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Salvage radiosurgery for selected patients with recurrent malignant gliomas. BIOMED RESEARCH INTERNATIONAL 2014; 2014:657953. [PMID: 24895599 PMCID: PMC4033521 DOI: 10.1155/2014/657953] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/13/2014] [Accepted: 04/16/2014] [Indexed: 12/21/2022]
Abstract
Purpose. To analyse the survival after salvage radiosurgery and to identify prognostic factors. Methods. We retrospectively reviewed 87 consecutive patients, with recurrent high-grade glioma, that underwent stereotactic radiosurgery between 1997 and 2010. We evaluated the survival after initial diagnosis and after reirradiation. The prognostic factors were analysed by bivariate and multivariate Cox regression model. Results. The median age was 48 years old. The primary histology included anaplastic astrocytoma (47%) and glioblastoma (53%). A margin dose of 18 Gy was administered in the majority of cases (74%). The median survival after initial diagnosis was 21 months (39 months for anaplastic astrocytoma and 18.5 months for glioblastoma) and after reirradiation it was 10 months (17 months for anaplastic astrocytoma and 7.5 months for glioblastoma). In the bivariate analyses, the prognostic factors significantly associated with survival after reirradiation were age, tumour and treatment volume at recurrence, recursive partitioning analyses classification, Karnofsky performance score, histology, and margin to the planning target volume. Only the last four showed significant association in the multivariate analyses. Conclusion. stereotactic radiosurgery is a safe and may be an effective treatment option for selected patients diagnosed with recurrent high-grade glioma. The identified prognostic factors could help individualise the treatment.
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Hwang CS, Marymont MH, Muro K. Photon radiotherapy for the treatment of high-grade gliomas. Expert Rev Anticancer Ther 2014; 7:S37-43. [DOI: 10.1586/14737140.7.12s.s37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chamberlain MC, Chowdhary SA, Glantz MJ. Anaplastic astrocytomas: biology and treatment. Expert Rev Neurother 2014; 8:575-86. [DOI: 10.1586/14737175.8.4.575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sloan AE, Ahluwalia MS, Valerio-Pascua J, Manjila S, Torchia MG, Jones SE, Sunshine JL, Phillips M, Griswold MA, Clampitt M, Brewer C, Jochum J, McGraw MV, Diorio D, Ditz G, Barnett GH. Results of the NeuroBlate System first-in-humans Phase I clinical trial for recurrent glioblastoma: clinical article. J Neurosurg 2013; 118:1202-19. [PMID: 23560574 DOI: 10.3171/2013.1.jns1291] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Laser interstitial thermal therapy has been used as an ablative treatment for glioma; however, its development was limited due to technical issues. The NeuroBlate System incorporates several technological advances to overcome these drawbacks. The authors report a Phase I, thermal dose-escalation trial assessing the safety and efficacy of NeuroBlate in recurrent glioblastoma multiforme (rGBM). METHODS Adults with suspected supratentorial rGBM of 15- to 40-mm dimension and a Karnofsky Performance Status score of ≥ 60 were eligible. After confirmatory biopsy, treatment was delivered using a rigid, gas-cooled, side-firing laser probe. Treatment was monitored using real-time MRI thermometry, and proprietary software providing predictive thermal damage feedback was used by the surgeon, along with control of probe rotation and depth, to tailor tissue coagulation. An external data safety monitoring board determined if toxicity at lower levels justified dose escalation. RESULTS Ten patients were treated at the Case Comprehensive Cancer Center (Cleveland Clinic and University Hospitals-Case Medical Center). Their average age was 55 years (range 34-69 years) and the median preoperative Karnofsky Performance Status score was 80 (range 70-90). The mean tumor volume was 6.8 ± 5 cm(3) (range 2.6-19 cm(3)), the percentage of tumor treated was 78% ± 12% (range 57%-90%), and the conformality index was 1.21 ± 0.33 (range 1.00-2.04). Treatment-related necrosis was evident on MRI studies at 24 and 48 hours. The median survival was 316 days (range 62-767 days). Three patients improved neurologically, 6 remained stable, and 1 worsened. Steroid-responsive treatment-related edema occurred in all patients but one. Three had Grade 3 adverse events at the highest dose. CONCLUSIONS NeuroBlate represents new technology for delivering laser interstitial thermal therapy, allowing controlled thermal ablation of deep hemispheric rGBM. CLINICAL TRIAL REGISTRATION NO.: NCT00747253 ( ClinicalTrials.gov ).
