A prospective study of quality of life in adults with newly diagnosed high-grade gliomas: the impact of the extent of resection on quality of life and survival

Recurrent Glioblastoma-Molecular Underpinnings and Evolving Treatment Paradigms

Glioblastoma is the most common and lethal central nervous system malignancy with a median survival after progression of only 6-9 months. Major biochemical mechanisms implicated in glioblastoma recurrence include aberrant molecular pathways, a recurrence-inducing tumor microenvironment, and epigenetic modifications. Contemporary standard-of-care (surgery, radiation, chemotherapy, and tumor treating fields) helps to control the primary tumor but rarely prevents relapse. Cytoreductive treatment such as surgery has shown benefits in recurrent glioblastoma; however, its use remains controversial. Several innovative treatments are emerging for recurrent glioblastoma, including checkpoint inhibitors, chimeric antigen receptor T cell therapy, oncolytic virotherapy, nanoparticle delivery, laser interstitial thermal therapy, and photodynamic therapy. This review seeks to provide readers with an overview of (1) recent discoveries in the molecular basis of recurrence; (2) the role of surgery in treating recurrence; and (3) novel treatment paradigms emerging for recurrent glioblastoma.

Triaxial accelerometer-measured physical activity and functional behaviours among people with High Grade Glioma: The BrainWear Study

BACKGROUND

High-grade gliomas (HGG) account for 60-75% of all adult gliomas. The complexity of treatment, recovery and survivorship creates a need for novel monitoring approaches. Accurate assessment of physical function plays a vital role in clinical evaluation. Digital wearable tools could help us address unmet needs by offering unique advantages such as scale, cost and continuous real-world objective data. We present data from 42 patients enrolled into the BrainWear study.

METHODS

An AX3 accelerometer was worn by patients from diagnosis or at recurrence. Age-, sex-matched UK Biobank control groups were chosen for comparison.

RESULTS

80% of data were categorised as high-quality demonstrating acceptability. Remote, passive monitoring identifies moderate activity reduces both during a course of radiotherapy (69 to 16 minutes/day) and at the time of progressive disease assessed by MRI (72 to 52 minutes/day). Mean acceleration (mg) and time spent walking daily (h/day) correlated positively with the global health quality of life and physical functioning scores and inversely with the fatigue score. Healthy controls walked on average 2.91h/day compared to 1.32h/day for the HGG group on weekdays and 0.91h/day on the weekend. The HGG cohort slept for longer on weekends (11.6h/day) than weekdays (11.2h/day) compared to healthy controls (8.9h/day).

CONCLUSION

Wrist-worn accelerometers are acceptable and longitudinal studies feasible. HGG patients receiving a course of radiotherapy reduce their moderate activity by 4-fold and are at least half as active as healthy controls at baseline. Remote monitoring can provide a more informed and objective understanding of patient activity levels to help optimise health related quality of life (HRQoL) among a patient cohort with an extremely limited lifespan.

Reconstruction of the Corticospinal Tract in Patients with Motor-Eloquent High-Grade Gliomas Using Multilevel Fiber Tractography Combined with Functional Motor Cortex Mapping

BACKGROUND AND PURPOSE

Tractography of the corticospinal tract is paramount to presurgical planning and guidance of intraoperative resection in patients with motor-eloquent gliomas. It is well-known that DTI-based tractography as the most frequently used technique has relevant shortcomings, particularly for resolving complex fiber architecture. The purpose of this study was to evaluate multilevel fiber tractography combined with functional motor cortex mapping in comparison with conventional deterministic tractography algorithms.

MATERIALS AND METHODS

Thirty-one patients (mean age, 61.5 [SD, 12.2] years) with motor-eloquent high-grade gliomas underwent MR imaging with DWI (TR/TE = 5000/78 ms, voxel size = 2 × 2 × 2 mm3, 1 volume at b = 0 s/mm2, 32 volumes at b = 1000 s/mm2). DTI, constrained spherical deconvolution, and multilevel fiber tractography-based reconstruction of the corticospinal tract within the tumor-affected hemispheres were performed. The functional motor cortex was enclosed by navigated transcranial magnetic stimulation motor mapping before tumor resection and used for seeding. A range of angular deviation and fractional anisotropy thresholds (for DTI) was tested.

RESULTS

For all investigated thresholds, multilevel fiber tractography achieved the highest mean coverage of the motor maps (eg, angular threshold = 60°; multilevel/constrained spherical deconvolution/DTI, 25% anisotropy threshold = 71.8%, 22.6%, and 11.7%) and the most extensive corticospinal tract reconstructions (eg, angular threshold = 60°; multilevel/constrained spherical deconvolution/DTI, 25% anisotropy threshold = 26,485 mm3, 6308 mm3, and 4270 mm3).

CONCLUSIONS

Multilevel fiber tractography may improve the coverage of the motor cortex by corticospinal tract fibers compared with conventional deterministic algorithms. Thus, it could provide a more detailed and complete visualization of corticospinal tract architecture, particularly by visualizing fiber trajectories with acute angles that might be of high relevance in patients with gliomas and distorted anatomy.

Complication Avoidance in Neurosurgery with Use of Intraoperative Ultrasonography

Intraoperative ultrasonography is an extremely valuable tool for avoidance of complications during neurosurgical procedures, including resection of intracranial and spinal cord tumors, removal of spontaneous intracerebral hemorrhages and arteriovenous malformations, and ventricular access for shunt placements. Nevertheless, application of this highly useful technique may be accompanied by some challenges and difficulties, as well as human errors; thus, it requires specific knowledge and continuous training.

DeepEOR: automated perioperative volumetric assessment of variable grade gliomas using deep learning

PURPOSE

Volumetric assessments, such as extent of resection (EOR) or residual tumor volume, are essential criterions in glioma resection surgery. Our goal is to develop and validate segmentation machine learning models for pre- and postoperative magnetic resonance imaging scans, allowing us to assess the percentagewise tumor reduction after intracranial surgery for gliomas.

METHODS

For the development of the preoperative segmentation model (U-Net), MRI scans of 1053 patients from the Multimodal Brain Tumor Segmentation Challenge (BraTS) 2021 as well as from patients who underwent surgery at the University Hospital in Zurich were used. Subsequently, the model was evaluated on a holdout set containing 285 images from the same sources. The postoperative model was developed using 72 scans and validated on 45 scans obtained from the BraTS 2015 and Zurich dataset. Performance is evaluated using Dice Similarity score, Jaccard coefficient and Hausdorff 95%.

RESULTS

We were able to achieve an overall mean Dice Similarity Score of 0.59 and 0.29 on the pre- and postoperative holdout sets, respectively. Our algorithm managed to determine correct EOR in 44.1%.

CONCLUSION

Although our models are not suitable for clinical use at this point, the possible applications are vast, going from automated lesion detection to disease progression evaluation. Precise determination of EOR is a challenging task, but we managed to show that deep learning can provide fast and objective estimates.

Dyadic versus individual delivery of a yoga program for family caregivers of glioma patients undergoing radiotherapy: Results of a 3‐arm randomized controlled trial

BACKGROUND

Despite their significant distress, supportive care interventions for caregivers of glioma patients are generally lacking. And, whether caregivers are more likely to benefit from interventions targeting patient-caregiver dyads or caregivers individually is unknown. This pilot randomized controlled trial compared the feasibility and preliminary efficacy of a dyadic yoga (DY) versus an individual caregiver yoga (CY) intervention as a supportive care strategy for family caregivers.

METHODS

Patient-caregiver dyads were randomized to a DY, CY or usual care (UC) arm. DY and CY interventions were delivered over 15 sessions. Caregivers completed assessments of their depressive symptoms, quality of life (QOL), and caregiving reactions at baseline, 6 weeks, and 12 weeks, and a subset completed qualitative interviews at 12 weeks.

RESULTS

With a consent rate of 63%, 67 dyads were randomized. Attendance in the DY was higher than in the CY group (session means, DY = 12.23, CY = 9.00; p = 0.06). Caregivers (79% female; 78% non-Hispanic White; mean age, 53 years) reported significantly more subjective benefit in the CY arm than in the DY arm (d = 2.1; p < .01), which was consistent with the qualitative assessment. There were medium effect sizes for improved mental QOL (d = 0.46) and financial burden (d = 0.53) in favor of the CY over the UC group. Caregivers in the CY group reported more caregiving esteem (d = 0.56) and less health decline (d = 0.60) than those in the DY group.

