Effect of pretreatment clinical factors on overall survival in glioblastoma multiforme: a Surveillance Epidemiology and End Results (SEER) population analysis

All-cause and tumor-specific mortality trends in elderly primary central nervous system lymphoma (PCNSL) patients: a surveillance, epidemiology, and end results (SEER) analysis

BACKGROUND

Recent primary central nervous system lymphoma (PCNSL) literature indicates that younger patients benefit from improved survival; however, this benefit is not shared by those 70+ years of age. The purpose of this study was to examine mortality trends in PCNSL patients 70+ years of age to better understand why improved prognosis has not yet reached this rapidly growing population subset.

METHODS

Two thousand seventy-five cases (1973-2012, age at diagnosis 70+ years) within the Surveillance, Epidemiology, and End Results (SEER) database were included in Kaplan-Meier and multivariate Cox Regression analyses. Variables include age at diagnosis, decade of diagnosis (1=1973-1982, 2=1983-1992, 3=1993-2002, 4=2003-2012), sex, race and surgery.

RESULTS

Before stratification, both univariate and multivariate analyses agreed that patients aged 70-74 years at diagnosis lived the longest, while those 85+ years lived the shortest (median±SD; 6.0±0.5 months vs. 2.0±0.2 months, respectively, P<0.0005); women lived longer than men (5.0±0.3 months vs. 4.0±0.3 months, respectively, P=0.01); patients who received surgery (6.0±0.5 months) lived longer than those who did not (contraindicated=1.0±0.5 months, P<0.0005; not performed=4.0±0.3 months, P<0.0005). Univariate analysis showed decade 4 lived longer than only decade 3 (4.0±0.3 vs. 4.0±0.5, respectively, P=0.008), while multivariate analysis showed decade 4 lived longer than both 2 (5.0±0.8 months, P=0.03) and 3 (P<0.0005). Following stratification, decade and sex no longer influenced survival. Race did not influence survival.

CONCLUSIONS

Minimal clinically meaningful improvements in elderly PCNSL patient all-cause and tumor-specific mortality have been made since 1973, while the best predictors of longevity include younger age and surgery.

Survival prediction of glioblastoma patients using modern deep learning and machine learning techniques

In this study, we utilized data from the Surveillance, Epidemiology, and End Results (SEER) database to predict the glioblastoma patients' survival outcomes. To assess dataset skewness and detect feature importance, we applied Pearson's second coefficient test of skewness and the Ordinary Least Squares method, respectively. Using two sampling strategies, holdout and five-fold cross-validation, we developed five machine learning (ML) models alongside a feed-forward deep neural network (DNN) for the multiclass classification and regression prediction of glioblastoma patient survival. After balancing the classification and regression datasets, we obtained 46,340 and 28,573 samples, respectively. Shapley additive explanations (SHAP) were then used to explain the decision-making process of the best model. In both classification and regression tasks, as well as across holdout and cross-validation sampling strategies, the DNN consistently outperformed the ML models. Notably, the accuracy were 90.25% and 90.22% for holdout and five-fold cross-validation, respectively, while the corresponding R2 values were 0.6565 and 0.6622. SHAP analysis revealed the importance of age at diagnosis as the most influential feature in the DNN's survival predictions. These findings suggest that the DNN holds promise as a practical auxiliary tool for clinicians, aiding them in optimal decision-making concerning the treatment and care trajectories for glioblastoma patients.

Artificial intelligence in neuro-oncology

Artificial intelligence (AI) describes the application of computer algorithms to the solution of problems that have traditionally required human intelligence. Although formal work in AI has been slowly advancing for almost 70 years, developments in the last decade, and particularly in the last year, have led to an explosion of AI applications in multiple fields. Neuro-oncology has not escaped this trend. Given the expected integration of AI-based methods to neuro-oncology practice over the coming years, we set to provide an overview of existing technologies as they are applied to the neuropathology and neuroradiology of brain tumors. We highlight current benefits and limitations of these technologies and offer recommendations on how to appraise novel AI-tools as they undergo consideration for integration into clinical workflows.

A novel immunogenic cell death signature for the prediction of prognosis and therapies in glioma

Glioma is a primary cranial malignancy with high recurrence rate, poor prognosis and high mortality. However, the roles of immunogenic cell death (ICD) in glioma remain unclear. Twenty ICD genes were analyzed to be differentially expressed between glioma tissues and non-tumor tissues in 371 glioma patients from The Cancer Genome Atlas (TCGA). Patients were classified into three subgroups via unsupervised clustering. Interestingly, the features of cell-infiltrating from three clusters were matched with three immune phenotypes. An applied scoring system was built depending on the expression of hub ICD-related genes. Notably, the ICD-related score was linked with immune checkpoints and the prognosis of glioma patients. In addition, the applied risk model could be used for the prediction of the effect of chemotherapy and immunotherapy for glioma patients. Furthermore, MYD88 was identified to play key roles in the risk model for glioma patients. MYD88 was specifically expressed in malignant cells and validated to correlate with cell proliferation and invasion. Ligand-receptor pairs are determined as novel communications indicating between immunocytes and malignant cells. Therefore, our research established an ICD-related score to investigate the potential effect to chemotherapy and immunotherapy for glioma patients and indicated that MYD88 was a key role in this risk model.

An integrative survival analysis and a systematic review of the cerebellopontine angle glioblastomas

Glioblastomas presenting topographically at the cerebellopontine angle (CPA) are exceedingly rare. Given the specific anatomical considerations and their rarity, overall survival (OS) and management are not discussed in detail. The authors performed an integrative survival analysis of CPA glioblastomas. A literature search of PubMed, Scopus, and Web of Science databases was performed per PRISMA guidelines. Patient data including demographics, clinical features, neuroimaging, management, follow-up, and OS were extracted. The mean age was 39 ± 26.2 years. The mean OS was 8.9 months. Kaplan-Meier log-rank test and univariate Cox proportional-hazards model identified hydrocephalus (log-rank, p = 0.034; HR 0.34; 95% CI 0.12-0.94; p = 0.038), chemotherapy (log-rank, p < 0.005; HR 5.66; 95% CI 1.53-20.88; p = 0.009), and radiotherapy (log-rank, p < 0.0001; HR 12.01; 95% CI 3.44-41.89; p < 0.001) as factors influencing OS. Hydrocephalus (HR 3.57; 95% CI 1.07-11.1; p = 0.038) and no adjuvant radiotherapy (HR 0.12; 95% CI 0.02-0.59; p < 0.01) remained prognostic on multivariable analysis with fourfold and twofold higher risk for the time-related onset of death, respectively. This should be considered when assessing the risk-to-benefit ratio for patients undergoing surgery for CPA glioblastoma.

