between 1991 and 2013. We used the partitioning deletion/substitution/addition algorithm to identify potential predictor covariate cut points and Kaplan-Meier and proportional hazards modeling to identify factors associated with post-SRS and postdiagnosis survival. RESULTS One hundred seventy-four glioblastoma patients (median age, 54.1 years) underwent SRS a median of 8.7 months after initial diagnosis. Seventy-five percent had 1 treatment target (range, 1-6), and median target volume and prescriptions were 7.0 cm 3 (range, 0.3-39.0 cm 3 ) and 16.0 Gy (range, 10-22 Gy), respectively. Median overall survival was 10.6 months after SRS and 19.1 months after diagnosis. Kaplan-Meier and multivariable modeling revealed that younger age at SRS, higher prescription dose, and longer interval between original surgery and SRS are significantly associated with improved post-SRS survival. Forty-six patients (26%) underwent salvage craniotomy after SRS, with 63% showing radionecrosis or mixed tumor/necrosis vs 35% showing purely recurrent tumor. The necrosis/mixed group had lower mean isodose prescription compared with the tumor group (16.2 vs 17.8 Gy; P = .003) and larger mean treatment volume (10.0 vs 5.4 cm 3 ; P = .009). CONCLUSION Gamma Knife may benefit a subset of focally recurrent patients, particularly those who are younger with smaller recurrences. Higher prescriptions are associated with improved post-SRS survival and do not seem to have greater risk of symptomatic treatment effect.
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Affiliation(s)
- Brandon S Imber
- University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Igor J Barani
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Jean L Nakamura
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | | | | | | | | | | | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
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29
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Fetcko K, Lukas RV, Watson GA, Zhang L, Dey M. Survival and complications of stereotactic radiosurgery: A systematic review of stereotactic radiosurgery for newly diagnosed and recurrent high-grade gliomas. Medicine (Baltimore) 2017; 96:e8293. [PMID: 29068998 PMCID: PMC5671831 DOI: 10.1097/md.0000000000008293] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Utilization of stereotactic radiosurgery (SRS) for treatment of high-grade gliomas (HGGs) has been slowly increasing with variable reported success rates. OBJECTIVE Systematic review of the available data to evaluate the efficacy of SRS as a treatment for HGG with regards to median overall survival (OS) and progression-free survival (PFS), in addition to ascertaining the rate of radiation necrosis and other SRS-related major neurological complications. METHODS Literature searches were performed for publications from 1992 to 2016. The pooled estimates of median PFS and median OS were calculated as a weighted estimate of population medians. Meta-analyses of published rates of radiation necrosis and other major neurological complications were also performed. RESULTS Twenty-nine studies reported the use of SRS for recurrent HGG, and 16 studies reported the use of SRS for newly diagnosed HGG. For recurrent HGG, the pooled estimates of median PFS and median OS were 5.42 months (3-16 months) and 20.19 months (9-65 months), respectively; the pooled radiation necrosis rate was 5.9% (0-44%); and the pooled estimates of major neurological complications rate was 3.3% (0-23%). For newly diagnosed HGG, the pooled estimates of median PFS and median OS were 7.89 months (5.5-11 months) and 16.87 months (9.5-33 months) respectively; the pooled radiation necrosis rate was 6.5% (0-33%); and the pooled estimates of other major neurological complications rate was 1.5% (0-25%). CONCLUSION Our results suggest that SRS holds promise as a relatively safe treatment option for HGG. In terms of efficacy at this time, there are inadequate data to support routine utilization of SRS as the standard of care for newly diagnosed or recurrent HGG. Further studies should be pursued to define more clearly the therapeutic role of SRS.