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Affiliation(s)
- Andrew E Sloan
- Brain Tumor & Neuro-Oncology Center and Department of Neurosurgery, University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio, USA
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Elder JB, Chiocca EA. Editorial: Glioblastoma multiforme and laser interstitial thermal therapy. J Neurosurg 2013; 118:1199-200; discussion 1200-1. [PMID: 23560576 DOI: 10.3171/2012.9.jns121563] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Binello E, Green S, Germano IM. Radiosurgery for high-grade glioma. Surg Neurol Int 2012; 3:S118-26. [PMID: 22826815 PMCID: PMC3400492 DOI: 10.4103/2152-7806.95423] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 03/28/2012] [Indexed: 01/08/2023] Open
Abstract
Background: For patients with newly diagnosed high-grade gliomas (HGG), the current standard-of-care treatment involves surgical resection, followed by concomitant temozolomide (TMZ) and external beam radiation therapy (XRT), and subsequent TMZ chemotherapy. For patients with recurrent HGG, there is no standard of care. Stereotactic radiosurgery (SRS) is used to deliver focused, relatively large doses of radiation to a small, precisely defined target. Treatment is usually delivered in a single fraction, but may be delivered in up to five fractions. The role of SRS in the management of patients with HGG is not well established. Methods: The PubMed database was searched with combinations of relevant MESH headings and limits. Case reports and/or small case series were excluded. Attention was focused on overall median survival as an objective measure, and data were examined separately for newly diagnosed and recurrent HGG. Results: With respect to newly diagnosed HGG, there is strong evidence that addition of an SRS boost prior to standard XRT provides no survival benefit. However, recent retrospective evidence suggests a possible survival benefit when SRS is performed after XRT. With respect to recurrent HGG, there is suggestion that SRS may confer a survival benefit but with potentially higher complication rates. Newer studies are investigating the combination of SRS with targeted molecular agents. Controlled prospective clinical trials using advanced imaging techniques are necessary for a complete assessment. Conclusions: SRS has the potential to provide a survival benefit for patients with HGG. Further research is clearly warranted to define its role in the management of newly diagnosed and recurrent HGG.
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Affiliation(s)
- Emanuela Binello
- Department of Neurosurgery, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, NY 10129, USA
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Noël G, Mazeron JJ. Réirradiation cérébrale des tumeurs primitives malignes ou secondaires. Cancer Radiother 2010; 14:421-37. [DOI: 10.1016/j.canrad.2010.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 06/02/2010] [Indexed: 10/19/2022]
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Clavier JB, Voirin J, Kehrli P, Noël G. [Systematic review of stereotactic radiotherapy for high-grade gliomas]. Cancer Radiother 2010; 14:739-54. [PMID: 20724193 DOI: 10.1016/j.canrad.2010.03.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Revised: 03/23/2010] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
Abstract
The purpose of this literature systematic review was the use of stereotactic radiotherapy in glioma. Research was performed in Medline/PubMed and associated references found in published articles without publication date limit. The quality of series is variable and many biases can be evidenced. Only two randomized trials have been published using stereotactic radiotherapy for up-front treatment. There is a lack of evidence of survival advantages to use this treatment at the time of diagnosis or relapse. There is also insufficient evidence regarding the benefice/harms in the use of stereotactic fractionated radiation therapy for patients with glioma. No recommendations can be enounced. Stereotactic irradiation as boost in primary diagnosed glioma or relapsed tumour is not associated with survival improvement. For relapsed patients, treatment needs to be discussed according to the other treatment options.