CONCLUSION

Individual rather than dyadic delivery may be a superior supportive care approach for this vulnerable caregiver population. A larger, adequately powered efficacy trial is warranted.

A Prospective Evaluation of Fatigue in Pediatric Brain Tumor Patients Treated With Radiation Therapy

Background: Fatigue is a well-established consequence of cranial radiotherapy in survivors of pediatric brain tumor, but less is known about acute fatigue during radiotherapy treatment. This study aimed to longitudinally evaluate fatigue in newly diagnosed pediatric patients with brain tumors during treatment. Methods: Primary caregivers of pediatric patients with brain tumors completed the proxy-reported Parent Fatigue Scale assessments prior to radiotherapy and weekly during radiotherapy treatment. The association between clinical factors and fatigue at each assessment was evaluated with multiple linear regressions. A comparison of fatigue between radiation modalities was also analyzed. Results: A total of 33 caregivers completed pre-radiation fatigue assessments, with 29 reporting fatigue during radiotherapy. Patients were aged 3 to 16 years (M = 8.32) at diagnosis and diagnosed with medulloblastoma (n = 23), primitive neuroectodermal tumor (n = 2), ependymoma (n = 1), germ cell tumor (n = 1), pineoblastoma (n = 1), atypical teratoid rhabdoid (n = 1), and other unspecific tumors (n = 3). Moderate-to-severe fatigue was reported for the majority of patients (31/33; 94%) during treatment. Craniospinal irradiation dose was the only significant predictor of fatigue (p < .05), but this association was restricted to the first week of therapy and was attenuated by therapy completion. Discussion: Although fatigue is often considered a long-term consequence of cranial radiotherapy, this pilot study demonstrates that moderate-to-severe fatigue is pervasive prior to radiotherapy and persists throughout treatment in pediatric patients with brain tumors, regardless of radiation modality or clinical factors. Additional research is warranted to establish a link between acute and long-term fatigue and develop interventions to mitigate this adverse outcome.

Comparative Study Between a Customized Bimodal Endoscope and a Benchtop Microscope for Quantitative Tissue Diagnosis

Nowadays, surgical removal remains the standard method to treat brain tumors. During surgery, the neurosurgeon may encounter difficulties to delimitate tumor boundaries and the infiltrating areas as they have a similar visual appearance to adjacent healthy zones. These infiltrating residuals increase the tumor recurrence risk, which decreases the patient’s post-operation survival time. To help neurosurgeons improve the surgical act by accurately delimitating healthy from cancerous areas, our team is developing an intraoperative multimodal imaging tool. It consists of a two-photon fluorescence fibered endomicroscope that is intended to provide a fast, real-time, and reliable diagnosis information. In parallel to the instrumental development, a large optical database is currently under construction in order to characterize healthy and tumor brain tissues with their specific optical signature using multimodal analysis of the endogenous fluorescence. Our previous works show that this multimodal analysis could provide a reliable discrimination response between different tissue types based on several optical indicators. Here, our goal is to show that the two-photon fibered endomicroscope is able to provide, based on the same approved indicators in the tissue database, the same reliable response that could be used intraoperatively. We compared the spectrally resolved and time-resolved fluorescence signal, generated by our two-photon bimodal endoscope from 46 fresh brain tissue samples, with a similar signal provided by a standard reference benchtop multiphoton microscope that has been validated for tissue diagnosis. The higher excitation efficiency and collection ability of an endogenous fluorescence signal were shown for the endoscope setup. Similar molecular ratios and fluorescence lifetime distributions were extracted from the two compared setups. Spectral discrimination ability of the bimodal endoscope was validated. As a preliminary step before tackling multimodality, the ability of the developed bimodal fibered endoscope to excite and to collect efficiently as well as to provide a fast exploitable high-quality signal that is reliable to discriminate different types of human brain tissues was validated.

Surgical Neuro-Oncology

Gliomas are the most common intrinsic brain tumor in adults. Although maximal tumor resection improves survival, this must be balanced with preservation of neurologic function. Technological advancements have greatly expanded our ability to safely maximize tumor resection and design innovative therapeutic trials that take advantage of intracavitary delivery of therapeutic agents after resection. In this article, we review the role of surgical intervention for both low-grade and high-grade gliomas and the innovations that are driving and expanding the role of surgery in this therapeutically challenging group of malignancies.

Correlation of natural language assessment results with health-related quality of life in adult glioma patients

OBJECTIVE

Impairments of speech are common in patients with glioma and negatively impact health-related quality of life (HRQoL). The benchmark for clinical assessments is task-based measures, which are not always feasible to administer and may miss essential components of HRQoL. In this study, the authors tested the hypothesis that variations in natural language (NL) correlate with HRQoL in a pattern distinct from task-based measures of language performance.

METHODS

NL use was assessed using audio samples collected unobtrusively from 18 patients with newly diagnosed low- and high-grade glioma. NL measures were calculated using manual segmentation and correlated with Quality of Life in Neurological Disorders (Neuro-QoL) outcomes. Spearman's rank-order correlation was used to determine relationships between Neuro-QoL scores and NL measures.

RESULTS

The distribution of NL measures across the entire patient cohort included a mean ± SD total time speaking of 11.5 ± 2.20 seconds, total number of words of 27.2 ± 4.44, number of function words of 10.9 ± 1.68, number of content words of 16.3 ± 2.91, and speech rate of 2.61 ± 0.20 words/second. Speech rate was negatively correlated with functional domains (rho = -0.62 and p = 0.007 for satisfaction with social roles; rho = -0.74 and p < 0.001 for participation in social roles) but positively correlated with impairment domains (rho = 0.58 and p = 0.009 for fatigue) of Neuro-QoL.

CONCLUSIONS

Assessment of NL at the time of diagnosis may be a useful measure in the context of treatment planning and monitoring outcomes for adult patients with glioma.

Tracking the Corticospinal Tract in Patients With High-Grade Glioma: Clinical Evaluation of Multi-Level Fiber Tracking and Comparison to Conventional Deterministic Approaches

While the diagnosis of high-grade glioma (HGG) is still associated with a considerably poor prognosis, neurosurgical tumor resection provides an opportunity for prolonged survival and improved quality of life for affected patients. However, successful tumor resection is dependent on a proper surgical planning to avoid surgery-induced functional deficits whilst achieving a maximum extent of resection (EOR). With diffusion magnetic resonance imaging (MRI) providing insight into individual white matter neuroanatomy, the challenge remains to disentangle that information as correctly and as completely as possible. In particular, due to the lack of sensitivity and accuracy, the clinical value of widely used diffusion tensor imaging (DTI)-based tractography is increasingly questioned. We evaluated whether the recently developed multi-level fiber tracking (MLFT) technique can improve tractography of the corticospinal tract (CST) in patients with motor-eloquent HGGs. Forty patients with therapy-naïve HGGs (mean age: 62.6 ± 13.4 years, 57.5% males) and preoperative diffusion MRI [repetition time (TR)/echo time (TE): 5000/78 ms, voxel size: 2x2x2 mm3, one volume at b=0 s/mm2, 32 volumes at b=1000 s/mm2] underwent reconstruction of the CST of the tumor-affected and unaffected hemispheres using MLFT in addition to deterministic DTI-based and deterministic constrained spherical deconvolution (CSD)-based fiber tractography. The brain stem was used as a seeding region, with a motor cortex mask serving as a target region for MLFT and a region of interest (ROI) for the other two algorithms. Application of the MLFT method substantially improved bundle reconstruction, leading to CST bundles with higher radial extent compared to the two other algorithms (delineation of CST fanning with a wider range; median radial extent for tumor-affected vs. unaffected hemisphere - DTI: 19.46° vs. 18.99°, p=0.8931; CSD: 30.54° vs. 27.63°, p=0.0546; MLFT: 81.17° vs. 74.59°, p=0.0134). In addition, reconstructions by MLFT and CSD-based tractography nearly completely included respective bundles derived from DTI-based tractography, which was however favorable for MLFT compared to CSD-based tractography (median coverage of the DTI-based CST for affected vs. unaffected hemispheres - CSD: 68.16% vs. 77.59%, p=0.0075; MLFT: 93.09% vs. 95.49%; p=0.0046). Thus, a more complete picture of the CST in patients with motor-eloquent HGGs might be achieved based on routinely acquired diffusion MRI data using MLFT.

Neurosurgeons' opinions on discussing sexual health among brain tumor patients: Room for improvement?

