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Ishida N, Matsuo Y, Fukuda J, Ri A, Tatsuno S, Uehara T, Inada M, Matsuura T, Doi H, Nakamatsu K, Hosono M. Radiation-Induced Lymphopenia and Its Impact on Survival in Patients with Brain Metastasis. Curr Oncol 2024; 31:4559-4567. [PMID: 39195323 DOI: 10.3390/curroncol31080340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Differences in radiation-induced lymphopenia and prognosis between methods of radiotherapy (RT) for brain metastases remain unclear. METHODS In this retrospective analysis of patients who underwent whole-brain radiotherapy (WBRT) or stereotactic radiosurgery/radiotherapy (SRS/SRT) for brain metastases, baseline total lymphocyte count (TLC) data were obtained within 2 weeks before RT initiation. Follow-up TLC data were evaluated at 0-2, 2-4, and 4-8 weeks after RT completion. Persistent lymphopenia was defined as <800/μL at any time point. RESULTS Overall, 138 RT courses in 128 patients were eligible (94 WBRT; 44 SRS/SRT). In the WBRT courses, the median baseline TLC was 1325/μL (IQR: 923-1799). Follow-up TLC decreased significantly to 946/μL (626-1316), 992/μL (675-1291), and 1075/μL (762-1435) (p < 0.001). SRS/SRT courses showed no significant TLC decrease. Multivariate analysis revealed female sex, prior RT, baseline TLC < 800/μL, and WBRT use were significantly associated with persistent lymphopenia. In the WBRT group, overall survival was significantly different between those with and without persistent lymphopenia (median, 2.6 and 6.1 months; p < 0.001). However, there was no significant difference in survival in the SRS/SRT group (p = 0.60). CONCLUSION This study suggests SRS/SRT might be preferable for lymphocyte preservation in brain metastasis patients.
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Affiliation(s)
- Naoko Ishida
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Junki Fukuda
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Aritoshi Ri
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
- Department of Radiation Oncology, Yamato Takada Municipal Hospital, 1-1 Isonokita-cho, Yamatotakada 635-0094, Nara, Japan
| | - Saori Tatsuno
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Takuya Uehara
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Masahiro Inada
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Tomohiro Matsuura
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
- Department of Radiation Oncology, Fuchu Hospital, 1-10-17 Hiko-cho, Izumi 594-0076, Osaka, Japan
| | - Hiroshi Doi
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Kiyoshi Nakamatsu
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
| | - Makoto Hosono
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama 589-8511, Osaka, Japan
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Takeda K, Umezawa R, Yamamoto T, Takahashi N, Suzuki Y, Kishida K, Omata S, Jingu K. Lymphopenia after palliative radiotherapy for vertebral metastases. JOURNAL OF RADIATION RESEARCH 2024; 65:523-531. [PMID: 38818633 PMCID: PMC11262856 DOI: 10.1093/jrr/rrae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/04/2024] [Indexed: 06/01/2024]
Abstract
Lymphopenia is a well-known side effect of radiotherapy and has been shown to have a negative impact on patient outcomes. However, the extent of lymphopenia caused by palliative radiotherapy and its effect on patient prognosis has not been clarified. The aim of this study was to determine the incidence and severity of lymphopenia after palliative radiotherapy for vertebral metastases and to determine their effects on patients' survival outcomes. We conducted a retrospective analysis for patients who underwent palliative radiotherapy for vertebral metastases and could be followed up for 12 weeks. Lymphocyte counts were documented at baseline and throughout the 12-week period following the start of radiotherapy and their medians and interquartile ranges (IQRs) were recorded. Exploratory analyses were performed to identify predictive factors for lymphopenia and its impact on overall survival (OS). A total of 282 cases that met the inclusion criteria were analyzed. The median baseline lymphocyte count was 1.26 × 103/μl (IQR: 0.89-1.72 × 103/μl). Peak lymphopenia occurred at a median of 26 days (IQR: 15-45 days) with a median nadir of 0.52 × 103/μl (IQR: 0.31-0.81 × 103/μl). Long-term analysis of patients surviving for 1 year showed that lymphopenia persisted at 1 year after radiotherapy. The main irradiation site, radiation field length and pretreatment lymphocyte count were significantly related to grade 3 or higher lymphopenia. Lymphopenia was identified as a significant predictor of OS by multivariate Cox regression analysis. This study demonstrated the incidence of lymphopenia after palliative radiotherapy for vertebral metastases and its effect on patients' OS.
