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Hagiwara A, Schlossman J, Shabani S, Raymond C, Tatekawa H, Abrey LE, Garcia J, Chinot O, Saran F, Nishikawa R, Henriksson R, Mason WP, Wick W, Cloughesy TF, Ellingson BM. Incidence, molecular characteristics, and imaging features of “clinically-defined pseudoprogression” in newly diagnosed glioblastoma treated with chemoradiation. J Neurooncol 2022; 159:509-518. [DOI: 10.1007/s11060-022-04088-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/02/2022] [Indexed: 11/27/2022]
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Zeng J, Li X, Sander M, Zhang H, Yan G, Lin Y. Oncolytic Viro-Immunotherapy: An Emerging Option in the Treatment of Gliomas. Front Immunol 2021; 12:721830. [PMID: 34675919 PMCID: PMC8524046 DOI: 10.3389/fimmu.2021.721830] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/16/2021] [Indexed: 01/17/2023] Open
Abstract
The prognosis of malignant gliomas remains poor, with median survival fewer than 20 months and a 5-year survival rate merely 5%. Their primary location in the central nervous system (CNS) and its immunosuppressive environment with little T cell infiltration has rendered cancer therapies mostly ineffective, and breakthrough therapies such as immune checkpoint inhibitors (ICIs) have shown limited benefit. However, tumor immunotherapy is developing rapidly and can help overcome these obstacles. But for now, malignant gliomas remain fatal with short survival and limited therapeutic options. Oncolytic virotherapy (OVT) is a unique antitumor immunotherapy wherein viruses selectively or preferentially kill tumor cells, replicate and spread through tumors while inducing antitumor immune responses. OVTs can also recondition the tumor microenvironment and improve the efficacy of other immunotherapies by escalating the infiltration of immune cells into tumors. Some OVTs can penetrate the blood-brain barrier (BBB) and possess tropism for the CNS, enabling intravenous delivery. Despite the therapeutic potential displayed by oncolytic viruses (OVs), optimizing OVT has proved challenging in clinical development, and marketing approvals for OVTs have been rare. In June 2021 however, as a genetically engineered OV based on herpes simplex virus-1 (G47Δ), teserpaturev got conditional and time-limited approval for the treatment of malignant gliomas in Japan. In this review, we summarize the current state of OVT, the synergistic effect of OVT in combination with other immunotherapies as well as the hurdles to successful clinical use. We also provide some suggestions to overcome the challenges in treating of gliomas.
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Affiliation(s)
- Jiayi Zeng
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Xiangxue Li
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Max Sander
- Department of International Cooperation, Guangzhou Virotech Pharmaceutical Co., Ltd., Guangzhou, China
| | - Haipeng Zhang
- Department of Pharmacology, School of Medicine, Jinan University, Guangzhou, China
| | - Guangmei Yan
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yuan Lin
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
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Mesti T, Ocvirk J. Malignant gliomas: old and new systemic treatment approaches. Radiol Oncol 2016; 50:129-38. [PMID: 27247544 PMCID: PMC4852970 DOI: 10.1515/raon-2015-0003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/29/2014] [Indexed: 12/15/2022] Open
Abstract
Background Malignant (high-grade) gliomas are rapidly progressive brain tumours with very high morbidity and mortality. Until recently, treatment options for patients with malignant gliomas were limited and mainly the same for all subtypes of malignant gliomas. The treatment included surgery and radiotherapy. Chemotherapy used as an adjuvant treatment or at recurrence had a marginal role. Conclusions Nowadays, the treatment of malignant gliomas requires a multidisciplinary approach. The treatment includes surgery, radiotherapy and chemotherapy. The chosen approach is more complex and individually adjusted. By that, the effect on the survival and quality of life is notable higher.
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Affiliation(s)
- Tanja Mesti
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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Response Assessment and Magnetic Resonance Imaging Issues for Clinical Trials Involving High-Grade Gliomas. Top Magn Reson Imaging 2016; 24:127-36. [PMID: 26049816 DOI: 10.1097/rmr.0000000000000054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There exist multiple challenges associated with the current response assessment criteria for high-grade gliomas, including the uncertain role of changes in nonenhancing T2 hyperintensity, and the phenomena of pseudoresponse and pseudoprogression in the setting of antiangiogenic and chemoradiation therapies, respectively. Advanced physiological magnetic resonance imaging (MRI), including diffusion and perfusion (dynamic susceptibility contrast MRI and dynamic contrast-enhanced MRI) sensitive techniques for overcoming response assessment challenges, has been proposed, with their own potential advantages and inherent shortcomings. Measurement variability exists for conventional and advanced MRI techniques, necessitating the standardization of image acquisition parameters in order to establish the utility of these imaging methods in multicenter trials for high-grade gliomas. This review chapter highlights the important features of MRI in clinical brain tumor trials, focusing on the current state of response assessment in brain tumors, advanced imaging techniques that may provide additional value for determining response, and imaging issues to be considered for multicenter trials.