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Affiliation(s)
- Kaleigh Fetcko
- Department of Neurosurgery, Indiana University, Indianapolis, IN
| | - Rimas V. Lukas
- Department of Neurology, Northwestern University, Chicago, IL
| | - Gordon A. Watson
- Department of Radiation Oncology, Simon Cancer Center, Indiana University, Indianapolis, IN
| | - Lingjiao Zhang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philidelphia, PA
| | - Mahua Dey
- Department of Neurosurgery, Indiana University, Indianapolis, IN
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30
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Clarke J, Neil E, Terziev R, Gutin P, Barani I, Kaley T, Lassman AB, Chan TA, Yamada J, DeAngelis L, Ballangrud A, Young R, Panageas KS, Beal K, Omuro A. Multicenter, Phase 1, Dose Escalation Study of Hypofractionated Stereotactic Radiation Therapy With Bevacizumab for Recurrent Glioblastoma and Anaplastic Astrocytoma. Int J Radiat Oncol Biol Phys 2017; 99:797-804. [PMID: 28870792 DOI: 10.1016/j.ijrobp.2017.06.2466] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To establish the maximum tolerated dose of a 3-fraction hypofractionated stereotactic reirradiation schedule when delivered with concomitant bevacizumab to treat recurrent high-grade gliomas. METHODS AND MATERIALS Patients with recurrent high-grade glioma with Karnofsky performance status ≥60, history of standard fractionated initial radiation, tumor volume at recurrence ≤40 cm3, and absence of brainstem or corpus callosum involvement were eligible. A standard 3+3 phase 1 dose escalation trial design was utilized, with dose-limiting toxicities defined as any grade 3 to 5 toxicities possibly, probably, or definitely related to radiation. Bevacizumab was given at a dose of 10 mg/kg every 2 weeks. Hypofractionated stereotactic reirradiation was initiated after 2 bevacizumab doses, delivered in 3 fractions every other day, starting at 9 Gy per fraction. RESULTS A total of 3 patients were enrolled at the 9 Gy × 3 dose level cohort, 5 in the 10 Gy × 3 cohort, and 7 in the 11 Gy × 3 cohort. One dose-limiting toxicity of grade 3 fatigue and cognitive deterioration possibly related to hypofractionated stereotactic reirradiation was observed in the 11 Gy × 3 cohort, and this dose was declared the maximum tolerated dose in combination with bevacizumab. Although no symptomatic radionecrosis was observed, substantial treatment-related effects and necrosis were observed in resected specimens. The intent-to-treat median overall survival was 13 months. CONCLUSIONS Reirradiation using a 3-fraction schedule with bevacizumab support is feasible and reasonably well tolerated. Dose-escalation was possible up to 11 Gy × 3, which achieves a near doubling in the delivered biological equivalent dose to normal brain, in comparison with our previous 6 Gy × 5 schedule. Promising overall survival warrants further investigation.
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Affiliation(s)
- Jennifer Clarke
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Elizabeth Neil
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Robert Terziev
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Philip Gutin
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Igor Barani
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Thomas Kaley
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew B Lassman
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York; Department of Neurology & Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Josh Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lisa DeAngelis
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ase Ballangrud
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Robert Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Antonio Omuro
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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Re-irradiation after gross total resection of recurrent glioblastoma : Spatial pattern of recurrence and a review of the literature as a basis for target volume definition. Strahlenther Onkol 2017; 193:897-909. [PMID: 28616821 DOI: 10.1007/s00066-017-1161-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Currently, patients with gross total resection (GTR) of recurrent glioblastoma (rGBM) undergo adjuvant chemotherapy or are followed up until progression. Re-irradiation, as one of the most effective treatments in macroscopic rGBM, is withheld in this situation, as uncertainties about the pattern of re-recurrence, the target volume, and also the efficacy of early re-irradiation after GTR exist. METHODS Imaging and clinical data from 26 consecutive patients with GTR of rGBM were analyzed. The spatial pattern of recurrences was analyzed according to the RANO-HGG criteria ("response assessment in neuro-oncology criteria for high-grade gliomas"). Progression-free (PFS) and overall survival (OS) were analyzed by the Kaplan-Meier method. Furthermore, a systematic review was performed in PubMed. RESULTS All but 4 patients underwent adjuvant chemotherapy after GTR. Progression was diagnosed in 20 of 26 patients and 70% of recurrent tumors occurred adjacent to the resection cavity. The median extension beyond the edge of the resection cavity was 20 mm. Median PFS was 6 months; OS was 12.8 months. We propose a target volume containing the resection cavity and every contrast enhancing lesion as the gross tumor volume (GTV), a spherical margin of 5-10 mm to generate the clinical target volume (CTV), and a margin of 1-3 mm to generate the planning target volume (PTV). Re-irradiation of this volume is deemed to be safe and likely to prolong PFS. CONCLUSION Re-irradiation is worth considering also after GTR, as the volumes that need to be treated are limited and re-irradiation has already proven to be a safe treatment option in general. The strategy of early re-irradiation is currently being tested within the GlioCave/NOA 17/Aro 2016/03 trial.