BACKGROUND

As sexual health is an important aspect of general quality of life, discussing and treating sexual health issues should also be part of the oncological care given to patients. It is unknown to what extent neurosurgeons discuss sexual health issues with patients suffering from brain tumors.

METHODS

A 25-question survey was sent to members of the Congress of Neurological Surgeons by email.

RESULTS

Of all neurosurgeons who replied, 59.1% never discussed sexual health with patients suffering from brain tumors. There was a trend of less discussing sexual health with older patients. Furthermore, discussing sexual health did not depend on the stage or type of brain tumor patients were suffering from. A majority of 57.7% of the neurosurgeons stated that patients themselves are responsible for discussing health and 41.6% think that neurosurgeons are responsible. The biggest barriers for avoiding discussing sexual health were that 'patients do not express sexual problems spontaneously', 'insufficient training/knowledge of the neurosurgeon' and 'insufficient time'. Furthermore, 59.1% stated they had insufficient/no knowledge about sexual health and 70% found it (slightly/very) important to screen for sexual health after meningioma surgery. About 63.1% wanted to extend their knowledge on sexual health.

CONCLUSION

Sexual health is an underexposed area in the neurosurgical care for patients suffering from brain tumors. There is a need for more awareness on recognizing and treating of sexual dysfunction after neurosurgery.

BOLD Coupling between Lesioned and Healthy Brain Is Associated with Glioma Patients' Recovery

Predicting functional outcomes after surgery and early adjuvant treatment is difficult due to the complex, extended, interlocking brain networks that underpin cognition. The aim of this study was to test glioma functional interactions with the rest of the brain, thereby identifying the risk factors of cognitive recovery or deterioration. Seventeen patients with diffuse non-enhancing glioma (aged 22-56 years) were longitudinally MRI scanned and cognitively assessed before and after surgery and during a 12-month recovery period (55 MRI scans in total after exclusions). We initially found, and then replicated in an independent dataset, that the spatial correlation pattern between regional and global BOLD signals (also known as global signal topography) was associated with tumour occurrence. We then estimated the coupling between the BOLD signal from within the tumour and the signal extracted from different brain tissues. We observed that the normative global signal topography is reorganised in glioma patients during the recovery period. Moreover, we found that the BOLD signal within the tumour and lesioned brain was coupled with the global signal and that this coupling was associated with cognitive recovery. Nevertheless, patients did not show any apparent disruption of functional connectivity within canonical functional networks. Understanding how tumour infiltration and coupling are related to patients' recovery represents a major step forward in prognostic development.

Mapping of Motor Function with Neuronavigated Transcranial Magnetic Stimulation: A Review on Clinical Application in Brain Tumors and Methods for Ensuring Feasible Accuracy

Navigated transcranial magnetic stimulation (nTMS) has developed into a reliable non-invasive clinical and scientific tool over the past decade. Specifically, it has undergone several validating clinical trials that demonstrated high agreement with intraoperative direct electrical stimulation (DES), which paved the way for increasing application for the purpose of motor mapping in patients harboring motor-eloquent intracranial neoplasms. Based on this clinical use case of the technique, in this article we review the evidence for the feasibility of motor mapping and derived models (risk stratification and prediction, nTMS-based fiber tracking, improvement of clinical outcome, and assessment of functional plasticity), and provide collected sets of evidence for the applicability of quantitative mapping with nTMS. In addition, we provide evidence-based demonstrations on factors that ensure methodological feasibility and accuracy of the motor mapping procedure. We demonstrate that selection of the stimulation intensity (SI) for nTMS and spatial density of stimuli are crucial factors for applying motor mapping accurately, while also demonstrating the effect on the motor maps. We conclude that while the application of nTMS motor mapping has been impressively spread over the past decade, there are still variations in the applied protocols and parameters, which could be optimized for the purpose of reliable quantitative mapping.

Overall Survival in Patients With Resected Glioblastoma Treated With Adjuvant Therapy: A Retrospective Study in a Public Hospital in Chile

Glioblastoma (GB) is the most frequent and aggressive primary tumor of the central nervous system (CNS) in adults. Standard treatment is complete tumor resection followed by concomitant radiochemotherapy (RCT) and subsequent adjuvant temozolomide (TMZ). Information about brain tumors statistics in Latin American countries is scarce, so we aimed to measure the overall survival (OS) of patients with resected GB in a single institution in Chile.

This is a retrospective report of 67 patients treated between 2012 and 2019 with resected GB and who received adjuvant treatment with radiotherapy (RT) with and without TMZ during 2012-2019 in this center (Chilean NCI). Most of them were men (72%), ages > 50 years old (57%), with Karnofsky performance status (KPS) scale ≥ 70% (94%) and recursive partitioning analysis-IV (RPA-IV) (60%). Some 54% received concomitant TMZ and RT. Median OS was 11.4 months, with 1-, 2-, and 5-year OS of 48%,15%, and 3% respectively. 

In conclusion, in patients with GB treated with RCT at the NCI, OS was the same as expected from international articles.

Adjuvant RCT therefore is considered the standard of care at NCI.

Neuropsychological outcomes following supratotal resection for high-grade glioma: a review

PURPOSE

Supratotal resection (SpTR) of high-grade glioma (HGG), in which surgical removal of the tumor is extended outside the margins of the preoperative radiographic abnormality, has been suggested to improve overall survival (OS) and progression free survival (PFS) in patients harboring tumors of non-eloquent cortex when compared to gross total resection (GTR). While current literature demonstrates these findings without an increase in post-operative complications or neurological deficits, there remains a paucity of data examining the neuropsychological outcomes of SpTR for HGG. As quality of life dramatically influences survival rates in these patients, it is crucial for neurosurgeons, neuro-oncologists, and neuropsychiatrists to understand the behavioral and cognitive outcomes following SpTR, such that optimal treatment strategies can be tailored for each patient.

METHODS

We performed a comprehensive review of the available literature regarding survival, neuropsychological, and quality of life (QOL) outcomes following SpTR for HGG. We also review neuropsychological and QOL outcomes following GTR for HGG to serve as a framework for better understanding potential implications of SpTR.

RESULTS

While results are limited following SpTR for HGG, available data suggests similar outcomes to those seen in patients undergoing GTR of HGG, as well as low-grade glioma. These include a short-term decline in neuropsychological functioning post-surgically with a return to baseline across most neurocognitive domains occurring within several months. Memory and attention remain relatively diminished at long term follow-up.

CONCLUSIONS

Limited data exist examining postoperative cognitive and behavioral outcomes following SpTR for HGG. While the available data suggests a return to baseline for many neurocognitive domains, attention and memory deficits may persist. However, sample sizes are relatively small and have not been examined in the context of QOL and OS/PFS. More rigorous pre- and post-surgical neuropsychological assessment will help shed light on the long-term cognitive and behavioral effects of SpTR in the setting of HGG and inform clinical care and counseling when SpTR is considered.

Towards in-vivo label-free detection of brain tumor margins with epi-illumination tomographic quantitative phase imaging

Brain tumor surgery involves a delicate balance between maximizing the extent of tumor resection while minimizing damage to healthy brain tissue that is vital for neurological function. However, differentiating between tumor, particularly infiltrative disease, and healthy brain in-vivo remains a significant clinical challenge. Here we demonstrate that quantitative oblique back illumination microscopy (qOBM)-a novel label-free optical imaging technique that achieves tomographic quantitative phase imaging in thick scattering samples-clearly differentiates between healthy brain tissue and tumor, including infiltrative disease. Data from a bulk and infiltrative brain tumor animal model show that qOBM enables quantitative phase imaging of thick fresh brain tissues with remarkable cellular and subcellular detail that closely resembles histopathology using hematoxylin and eosin (H&E) stained fixed tissue sections, the gold standard for cancer detection. Quantitative biophysical features are also extracted from qOBM which yield robust surrogate biomarkers of disease that enable (1) automated tumor and margin detection with high sensitivity and specificity and (2) facile visualization of tumor regions. Finally, we develop a low-cost, flexible, fiber-based handheld qOBM device which brings this technology one step closer to in-vivo clinical use. This work has significant implications for guiding neurosurgery by paving the way for a tool that delivers real-time, label-free, in-vivo brain tumor margin detection.

MR imaging by 3D T1-weighted black blood sequences may improve delineation of therapy-naive high-grade gliomas

Objectives

To investigate the value of contrast-enhanced (CE) turbo spin echo black blood (BB) sequences for imaging of therapy-naive high-grade gliomas (HGGs).