Epidemiological characteristics and genetic alterations in adult diffuse glioma in East Asian populations

Understanding the racial specificities of diseases-such as adult diffuse glioma, the most common primary malignant tumor of the central nervous system-is a critical step toward precision medicine. Here, we comprehensively review studies of gliomas in East Asian populations and other ancestry groups to clarify the racial differences in terms of epidemiology and genomic characteristics. Overall, we observed a lower glioma incidence in East Asians than in Whites; notably, patients with glioblastoma had significantly younger ages of onset and longer overall survival than the Whites. Multiple genome-wide association studies of various cohorts have revealed single nucleotide polymorphisms associated with overall and subtype-specific glioma susceptibility. Notably, only 3 risk loci-5p15.33, 11q23.3, and 20q13.33-were shared between patients with East Asian and White ancestry, whereas other loci predominated only in particular populations. For instance, risk loci 12p11.23, 15q15-21.1, and 19p13.12 were reported in East Asians, whereas risk loci 8q24.21, 1p31.3, and 1q32.1 were reported in studies in White patients. Although the somatic mutational profiles of gliomas between East Asians and non-East Asians were broadly consistent, a lower incidence of EGFR amplification in glioblastoma and a higher incidence of 1p19q-IDH-TERT triple-negative low-grade glioma were observed in East Asian cohorts. By summarizing large-scale disease surveillance, germline, and somatic genomic studies, this review reveals the unique characteristics of adult diffuse glioma among East Asians, to guide clinical management and policy design focused on patients with East Asian ancestry.

Ferroptosis: A novel therapeutic strategy and mechanism of action in glioma

Glioma is the most common malignant tumor of the central nervous system and resistance is easily developed to chemotherapy drugs during the treatment process, resulting in high mortality and short survival in glioma patients. Novel therapeutic approaches are urgently needed to improve the therapeutic efficacy of chemotherapeutic drugs and to improve the prognosis of patients with glioma. Ferroptosis is a novel regulatory cell death mechanism that plays a key role in cancer, neurodegenerative diseases, and other diseases. Studies have found that ferroptosis-related regulators are closely related to the survival of patients with glioma, and induction of ferroptosis can improve glioma resistance to chemotherapy drugs. Therefore, induction of tumor cell ferroptosis may be an effective therapeutic strategy for glioma. This review summarizes the relevant mechanisms of ferroptosis, systematically summarizes the key role of ferroptosis in the treatment of glioma and outlines the relationship between ferroptosis-related ncRNAs and the progression of glioma.

Surgical Management of Malignant Glioma in the Elderly

Background

The median age for diagnosis of glioblastoma is 64 years and the incidence rises with increasing age to a peak at 75-84 years. As the total number of high-grade glioma patients is expected to increase with an aging population, neuro-oncological surgery faces new treatment challenges, especially regarding aggressiveness of the surgical approach and extent of resection. In the elderly, aspects like frailty and functional recovery time have to be taken into account before performing surgery.

Material & Methods

Patients undergoing surgery for malignant glioma (WHO grade III and IV) at our institution between 2015 and 2020 were compiled in a centralized tumor database and analyzed retrospectively. Karnofsky Performance Scale (KPS) and Clinical Frailty Scale (CFS) were used to determine functional performance pre- and postoperatively. Overall survival (OS) was compared between age groups of 65-69 years, 70-74 years, 75-79 years, 80-84 years and >85 years in view of extent of resection (EOR). Furthermore, we performed a literature evaluation focusing on surgical treatment of newly diagnosed malignant glioma in the elderly.

Results

We analyzed 121 patients aged 65 years and above (range 65 to 88, mean 74 years). Mean overall survival (OS) was 10.35 months (SD = 11.38). Of all patients, only a minority (22.3%) received tumor biopsy instead of gross total resection (GTR, 61.2%) or subtotal resection (STR, 16.5%). Postoperatively, 52.9% of patients were treated according to the Stupp protocol. OS differed significantly between extent of resection (EOR) groups (4.0 months after biopsy vs. 8.3 after STR vs. 13.8 after GTR, p < 0.05 and p < 0.001 correspondingly). No significant difference was observed regarding EOR across different age groups.

Conclusion

GTR should be the treatment of choice also in elderly patients with malignant glioma as functional outcome and survival after surgery are remarkably better compared to less aggressive treatment. Elderly patients who received GTR of high-grade gliomas survived significantly longer compared to patients who underwent biopsy and STR. Age seems to have little influence on overall survival in selected surgically extensive treated patients, but high preoperative functional performance is mandatory.

The Impact of Extent of Resection on the Prognosis of Glioblastoma Multiforme: A Systematic Review and Meta-analysis

Purpose: To investigate the predictor factors of mortality describing the prognosis of primary surgical resection of Glioblastoma Multiforme (GBM). Materials and Methods: A systemic search was conducted from electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from inception to 12th September 2021.  All statistical analysis was conducted in Review Manager 5.4.1. Studies meeting inclusion criteria were selected. A random-effect model was used when heterogeneity was seen to pool the studies, and the result were reported in the Hazards Ratio (HR) and corresponding 95% Confidence interval (CI). Result: Twenty-three cohort studies were selected for meta-analysis. There was statistically significant effect of extent of resection on prognosis of surgery in GBM patients (HR= 0.90 [0.86, 0.95]; p< 0.0001; I2= 96%), male gender (HR= 1.19 [1.06, 1.34]; p= 0.002; I2= 0%) and decrease Karnofsky Performance Status (HR= 0.97 [0.95, 0.99]; p= 0.003; I2= 90%). Age and tumor volume was also analyzed in the study. Conclusion: The results of our meta-analysis suggested that age, gender, pre-operative KPS score and extent of resection have significant effects on the post-surgical mortality rate, therefore, these factors can be used significant predictor of mortality in GBM patients.

Utility of Administrative Databases and Big Data on Understanding Glioma Treatment—A Systematic Review

Background Gliomas are a heterogeneous group of tumors where large multicenter clinical and genetic studies have become increasingly popular in their understanding. We reviewed and analyzed the findings from large databases in gliomas, seeking to understand clinically relevant information.

Methods A systematic review was performed for gliomas studied using large administrative databases up to January 2020 (e.g., National Inpatient Sample [NIS], National Surgical Quality Improvement Program [NSQIP], and Surveillance, Epidemiology, and End Results Program [SEER], National Cancer Database [NCDB], and others).

Results Out of 390 screened studies, 122 were analyzed. Studies included a wide range of gliomas including low- and high-grade gliomas. The SEER database (n = 83) was the most used database followed by NCDB (n = 28). The most common pathologies included glioblastoma multiforme (GBM) (n = 67), with the next category including mixes of grades II to IV glioma (n = 31). Common study themes involved evaluation of descriptive epidemiological trends, prognostic factors, comparison of different pathologies, and evaluation of outcome trends over time. Persistent health care disparities in patient outcomes were frequently seen depending on race, marital status, insurance status, hospital volume, and location, which did not change over time. Most studies showed improvement in survival because of advances in surgical and adjuvant treatments.

Conclusions This study helps summarize the use of clinical administrative databases in gliomas research, informing on socioeconomic issues, surgical outcomes, and adjuvant treatments over time on a national level. Large databases allow for some study questions that would not be possible with single institution data; however, limitations remain in data curation, analysis, and reporting methods.

Radiotherapy for glioblastoma in the elderly: A protocol for systematic review and meta-analysis

BACKGROUND

Glioblastoma is an aggressive form of brain cancer with significant morbidity and mortality. This study aims to determine the radiotherapy for treatment of elderly people with diagnosed glioblastoma.