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Dong Y, Fu C, Guan H, Zhang T, Zhang Z, Zhou T, Li B. Re-irradiation alternatives for recurrent high-grade glioma. Oncol Lett 2016; 12:2261-2270. [PMID: 27703519 PMCID: PMC5038913 DOI: 10.3892/ol.2016.4926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/01/2016] [Indexed: 12/28/2022] Open
Abstract
Despite advances in the fields of surgery, chemotherapy and radiotherapy, the prognosis for high-grade glioma (HGG) remains unsatisfactory. The majority of HGG patients experience disease recurrence. To date, no standard treatments have been established for recurrent HGG. Repeat surgery and chemotherapy demonstrate moderate efficacy. As recurrent lesions are usually located within the previously irradiated field, a second course of irradiation was once considered controversial, as it was considered to exhibit unsatisfactory efficacy and radiation-related toxicities. However, an increasing number of studies have indicated that re-irradiation may present an efficacious treatment for recurrent HGG. Re-irradiation may be delivered via conventionally fractionated stereotactic radiotherapy, hypofractionated stereotactic radiation therapy, stereotactic radiosurgery and brachytherapy techniques. In the present review, the current literature regarding re-irradiation treatment for recurrent HGG is summarized with regard to survival outcome and side effects.
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Affiliation(s)
- Yuanli Dong
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Chengrui Fu
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Hui Guan
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Tianyi Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zicheng Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Tao Zhou
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Baosheng Li
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
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Taunk NK, Moraes FY, Escorcia FE, Mendez LC, Beal K, Marta GN. External beam re-irradiation, combination chemoradiotherapy, and particle therapy for the treatment of recurrent glioblastoma. Expert Rev Anticancer Ther 2016; 16:347-58. [PMID: 26781426 DOI: 10.1586/14737140.2016.1143364] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Glioblastoma is a common aggressive primary malignant brain tumor, and is nearly universal in progression and mortality after initial treatment. Re-irradiation presents a promising treatment option for progressive disease, both palliating symptoms and potentially extending survival. Highly conformal radiation techniques such as stereotactic radiosurgery and hypofractionated radiosurgery are effective short courses of treatment that allow delivery of high doses of therapeutic radiation with steep dose gradients to protect normal tissue. Patients with higher performance status, younger age, and longer interval between primary treatment and progression represent the best candidates for re-irradiation. Multiple studies are also underway involving combinations of radiation and systemic therapy to bend the survival curve and improve the therapeutic index. In the multimodal treatment of recurrent high-grade glioma, the use of surgery, radiation, and systemic therapy should be highly individualized. Here we comprehensively review radiation therapy and techniques, along with discussion of combination treatment and novel strategies.