Methods

Consecutive patients with histopathologically confirmed World Health Organization (WHO) grade III or IV gliomas and no oncological treatment prior to index imaging (March 2019 to January 2020) were retrospectively included. Magnetic resonance imaging (MRI) at 3 Tesla comprised CE BB and CE turbo field echo (TFE) sequences. The lack/presence of tumor-related contrast enhancement and satellite lesions were evaluated by two readers. Sharper delineation of tumor boundaries (1, bad; 2, intermediate; 3, good delineation) and vaster expansion of HGGs into the adjacent brain parenchyma on CE BB imaging were the endpoints. Furthermore, contrast-to-noise ratios (CNRs) were calculated and compared between sequences.

Results

Fifty-four patients were included (mean age: 61.2 ± 15.9 years, 64% male). The vast majority of HGGs (51/54) showed contrast enhancement in both sequences, while two HGGs as well as one of six detected satellite lesions were depicted in CE BB imaging only. Tumor boundaries were significantly sharper (R1: 2.43 ± 0.71 vs. 2.73 ± 0.62, p < 0.001; R2: 2.44 ± 0.74 vs. 2.77 ± 0.60, p = 0.001), while the spread of HGGs into the adjacent parenchyma was larger when considering CE BB sequences according to both readers (larger spread in CE BB sequences: R1: 23 patients; R2: 20 patients). The CNR for CE BB sequences significantly exceeded that of CE TFE sequences (43.4 ± 27.1 vs. 32.5 ± 25.0, p = 0.0028).

Conclusions

Our findings suggest that BB imaging may considerably improve delineation of therapy-naive HGGs when compared with established TFE imaging. Thus, CE BB sequences might supplement MRI protocols for brain tumors.

Key Points

• This study investigated contrast-enhanced (CE) T1-weighted black blood (BB) sequences for improved MRI in patients with therapy-naive high-grade gliomas (HGGs).

• Compared with conventionally used turbo field echo (TFE) sequences, CE BB sequences depicted tumor boundaries and spread of HGGs into adjacent parenchyma considerably better, which also showed higher CNRs.

• Two enhancing tumor masses and one satellite lesion were exclusively identified in CE BB sequences, but remained undetected in conventionally used CE TFE sequences.

Impact of surgical treatment on the performance status of patients with high-grade gliomas

OBJECTIVES

The objective of our study is to evaluate the impact of neurosurgical operative treatment on the performance status assessed by the Karnofsky Performance Scale (KPS) in patients with HGG for the first, for the second intervention and for the different age groups.

METHODS

A group of 425 patients operated consecutively for high-grade gliomas were included in this study. The performance status was evaluated preoperatively and 15 days postoperatively with the KPS. Analyses for the different histological grade, tumor locations and age groups divided by decades have been made.

RESULTS

The initial, preoperative KPS score for patients with grade III tumor was 77.65 and for grade IV - 71.35. Following the first operation mean KPS has a statistically significant increase and reaches 82.24 and 78.41, respectively. The improvement of the performance status after the first operation was significant for all relevant age groups, including the sixth, seventh and eighth decades. Although the obtained mean KPS scores after the second operation did not show improvement there was also no clear evidence for worsening in this group of patients (n = 100) and the negative results obtained were not statistically significant.

CONCLUSION

According to our study, the first operation has a beneficial effect on the performance status in patients with HGG. The results for the second operation are more ambiguous, but there is no clear evidence for worsening of the KPS score after the second intervention. These results were relevant for all age groups, so we may expect amelioration in the performance status even in older patients.

Staged Laser Interstitial Thermal Therapy (LITT) Treatments to Left Insular Low-Grade Glioma

BACKGROUND AND IMPORTANCE

Low-grade insular gliomas remain challenging tumors for aggressive resection because of the numerous functional and vascular structures surrounding them. Because of the potential morbidities associated with open surgical resection, less invasive techniques may confer a more optimal balance between cytoreduction and surgical complications. For this reason, we evaluated the use of laser interstitial thermal therapy (LITT) for resection of a dominant hemisphere oligodendroglioma World Health Organization (WHO) grade II in a 68-yr-old patient by use of multiple staged surgeries for its resection.

CLINICAL PRESENTATION

Patient KK was a 68-yr-old female who was found to have a large, left-sided insular mass that was shown to be an oligodendroglioma WHO grade II, positive for codeletion 1p/19q and IDH1 mutant on biopsy. Over the course of 3 mo, KK underwent 2 stages of LITT, targeting different areas of the 5-cm tumor. The 60-d magnetic resonance imaging (MRI) demonstrated a reduction in size of the tumor from 5.2 × 3.3 × 2.4 cm to 3.6 × 1.9 × 1.4 cm. She returned for a second stage targeting the anterior portion of the tumor. KK did well postoperatively and went on to postsurgical chemoradiation. At the 2-yr follow-up, the lesion showed near resolution on MRI.

CONCLUSION

This case report demonstrates successful use of LITT for staged surgeries to treat a left hemisphere-dominant insular lesion. This establishes the use of LITT as a viable, minimally invasive option to treat tumors that are difficult to access or pose concerns for increased morbidity through an open surgery.

Assessment of the Extent of Resection in Surgery of High-Grade Glioma-Evaluation of Black Blood Sequences for Intraoperative Magnetic Resonance Imaging at 3 Tesla

Achieving an optimal extent of resection (EOR) whilst keeping lasting neurological decline to a minimum is paramount for modern neurosurgery in patients with high-grade glioma (HGG). To improve EOR assessment, this study introduces Black Blood (BB) imaging, which uses a selective saturation pulse to suppress the blood signal, to 3-Tesla intraoperative magnetic resonance imaging (iMRI). Seventy-three patients (56.4 ± 13.9 years, 64.4% male) with contrast-enhancing HGGs underwent iMRI, including contrast-enhanced (CE) and non-CE 3D turbo field-echo imaging (TFE; acquisition time: 4:20 min per sequence) and CE and non-CE 3D BB imaging (acquisition time: 1:36 min per sequence). Two readers (R1 and R2) retrospectively evaluated the EOR and diagnostic confidence (1—very inconfident to 5—very confident) as well as the delineation of tumor boarders and spread of contrast-enhancing tumor components (in case of contrast-enhancing tumor residuals). Furthermore, the contrast-to-noise ratio (CNR) was measured for contrast-enhancing tumor residuals. Both BB and conventional TFE imaging allowed for the correct detection of all contrast-enhancing tumor residuals intraoperatively (considering postsurgical MRI and histopathological evaluation as the ground truth for determination of the lack/presence of contrast-enhancing tumor residuals), but BB imaging showed significantly higher diagnostic confidence (R1: 4.65 ± 0.53 vs. 3.88 ± 1.02, p < 0.0001; R2: 4.75 ± 0.50 vs. 4.25 ± 0.81, p < 0.0001). Delineation of contrast-enhancing tumor residuals and detection of their spread into adjacent brain parenchyma was better for BB imaging. Accordingly, significantly higher CNRs were noted for BB imaging (48.1 ± 32.1 vs. 24.4 ± 15.3, p < 0.0001). In conclusion, BB imaging is not inferior to conventional TFE imaging for EOR assessment, but may significantly reduce scanning time for iMRI whilst increasing diagnostic confidence. Furthermore, given the better depiction of contrast-enhancing tumor residual spread and borders, BB imaging could support achieving complete macroscopic resection in patients suffering from HGG, which is clinically relevant as an optimal EOR is correlated to prolonged survival.

Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients

BACKGROUND

Laser ablation (LA) is used as an upfront treatment in patients with deep seated newly diagnosed Glioblastoma (nGBM).

OBJECTIVE

To evaluate the outcomes of LA in patients with nGBM and compare them with a matched biopsy-only cohort.

METHODS

Twenty-four nGBM patients underwent upfront LA at Cleveland clinic, Washington University in St. Louis, and Yale University (6/2011-12/2014) followed by chemo/radiotherapy. Also, 24 out of 171 nGBM patients with biopsy followed by chemo/radiotherapy were matched based on age (< 70 vs ≥ 70), gender, tumor location (deep vs lobar), and volume (<11 cc vs ≥11 cc). Progression-free survival (PFS), overall survival (OS), and disease-specific PFS and OS were outcome measures. Three prognostic groups were identified based on extent of tumor ablation by thermal-damage-threshold (TDT)-lines.