METHOD

This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Protocols. Chinese electronic Database (CBM, Wanfang, and CNKI) and international electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) will be searched for all relevant published articles, with no restrictions on the year of publication or language. Study selection, data collection, and assessment of study bias will be conducted independently by a pair of independent reviewers. The Cochrane Risk of bias (ROB) tool will be used for the risk of bias assessment. The Grading of Recommendations Assessment Development and Evaluation (GRADE) system will be used to assess the quality of evidence. The statistical analysis of this meta-analysis will be calculated by Review manager version 5.3.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

The findings of this review will to provide high-level evidence in terms of the benefits and harms of radiotherapy in people with glioblastoma to provide meaningful conclusions for clinical practice and further research.

TRIAL REGISTRATION

This study protocol was registered in open Science framework (OSF), (Registration DOI: 10.17605/OSF.IO/A6BCS).

Global Trends in Survival From Astrocytic Tumors in Adolescents and Young Adults: A Systematic Review

Background

Brain tumors represent an important cause of cancer-related death in adolescents and young adults. Most are diagnosed in low-income and middle-income countries. We aimed to conduct the first, to our knowledge, systematic review of time trends and geographical variation in survival in this age group.

Methods

We included observational studies describing population-based survival from astrocytic tumors in patients aged 15-39 years. We queried 6 electronic databases from database inception to December 31, 2019. This review is registered with PROSPERO, number CRD42018111981.

Results

Among 5640 retrieved records, 20 studies fulfilled the inclusion criteria. All but 1 study focused on high-income countries. Five-year survival from astrocytoma (broad morphology group) mostly varied between 48.0% and 71.0% (1973-2004) without clear trends or geographic differences. Adolescents with astrocytoma had better outcomes than young adults, but survival values were similar when nonmalignant tumors were excluded. During 2002-2007, 5-year survival for World Health Organization grade I-II tumors was in the range of 72.6%-89.1% in England, Germany, and the United States but lower in Southeastern Europe (59.0%). Five-year survival for anaplastic astrocytoma varied between 39.6% and 55.4% (2002-2007). Five-year survival from glioblastoma was in the range of 14.2%-23.1% (1991-2009).

Conclusions

Survival from astrocytic tumors remained somewhat steady over time, with little change between 1973 and 2009. Survival disparities were difficult to examine, because nearly all the studies were conducted in affluent countries. Studies often adopted the International Classification of Childhood Cancer, which, however, did not allow to accurately describe variation in survival. Larger studies are warranted, including underrepresented populations and providing more recent survival estimates.

Deep Learning AI Applications in the Imaging of Glioma

This manuscript will review emerging applications of artificial intelligence, specifically deep learning, and its application to glioblastoma multiforme (GBM), the most common primary malignant brain tumor. Current deep learning approaches, commonly convolutional neural networks (CNNs), that take input data from MR images to grade gliomas (high grade from low grade) and predict overall survival will be shown. There will be more in-depth review of recent articles that have applied different CNNs to predict the genetics of glioma on pre-operative MR images, specifically 1p19q codeletion, MGMT promoter, and IDH mutations, which are important criteria for the diagnosis, treatment management, and prognostication of patients with GBM. Finally, there will be a brief mention of current challenges with DL techniques and their application to image analysis in GBM.

Comparative epidemiology of gliosarcoma and glioblastoma and the impact of Race on overall survival: A systematic literature review

OBJECTIVE

Gliosarcoma (GSM) is a rare subtype of glioblastoma (GBM) that accounts for approximately four percent of high-grade gliomas. There is scarce epidemiological data on patients with GSM as a distinct subgroup of GBM.

METHODS

A systematic literature review was performed of peer-reviewed databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to evaluate the impact of race and ethnicity on survival in patients with GSM compared to patients with GBM.

RESULTS

Following initial abstract screening, a total of 138 articles pertaining to GSM and 275 pertaining to GBM met criteria for full-text review, with 5 and 27 articles included in the final analysis for GSM and GBM, respectively. The majority of patients in both cohorts were non-Hispanic Whites, representing 85.6 % of total GSM patients and 87.7 % of GBM patients analyzed. Two GSM studies stratified survival by race, with one reporting the longest median survival for the Hispanic population of 10.6 months and the shortest median survival for the Asian population of 9 months. Among the GBM studies analyzed, the majority of studies reported shorter survival and higher risk of mortality among White Non-Hispanics compared to non-White patients; and of the 15 studies which reported data for the Asian population, 12 studies reported this race category to have the longest survival compared to all other races studied. Younger age, female sex, MGMT promoter methylation status, and adjuvant chemoradiation therapy were associated with improved survival in both GSM and GBM cohorts, although these were not further stratified by race.

CONCLUSION

GSM portends a similarly poor prognosis to other GBM subtypes; however, few studies exist which have examined factors associated with differences in survival between these histologic variants. This review of the literature suggests there is a possible association between race and survival for patients with GBM, however data supporting this conclusion for patients with GSM is lacking. These findings suggest that GSM is a distinct disease from other GBM subtypes, with epidemiologic differences that should be further explored.

Treatment of newly diagnosed glioblastoma in the elderly: a network meta-analysis

BACKGROUND

A glioblastoma is a fatal type of brain tumour for which the standard of care is maximum surgical resection followed by chemoradiotherapy, when possible. Age is an important consideration in this disease, as older age is associated with shorter survival and a higher risk of treatment-related toxicity.

OBJECTIVES

To determine the most effective and best-tolerated approaches for the treatment of elderly people with newly diagnosed glioblastoma. To summarise current evidence for the incremental resource use, utilities, costs and cost-effectiveness associated with these approaches.

SEARCH METHODS

We searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase to 3 April 2019, and the NHS Economic Evaluation Database (EED) up to database closure. We handsearched clinical trial registries and selected neuro-oncology society conference proceedings from the past five years.

SELECTION CRITERIA

Randomised trials (RCTs) of treatments for glioblastoma in elderly people. We defined 'elderly' as 70+ years but included studies defining 'elderly' as over 65+ years if so reported.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for study selection and data extraction. Where sufficient data were available, treatment options were compared in a network meta-analysis (NMA) using Stata software (version 15.1). For outcomes with insufficient data for NMA, pairwise meta-analysis were conducted in RevMan. The GRADE approach was used to grade the evidence.