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Ellingson BM, Wen PY, van den Bent MJ, Cloughesy TF. Pros and cons of current brain tumor imaging. Neuro Oncol 2015; 16 Suppl 7:vii2-11. [PMID: 25313235 DOI: 10.1093/neuonc/nou224] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Over the past 20 years, very few agents have been approved for the treatment of brain tumors. Recent studies have highlighted some of the challenges in assessing activity in novel agents for the treatment of brain tumors. This paper reviews some of the key challenges related to assessment of tumor response to therapy in adult high-grade gliomas and discusses the strengths and limitations of imaging-based endpoints. Although overall survival is considered the "gold standard" endpoint in the field of oncology, progression-free survival and response rate are endpoints that hold great value in neuro-oncology. Particular focus is given to advancements made since the January 2006 Brain Tumor Endpoints Workshop, including the development of Response Assessment in Neuro-Oncology criteria, the value of T2/fluid-attenuated inversion recovery, use of objective response rates and progression-free survival in clinical trials, and the evaluation of pseudoprogression, pseudoresponse, and inflammatory response in radiographic images.
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Affiliation(s)
- Benjamin M Ellingson
- Department of Radiological Sciences (B.M.E.), Department of Biomedical Physics, David Geffen School of Medicine at UCLA (B.M.E.); Department of Bioengineering, Henry Samueli School of Engineering and Applied Science at UCLA (B.M.E.); Brain Research Institute, David Geffen School of Medicine at UCLA (B.M.E., T.F.C.); UCLA Neuro-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California (B.M.E., T.F.C.); Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts (P.Y.W.); Department of Neuro-Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.); Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California (T.F.C.)
| | - Patrick Y Wen
- Department of Radiological Sciences (B.M.E.), Department of Biomedical Physics, David Geffen School of Medicine at UCLA (B.M.E.); Department of Bioengineering, Henry Samueli School of Engineering and Applied Science at UCLA (B.M.E.); Brain Research Institute, David Geffen School of Medicine at UCLA (B.M.E., T.F.C.); UCLA Neuro-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California (B.M.E., T.F.C.); Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts (P.Y.W.); Department of Neuro-Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.); Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California (T.F.C.)
| | - Martin J van den Bent
- Department of Radiological Sciences (B.M.E.), Department of Biomedical Physics, David Geffen School of Medicine at UCLA (B.M.E.); Department of Bioengineering, Henry Samueli School of Engineering and Applied Science at UCLA (B.M.E.); Brain Research Institute, David Geffen School of Medicine at UCLA (B.M.E., T.F.C.); UCLA Neuro-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California (B.M.E., T.F.C.); Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts (P.Y.W.); Department of Neuro-Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.); Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California (T.F.C.)
| | - Timothy F Cloughesy
- Department of Radiological Sciences (B.M.E.), Department of Biomedical Physics, David Geffen School of Medicine at UCLA (B.M.E.); Department of Bioengineering, Henry Samueli School of Engineering and Applied Science at UCLA (B.M.E.); Brain Research Institute, David Geffen School of Medicine at UCLA (B.M.E., T.F.C.); UCLA Neuro-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California (B.M.E., T.F.C.); Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts (P.Y.W.); Department of Neuro-Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.); Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California (T.F.C.)
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Walker AJ, Ruzevick J, Malayeri AA, Rigamonti D, Lim M, Redmond KJ, Kleinberg L. Postradiation imaging changes in the CNS: how can we differentiate between treatment effect and disease progression? Future Oncol 2015; 10:1277-97. [PMID: 24947265 DOI: 10.2217/fon.13.271] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A familiar challenge for neuroradiologists and neuro-oncologists is differentiating between radiation treatment effect and disease progression in the CNS. Both entities are characterized by an increase in contrast enhancement on MRI and present with similar clinical signs and symptoms that may occur either in close temporal proximity to the treatment or later in the disease course. When radiation-related imaging changes or clinical deterioration are mistaken for disease progression, patients may be subject to unnecessary surgery and/or a change from otherwise effective therapy. Similarly, when disease progression is mistaken for treatment effect, a potentially ineffective therapy may be continued in the face of progressive disease. Here we describe the three types of radiation injury to the brain based on the time to development of signs and symptoms--acute, subacute and late--and then review specific imaging changes after intensity-modulated radiation therapy, stereotactic radiosurgery and brachytherapy. We provide an overview of these phenomena in the treatment of a wide range of malignant and benign CNS illnesses. Finally, we review the published data regarding imaging techniques under investigation to address this well-known problem.