RESULTS

The median tumor volume in LA (n = 24) and biopsy only (n = 24) groups was 9.3 cm3 and 8.2 cm3 respectively. Overall, median estimate of OS and PFS in LA cohort was 14.4 and 4.3 mo compared to 15.8 mo and 5.9 mo for biopsy only cohort. On multivariate analysis, favorable TDT-line prognostic groups were associated with lower incidence of disease specific death (P = .03) and progression (P = .05) compared to other groups including biopsy only cohort. Only age (<70 yr, P = .02) and tumor volume (<11 cc, P = .03) were favorable prognostic factors for OS.

CONCLUSION

The maximum tumor coverage by LA followed by radiation/chemotherapy is an effective treatment modality in patients with nGBM, compared to biopsy only cohort. The TDT-line prognostic groups were independent predictor of disease specific death and progression after LA.

Craniotomy and Survival for Primary Central Nervous System Lymphoma

BACKGROUND

Cytoreductive surgery is considered controversial for primary central nervous system lymphoma (PCNSL).

OBJECTIVE

To investigate survival following craniotomy or biopsy for PCNSL.

METHODS

The National Cancer Database-Participant User File (NCDB, n = 8936), Surveillance, Epidemiology, and End Results Program (SEER, n = 4636), and an institutional series (IS, n = 132) were used. We retrospectively investigated the relationship between craniotomy, prognostic factors, and survival for PCNSL using case-control design.

RESULTS

In NCDB, craniotomy was associated with increased median survival over biopsy (19.5 vs 11.0 mo), independent of subsequent radiation and chemotherapy (hazard ratio [HR] 0.80, P < .001). We found a similar trend with survival for craniotomy vs biopsy in the IS (HR 0.68, P = .15). In SEER, gross total resection was associated with increased median survival over biopsy (29 vs 10 mo, HR 0.68, P < .001). The survival benefit associated with craniotomy was greater within recursive partitioning analysis (RPA) class 1 group in NCDB (95.1 vs 29.1 mo, HR 0.66, P < .001), but was smaller for RPA 2-3 (14.9 vs 10.0 mo, HR 0.86, P < .001). A surgical risk category (RC) considering lesion location and number, age, and frailty was developed. Craniotomy was associated with increased survival vs biopsy for patients with low RC (133.4 vs 41.0 mo, HR 0.33, P = .01), but not high RC in the IS.

CONCLUSION

Craniotomy is associated with increased survival over biopsy for PCNSL in 3 retrospective datasets. Prospective studies are necessary to adequately evaluate this relationship. Such studies should evaluate patients most likely to benefit from cytoreductive surgery, ie, those with favorable RPA and RC.

Advancements in predicting outcomes in patients with glioma: a surgical perspective

Introduction: Diffuse glioma is a challenging neurosurgical entity. Although surgery does not provide a cure, it may greatly influence survival, brain function, and quality of life. Surgical treatment is by nature highly personalized and outcome prediction is very complex. To engage and succeed in this balancing act it is important to make best use of the information available to the neurosurgeon.Areas covered: This narrative review provides an update on advancements in predicting outcomes in patients with glioma that are relevant to neurosurgeons.Expert opinion: The classical 'gut feeling' is notoriously unreliable and better prediction strategies for patients with glioma are warranted. There are numerous tools readily available for the neurosurgeon in predicting tumor biology and survival. Predicting extent of resection, functional outcome, and quality of life remains difficult. Although machine-learning approaches are currently not readily available in daily clinical practice, there are several ongoing efforts with the use of big data sets that are likely to create new prediction models and refine the existing models.

Surgery plus adjuvant radiotherapy for primary central nervous system lymphoma

Objective: Recent studies of primary central nervous system lymphoma (PCNSL) have found a positive association between cytoreductive surgery and survival, challenging the traditional notion that surgery is not beneficial and potentially harmful. However, no studies have examined the potential added benefits of adjuvant treatment in the post-operative setting. Here, we investigate survival in PCNSL patients treated with surgery plus radiation therapy (RT).Methods: The Surveillance, Epidemiology, and End-Results Program was used to identify patients with PCNSL from 1995-2013. We retrospectively analyzed the relationship between treatment, prognostic factors, and survival using case-control design. Treatment categories were compared to biopsy alone.Results: We identified 5417 cases. Median survival times for biopsy alone (n = 1824, 34%), biopsy + RT (n = 1460, 27%), surgery alone (n = 1222, 27%), and surgery + RT (n = 911, 17%) were 7, 8, 20, and 27 months, respectively. On multivariable analysis, surgery + RT was associated with improved survival over surgery alone (hazard ratio [HR] = 0.58 [95% confidence interval = 0.53-0.64] vs. HR = 0.71 [0.65-0.77]). Adjuvant RT was associated with improved survival, regardless of the extent of resection. HR's for subtotal resection, gross-total resection, subtotal resection + RT, and gross-total resection + RT were 0.77 (0.66-0.89), 0.66 (0.57-0.76), 0.62 (0.52-0.72), and 0.54 (0.46-0.63), respectively. Survival improved after adjuvant RT in patients under and over 60 years old. All findings were confirmed by multivariable analysis of cause-specific survival.Conclusion: Adjuvant RT was associated with improved survival in PCNSL patients who underwent surgery. Although these data are hypothesis-generating, additional information on neurotoxicity, dosing, and concurrent chemotherapy will be necessary to validate these findings. Cytoreductive surgery for PCNSL is common in the general population, and more studies are needed to assess optimal treatment in the post-operative setting.

Does preoperative health-related quality of life predict survival in high-grade glioma patients? - a prospective study

Purpose: To explore if preoperative patient-reported health-related quality of life (HRQoL) provides additional prognostic value as a supplement to other preoperatively known clinical factors in patients with high-grade glioma (HGG).Methods: In a prospective explorative study, 114 patients with high-grade glioma were included. The participants completed the generic HRQoL questionnaire EQ-5D 3L, and the disease-specific questionnaires EORTC QLQ-C30 and EORTC QLQ-BN20 1-3 days before surgery. Operating neurosurgeons scored the patient's preoperative functional level by using Karnofsky Performance Status (KPS). Univariate and multivariate Cox regression analyses were performed to identify HRQoL domains that were associated with survival. Kaplan-Meier survival curves and Log-rank tests were used to visualize differences in survival between groups.Results: In addition to preoperative KPS and age, the EORTC QLQ-BN20 subdomains 'seizures' (HR 0.98, p < .006), 'itchy skin' (HR 1.01, p < .036) and 'bladder control' (HR 1.01, p < .023) were statistically significant independent predictors of survival in a multivariate cox model.Conclusions: Our results suggest that in patients with HGG, certain preoperative symptom scales within EORTC QLQ-BN20 may provide additional prognostic information to supplement other clinical prognostic factors. However, further studies are required to validate our findings. Overall the instruments EQ-5D 3L and EORTC QLQ-C30 do not seem to provide much additional valuable prognostic information to already known prognostic factors.

Cost-effectiveness of preoperative motor mapping with navigated transcranial magnetic brain stimulation in patients with high-grade glioma

OBJECTIVE Navigated transcranial magnetic stimulation (nTMS) is used to identify the motor cortex prior to surgery. Yet, there has, until now, been no published evidence on the economic impact of nTMS. This study aims to analyze the cost-effectiveness of nTMS, evaluating the incremental costs of nTMS motor mapping per additional quality-adjusted life year (QALY). By doing so, this study also provides a model allowing for future analysis of general cost-effectiveness of new neuro-oncological treatment options. METHODS The authors used a microsimulation model based on their cohort population sampled for 1000 patients over the time horizon of 2 years. A health care provider perspective was used to assemble direct costs of total treatment. Transition probabilities and health utilities were based on published literature. Effects were stated in QALYs and established for health state subgroups. RESULTS In all scenarios, preoperative mapping was considered cost-effective with a willingness-to-pay threshold < 3*per capita GDP (gross domestic product). The incremental cost-effectiveness ratio (ICER) of nTMS versus no nTMS was 45,086 Euros/QALY. Sensitivity analyses showed robust results with a high impact of total treatment costs and utility of progression-free survival. Comparing the incremental costs caused by nTMS implementation only, the ICER decreased to 1967 Euros/QALY. CONCLUSIONS Motor mapping prior to surgery provides a cost-effective tool to improve the clinical outcome and overall survival of high-grade glioma patients in a resource-limited setting. Moreover, the model used in this study can be used in the future to analyze new treatment options in neuro-oncology in terms of their general cost-effectiveness.