MAIN RESULTS

We included 12 RCTs involving approximately 1818 participants. Six were conducted exclusively among elderly people (either defined as 65 years or older or 70 years or older) with newly diagnosed glioblastoma, the other six reported data for an elderly subgroup among a broader age range of participants. Most participants were capable of self-care. Study quality was commonly undermined by lack of outcome assessor blinding and attrition. NMA was only possible for overall survival; other analyses were pair-wise meta-analyses or narrative syntheses. Seven trials contributed to the NMA for overall survival, with interventions including supportive care only (one trial arm); hypofractionated radiotherapy (RT40; four trial arms); standard radiotherapy (RT60; five trial arms); temozolomide (TMZ; three trial arms); chemoradiotherapy (CRT; three trial arms); bevacizumab with chemoradiotherapy (BEV_CRT; one trial arm); and bevacizumab with radiotherapy (BEV_RT). Compared with supportive care only, NMA evidence suggested that all treatments apart from BEV_RT prolonged survival to some extent. Overall survival High-certainty evidence shows that CRT prolongs overall survival (OS) compared with RT40 (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.56 to 0.80) and low-certainty evidence suggests that CRT may prolong overall survival compared with TMZ (TMZ versus CRT: HR 1.42, 95% CI 1.01 to 1.98). Low-certainty evidence also suggests that adding BEV to CRT may make little or no difference (BEV_CRT versus CRT: HR 0.83, 95% CrI 0.48 to 1.44). We could not compare the survival effects of CRT with different radiotherapy fractionation schedules (60 Gy/30 fractions and 40 Gy/15 fractions) due to a lack of data. When treatments were ranked according to their effects on OS, CRT ranked higher than TMZ, RT and supportive care only, with the latter ranked last. BEV plus RT was the only treatment for which there was no clear benefit in OS over supportive care only.   One trial comparing tumour treating fields (TTF) plus adjuvant chemotherapy (TTF_AC) with adjuvant chemotherapy alone could not be included in the NMA as participants were randomised after receiving concomitant chemoradiotherapy, not before. Findings from the trial suggest that the intervention probably improves overall survival in this selected patient population. We were unable to perform NMA for other outcomes due to insufficient data. Pairwise analyses were conducted for the following. Quality of life Moderate-certainty narrative evidence suggests that overall, there may be little difference in QoL between TMZ and RT, except for discomfort from communication deficits, which are probably more common with RT (1 study, 306 participants, P = 0.002). Data on QoL for other comparisons were sparse, partly due to high dropout rates, and the certainty of the evidence tended to be low or very low. Progression-free survival High-certainty evidence shows that CRT increases time to disease progression compared with RT40 (HR 0.50, 95% CI 0.41 to 0.61); moderate-certainty evidence suggests that RT60 probably increases time to disease progression compared with supportive care only (HR 0.28, 95% CI 0.17 to 0.46), and that BEV_RT probably increases time to disease progression compared with RT40 alone (HR 0.46, 95% CI 0.27 to 0.78). Evidence for other treatment comparisons was of low- or very low-certainty. Severe adverse events Moderate-certainty evidence suggests that TMZ probably increases the risk of grade 3+ thromboembolic events compared with RT60 (risk ratio (RR) 2.74, 95% CI 1.26 to 5.94; participants = 373; studies = 1) and also the risk of grade 3+ neutropenia, lymphopenia, and thrombocytopenia. Moderate-certainty evidence also suggests that CRT probably increases the risk of grade 3+ neutropenia, leucopenia and thrombocytopenia compared with hypofractionated RT alone. Adding BEV to CRT probably increases the risk of thromboembolism (RR 16.63, 95% CI 1.00 to 275.42; moderate-certainty evidence). Economic evidence There is a paucity of economic evidence regarding the management of newly diagnosed glioblastoma in the elderly. Only one economic evaluation on two short course radiotherapy regimen (25 Gy versus 40 Gy) was identified and its findings were considered unreliable.

AUTHORS' CONCLUSIONS

For elderly people with glioblastoma who are self-caring, evidence suggests that CRT prolongs survival compared with RT and may prolong overall survival compared with TMZ alone. For those undergoing RT or TMZ therapy, there is probably little difference in QoL overall. Systemic anti-cancer treatments TMZ and BEV carry a higher risk of severe haematological and thromboembolic events and CRT is probably associated with a higher risk of these events. Current evidence provides little justification for using BEV in elderly patients outside a clinical trial setting. Whilst the novel TTF device appears promising, evidence on QoL and tolerability is needed in an elderly population. QoL and economic assessments of CRT versus TMZ and RT are needed. More high-quality economic evaluations are needed, in which a broader scope of costs (both direct and indirect) and outcomes should be included.

Molecular Study of Long-Term Survivors of Glioblastoma by Gene-Targeted Next-Generation Sequencing

Glioblastoma (GBM) is the most common malignant adult primary brain tumor. Despite its high lethality, a small proportion of patients have a relatively long overall survival (OS). Here we report a study of a series of 74 GBM samples from 29 long-term survivors ([LTS] OS ≥36 months) and 45 non-LTS. Using next-generation sequencing, we analyzed genetic alterations in the genes most frequently altered in gliomas. Approximately 20% of LTS had a mutation in the IDH1 or IDH2 (IDH) genes, denoting the relevance of this molecular prognostic factor. A new molecular group of GBMs harbored alterations in ATRX or DAXX genes in the absence of driver IDH or H3F3A mutations. These patients tended to have a slightly better prognosis, to be younger at diagnosis, and to present frontal or temporal tumors, and, morphologically, to present giant tumor cells. A significant fraction of LTS GBM patients had tumors with 1 or more alterations in the relevant GBM signaling pathways (RTK/PI3K, TP53 and RB1). In these patients, the PDGFRA alteration is suggested to be a favorable molecular factor. Our findings here are relevant for developing future targeted therapies and for identifying molecular prognostic factors in GBM patients.

Insurance correlates with improved access to care and outcome among glioblastoma patients

Background

The current standard of care for glioblastoma (GBM) constitutes maximal safe surgical resection, followed by fractionated radiation and temozolomide. This treatment regimen is logistically burdensome, and in a health care system in which access to care is variable, there may be patients with worsened outcomes due to inadequate access to optimal treatment.

Methods

The National Cancer Database was queried for patients with diagnoses of GBM in 2006-2014. Patients were grouped according to insurance status: private insurance, Medicare, Medicaid, or uninsured. Treatments provided (surgery, radiation, and chemotherapy) were compared between groups in univariate and multivariable logistic regression analysis.

Results

A total of 61614 patients were analyzed. Compared with private insurance, the odds of surgery for Medicaid and uninsured patients were 0.72 (95% CI: 0.66-0.79) and 0.77 (95% CI: 0.69-0.87), respectively (P < 0.001). The multivariable odds of receiving radiotherapy were 0.91 (95% CI: 0.86-0.96), 0.62 (95% CI: 0.57-0.68), and 0.47 (95% CI: 0.43-0.52) for Medicare, Medicaid, and uninsured patients, respectively (all P < 0.001). In addition, the odds of receiving chemotherapy were 0.94 (95% CI: 0.89-0.99), 0.53 (95% CI: 0.49-0.57), and 0.41 (95% CI: 0.38-0.46) for Medicare, Medicaid, and uninsured patients, respectively (all P < 0.001).

Conclusion

Insurance status and type of insurance coverage appear to impact treatments rendered for GBM, independently of other variables. Furthermore, we find that such differential access to care significantly impacts survival. Ensuring adequate access to care for all patients with diagnoses of glioblastoma is critical to optimize survival, especially as therapies continue to advance.

Is a reduction of radiation dose feasible in patients affected by glioblastoma undergoing radio-chemotherapy according to MGMT promoter methylation status without jeopardizing survival?

OBJECTIVE

To explore therapeutic results of different radiotherapy (RT) dose schedules combined to Temozolomide (TMZ)-RT treatment in newly diagnosed glioblastoma (GB), according to the O (6)-methylguanine-DNA methyltransferase (MGMT) methylation status.

PATIENTS AND METHODS

Patients with newly diagnosed GB received either standard (60-59.4 Gy) or reduced (54-52 Gy) dose radiation therapy (RT) with concurrent and adjuvant TMZ between June 2010 and October 2016. We retrospectively evaluated the therapeutic effectiveness of the RT ranges schedules in terms of overall survival (OS) with univariate and multivariate analysis, after analyzing the MGMT methylation status.