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Affiliation(s)
- J-B Clavier
- Département de radiothérapie, centre de lutte contre le cancer Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, BP 42, 67065 Strasbourg cedex, France
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Kang TW, Kim ST, Byun HS, Jeon P, Kim K, Kim H, Lee JII. Morphological and functional MRI, MRS, perfusion and diffusion changes after radiosurgery of brain metastasis. Eur J Radiol 2009; 72:370-80. [DOI: 10.1016/j.ejrad.2008.08.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 08/11/2008] [Accepted: 08/11/2008] [Indexed: 10/21/2022]
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Xu D, Jia Q, Li Y, Kang C, Pu P. Effects of Gamma Knife surgery on C6 glioma in combination with adenoviral p53 in vitro and in vivo. J Neurosurg 2009; 105 Suppl:208-13. [PMID: 18503358 DOI: 10.3171/sup.2006.105.7.208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors sought to study the combined potential of wild-type p53 gene transfer and Gamma Knife surgery (GKS) for the treatment of glioblastomas multiforme. Modification of the radiation response in C6 glioma cells in vitro and in vivo by the wild-type p53 gene was investigated. METHODS Stable expression of wild-type p53 in C6 cells was achieved by transduction of the cells with adenoviral p53. Two days later, some cells were treated with GKS. Forty-eight hours after irradiation, the comparative survival rate was assessed by monotetrazolium (MTT) assays. Treated and control C6 glioma cells (4 x 10(3) per well) were plated into a 96-well plate in octuplicate and tested every 24 hours. Meanwhile, immunohistopathological examination of proliferating cell nuclear antigen (PCNA) and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate (TUNEL) assays were performed. The MTT assays indicated the p53, GKS, and combined treated cells proliferated at a significantly lower rate than those of the control group (p < 0.01, Days 2-6) and the positive fraction of PCNA in p53-treated group and GKS-treated group was 70.18 +/- 3.61 and 50.71 +/- 2.61, respectively, whereas the percentage in the combined group was 30.68 +/- 1.49 (p < 0.01). Fifty-six male Sprague-Dawley rats were anesthetized and inoculated with 10(6) cultured C6 glioma cells into the cerebrum. Forty-eight hours after transduction with adenoviral p53, some rats underwent GKS. A margin dose of 15 Gy was delivered to the 50% isodose line. Two days later, six rats in each group were killed. Their brains were removed and paraffin-embedded section were prepared for immunohistopathological examination and TUNEL assays. The remaining rats were observed for the duration of the survival period. The survival curve indicated that a modest but significant enhancement of survival duration was seen in the p53-treated or GKS alone groups, whereas a more marked and highly significant enhancement of survival duration was achieved when these two treatment modalities were combined. When PCNA expression was downregulated, apoptotic cells become obvious after TUNEL staining. CONCLUSIONS The findings of this study suggest that p53-based gene therapy in combination with GKS may be superior to single-modality treatment of C6 glioma.
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Affiliation(s)
- Desheng Xu
- Department of Neurosurgery, Tianjin Medical University 2nd Hospital, Tianjin, Republic of China.
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Kong DS, Lee JI, Park K, Kim JH, Lim DH, Nam DH. Efficacy of stereotactic radiosurgery as a salvage treatment for recurrent malignant gliomas. Cancer 2008; 112:2046-51. [PMID: 18338759 DOI: 10.1002/cncr.23402] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The objective of this prospective cohort study was to determine the efficacy of stereotactic radiosurgery (SRS) as a salvage treatment in patients with recurrent malignant gliomas. METHODS Between January 2000 and December 2006, 114 consecutive patients were treated with SRS as a salvage treatment for recurrent malignant gliomas at a single institution. Clinical outcome and its prognostic factors were analyzed and compared with the historical control group who were treated at the same institution between 1995 and 1999. RESULTS The median overall survival from the time of diagnosis was 37.5 months (95% confidence interval [95% CI], 11.7-63.2 months) for patients with grade 3 gliomas (according to World Health Organization criteria) and was 23 months (95% CI, 16.2-29.3 months) for patients with glioblastomas. The median progression-free survival after SRS was 8.6 months (95% CI, 1.1-16.2 months) for patients with grade 3 gliomas and 4.6 months for patients with glioblastomas (95% CI, 4.0-5.2 months). With regard to treatment-related complications, radiation-induced necrosis was observed in 22 of 114 patients (24.4%). Compared with this historic control group, SRS significantly prolonged survival as a salvage treatment in patients with recurrent glioblastomas (23 months vs 12 months; P < .0001), but it was not found to provide a significant surgical benefit in patients with recurrent grade 3 gliomas (37.5 months vs 26 months; P = .789). On univariate analysis of prognostic factors, tumor volume (<10 mL) and low histologic grade were found to significantly influence better survival (P = .009 and P = .041, respectively). CONCLUSIONS SRS is a safe and effective modality in selected patients with recurrent small-sized glioblastomas. However, the efficacy of SRS for recurrent grade 3 gliomas needs to be further evaluated in well-designed clinical studies.