A research protocol for a pilot, randomized controlled trial designed to examine the feasibility of a dyadic versus individual yoga program for family caregivers of glioma patients undergoing radiotherapy

BACKGROUND

Although the diagnosis and treatment of a primary brain tumor present unique challenges to patients and their family caregivers, evidence-based supportive care interventions are generally lacking. The primary aim of this research protocol is to determine the feasibility of implementing a dyadic yoga (DY) versus a caregiver yoga (CY) intervention or a wait-list control (WLC) group using a randomized controlled trial design.

METHODS

Seventy-five glioma patients undergoing radiotherapy and their family caregivers are randomized to the DY, CY, or a WLC group. Patient-caregiver dyads in the DY group and caregivers in the CY group receive 15 sessions (45 min each) over the course of patients' standard radiotherapy (6 weeks). Patients and caregivers in all groups complete baseline assessments of symptoms, quality of life (QOL), and health utilization outcomes prior to randomization. Follow-up assessments are performed 6 weeks and then again 3 months later. The primary outcome is feasibility (i.e., ≥ 50% of eligible dyads consent, ≥ 70% of enrolled dyads complete all assessments, and ≥ 50% of all practice sessions are attended). We will also perform primarily descriptive analyses of the self-reported outcomes (e.g., fatigue, overall QOL) and explore potential intervention moderators (e.g., performance status) to inform a larger future trial.

CONCLUSION

This trial will provide important information regarding the feasibility of a dyadic versus a caregiver yoga intervention regarding symptom, QOL, and health utilization outcomes in glioma patients and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02481349.

Toward Quantitative Neurosurgical Guidance With High-Resolution Microscopy of 5-Aminolevulinic Acid-Induced Protoporphyrin IX

Low-power fluorescence microscopy of 5-ALA-induced PpIX has emerged as a valuable intraoperative imaging technology for improving the resection of malignant gliomas. However, current fluorescence imaging tools are not highly sensitive nor quantitative, which limits their effectiveness for optimizing operative decisions near the surgical margins of gliomas, in particular non-enhancing low-grade gliomas. Intraoperative high-resolution optical-sectioning microscopy can potentially serve as a valuable complement to low-power fluorescence microscopy by providing reproducible quantification of tumor parameters at the infiltrative margins of diffuse gliomas. In this forward-looking perspective article, we provide a brief discussion of recent technical advancements, pilot clinical studies, and our vision of the future adoption of handheld optical-sectioning microscopy at the final stages of glioma surgeries to enhance the extent of resection. We list a number of challenges for clinical acceptance, as well as potential strategies to overcome such obstacles for the surgical implementation of these in vivo microscopy techniques.

High-field intraoperative MRI and glioma surgery: results after the first 100 consecutive patients

BACKGROUND

High-field intraoperative MRI (IoMRI) is part of the neurosurgical armamentarium to improve the extent of glioma resection (EOR).

OBJECTIVE

To report our oncological and functional outcomes using IoMRI for neuronavigated glioma surgery.

METHODS

In this prospective monocentric study, we reported 100 consecutive adult patients operated on for glioma using IoMRI with neuronavigation, under general anesthesia without intraoperative stimulation, from July 2014 to April 2017. The volumetric evaluation was based on the FLAIR hypersignal for non-enhancing tumors after Gadolinium infusion and on the T1 hypersignal after Gadolinium infusion for enhancing tumors. We evaluated the surgical workflow, the EOR and the clinical outcomes (using Karnofsky performance score (KPS)).

RESULTS

Sixty-nine patients underwent one IoMRI, and 31 from two IoMRI controls. At first IoMRI, the median tumor residue was higher in the FLAIR group than in the T1G+ group whereas no more difference was reported after the second IoMRI between the 2 groups (p = 0.56). Additional resection was performed 6 times more frequently in the FLAIR group (OR = 5.7, CI (1.9-17)). The median EOR was 100% (IQR, 93.6-100) whatever the tumor type (first surgery or recurrence) and location. Higher residues were reported only in the insula area (p = 0.004). The median KPS was 90 (IQR, 80-100) at discharge, 3, 6 and 12 months after surgery, with no statistical difference between low- and high-grade gliomas (p = 0.34).

CONCLUSION

IoMRI neuronavigated surgery provided maximal EOR whatever the type of glioma and location. IoMRI was all the more useful for non- or minimally enhancing tumors. The step by step surgical resection, introducing the concept of "staged volume" surgery, ensured a high security for the surgeon and low permanent morbidity for the patients.

Optical Signatures Derived From Deep UV to NIR Excitation Discriminates Healthy Samples From Low and High Grades Glioma

Among all the tumors of the central nervous system (CNS), glioma are the most deadly and the most malignant. Surgical resection is the standard therapeutic method to treat this type of brain cancer. But the diffusive character of these tumors create many problems for surgeons during the operation. In fact, these tumors migrate outside the tumor solid zone and invade the surrounding healthy tissues. These infiltrative tissues have the same visual appearance as healthy tissues, making it very difficult for surgeons to distinguish the healthy ones from the diffused ones. The surgeon, therefore, cannot properly remove the tumor margins increasing the recurrence risk of the tumor. To resolve this problem, our team has developed a multimodal two-photon fibered endomicroscope, compatible with the surgeon trocar, to better delimitate tumor boundaries by relying on the endogenous fluorescence of brain tissues. In this context, and in order to characterize the optical signature of glioma tumors, this study offers multimodal and multi-scaled optical measurements from healthy tissues to high grade glioma. We can interrogate tissue from deep ultra-violet to near infrared excitation by working with spectroscopy, fluorescence lifetime imaging, two-photon fluorescene imaging and Second Harmonic Generation (SHG) imaging. Optically derived ratios such as the Tryptophan/Collagen ratio, the optical redox ratio and the long lifetime intensity fraction, discriminated diseased tissue from its normal counterparts when fitted by Gaussian ellipsoids and choosing a threshold for each. Additionally two-photon fluorescence and SHG images were shown to display similar histological features as Hematoxylin-Eosin stained images.

Glioblastoma in Elderly Patients: Current Management and Future Perspectives

The incidence of glioblastoma (GBM) in the elderly population is slowly increasing in Western countries. Current management includes surgery, radiation therapy (RT) and chemotherapy; however, survival is significantly worse than that observed in younger patients and the optimal treatment in terms of efficacy and safety remains a matter of debate. Surgical resection is often employed as initial treatment for elderly patients with GBM, although the survival benefit is modest. Better survival has been reported in elderly patients treated with RT compared with those receiving supportive care alone, with similar survival outcome for patients undergoing standard RT (60 Gy over 6 weeks) and hypofractionated RT (25⁻40 Gy in 5⁻15 daily fractions). Temozolomide, an alkylating agent, may represent an effective and safe therapy in patients with promoter methylation of O⁶-methylguanine-DNA-methyltransferase (MGMT) gene which is predictor of responsiveness to alkylating agents. An abbreviated course of RT, 40 Gy in 15 daily fractions in combination with adjuvant and concomitant temozolomide has emerged as an effective treatment for patients aged 65 years old or over with GBM. Results of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG CE6) and European Organization for Research and Treatment of Cancer (EORTC 26062/22061) randomized study of short-course RT with or without concurrent and adjuvant temozolomide have demonstrated a significant improvement in progression-free survival and overall survival for patients receiving RT and temozolomide over RT alone, without impairing either quality of life or functional status. Although combined chemoradiation has become the recommended treatment in fit elderly patients with GBM, several questions remain unanswered, including the survival impact of chemoradiation in patients with impaired neurological status, advanced age (>75⁻80 years old), or for those with severe comorbidities. In addition, the efficacy and safety of alternative therapeutic approaches according to the methylation status of the O⁶-methylguanine-DNA methyl-transferase (MGMT) gene promoter need to be explored in future trials.

Brain atlas for assessing the impact of tumor location on perioperative quality of life in patients with high-grade glioma: A prospective population-based cohort study

Background

Tumor location is important for surgical decision making. Particular attention is paid to regions that contain sensorimotor and language functions, but it is unknown if these are the most important regions from the patients' perspective.

Objective

To develop an atlas for depicting and assessing the potential importance of tumor location for perioperative health-related quality of life (HRQoL) in patients with newly diagnosed high-grade glioma.