RESULTS

One hundred and seventeen patients were selected for the present analysis out of 146 total treated patients accrued. Seventy-two out of the selected cases received the standard RT-TMZ course (SDRT-TMZ) whereas the remaining 45 underwent the reduced dose schedule (RDRT-TMZ). The analysis according to the MGMT promoter methylation status showed that, in methylated-MGMT GB patients, SDRT-TMZ and RDRT-TMZ groups did not show different median OS (p = ns) according to the two RT schedules, independently by the extent of surgical resection. Instead, a difference in survival outcomes was confirmed in unmethylated-MGMT GB patients with better survival for patients undergoing to SDRT, particularly in sub-total resection.

CONCLUSION

In our experience, a reduction of radiation dose schedule does not seem to jeopardize survival in methylated-MGMT patients independently by the extent of resection. A therapeutic approach to a standard reduction of RT dose for the methylated subset of patients may be feasible and could deserve prospective trials for validation.

The effect of race on the prognosis of the glioblastoma patient: a brief review

Objectives: Glioblastoma is the most common primary malignant brain tumor in adults, and despite decades of intensive research regarding its pathophysiology and treatment, the prognosis for glioblastoma patients remains poor. While many studies have analyzed various factors that may influence survival outcomes, the focus of this brief review is to discuss the influence that apatient's race/ethnicity has on survival. This factor has been investigated in large population-based studies and in smaller institutional analyses, but the prognostic utility of this factor has been inconsistent. Discussion of this topic is therefore warranted to better equip providers to counsel and treat patients with glioblastoma, as well as to identify areas of future research. Methods: A comprehensive literature search is performed to identify studies that reported GBM survival outcomes by race/ethnicity. Results: Although some discrepancies exist, asignificant survival benefit is associated with the Asian or Pacific Islander (API) race, whereas white patients have the poorest survival and highest incidence. Hispanic patients tend to fare better than white patients but have worse survival than APIs. Discussion: Further analysis into the differences in survival among different races may lead to an increased understanding of potential molecular and genetic targets, thus guiding future treatment plans for these patients. Abbreviations: AAAIR: Average Annual Age-Adjusted Incidence Rate; AI/AN: American Indian or Alaska Native; API: Asian or Pacific Islander; CBTRUS: Central Brain Tumor Registry of the United States; CUMC: Columbia University Medical Center; EOR: Extent of Resection; Exc: Excluded; GBM: Glioblastoma; GTR: Gross Total Resection; IDH-1: Isocitrate Dehydrogenase 1; MGMT: O6-Methylguanine DNA Methyltransferase; NCDB: National Cancer Database; OS: Overall Survival; O/U: Other/Unknown; PFS: Progression-Free Survival; SEER: Surveillance, Epidemiology, and End Results; S&W BTR: Scott & White Brain Tumor Registry; UCLA: University of California Los Angeles; UM: University of Miami.

An independently validated nomogram for isocitrate dehydrogenase-wild-type glioblastoma patient survival

Background

In 2016, the World Health Organization reclassified the definition of glioblastoma (GBM), dividing these tumors into isocitrate dehydrogenase (IDH)-wild-type and IDH-mutant GBM, where the vast majority of GBMs are IDH-wild-type. Nomograms are useful tools for individualized estimation of survival. This study aimed to develop and independently validate a nomogram for IDH-wild-type patients with newly diagnosed GBM.

Methods

Data were obtained from newly diagnosed GBM patients from the Ohio Brain Tumor Study (OBTS) and the University of California San Francisco (UCSF) for diagnosis years 2007-2017 with the following variables: age at diagnosis, sex, extent of resection, concurrent radiation/temozolomide (TMZ) status, Karnofsky Performance Status (KPS), O⁶-methylguanine-DNA methyltransferase (MGMT) methylation status, and IDH mutation status. Survival was assessed using Cox proportional hazards regression, random survival forests, and recursive partitioning analysis, with adjustment for known prognostic factors. The models were developed using the OBTS data and independently validated using the UCSF data. Models were internally validated using 10-fold cross-validation and externally validated by plotting calibration curves.

Results

A final nomogram was validated for IDH-wild-type newly diagnosed GBM. Factors that increased the probability of survival included younger age at diagnosis, female sex, having gross total resection, having concurrent radiation/TMZ, having a high KPS, and having MGMT methylation.

Conclusions

A nomogram that calculates individualized survival probabilities for IDH-wild-type patients with newly diagnosed GBM could be useful to physicians for counseling patients regarding treatment decisions and optimizing therapeutic approaches. Free software for implementing this nomogram is provided: https://gcioffi.shinyapps.io/Nomogram_For_IDH_Wildtype_GBM_H_Gittleman/.

Locally dose-escalated radiotherapy may improve intracranial local control and overall survival among patients with glioblastoma

Background

The dismal overall survival (OS) prognosis of glioblastoma, even after trimodal therapy, can be attributed mainly to the frequent incidence of intracranial relapse (ICR), which tends to present as an in-field recurrence after a radiation dose of 60 Gray (Gy). In this study, molecular marker-based prognostic indices were used to compare the outcomes of radiation with a standard dose versus a moderate dose escalation.

Methods

This retrospective analysis included 156 patients treated between 2009 and 2016. All patients were medically fit for postoperative chemoradiotherapy. In the dose-escalation cohort a simultaneous integrated boost of up to 66 Gy (66 Gy RT) within small high-risk volumes was applied. All other patients received daily radiation to a total dose of 60 Gy or twice daily to a total dose of 59.2 Gy (60 Gy RT).

Results

A total of 133 patients received standard 60 Gy RT, while 23 received 66 Gy RT. Patients in the 66 Gy RT group were younger (p <  0.001), whereas concomitant temozolomide use was more frequent in the 60 Gy RT group (p <  0.001). Other intergroup differences in known prognostic factors were not observed. Notably, the median time to ICR was significantly prolonged in the 66 Gy RT arm versus the 60 Gy RT arm (12.2 versus 7.6 months, p = 0.011), and this translated to an improved OS (18.8 versus 15.3 months, p = 0.012). A multivariate analysis revealed a strong association of 66 Gy RT with a prolonged time to ICR (hazard ratio = 0.498, p = 0.01) and OS (hazard ratio = 0.451, p = 0.01). These differences remained significant after implementing molecular marker-based prognostic scores (ICR p = 0.008, OS p = 0.007) and propensity-scored matched pairing (ICR p = 0.099, OS p = 0.023).

Conclusion

Radiation dose escalation was found to correlate with an improved time to ICR and OS in this cohort of glioblastoma patients. However, further prospective validation of these results is warranted.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1194-8) contains supplementary material, which is available to authorized users.

The effects of clinical and sociodemographic factors on survival, resource use and lead times in patients with high-grade gliomas: a population-based register study

Background

Previous studies indicate an effect of sociodemographic factors on risk for being diagnosed with, as well as on survival of cancer in general. Our primary aim was to analyse sociodemographic factors, resource use and lead times in health care after diagnosis with high grade malignant glioma (HGG) in a large population based cohort.