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Affiliation(s)
- Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
- Department of Radiation Oncology, South Miyagi Medical Center, 38-1 Nishi, Ogawara, Shibata 989-1253, Miyagi, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
| | - Keita Kishida
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
| | - So Omata
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Miyagi Japan
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3
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Kim J, Choi H, Jeun SS, Ahn S. From lymphopenia to restoration: IL-7 immunotherapy for lymphocyte recovery in glioblastoma. Cancer Lett 2024; 588:216714. [PMID: 38369003 DOI: 10.1016/j.canlet.2024.216714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/20/2024]
Abstract
Glioblastoma, the most prevalent malignant primary brain tumor, presents substantial treatment challenges because of its inherent aggressiveness and limited therapeutic options. Lymphopenia, defined as reduced peripheral blood lymphocyte count, commonly occurs as a consequence of the disease and its treatment. Recent studies have associated lymphopenia with a poor prognosis. Factors that contribute to lymphopenia include radiotherapy, chemotherapy, and the tumor itself. Patients who are female, older, using dexamethasone, or receiving higher doses of radiation therapy are particularly vulnerable to this condition. Several preclinical studies have explored the use of interleukin-7, a crucial cytokine for lymphocyte homeostasis, to restore lymphocyte counts and potentially rebuild the immune system to combat glioblastoma cells. With the development of recombinant interleukin-7 for prolonged activity in the body, various clinical trials are underway to explore this treatment in patients with glioblastoma. Our study provides a comprehensive summary of the incidence of lymphopenia, its potential biological background, and the associated clinical risk factors. Furthermore, we reviewed several clinical trials using IL-7 cytokine therapy in glioblastoma patients. We propose IL-7 as a promising immunotherapeutic strategy for glioblastoma treatment. We are optimistic that our study will enhance understanding of the complex interplay between lymphopenia and glioblastoma and will pave the way for the development of more effective treatment modalities.
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Affiliation(s)
- Joonseok Kim
- College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Haeyoun Choi
- Department of Microbiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sin-Soo Jeun
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Stephen Ahn
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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4
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Scheffler P, Fung C, Momjian S, Koessinger D, Häni L, Neidert N, Straehle J, Volz F, Schnell O, Beck J, El Rahal A. Dexamethasone in Patients with Glioblastoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:1393. [PMID: 38611071 PMCID: PMC11011080 DOI: 10.3390/cancers16071393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE Glioblastomas are the most common primary central nervous system (CNS) tumors. Although modern management strategies have modestly improved overall survival, the prognosis remains dismal, with treatment side effects often impinging on the clinical course. Glioblastomas cause neurological dysfunction by infiltrating CNS tissue and via perifocal oedema formation. The administration of steroids such as dexamethasone is thought to alleviate symptoms by reducing oedema. However, despite its widespread use, the evidence for the administration of dexamethasone is limited and conflicting. Therefore, we aimed to review the current evidence concerning the use and outcomes of dexamethasone in patients with glioblastoma. METHODS We performed a systematic review and meta-analysis according to the PRISMA-P guidelines. We performed a restricted search using the keywords "Dexamethasone" and "Glioblastoma" on PubMed, Web of Science, Cochrane Library, and Academic Search Premier. We included studies reporting on overall survival (OS) and progression-free survival (PFS) in glioblastoma patients receiving higher or lower dexamethasone doses. The risk of bias was assessed using ROBINS-I. We performed a meta-analysis using a random effects model for OS and PFS. RESULTS Twenty-two retrospective studies were included. Higher doses of dexamethasone were associated with poorer OS (hazard ratio 1.62, confidence interval 1.40-1.88) and PFS (1.49, 1.23-1.81). OS remained worse even when studies corrected for clinical status (1.52, 1.38-1.67). CONCLUSION Despite the widespread use of dexamethasone in glioblastoma patients, its use is correlated with worse long-term outcomes. Consequently, Dexamethasone administration should be restricted to selected symptomatic patients. Future prospective studies are crucial to confirm these findings.