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Affiliation(s)
- Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-Gu, Seoul, Korea
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Kondziolka D, Lunsford LD, Flickinger JC. THE APPLICATION OF STEREOTACTIC RADIOSURGERY TO DISORDERS OF THE BRAIN. Neurosurgery 2008; 62 Suppl 2:707-19; discussion 719-20. [DOI: 10.1227/01.neu.0000316275.12962.0e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract
STEREOTACTIC RADIOSURGERY IS the first widely used “biological surgery.” The opportunity for surgeons working with radiation oncologists and medical physicists to affect cell structures with both direct and indirect vascular effects has transformed neurosurgery. As a minimal access surgical approach, it fits well into the patient goals of functional preservation, risk reduction, and cost-effectiveness. Longer-term results have been published for many indications. For many disorders, it may be better to “leave the tumor in rather than take it out.” Radiosurgery has had an impact on the management of patients with vascular malformations, all forms of cerebral neoplasia, and selected functional disorders such as trigeminal neuralgia and tremor. It can be performed alone when lesion volume is not excessive or as part of a multimodality strategy with resection or endovascular surgery. Epilepsy, behavioral disorders, and other novel indications are the topics of current investigation. The combination of high-resolution imaging, high-speed computer workstations, robotics, patient fixation techniques, and radiobiological research has put radiosurgery into the practice of almost all neurosurgeons.
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Affiliation(s)
- Douglas Kondziolka
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John C. Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Oh BC, Liu CY, Wang MY, Pagnini PG, Yu C, Apuzzo MLJ. Stereotactic Radiosurgery: Adjacent Tissue Injury and Response after High-Dose Single Fraction Radiation—Part II: Strategies for Therapeutic Enhancement, Brain Injury Mitigation, and Brain Injury Repair. Neurosurgery 2007; 60:799-814; discussion 799-814. [PMID: 17460515 DOI: 10.1227/01.neu.0000255454.28225.5c] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
IN THE FIRST part of this series, we reviewed the histological, radiographic, and molecular data gathered regarding the brain parenchymal response to radiosurgery and suggested future studies that could enhance our understanding of the topic. With this article, we begin by addressing methods of potentiating the effect of radiosurgery on target lesions of the central nervous system. Much of the work on potentiating the effects of cranial radiation has been performed in the field of whole-brain radiotherapy. Data from Phase III trials evaluating the efficacy of various agents as radiosensitizers or radioenhancers in whole-brain radiotherapy are reviewed, and trials for investigating certain agents as enhancers of radiosurgery are suggested. The roles of gene therapy and nanotechnology in enhancing the therapeutic efficacy of radiosurgery are then addressed. Focus is then shifted to a discussion of strategies of protecting healthy tissue from the potentially deleterious aspects of the brain's response to radiosurgery that were presented in the first article of this series. Finally, comments are made regarding the role of neural progenitor or stem cells in the repair of radiation-induced brain injury after radiosurgery. The importance of both the role of the extracellular matrix and properly directed axonal regrowth leading to appropriate target reinnervation is highlighted.
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