Methods

Patient-reported HRQoL data and semi-automatically segmented preoperative 3D MRI-images were combined in 170 patients. The images were registered to a standardized space where the individual tumors were given the values and color intensity of the corresponding HRQoL. Descriptive brain maps of HRQoL, defined quantitative analyses, and voxel-based lesion symptom mapping comparing patients with tumors in different locations were made.

Results

There was no statistical difference in overall perioperative HRQoL between patients with tumors located in left or right hemisphere, between patients with tumors in different lobes, or between patients with tumors located in non-eloquent, near eloquent, or eloquent areas. Patients with tumors involving the internal capsule, and patients with preoperative motor symptoms and postoperative motor deficits, reported significantly worse overall HRQoL-scores.

Conclusions

The impact of anatomical tumor location on overall perioperative HRQoL seems less than frequently believed, and the distinction between critical and less critical brain regions seems more unclear according to the patients than perhaps when judged by physicians. However, worse HRQoL was found in patients with tumors in motor-related regions, indicating that these areas are crucial also from the patients' perspective.

•

The impact of tumor location on patient-reported overall quality of life is low.

•

There is no “dominant hemisphere” from the patients' perspective.

•

Motor related regions seem to be most crucial for the patients.

Experience Profiling of Fluorescence-Guided Surgery I: Gliomas

Background

Numerous studies reported a usefulness of 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery (FGS) in high grade gliomas. However, fluorescence patterns and intensities are variable among gliomas. In this study, we report our extensive experience with FGS in various gliomas, focusing on epidemiological data of fluorescence patterns.

Methods

A total of 827 histologically proven glioma patients out of 900 brain tumor patients who had undergone FGS using 5-ALA during the period of 8.5 years between July 2010 and January 2019 were analyzed. Indications of FGS in glioma surgery are evidence for possible high-grade foci in putative gliomas in preoperative MRI.

Results

Among the 827 gliomas, the number of cases corresponding to 2016 World Health Organization (WHO) grade IV, III, II, and I are 528 (58.7%), 193 (21.4%), 87 (9.7%) and 19 (2.1%), respectively. In terms of fluorescence rate, grade IV gliomas showed positive fluorescence in 95.4% of cases including strong intensity in 85.6%. Grade III gliomas showed fluorescence in about half of cases (55.0%), but 45.0% of the cases showed no fluorescence at all. Anaplastic oligodendroglioma had a higher positive rate (63.9%) than anaplastic astrocytoma (46.2%). Both grade II and I gliomas still showed positive fluorescence in about one-fourth of cases (24.1% and 26.3% respectively). Among them ependymoma and pilocytic astrocytoma were fluorescence-prone tumors.

Conclusion

This epidemiological data of 5-ALA fluorescence in various grades of glioma provides a basic reference to the clinical application of FGS with 5-ALA in glioma surgery.

The Impact of Compressed Femtosecond Laser Pulse Durations on Neuronal Tissue Used for Two-Photon Excitation Through an Endoscope

Accurate intraoperative tumour margin assessment is a major challenge in neurooncology, where sparse tumours beyond the bulk tumour are left undetected under conventional resection. Non-linear optical imaging can diagnose tissue at the sub-micron level and provide functional label-free histopathology in vivo. For this reason, a non-linear endomicroscope is being developed to characterize brain tissue intraoperatively based on multiple endogenous optical contrasts such as spectrally- and temporally-resolved fluorescence. To produce highly sensitive optical signatures that are specific to a given tissue type, short femtosecond pulsed lasers are required for efficient two-photon excitation. Yet, the potential of causing bio-damage has not been studied on neuronal tissue. Therefore, as a prerequisite to clinically testing the non-linear endomicroscope in vivo, the effect of short laser pulse durations (40-340 fs) on ex vivo brain tissue was investigated by monitoring the intensity, the spectral, and the lifetime properties of endogenous fluorophores under 800 and 890 nm two-photon excitation using a bi-modal non-linear endoscope. These properties were also validated by imaging samples on a benchtop multiphoton microscope. Our results show that under a constant mean laser power, excitation pulses as short as 40 fs do not negatively alter the biochemical/ biophysical properties of tissue even for prolonged irradiation.

Quality of life of irradiated brain tumor survivors treated with donepezil or placebo: Results of the WFU CCOP research base protocol 91105

Background

The health-related quality of life (HRQL) and fatigue of brain cancer survivors treated with donepezil or placebo for cognitive symptoms after radiation therapy were examined.

Methods

One hundred ninety-eight patients who completed >30 Gy fractionated whole or partial brain irradiation at least 6 months prior to enrollment were randomized to either placebo or donepezil (5 mg for 6 weeks followed by 10 mg for 18 weeks) in a phase 3 trial. A neurocognitive battery, the Functional Assessment of Cancer Therapy-Brain (FACT-Br) and the Functional Assessment of Chronic Illness Therapy (FACIT)-fatigue, was administered at baseline, 12 weeks, and 24 weeks.

Results

At 12 weeks, donepezil resulted in improvements in only emotional functioning (P = .04), with no significant effects at week 24. Associations by level of baseline cognitive symptoms (above or below the median score of the baseline FACT-Br "additional concerns/brain" subscale), indicated that participants with more baseline symptoms who received donepezil versus placebo, showed improvements in social (P = .02) and emotional well-being (P = .038), other concerns/brain (P = .003) and the FACT-Br total score (P = .004) at 12 weeks, but not 24 weeks. However, participants with fewer baseline symptoms randomized to donepezil versus placebo reported lower functional well-being at both 12 (P = .015) and 24 weeks (P = .009), and greater fatigue (P = .02) at 24 weeks.

Conclusions

The positive impact of donepezil on HRQL was greater in survivors reporting more baseline cognitive symptoms. Donepezil had significantly worse effects on fatigue and functional well-being among participants with fewer baseline symptoms. Future interventions with donepezil should target participants with more baseline cognitive complaints to achieve greater therapeutic impact and lessen potential side effects of treatment.

Which Parameter Is More Important for the Prognosis of New-Onset Adult Glioblastoma: Residual Tumor Volume or Extent of Resection?

BACKGROUND

The extent of resection (EOR) and residual tumor volume (RTV) are 2 pivotal predictors influencing the survival of patients with new-onset adult glioblastoma. Which of these 2 factors is more important remains unclear, however. The present aimed to evaluate and compare the accuracy of EOR and RTV, based on contrast-enhancing (CE) T1-weighted magnetic resonance imaging (MRI) and T2-weighted/fluid-attenuated inversion recovery (F) MRI, as prognostic factors in these patients.

METHODS

In this retrospective study, data were extracted from the databases of 2 hospitals between January 1, 2013, and December 31, 2015. The subjects were divided into 2 groups, the total resection group and the partial resection group. The analysis comprised EOR and RTV. Statistical analysis was performed after controlling for other relevant factors.

RESULTS

We analyzed 292 patients with new-onset glioblastoma who met the inclusion criteria. In the partial resection group, univariate analysis revealed that CE-EOR, CE-RTV, F-EOR, and F-RTV were correlated with progression-free survival (PFS) and overall survival (OS), but multivariate analysis identified no correlation between CE-EOR or F-EOR and PFS or OS. In the total resection group, F-EOR and F-RTV were correlated with PFS and OS in univariate analysis, but F-EOR was not correlated in multivariate analysis.

CONCLUSIONS

Regardless of total or partial CE tumor resection, EOR might not be an independent prognostic factor. In contrast, RTV has the potential to offer greater predictive power for the prognosis of new-onset adult glioblastoma. Further investigations of the correlations of RTV and EOR with survival in patients with new-onset glioblastoma are needed.

High-field intraoperative MRI in glioma surgery: A prospective study with volumetric analysis of extent of resection and functional outcome

BACKGROUND

High-field intraoperative MRI (IoMRI) is a useful tool to improve the extent of glioma resection (EOR).

OBJECTIVE

To compare the interest of 1.5T IoMRI in glioma surgery between enhancing and non-enhancing tumors, based on volumetric analysis.

METHODS

A prospective single-center study included consecutive adult patients undergoing glioma surgery with IoMRI. Volumetric evaluation was based on FLAIR hypersignal after gadolinium injection in non-enhancing tumors and T1 hypersignal after gadolinium injection in enhancing tumors. Endpoints comprised: residual tumor volume (RTV), EOR, workflow and clinical outcome on Karnofsky performance score (KPS).