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Affiliation(s)
- Pierre Scheffler
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Christian Fung
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Shahan Momjian
- Department of Neurosurgery, Geneva University Hospital, Faculty of Medicine of Geneva, 1205 Geneva, Switzerland
| | - Dominik Koessinger
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Levin Häni
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Nicolas Neidert
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
- Berta-Ottenstein Programme, Faculty of Medicine, University of Freiburg, 79098 Freiburg, Germany
| | - Jakob Straehle
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Florian Volz
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center University of Freiburg, 79098 Freiburg, Germany; (P.S.)
- Department of Neurosurgery, Geneva University Hospital, Faculty of Medicine of Geneva, 1205 Geneva, Switzerland
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5
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Stepanenko AA, Sosnovtseva AO, Valikhov MP, Chernysheva AA, Abramova OV, Naumenko VA, Chekhonin VP. The need for paradigm shift: prognostic significance and implications of standard therapy-related systemic immunosuppression in glioblastoma for immunotherapy and oncolytic virotherapy. Front Immunol 2024; 15:1326757. [PMID: 38390330 PMCID: PMC10881776 DOI: 10.3389/fimmu.2024.1326757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Despite significant advances in our knowledge regarding the genetics and molecular biology of gliomas over the past two decades and hundreds of clinical trials, no effective therapeutic approach has been identified for adult patients with newly diagnosed glioblastoma, and overall survival remains dismal. Great hopes are now placed on combination immunotherapy. In clinical trials, immunotherapeutics are generally tested after standard therapy (radiation, temozolomide, and steroid dexamethasone) or concurrently with temozolomide and/or steroids. Only a minor subset of patients with progressive/recurrent glioblastoma have benefited from immunotherapies. In this review, we comprehensively discuss standard therapy-related systemic immunosuppression and lymphopenia, their prognostic significance, and the implications for immunotherapy/oncolytic virotherapy. The effectiveness of immunotherapy and oncolytic virotherapy (viro-immunotherapy) critically depends on the activity of the host immune cells. The absolute counts, ratios, and functional states of different circulating and tumor-infiltrating immune cell subsets determine the net immune fitness of patients with cancer and may have various effects on tumor progression, therapeutic response, and survival outcomes. Although different immunosuppressive mechanisms operate in patients with glioblastoma/gliomas at presentation, the immunological competence of patients may be significantly compromised by standard therapy, exacerbating tumor-related systemic immunosuppression. Standard therapy affects diverse immune cell subsets, including dendritic, CD4+, CD8+, natural killer (NK), NKT, macrophage, neutrophil, and myeloid-derived suppressor cell (MDSC). Systemic immunosuppression and lymphopenia limit the immune system's ability to target glioblastoma. Changes in the standard therapy are required to increase the success of immunotherapies. Steroid use, high neutrophil-to-lymphocyte ratio (NLR), and low post-treatment total lymphocyte count (TLC) are significant prognostic factors for shorter survival in patients with glioblastoma in retrospective studies; however, these clinically relevant variables are rarely reported and correlated with response and survival in immunotherapy studies (e.g., immune checkpoint inhibitors, vaccines, and oncolytic viruses). Our analysis should help in the development of a more rational clinical trial design and decision-making regarding the treatment to potentially improve the efficacy of immunotherapy or oncolytic virotherapy.