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Affiliation(s)
- Neil K Taunk
- a Department of Radiation Oncology , Memorial Sloan Kettering Cancer Center , New York , New York , USA
| | - Fabio Y Moraes
- b Department of Radiation Oncology , Hospital Sírio-Libanês , São Paulo , Brazil
| | - Freddy E Escorcia
- a Department of Radiation Oncology , Memorial Sloan Kettering Cancer Center , New York , New York , USA
| | - Lucas Castro Mendez
- d Department of Radiation Oncology , Instituto de Radiologia - Faculdade de Medicina da Universidade de São Paulo (FMUSP) , São Paulo , Brazil
| | - Kathryn Beal
- a Department of Radiation Oncology , Memorial Sloan Kettering Cancer Center , New York , New York , USA
| | - Gustavo N Marta
- b Department of Radiation Oncology , Hospital Sírio-Libanês , São Paulo , Brazil.,c Department of Radiation Oncology , Instituto do Câncer do Estado de São Paulo (ICESP) - Faculdade de Medicina da Universidade de São Paulo (FMUSP) , São Paulo , Brazil
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Bokstein F, Blumenthal DT, Corn BW, Gez E, Matceyevsky D, Shtraus N, Ram Z, Kanner AA. Stereotactic radiosurgery (SRS) in high-grade glioma: judicious selection of small target volumes improves results. J Neurooncol 2015; 126:551-7. [PMID: 26603164 DOI: 10.1007/s11060-015-1997-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 11/19/2015] [Indexed: 11/29/2022]
Abstract
We present a retrospective review of 55 Stereotactic Radiosurgery (SRS) procedures performed in 47 consecutive patients with high-grade glioma (HGG). Thirty-three (70.2%) patients were diagnosed with glioblastoma and 14 (29.8%) with grade III glioma. The indications for SRS were small (up to 30 mm in diameter) locally progressing lesions in 32/47 (68%) or new distant lesions in 15/47 (32%) patients. The median target volume was 2.2 cc (0.2-9.5 cc) and the median prescription dose was 18 Gy (14-24 Gy). Three patients (5.5% incidence in 55 treatments) developed radiation necrosis. In eight cases (17%) patients received a second salvage SRS treatment to nine new lesions detected during follow-up. In 22/55 SRS treatments (40.0%) patients received concurrent chemo- or biological therapy, including temozolamide (TMZ) (15 patients), bevacizumab (BVZ) (6 patients) and carboplatin in one patient. Median time to progression after SRS was 5.0 months (1.0-96.4). Median survival time after SRS was 15.9 months (2.3-109.3) overall median survival (since diagnosis) was 37.4 months (9.6-193.6 months). Long-lasting responses (>12 months) after SRS were observed in 25/46 (54.3%) patients. We compared a matched (histology, age, KPS) cohort of patients with recurrent HGG treated with BVZ alone with the current study group. Median survival was significantly longer for SRS treated patients compared to the BVZ only cohort (12.6 vs. 7.3 months, p = 0.0102). SRS may be considered an effective salvage procedure for selected patients with small volume, recurrent high-grade gliomas. Long-term radiological control was observed in more than 50% of the patients.
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Affiliation(s)
- Felix Bokstein
- Neuro-Oncology Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Deborah T Blumenthal
- Neuro-Oncology Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin W Corn
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Eliahu Gez
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Diana Matceyevsky
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Natan Shtraus
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Andrew A Kanner
- Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel. .,Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.