Methods

A register-based study using several unique high-coverage registries. All patients over the age of 18 diagnosed with HGG in the Swedish Stockholm–Gotland region between 2001 and 2013 (n = 1149) were included.

Results

In multivariable cox proportional hazard model of survival, older age, male sex and high tumour grade were associated with worse survival. No significant differences could be seen related to country of birth. A high disposable income was associated with better survival and fewer occasions of pre-diagnostic inpatient care. Older age and comorbidities were correlated with a significantly increased number of outpatient visits the year before HGG diagnosis. In addition, male sex, being born outside Sweden was associated to a higher number of outpatient visits the year after diagnosis in multivariable analysis. Leadtime from diagnosis (first suspicion on brain scan) to surgery showed that the oldest patients, patients with comorbidity and patients born outside Europe had to wait longer for surgery.

Conclusions

Sociodemographic factors like education, income and country of birth have impact on care processes both before and after the diagnosis HGG. This needs to be acknowledged in addition to important clinical factors like age, comorbidity and tumour grade, in order to accomplish more equal cancer care.

A 35-gene signature discriminates between rapidly- and slowly-progressing glioblastoma multiforme and predicts survival in known subtypes of the cancer

BACKGROUND

Gene expression can be employed for the discovery of prognostic gene or multigene signatures cancer. In this study, we assessed the prognostic value of a 35-gene expression signature selected by pathway and machine learning based methods in adjuvant therapy-linked glioblastoma multiforme (GBM) patients from the Cancer Genome Atlas.

METHODS

Genes with high expression variance was subjected to pathway enrichment analysis and those having roles in chemoradioresistance pathways were used in expression-based feature selection. A modified Support Vector Machine Recursive Feature Elimination algorithm was employed to select a subset of these genes that discriminated between rapidly-progressing and slowly-progressing patients.

RESULTS

Survival analysis on TCGA samples not used in feature selection and samples from four GBM subclasses, as well as from an entirely independent study, showed that the 35-gene signature discriminated between the survival groups in all cases (p<0.05) and could accurately predict survival irrespective of the subtype. In a multivariate analysis, the signature predicted progression-free and overall survival independently of other factors considered.

CONCLUSION

We propose that the performance of the signature makes it an attractive candidate for further studies to assess its utility as a clinical prognostic and predictive biomarker in GBM patients. Additionally, the signature genes may also be useful therapeutic targets to improve both progression-free and overall survival in GBM patients.

Impact on Radiation Dose and Volume V57 Gy of the Brain on Recurrence and Survival of Patients with Glioblastoma Multiformae

BACKGROUND

The aim of the study was to analyze impact of irradiated brain volume V57 Gy (volume receiving 57 Gy and more) on time to progression and survival of patients with glioblastoma.

PATIENTS AND METHODS

Dosimetric analysis of treatment plan data has been performed on 70 patients with glioblastoma, treated with postoperative radiochemotherapy with temozolomide, followed by adjuvant temozolomide. Patients were treated with 2 different methods of definition of treatment volumes and prescription of radiation dose. First group of patients has been treated with one treatment volume receiving 60 Gy in 2 Gy daily fraction (31 patients) and second group of the patients has been treated with "cone-down" technique, which consisted of two phases of treatment: the first phase of 46 Gy in 2 Gy fraction followed by "cone-down" boost of 14 Gy in 2 Gy fraction (39 patients). Quantification of V57 Gy and ratio brain volume/V57Gy has been done. Average values of both parameters have been taken as a threshold value and patients have been split into 2 groups for each parameter (values smaller/ lager than threshold value).

RESULTS

Mean value for V57 Gy was 593.39 cm3 (range 166.94 to 968.60 cm3), mean value of brain volume has was 1332.86 cm3 (range 1047.00 to 1671.90 cm3) and mean value of brain-to-V57Gy ratio was 2.46 (range 1.42 to 7.67). There was no significant difference between two groups for both V57 Gy and ratio between brain volume and V57 Gy.

CONCLUSIONS

Irradiated volume with dose 57 Gy or more (V57 Gy) and ration between whole brain volume and 57 Gy had no impact on time to progression and survival of patients with glioblastoma.

Genomic and Molecular Characterization of Brain Tumors in Asian and Non-Asian Patients of Los Angeles: A Single Institution Analysis

Background

Worldwide, approximately 2% of new cancers are of the brain. Five-year survival rates among brain cancer patients have been reported as a little over a third. Differences in clinical outcomes between brain tumor patients of different races remain poorly understood.

Methods

A retrospective chart review was performed on brain tumor resection patients≥18 years old. Demographics, treatment variables, and survival outcomes were collected. Primary outcomes were length of stay, recurrence rate, progression-free survival (PFS), and overall survival (OS).

Results

A total of 452 patients were included in analysis. Females and males had nearly a 1:1 ratio (n=242 and n=220, respectively). Mean age was 54.8 years (SD: 14.5 range: 18–90). Females composed 69% (n=48) of Asian patients; males constituted 31% (n=22). Mean age of the Asian patients was 55.9 years (SD: 14.6 range: 26–89). Asian-only cohort tumor pathologies included glioblastoma (GBM) (n=14), high-grade glioma (n=7), low-grade glioma (n=4), meningioma (n=38), and metastases (n=7). Of the 185 meningioma patients, non-Asian patients comprised 79% of the group (n=146). Of the 65 GBM patients in total, non-Asian patients made up 89% of the GBM cohort (n=58). There were no statistically significant differences between these groups of both cohorts in recurrence (p=0.1580 and p=0.6294, respectively), PFS (p=0.9662 and p=0.4048, respectively), or OS (p=0.3711 and p=0.8183, respectively).

Conclusion

Studies evaluating the survival between patients of different racial backgrounds against several tumor varieties are rare. Patients of certain racial backgrounds may need additional consideration when being attended to despite the same mutational composition as their counterparts. Repeated studies using national databases may yield more conclusive results.

Integrated Cox's model for predicting survival time of glioblastoma multiforme

Glioblastoma multiforme is the most common primary brain tumor and is highly lethal. This study aims to figure out signatures for predicting the survival time of patients with glioblastoma multiforme. Clinical information, messenger RNA expression, microRNA expression, and single-nucleotide polymorphism array data of patients with glioblastoma multiforme were retrieved from The Cancer Genome Atlas. Patients were separated into two groups by using 1 year as a cutoff, and a logistic regression model was used to figure out any variables that can predict whether the patient was able to live longer than 1 year. Furthermore, Cox's model was used to find out features that were correlated with the survival time. Finally, a Cox model integrated the significant clinical variables, messenger RNA expression, microRNA expression, and single-nucleotide polymorphism was built. Although the classification method failed, signatures of clinical features, messenger RNA expression levels, and microRNA expression levels were figured out by using Cox's model. However, no single-nucleotide polymorphisms related to prognosis were found. The selected clinical features were age at initial diagnosis, Karnofsky score, and race, all of which had been suggested to correlate with survival time. Both of the two significant microRNAs, microRNA-221 and microRNA-222, were targeted to p27^Kip1 protein, which implied the important role of p27^Kip1 on the prognosis of glioblastoma multiforme patients. Our results suggested that survival modeling was more suitable than classification to figure out prognostic biomarkers for patients with glioblastoma multiforme. An integrated model containing clinical features, messenger RNA levels, and microRNA expression levels was built, which has the potential to be used in clinics and thus to improve the survival status of glioblastoma multiforme patients.