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Affiliation(s)
- Aleksei A. Stepanenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anastasiia O. Sosnovtseva
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Marat P. Valikhov
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anastasia A. Chernysheva
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Olga V. Abramova
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Victor A. Naumenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Vladimir P. Chekhonin
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
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6
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Arora H, Mammi M, Patel NM, Zyfi D, Dasari HR, Yunusa I, Simjian T, Smith TR, Mekary RA. Dexamethasone and overall survival and progression free survival in patients with newly diagnosed glioblastoma: a meta-analysis. J Neurooncol 2024; 166:17-26. [PMID: 38151699 DOI: 10.1007/s11060-023-04549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/16/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE Glioblastomas, the most common primary malignant brain tumors in adults, still hold poor prognosis. Corticosteroids, such as dexamethasone, are usually prescribed to reduce peritumoral edema and limit neurological symptoms, although potential detrimental effects of these drugs have been described. The present meta-analysis aimed to explore the association of dexamethasone with overall survival (OS) and progression free survival (PFS) in patients with newly diagnosed glioblastoma. METHODS PubMed, Cochrane Library, Embase, and ClinicalTrials.gov were searched for pertinent studies following the Preferred Reporting Items of Systematic Review and Meta-Analysis checklist. Pooled multivariable-adjusted hazard ratios (HR) for OS and PFS and their associated 95% confidence intervals (CIs) were calculated using the random-effects model and the heterogeneity among studies was assessed using I2. The quality of evidence was assessed using the GRADE criteria. RESULTS Seven studies were included, pooling data of 1,257 patients, with age varying from 11 to 81 years. Glioblastoma patients on pre- or peri-operative dexamethasone were associated with a significantly poorer overall survival (HR: 1.33, 95% CI: 1.15, 1.55; 7 studies; I2: 59.9%) and progression free survival (HR: 1.77, 95% CI: 1.05, 2.97; 3 studies; I2: 71.1%) compared to patients not on dexamethasone. The quality of evidence was moderate for overall survival and low for progression free survival. CONCLUSION Dexamethasone appeared to be associated with poor survival outcomes of glioblastoma patients.
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Affiliation(s)
- Harshit Arora
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Mammi
- Neurosurgery Division, "M. Bufalini" Hospital, Cesena, Italy
| | - Naisargi Manishkumar Patel
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Dea Zyfi
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Hema Reddy Dasari
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Ismael Yunusa
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Thomas Simjian
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA.
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7
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Mistry AM. Perioperative dexamethasone in high-grade gliomas: the short-term benefits and long-term harms. Front Oncol 2023; 13:1335730. [PMID: 38162484 PMCID: PMC10755919 DOI: 10.3389/fonc.2023.1335730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
Dexamethasone has been commonly given to patients with a presumed new GBM in relatively large doses (6-16 mg daily for 1-2 weeks) since the 1960s without any rigorous evidence. This treatment with dexamethasone before the diagnosis and adjuvant therapy makes GBM patients unique compared to other newly diagnosed cancer patients. While dexamethasone may be beneficial, recent studies suggest that this potent immunosuppressant with pleiotropic effects is harmful in the long term. This perspective article summarizes the disadvantages of perioperative dexamethasone from multiple facets. It concludes that these growing data mandate rigorously testing the benefits of using perioperative dexamethasone.