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35
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Hasan S, Chen E, Lanciano R, Yang J, Hanlon A, Lamond J, Arrigo S, Ding W, Mikhail M, Ghaneie A, Brady L. Salvage Fractionated Stereotactic Radiotherapy with or without Chemotherapy and Immunotherapy for Recurrent Glioblastoma Multiforme: A Single Institution Experience. Front Oncol 2015; 5:106. [PMID: 26029663 PMCID: PMC4432688 DOI: 10.3389/fonc.2015.00106] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/21/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The current standard of care for salvage treatment of glioblastoma multiforme (GBM) is gross total resection and adjuvant chemoradiation for operable patients. Limited evidence exists to suggest that any particular treatment modality improves survival for recurrent GBM, especially if inoperable. We report our experience with fractionated stereotactic radiotherapy (fSRT) with and without chemo/immunotherapy, identifying prognostic factors associated with prolonged survival. METHODS From 2007 to 2014, 19 patients between 29 and 78 years old (median 55) with recurrent GBM following resection and chemoradiation for their initial tumor, received 18-35 Gy (median 25) in three to five fractions via CyberKnife fSRT. Clinical target volume (CTV) ranged from 0.9 to 152 cc. Sixteen patients received adjuvant systemic therapy with bevacizumab (BEV), temozolomide (TMZ), anti-epidermal growth factor receptor (125)I-mAb 425, or some combination thereof. RESULTS The median overall survival (OS) from date of recurrence was 8 months (2.5-61) and 5.3 months (0.6-58) from the end of fSRT. The OS at 6 and 12 months was 47 and 32%, respectively. Three of 19 patients were alive at the time of this review at 20, 49, and 58 months from completion of fSRT. Hazard ratios for survival indicated that patients with a frontal lobe tumor, adjuvant treatment with either BEV or TMZ, time to first recurrence >16 months, CTV <36 cc, recursive partitioning analysis <5, and Eastern Cooperative Oncology Group performance status <2 were all associated with improved survival (P < 0.05). There was no evidence of radionecrosis for any patient. CONCLUSION Radiation Therapy Oncology Group (RTOG) 1205 will establish the role of re-irradiation for recurrent GBM, however our study suggests that CyberKnife with chemotherapy can be safely delivered, and is most effective in patients with smaller frontal lobe tumors, good performance status, or long interval from diagnosis.
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Affiliation(s)
- Shaakir Hasan
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Eda Chen
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Rachelle Lanciano
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Jun Yang
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Alex Hanlon
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Nursing, University of Pennsylvania , Philadelphia, PA , USA
| | - John Lamond
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Stephen Arrigo
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - William Ding
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Michael Mikhail
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Arezoo Ghaneie
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Luther Brady
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
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Radiosurgery reirradiation for high-grade glioma recurrence: a retrospective analysis. Neurol Sci 2015; 36:1431-40. [PMID: 25805705 DOI: 10.1007/s10072-015-2172-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/13/2015] [Indexed: 12/15/2022]
Abstract
Despite various treatment strategies being available, recurrent high-grade gliomas (r-HGG) are difficult to manage. To obtain local control, radiosurgery (SRS) reirradiation has been considered as potential treatment. In the present study, a retrospective analysis was performed on r-HGG patients treated with salvage single- (s-SRS) or multi-fraction SRS (m-SRS). The aim of this study was to evaluate the effectiveness of salvage SRS in terms of overall survival (OS); toxicity was analyzed as well. Between 2004 May and 2011 December, 128 r-HGG patients (161 lesions) treated with CyberKnife(®) SRS reirradiation were retrospectively analyzed. Toxicity was graded according to Radiation Therapy Oncology Group and by Common Terminology Criteria for Adverse Events v.3 criteria. OS from the diagnosis date and OS from reirradiation were estimated using the Kaplan-Meier method. Median follow-up was 9 months (range 15 days-82 months). All patients completed SRS without high-grade toxicity. Radiation necrosis was observed in seven patients (6 %) with large volume lesions. The median survival from initial diagnosis was 32 months. The 1-, 2-, and 3-years survival rates from diagnosis were 95, 62, and 45 % respectively. Median survival following SRS was 11.5 months. The 1-, 2-, and 3-years survival rate following SRS was 48, 20, and 17 % respectively. On multivariate analysis, age <40 years, salvage surgery before SRS, and other post-SRS therapies (second-line chemotherapy and/or surgery) were found to significantly improve survival (p = 0.03). SRS represents a safe and feasible option to treat r-HGG patients with low complication rates and potential survival benefit.
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Hickmann AK, Nadji-Ohl M, Hopf NJ. Feasibility of fluorescence-guided resection of recurrent gliomas using five-aminolevulinic acid: retrospective analysis of surgical and neurological outcome in 58 patients. J Neurooncol 2015; 122:151-60. [DOI: 10.1007/s11060-014-1694-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
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