Risk of subsequent cancer among pediatric, adult and elderly patients following a primary diagnosis of glioblastoma multiforme: a population-based study of the SEER database

Purpose/aim of the study: Our objective was to determine the risk of a subsequent malignancy in patients with glioblastoma multiforme (GBM).

MATERIALS AND METHODS

Data of patients with a primary diagnosis of GBM were extracted from the Surveillance, Epidemiology, and End Results database. Patients were divided into three age groups: pediatric, ≤19 years of age; adult, 20-59 years; elderly, ≥60 years. Outcomes were overall survival and incidence of second cancer.

RESULTS

A total of 24 348 patients with primary GBM were identified during the period from 2004 to 2013: 349 pediatric, 9841 adults and 14 518 elderly. There were significant differences in terms of sex, race, registry site, tumor histological type, tumor size and extension among the groups. The median survival time for pediatric, adult and elderly patients was 15, 15 and 5 months, respectively. Of the study population, 1.8% developed a second malignancy and the rates of the three groups were statistically different. Secondary tumors of the cranial nerves and other nervous system were the most common occurrence in the adults and elderly. Female, registry site, giant cell glioblastoma, undergoing surgery or radiation therapy were associated with developing a second malignancy.

CONCLUSIONS

The risk of a second malignancy in GBM patients is 1.8%, and associated with certain patient and treatment factors.

Incidence, survival, pathology, and genetics of adult Latino Americans with glioblastoma

Latino Americans are a rapidly growing ethnic group in the United States but studies of glioblastoma in this population are limited. We have evaluated characteristics of 21,184 glioblastoma patients from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. This SEER data from 2001 to 2011 draws from 28% of the U.S.

POPULATION

Latinos have a lower incidence of GBM and present slightly younger than non-Latino Whites. Cubans present at an older age than other Latino sub-populations. Latinos have a higher incidence of giant cell glioblastoma than non-Latino Whites while the incidence of gliosarcoma is similar. Despite lower rates of radiation therapy and greater rates of sub-total resection than non-Latino Whites, Latinos have better 1 and 5 year survival rates. SEER does not record chemotherapy data. Survivals of Latino sub-populations are similar with each other. Age, extent of resection, and the use of radiation therapy are associated with improved survival but none of these variables are sufficient in a multivariate analysis to explain the improved survival of Latinos relative to non-Latino Whites. As molecular data is not available in SEER records, we studied the MGMT and IDH status of 571 patients from a UCLA database. MGMT methylation and IDH1 mutation rates are not statistically significantly different between non-Latino Whites and Latinos. For UCLA patients with available information, chemotherapy and radiation rates are similar for non-Latino White and Latino patients, but the latter have lower rates of gross total resection and present at a younger age.

Generation of Microtumors Using 3D Human Biogel Culture System and Patient-derived Glioblastoma Cells for Kinomic Profiling and Drug Response Testing

The use of patient-derived xenografts for modeling cancers has provided important insight into cancer biology and drug responsiveness. However, they are time consuming, expensive, and labor intensive. To overcome these obstacles, many research groups have turned to spheroid cultures of cancer cells. While useful, tumor spheroids or aggregates do not replicate cell-matrix interactions as found in vivo. As such, three-dimensional (3D) culture approaches utilizing an extracellular matrix scaffold provide a more realistic model system for investigation. Starting from subcutaneous or intracranial xenografts, tumor tissue is dissociated into a single cell suspension akin to cancer stem cell neurospheres. These cells are then embedded into a human-derived extracellular matrix, 3D human biogel, to generate a large number of microtumors. Interestingly, microtumors can be cultured for about a month with high viability and can be used for drug response testing using standard cytotoxicity assays such as 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and live cell imaging using Calcein-AM. Moreover, they can be analyzed via immunohistochemistry or harvested for molecular profiling, such as array-based high-throughput kinomic profiling, which is detailed here as well. 3D microtumors, thus, represent a versatile high-throughput model system that can more closely replicate in vivo tumor biology than traditional approaches.

Identification of key genes in glioblastoma-associated stromal cells using bioinformatics analysis

The aim of the present study was to identify key genes and pathways in glioblastoma-associated stromal cells (GASCs) using bioinformatics. The expression profile of microarray GSE24100 was obtained from the Gene Expression Omnibus database, which included the expression profile of 4 GASC samples and 3 control stromal cell samples. Differentially expressed genes (DEGs) were identified using limma software in R language, and Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis of DEGs were performed using the Database for Annotation, Visualization and Integrated Discovery software. In addition, a protein-protein interaction (PPI) network was constructed. Subsequently, a sub-network was constructed to obtain additional information on genes identified in the PPI network using CFinder software. In total, 502 DEGs were identified in GASCs, including 331 upregulated genes and 171 downregulated genes. Cyclin-dependent kinase 1 (CDK1), cyclin A2, mitotic checkpoint serine/threonine kinase (BUB1), cell division cycle 20 (CDC20), polo-like kinase 1 (PLK1), and transcription factor breast cancer 1, early onset (BRCA1) were identified from the PPI network, and sub-networks revealed these genes as hub genes that were involved in significant pathways, including mitotic, cell cycle and p53 signaling pathways. In conclusion, CDK1, BUB1, CDC20, PLK1 and BRCA1 may be key genes that are involved in significant pathways associated with glioblastoma. This information may lead to the identification of the mechanism of glioblastoma tumorigenesis.

Glioblastoma multiforme outcomes of 107 patients treated in two Singapore institutions

INTRODUCTION

Glioblastoma multiforme (GBM) is the most common primary brain tumour in adults. Although the survival rate for GBM has improved with recent advancements in treatment, the prognosis remains generally poor.

METHODS

We conducted a retrospective review of GBM patients seen in National University Hospital, Singapore, and Tan Tock Seng Hospital, Singapore, from January 2002 to December 2011. Data on disease and treatment factors was collected and correlated with survival.

RESULTS

Data on a total of 107 GBM patients was analysed. Their median survival time was 15.1 months and the two-year survival rate was 23.5%, which is comparable with data published in other series. The factors associated with improved median survival time were radiotherapy dose > 50 Gy (16.1 months vs. 8.7 months, p = 0.01) and adjuvant concurrent chemotherapy (16.4 months vs. 9.2 months, p = 0.003).

CONCLUSION

GBM confers a poor prognosis. Adjuvant radiotherapy and chemotherapy are associated with improved survival. Ethnicity may be a contributing factor to differences in GBM incidence and prognosis.

IDH-Mutation Is a Weak Predictor of Long-Term Survival in Glioblastoma Patients

BACKGROUND

A very small proportion of patients diagnosed with glioblastoma (GBM) survive more than 3 years. Isocitrate dehydrogenase 1 or 2 (IDH1/2) mutations define a small subgroup of GBM patients with favourable prognosis. However, it remains controversial whether long-term survivors (LTS) are found among those IDH1/2 mutated patients.