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Affiliation(s)
- Akshitkumar M. Mistry
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States
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8
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de Kermenguy F, Meziani L, Mondini M, Clémenson C, Morel D, Deutsch E, Robert C. Radio-induced lymphopenia in the era of anti-cancer immunotherapy. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2023. [DOI: 10.1016/bs.ircmb.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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9
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Zhang Y, Chen S, Chen H, Chen S, Li Z, Feng E, Li W. Prognostic Value and Risk Factors of Treatment-Related Lymphopenia in Malignant Glioma Patients Treated With Chemoradiotherapy: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:726561. [PMID: 35058869 PMCID: PMC8764122 DOI: 10.3389/fneur.2021.726561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/09/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Immunotherapy has shown promising therapeutic efficacy in various cancers but not gliomas. Circulating lymphocytes play critical roles in cancer control and responses to immune checkpoint inhibitors. Treatment-related lymphopenia has been associated with poor survival in patients with various tumors. This meta-analysis evaluated the risk and impact of lymphopenia in patients with glioma. Methods: The PubMed, Embase, Web of Science, and Cochrane Library databases were comprehensively searched. Eligible studies were included if they reported the incidence and risk factors of lymphopenia and the impact of lymphopenia on survival. Stata 16.0 was used for this meta-analysis. Results: A total of 21 studies were included in the final systematic review and 20 were included in the quantitative analysis. The overall incidence of grade III/IV lymphopenia was 31.6% [95% confidence interval (CI), 22.3-40.8%]. Pooled results based on pathology of glioma revealed that the incidence in astrocytoma and astrocytoma oligodendroglioma patients was 20.2% (95% CI:5.9-34.4%), and the incidence in glioblastoma patients was 27.6% (95% CI:16.2-38.9%). Lymphopenia was associated with poor overall survival (hazard ratio, 1.99; 95% CI, 1.74-2.27; P< 0.001) compared to no lymphopenia. Brain receiving radiation dose of 20 or 25 Gy, female sex, older age, lower baseline lymphocyte count, and dexamethasone dose > 2 mg instead of baseline use were risk factors for lymphopenia. Conclusions: Treatment-related lymphopenia was associated with decreased survival in patients with glioma. Optimization of chemoradiation regimens, particularly in patients with concurrent risk factors, can reduce lymphopenia and potentially improve survival in the era of immunotherapy.
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Affiliation(s)
- Yongchao Zhang
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shichao Chen
- Neurosurgery Department, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hualei Chen
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shanshan Chen
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Zhen Li
- Emergency Department, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Enshan Feng
- Neurosurgery Department, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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10
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Werlenius K, Stragliotto G, Strandeus M, Blomstrand M, Carén H, Jakola AS, Rydenhag B, Dyregaard D, Dzhandzhugazyan KN, Kirkin AF, Raida MK, Smits A, Kinhult S. A randomized phase II trial of efficacy and safety of the immunotherapy ALECSAT as an adjunct to radiotherapy and temozolomide for newly diagnosed glioblastoma. Neurooncol Adv 2021; 3:vdab156. [PMID: 34765977 PMCID: PMC8577524 DOI: 10.1093/noajnl/vdab156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background There is an urgent need for effective treatments against glioblastoma (GBM). In this trial, we investigated the efficacy and safety of an adoptive cell-based immunotherapy. Methods Patients with newly diagnosed GBM were recruited at 4 study sites in Sweden. The patients were randomized 1:2 to receive either radiotherapy (RT), 60 Gy/30 fractions, with concomitant and adjuvant temozolomide (TMZ) only, or RT and TMZ with the addition of Autologous Lymphoid Effector Cells Specific Against Tumor (ALECSAT) in an open-label phase II trial. The primary endpoint was investigator-assessed progression-free survival (PFS). The secondary endpoints were survival and safety of ALECSAT. Results Sixty-two patients were randomized to either standard of care (SOC) with RT and TMZ alone (n = 22) or SOC with ALECSAT (n = 40). Median age was 57 years (range 38–69), 95% of the patients were in good performance status (WHO 0–1). There was no significant difference between the study arms (SOC vs ALECSAT + SOC) in PFS (7.9 vs 7.8 months; hazard ratio [HR] 1.28; 95% confidence interval [CI] 0.70–2.36; P = .42) or in median overall survival (OS) (18.3 vs 19.2 months; HR 1.16, 95% CI 0.58–2.31; P = .67). The treatment groups were balanced in terms of serious adverse events (52.4% vs 52.5%), but adverse events ≥grade 3 were more common in the experimental arm (81.0% vs 92.5%). Conclusion Addition of ALECSAT immunotherapy to standard treatment with radiochemotherapy was well tolerated but did not improve PFS or OS for patients with newly diagnosed GBM.