RESULTS

Fifty-three surgeries were performed from July 2014 to January 2016. Thirty-four patients underwent one IoMRI, and 19 two IoMRIs. In non-enhancing tumors, intraoperative RTV on 1st IoMRI T2/FLAIR was higher than in enhancing tumors on T1 sequences (7.25cm³ vs. 0.74cm³, respectively; P=0.008), whereas the RTV on 2nd IoMRIs and final RTV were no longer significantly different. After IoMRI, 72% of patients underwent additional resection. In non-enhancing tumors, EOR increased from 77.3% on 1st IoMRI to 97.4% on last MRI (P<0.001). Taking all tumors together, final RTV values were: median=0cm³, mean=3.9cm³. Mean final EOR was 94%. In 25% of patients, KPS was reduced during early postoperative course; at 3 and 6 months postoperatively, median KPS was 90.

CONCLUSION

Intraoperative MRI guidance significantly enhanced the extent of glioma resection, especially for non- or minimally enhancing tumors, while preserving patient autonomy.

Overview on current treatment standards in high-grade gliomas

High-grade gliomas (HGGs) are the most common primary tumors of the central nervous system, which include anaplastic gliomas (grade III) and glioblastomas (GBM, grade IV). Surgery is the mainstay of treatment in HGGs in order to achieve a histological and molecular characterization, as well as relieve neurological symptoms and improve seizure control. Combinations of some molecular factors, such as IDH 1-2 mutations, 1p/19q codeletion and MGMT methylation status, allow to classify different subtypes of gliomas and identify patients with different outcome. The SOC in HGGs consists in a combination of radiotherapy and chemotherapy with alkylating agents. Despite this therapeutic approach, tumor recurrence occurs in HGGs, and new surgical debulking, reirradiation or second-line chemotherapy are needed. Considering the poor results in terms of survival, several clinical trials have explored the efficacy and tolerability of antiangiogenic agents, targeted therapies against epidermal growth factor receptor (EGFR) and different immunotherapeutic approaches in recurrent and newly-diagnosed GBM, including immune checkpoint inhibitors (ICIs), and cell- or peptide-based vaccination with unsatisfactory results in term of disease control. In this review we describe the major updates in molecular biology of HGGs according to 2016 WHO Classification, the current management in newly-diagnosed and recurrent GBM and grade III gliomas, and the results of the most relevant clinical trials on targeted agents and immunotherapy.

Treatment of Glioblastoma in Elderly Patients: An Overview of Current Treatments and Future Perspective

Current treatment of glioblastoma in the elderly includes surgery, radiotherapy and chemotherapy, but the prognosis remains extremely poor, and its optimal management is still debated. Longer survival after extensive resection compared with biopsy only has been reported, although the survival advantage remains modest. Radiation in the form of standard (60 Gy in 30 fractions over 6 weeks) and abbreviated courses of radiotherapy (30–50 Gy in 6–20 fractions over 2–4 weeks) has been employed in elderly patients with glioblastoma, showing survival benefits compared with supportive care alone. Temozolomide is an alkylating agent recently employed in older patients with newly diagnosed glioblastoma. The addition of concomitant and/or adjuvant chemotherapy with temozolomide to radiotherapy, which is currently the standard treatment in adults with glioblastoma, is emerging as an effective therapeutic option for older patients with favorable prognostic factors. The potential benefits on survival, improvement in quality of life and toxicity of different schedules of radiotherapy plus temozolomide need to be addressed in future randomized studies. Free full text available at www.tumorionline.it

Long-term Survivors of Childhood Brain Tumors: Impact on General Health and Quality of Life

PURPOSE OF REVIEW

We review and summarize the key issues affecting general health and quality of life (QOL) of pediatric long-term survivors of brain tumors.

RECENT FINDINGS

Long-term survivors of brain tumors are at risk of considerable late morbidity and mortality. Lengthening survival in brain tumors has highlighted the deep impact of tumor and its treatment on the physical, psychological, functional, and social health and QOL of these survivors. Evolution in tumor therapy including surgery, radiotherapy, and systemic therapies, etc., has the potential to mitigate this impact to some extent. Sensitization of health staff, policy makers, and the primary designers of clinical trials towards integration of QOL end points while measuring survival in brain tumor patients is the need of the hour. New developments in tumor therapeutics must not only provide quantitative gain but also improve the quality of survival in these long-term survivors. While majority of the issues presented pertain to survivorship in pediatric brain tumor population, similar challenges are likely to exist in young adults surviving brain tumors as well.

Estimating progression-free survival in patients with glioblastoma using routinely collected data

Glioblastoma (GBM) represents 80% of all primary malignant brain tumours in adults. Prognosis is poor, and there is a clear correlation between disease progression and deterioration in functional status. In this pilot study we assess whether we can estimate disease progression and progression free survival (PFS) from routinely collected electronic healthcare data. We identified fifty patients with glioblastoma who had chemo-radiotherapy. For each patient we manually collected a reference data set recording demographics, surgery, radiotherapy, chemotherapy, follow-up and death. We also obtained an electronic routine data set for each patient by combining local data on chemotherapy/radiotherapy and hospital admissions. We calculated overall survival (OS) and PFS using the reference data set, and estimated them using the routine data sets using two different methods, and compared the estimated measures with the reference measures. Overall survival was 68% at 1 year and median OS was 12.8 months. The routine data correctly identified progressive disease in 37 of 40 patients and stable disease in 7 of 10 patients. PFS was 7.4 months and the estimated PFS using routine data was 9.1 and 7.8 months with methods 1 and 2 respectively. There was acceptable agreement between reference and routine data in 49 of 50 patients for OS and 35 of 50 patients for PFS. The event of progression, subsequent treatment and OS are well estimated using our approach, but PFS estimation is less accurate. Our approach could refine our understanding of the disease course and allow us to report PFS, OS and treatment nationally.

Assessing the Safety of Craniotomy for Resection of Primary Central Nervous System Lymphoma: A Nationwide Inpatient Sample Analysis

Background

Unlike many other central nervous system (CNS) tumors, the surgical management of primary central nervous system lymphomas (PCNSL) is traditionally limited by diagnostic biopsy. Studies that predate the use of modern neurosurgical techniques have reported a prohibitive operative morbidity for this surgery. These early experiences have dictated the non-surgical management of PCNSL, whereas resection for cytoreduction is a mainstay of treatment in other CNS malignancies. Recent studies have suggested that craniotomy with the goal of cytoreduction might be associated with a favorable overall and progression-free survival for some patients with PCNSL. To challenge the traditional non-surgical paradigm, it is essential to first investigate the safety of resection for PCNSL.

Methods

To determine the operative morbidity of resection for this disease, we performed a population-based assessment of complications using the nationwide inpatient sample database for the years 1998–2013 for biopsies and open craniotomies for PCNSL and other brain tumors.

Results

Among 95 patients who underwent biopsy and 34 patients who underwent craniotomy, we found no significant difference in complication rates between craniotomy for resection and biopsy procedures for PCNSL (23.16 versus 20.59%). The types of complications differ between diagnoses, with the PCNSL cohort suffering mainly medical complications and the non-PCNSL cohort suffering mainly from neurological complications.

Conclusion

These findings support the safety of craniotomies in PCNSL and help provide a rationale for future prospective studies to evaluate the safety and efficacy of resection for this disease.

Emotional Problems, Quality of Life, and Symptom Burden in Patients With Lung Cancer

OBJECTIVES

Lung cancer is associated with a greater symptom burden than other cancers, yet little is known about the prevalence of emotional problems and how emotional problems may be related to the physical symptom burden and quality of life in newly diagnosed patients with lung cancer. This study aimed to identify the patient and disease characteristics of patients with lung cancer experiencing emotional problems and to examine how emotional problems relate to quality of life and symptom burden.

PATIENTS AND METHODS

A total of 2205 newly diagnosed patients with lung cancer completed questionnaires on emotional problems, quality of life, and symptom burden.

RESULTS

Emotional problems at diagnosis were associated with younger age, female gender, current cigarette smoking, current employment, advanced lung cancer disease, surgical or chemotherapy treatment, and a lower Eastern Cooperative Oncology Group performance score. Additionally, strong associations were found between greater severity of emotional problems, lower quality of life, and greater symptom burden.

CONCLUSION

Certain characteristics place patients with lung cancer at greater risk for emotional problems, which are associated with a reduced quality of life and greater symptom burden. Assessment of the presence of emotional problems at the time of lung cancer diagnosis provides the opportunity to offer tailored strategies for managing negative mood, and for improving the quality of life and symptom burden management of patients with lung cancer.