METHODS

We retrospectively analyzed 207 GBM patients followed at Lariboisière Hospital (Paris) between 2005 and 2010. Clinical parameters were obtained from medical records. Mutations of IDH1/2 were analyzed in these patients, by immunohistochemistry for the R132H mutation of IDH1 and by high-resolution melting-curve analysis, followed by Sanger sequencing for IDH1 and IDH2 exon 4 mutations. Mutation rates in LTS and non-LTS groups were compared by Chi square Pearson test.

RESULTS

Seventeen patients with survival >3 years were identified (8.2% of the total series). The median overall survival in long-term survivors was 4.6 years. Subgroup analysis found that the median age at diagnosis was significantly higher for non long-term survivors (non-LTS) compared to LTS (60 versus 51 years, p <0.03). The difference in the rate of IDH mutation between non-LTS and LTS was statistically not significant (1.16% versus 5.9%, p = 0.144). Among LTS, 10 out of 16 tumors presented a methylation of MGMT promoter.

CONCLUSIONS

This study confirms that long-term survival in GBM patients is if at all only weakly correlated to IDH-mutation.

Patient and treatment factors associated with survival among adult glioblastoma patients: A USA population-based study from 2000-2010

In this study, we utilized the USA surveillance, epidemiology, and end results (SEER) database to examine factors influencing survival of glioblastoma multiforme (GBM) patients. GBM is the most common primary malignant brain tumor in adults and despite advances in treatment, prognosis remains poor. Using the SEER database, we defined a cohort of adult patients for the years 2000-2009 with confirmed GBM and minimum follow-up of 12 months. A total of 14,675 patients with GBM met the inclusion criteria. Demographic, clinical, and treatment variables were examined. Death was the primary outcome. Median survival time was 11 months. Patients had increasingly longer survival over the decade span. We found, on multivariate analysis, that significantly worse survival was associated with age >75 years, male sex, unmarried status, and non-Hispanic Caucasian race/ethnicity. Patients in the Northeast had a significantly lower risk of mortality. Patients with tumors that were non-lateralized and >3 cm fared worse. Patients who did not receive adjuvant radiation also had worse outcomes. Gross total resection imparted a survival advantage for patients compared to biopsy or partial resection. Thus, this report adds to the growing body of literature supporting the positive role of maximal resection on patient survival.

Kinomic exploration of temozolomide and radiation resistance in Glioblastoma multiforme xenolines

BACKGROUND AND PURPOSE

Glioblastoma multiforme (GBM) represents the most common and deadly primary brain malignancy, particularly due to temozolomide (TMZ) and radiation (RT) resistance. To better understand resistance mechanisms, we examined global kinase activity (kinomic profiling) in both treatment sensitive and resistant human GBM patient-derived xenografts (PDX or "xenolines").

MATERIALS AND METHODS

Thirteen orthotopically-implanted xenolines were examined including 8 with known RT sensitivity/resistance, while 5 TMZ resistant xenolines were generated through serial TMZ treatment in vivo. Tumors were harvested, prepared as total protein lysates, and kinomically analyzed on a PamStation®12 high-throughput microarray platform with subsequent upstream kinase prediction and network modeling.

RESULTS

Kinomic profiles indicated elevated tyrosine kinase activity associated with the radiation resistance phenotype, including FAK and FGFR1. Furthermore, network modeling showed VEGFR1/2 and c-Raf hubs could be involved. Analysis of acquired TMZ resistance revealed more kinomic variability among TMZ resistant tumors. Two of the five tumors displayed significantly altered kinase activity in the TMZ resistant xenolines and network modeling indicated PKC, JAK1, PI3K, CDK2, and VEGFR as potential mediators of this resistance.

CONCLUSION

GBM xenolines provide a phenotypic model for GBM drug response and resistance that when paired with kinomic profiling identified targetable pathways to inherent (radiation) or acquired (TMZ) resistance.

PID1 (NYGGF4), a new growth-inhibitory gene in embryonal brain tumors and gliomas

PURPOSE

We present here the first report of PID1 (Phosphotyrosine Interaction Domain containing 1; NYGGF4) in cancer. PID1 was identified in 2006 as a gene that modulates insulin signaling and mitochondrial function in adipocytes and muscle cells.

EXPERIMENTAL DESIGN AND RESULTS

Using four independent medulloblastoma datasets, we show that mean PID1 mRNA levels were lower in unfavorable medulloblastomas (groups 3 and 4, and anaplastic histology) compared with favorable medulloblastomas (SHH and WNT groups, and desmoplastic/nodular histology) and with fetal cerebellum. In two large independent glioma datasets, PID1 mRNA was lower in glioblastomas (GBM), the most malignant gliomas, compared with other astrocytomas, oligodendrogliomas and nontumor brains. Neural and proneural GBM subtypes had higher PID1 mRNA compared with classical and mesenchymal GBM. Importantly, overall survival and radiation-free progression-free survival were longer in medulloblastoma patients whose tumors had higher PID1 mRNA (univariate and multivariate analyses). Higher PID1 mRNA also correlated with longer overall survival in patients with glioma and GBM. In cell culture, overexpression of PID1 inhibited colony formation in medulloblastoma, atypical teratoid rhabdoid tumor (ATRT), and GBM cell lines. Increasing PID1 also increased cell death and apoptosis, inhibited proliferation, induced mitochondrial depolaization, and decreased serum-mediated phosphorylation of AKT and ERK in medulloblastoma, ATRT, and/or GBM cell lines, whereas siRNA to PID1 diminished mitochondrial depolarization.

CONCLUSIONS

These data are the first to link PID1 to cancer and suggest that PID1 may have a tumor inhibitory function in these pediatric and adult brain tumors.

Treatment results of glioblastoma during the last 30 years in a single institute

Treatment results of glioblastoma (GB) during the last 30 years in Tohoku University were analyzed to identify any improvements in patient outcome in all 332 histologically proven cases of newly diagnosed GB treated consecutively in our department between 1982 and 2011. These 30 years was divided into 5 treatment eras, Group 1 (1982–1988, without preoperative evaluation by magnetic resonance [MR] imaging, n = 46), Group 2 (1989–1996, with preoperative MR imaging, n = 41), Group 3 (1997–1999, additionally underwent intraoperative functional brain mapping and neuronavigation system, n = 38), Group 4 (2000–August 2006, underwent 30 Gy of whole brain radiation followed by 30 Gy of extended local accelerated hyperfractionated radiation therapy, n = 96), and Group 5 (September 2006–2011, adjuvant usage of temozolomide [TMZ], n = 111). Overall survival (OS) was calculated from the date of surgery to the death from any cause. The median survival time/2-year OS/5-year OS of Groups 1 to 5 were 10.7 months/10.9%/0%, 17.3 months/26.2%/6.9%, 15.9 months/23.7%/5.3%, 20.1 months/34.8%/15.5%, and 20.9 months/45.5%/19.7%. The prognosis for patients with GB improved significantly after the introduction of MR imaging. Younger GB, defined as patients aged below 60 years, or total tumor resection with all ages in Group 5 had 5-year 0S of 31.0% and 30.1%, respectively. The prognosis of GB was improved significantly after the introduction of TMZ for elderly GB, recursive partitioning analysis class 5, or totally resected GB. Introduction of MR imaging and TMZ, and total resection of the tumor were important in the improvement of outcome for patients with GB.