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Affiliation(s)
- Katja Werlenius
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Malin Blomstrand
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Carén
- Sahlgrenska Center for Cancer Research, Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | | | | | - Anja Smits
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Sara Kinhult
- Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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11
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Song AJ, Ding K, Alnahhas I, Laperriere NJ, Perry J, Mason WP, Winch C, O'Callaghan CJ, Menten JJ, Brandes AA, Phillips C, Fay MF, Nishikawa R, Osoba D, Cairncross JG, Roa W, Wick W, Shi W. Impact of lymphopenia on survival for elderly patients with glioblastoma: A secondary analysis of the CCTG CE.6 (EORTC 26062-22061, TROG03.01) randomized clinical trial. Neurooncol Adv 2021; 3:vdab153. [PMID: 34765975 PMCID: PMC8577525 DOI: 10.1093/noajnl/vdab153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Lymphopenia may lead to worse outcomes for glioblastoma patients. This study is a secondary analysis of the CCTG CE.6 trial evaluating the impact of chemotherapy and radiation on lymphopenia, and effects of lymphopenia on overall survival (OS). Methods CCTG CE.6 randomized elderly glioblastoma patients (≥ 65 years) to short-course radiation alone (RT) or short-course radiation with temozolomide (RT + TMZ). Lymphopenia (mild-moderate: grade 1–2; severe: grade 3–4) was defined per CTCAE v3.0, and measured at baseline, 1 week and 4 weeks post-RT. Preselected key factors for analysis included age, sex, ECOG, resection extent, MGMT methylation, Mini-Mental State Examination, and steroid use. Multinomial logistic regression and multivariable Cox regression models were used to identify lymphopenia-associated factors and association with survival. Results Five hundred and sixty-two patients were analyzed (281 RT vs 281 RT+TMZ). At baseline, both arms had similar rates of mild-moderate (21.4% vs 21.4%) and severe (3.2% vs 2.9%) lymphopenia. However, at 4 weeks post-RT, RT+TMZ was more likely to develop lymphopenia (mild-moderate: 27.9% vs 18.2%; severe: 9.3% vs 1.8%; p<0.001). Developing any lymphopenia post-RT was associated with baseline lymphopenia (P < .001). Baseline lymphopenia (hazard ratio [HR] 1.3) was associated with worse OS (HR: 1.30, 95% confidence interval [CI] 1.05–1.62; P = .02), regardless of MGMT status. Conclusions Development of post-RT lymphopenia is associated with addition of TMZ and baseline lymphopenia and not with RT alone in patients treated with short-course radiation. However, regardless of MGMT status, only baseline lymphopenia is associated with worse OS, which may be considered as a prognostic biomarker for elderly glioblastoma patients.
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Affiliation(s)
- Andrew J Song
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Keyue Ding
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Iyad Alnahhas
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Normand J Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - James Perry
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Warren P Mason
- Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chad Winch
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Chris J O'Callaghan
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Johan J Menten
- Department of Experimental Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Alba A Brandes
- Department of Medical oncology, IRCCS Istituto Scienze Neurologiche - Bologna, Italy
| | - Claire Phillips
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - David Osoba
- QOL Consulting, West Vancouver, British Columbia, Canada
| | - J Gregory Cairncross
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Wilson Roa
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Wolfgang Wick
- Division of Neurology, Heidelberg University Medical Center, Clinical Cooperation Unit Neurooncology, German Cancer Research Center, Heidelberg, Germany
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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12
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Mistry AM, Jonathan SV, Monsour MA, Mobley BC, Clark SW, Moots PL. Impact of postoperative dexamethasone on survival, steroid dependency, and infections in newly diagnosed glioblastoma patients. Neurooncol Pract 2021; 8:589-600. [PMID: 34594571 PMCID: PMC8475235 DOI: 10.1093/nop/npab039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND We examined the effect of dexamethasone prescribed in the initial 3 postoperative weeks on survival, steroid dependency, and infection in glioblastoma patients. METHODS In this single-center retrospective cohort analysis, we electronically retrieved inpatient administration and outpatient prescriptions of dexamethasone and laboratory values from the medical record of 360 glioblastoma patients. We correlated total dexamethasone prescribed from postoperative day (POD) 0 to 21 with survival, dexamethasone prescription from POD30 to POD90, and diagnosis of an infection by POD90. These analyses were adjusted for age, Karnofsky performance status score, tumor volume, extent of resection, IDH1/2 tumor mutation, tumor MGMT promoter methylation, temozolomide and radiotherapy initiation, and maximum blood glucose level. RESULTS Patients were prescribed a median of 159 mg [109-190] of dexamethasone cumulatively by POD21. Every 16-mg increment (4 mg every 6 hours/day) of total dexamethasone associated with a 4% increase in mortality (95% confidence interval [CI] 1%-7%, P < .01), 12% increase in the odds of being prescribed dexamethasone from POD30 to POD90 (95% CI 6%-19%, P < .01), and 10% increase in the odds of being diagnosed with an infection (95% CI, 4%-17%, P < .01). Of the 175 patients who had their absolute lymphocyte count measured in the preoperative week, 80 (45.7%) had a value indicative of lymphopenia. In the POD1-POD28 period, this proportion was 82/167 (49.1%). CONCLUSIONS Lower survival, steroid dependency, and higher infection rate in glioblastoma patients associated with higher dexamethasone administration in the initial 3 postoperative weeks. Nearly half of the glioblastoma patients are lymphopenic preoperatively and up to 1 month postoperatively.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | | | | | - Bret C Mobley
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen W Clark
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paul L Moots
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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13
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Zhou L, Shen Y, Huang T, Sun Y, Alolga RN, Zhang G, Ge Y. The Prognostic Effect of Dexamethasone on Patients With Glioblastoma: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:727707. [PMID: 34531751 PMCID: PMC8438116 DOI: 10.3389/fphar.2021.727707] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/18/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Dexamethasone (DEX) is widely adopted to reduce tumor-associated edema in glioblastoma (GBM) patients despite its side effects. However, the benefits of using DEX in GBM patients remains elusive. Methods: In this study, we performed a comprehensive meta-analysis to address this concern. We searched the relevant studies from PubMed, Web of Science, and EMBASE databases, and then applied random or fixed-effects models to generate estimated summary hazard radios (HRs) and the 95% confidence intervals (CIs). Moreover, subgroup and sensitivity analysis were conducted and publication bias were further evaluated. Results: Ten articles with a total of 2,230 GBM patients were eligible according to the inclusion criteria. In the assessment of overall survival (OS), meta-analysis data revealed that DEX was significantly associated with the poor prognosis of GBM patients (HR=1.44, 95% CI=1.32−1.57). In the progression-free survival (PFS), the pooled results indicated that the use of DEX can increase 48% death risk for GBM patients (HR=1.48, 95% CI=1.11−1.98). Subgroup analyses revealed that DEX was associated with poorer outcome of GBM in subgroup of newly diagnosed patients and GBM patients treated with ≥ 2mg/day. Sensitivity analyses showed that no study changed the pooled results materially for both OS and PFS analyses. The funnel plot had no obvious asymmetry. Conclusion: Our findings partly confirmed that use of DEX was associated with poor treatment outcome in GBM patients. To reach a definitive conclusion, large samples from multi-centers are urgent to address this concern.
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Affiliation(s)
- Lingling Zhou
- Department of Orthopaedic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Shen
- Department of Urology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Tingting Huang
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yangyang Sun
- Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Raphael N Alolga
- Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Gang Zhang
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuqiu Ge
- Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, China
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14
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The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2021; 111:936-948. [PMID: 34329738 DOI: 10.1016/j.ijrobp.2021.07.1695] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Emerging evidence suggests a detrimental prognostic association between radiation-induced lymphopenia (RIL) and pathologic response, progression-free survival, and overall survival (OS) in patients who undergo radiation therapy for cancer. The aim of this study was to systematically review and meta-analyze the prognostic impact of RIL on OS in patients with solid tumors. METHODS AND MATERIALS PubMed/MEDLINE and Embase were systematically searched. The analysis included intervention and prognostic studies that reported on the prognostic relationship between RIL and survival in patients with solid tumors. An overall pooled adjusted hazard ratio (aHR) was calculated using a random-effects model. Subgroup analyses for different patient-, tumor-, treatment-, and study-related characteristics were performed using meta-regression. RESULTS Pooling of 21 cohorts within 20 eligible studies demonstrated a statistically significant association between OS and grade ≥3 versus grade 0-2 RIL (n = 16; pooled aHR, 1.65; 95% confidence interval [CI], 1.43-1.90) and grade 4 RIL versus grade 0-3 (n = 5; aHR, 1.53; 95% CI, 1.24-1.90). Moderate heterogeneity among aHRs was observed, mostly attributable to overestimated aHRs in 7 studies likely subject to model-overfitting. Subgroup analysis showed significant prognostic impact of grade ≥3 RIL in 4 brain tumor (aHR, 1.63; 95% CI, 1.06-2.51), 4 lung cancer (aHR, 1.52; 95% CI, 1.01-2.29), and 3 pancreatic cancer (aHR, 1.92; 95% CI, 1.10-3.36) cohorts. CONCLUSIONS This meta-analysis demonstrates a significant detrimental prognostic association between grade ≥3 lymphopenia and OS in patients receiving radiation therapy for solid tumors. This finding appears consistent for tumors of the brain, thorax, and upper abdomen and provides an imperative to further elucidate the potential survival benefit of lymphopenia-mitigating strategies.
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15
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Kast RE, Burns TC, Halatsch ME. Short review of SEC, a potential dexamethasone-sparing regimen for glioblastoma: Spironolactone, ecallantide, clotrimazole. Neurochirurgie 2021; 67:508-515. [PMID: 33450263 DOI: 10.1016/j.neuchi.2020.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/31/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022]
Abstract
This paper presents a short review of data supporting a dexamethasone sparing regimen, SEC, to reduce glioblastoma related brain edema. The conclusion of the reviewed data is that the rationale and risk/benefit ratio favors a pilot study to determine if the three drug regimen of SEC can reduce need for corticosteroid use during the course of glioblastoma. Details of how selected pathophysiological aspects of brain edema occurring during the course of glioblastoma and its treatment intersect with the established action of the three old drugs of SEC indicate that they can be repurposed to reduce that edema. Current first-line treatment of this edema is dexamethasone or related corticosteroids. There are multiple negative prognostic implications of both the edema itself and of dexamethasone, prime among them shortened survival, making a dexamethasone sparing regimen highly desirable. SEC uses spironolactone, an antihypertensive potassium-sparing diuretic acting by mineralocorticoid receptor inhibition, ecallantide acting to inhibit kallikrein activation marketed to treat hereditary angioedema, and clotrimazole, an old antifungal drug that inhibits intermediate conductance Ca++ activated K+ channel (KCa3.1). These three old drugs are well known to most clinicians, have a well-tolerated safety history, and have a robust preclinical database showing their potential to reduce the specific edema of glioblastoma. Additionally, these three drugs were chosen by virtue of each having preclinical evidence of glioblastoma growth and/or migration inhibition independent of their edema reduction action. A clinical study of SEC is being planned.
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Affiliation(s)
- R E Kast
- IIAIGC Study Center, 11, Arlington Ct, VT 05408 Burlington, USA.
| | - T C Burns
- Department of Neurologic Surgery, Mayo Clinic, 200, First St SW, MN 55905 Rochester, USA
| | - M-E Halatsch
- Department of Neurosurgery, Ulm University Hospital, Albert-Einstein-Allée 23, D-89081 Ulm, Germany; Department of Neurosurgery, Cantonal Hospital of Winterthur, Brauerstr, 15, CH-8401, Winterthur, Switzerland
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