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Affiliation(s)
- Amanda J Walker
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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Kruser TJ, Mehta MP, Robins HI. Pseudoprogression after glioma therapy: a comprehensive review. Expert Rev Neurother 2013; 13:389-403. [PMID: 23545054 DOI: 10.1586/ern.13.7] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last decade, pseudoprogression as a clinically significant entity affecting both glioma patient management and the conduct of clinical trials has been recognized as a significant issue. The authors have summarized the literature relative to the incidence, chronological sequence, therapy-relatedness, impact of O-6-methylguanine-DNA methyltransferase methylation status and clinical features of pseudoprogression. Evidence regarding numerous neuroradiologic techniques to differentiate pseudoprogression from tumor recurrence is summarized. The implications of pseudoprogression on prognosis and clinical trial design are substantial, and are reviewed. Relative to this, the overlapping terms pseudoprogression and radiation necrosis are clarified to produce an appropriate basis for future consideration and research regarding this important biological phenomenon.
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Affiliation(s)
- Tim J Kruser
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
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Sawlani V, Taylor R, Rowley K, Redfern R, Martin J, Poptani H. Magnetic Resonance Spectroscopy for Differentiating Pseudo-Progression from True Progression in GBM on Concurrent Chemoradiotherapy. Neuroradiol J 2012; 25:575-86. [PMID: 24029093 DOI: 10.1177/197140091202500511] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 08/20/2012] [Indexed: 11/16/2022] Open
Abstract
Neoadjuvant chemo-radiation therapy including temozolomide is commonly used for the treatment of gliomas. However, increased lesion size and contrast enhancement are frequently observed following this therapy and this appearance is termed as 'pseudo-progression'. Since conventional imaging is unable to differentiate pseudo-progression from tumour recurrence, we evaluated the utility of MR spectroscopy (MRS) to differentiate these two pathological entities. Longitudinal MRI and MRS studies prior to and within four months post chemo-radiation therapy including diffusion-weighted imaging and single voxel spectroscopy (short and intermediate echo) were performed in 62 glioblastoma (GBM) patients undergoing chemo-radiation therapy. Clinical follow-up demonstrated four cases of pseudo-progression. In this study, results from these four cases and a known case of tumour recurrence are reported. Metabolite ratios and presence or absence of lipids at 1.3 ppm were used to differentiate between pseudo-progression and tumour recurrence. All four cases of pseudo-progression demonstrated elevated lipid signals on MRS. Additionally, an absence of choline or a low choline/NAA ratio was also observed. In comparison, the patient with tumour recurrence showed lower lipid signals and a high choline/NAA ratio. The presence of elevated lipid signals along with low choline/NAA ratios can aid in differentiation of pseudo-progression from tumour recurrence.
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Affiliation(s)
- V Sawlani
- Radiology Department, Morriston Hospital; Swansea, United Kingdom -
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Siu A, Wind JJ, Iorgulescu JB, Chan TA, Yamada Y, Sherman JH. Radiation necrosis following treatment of high grade glioma--a review of the literature and current understanding. Acta Neurochir (Wien) 2012; 154:191-201; discussion 201. [PMID: 22130634 DOI: 10.1007/s00701-011-1228-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 11/07/2011] [Indexed: 10/15/2022]
Abstract
Radiation therapy is an integral part of the standard treatment paradigm for malignant gliomas, with proven efficacy in randomized control trials. Radiation treatment is not without risk however, and radiation injury occurs in a certain proportion of patients. Difficulties in differentiating recurrence from radiation injury complicate the treatment course and can compromise care. These complexities are compounded by the recent distinction of two types of radiation injury: pseudoprogression and radiation necrosis, which are likely the result of radiation injury to the tumor and normal tissue, respectively. A thorough understanding of radiation-induced injury offers insights to guide further therapies. We detail the current knowledge of the mechanisms of radiation injury, along with potential targets for therapeutic intervention. Various diagnostic modalities are also described, in addition to the multiple options for treatment within the context of their pathophysiology and clinical efficacy. Radiation therapy is an integral part of the multidisciplinary management of gliomas, and the optimal diagnosis and management of radiation injury is paramount to improving patient outcomes.
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Young RJ, Gupta A, Shah AD, Graber JJ, Zhang Z, Shi W, Holodny AI, Omuro AMP. Potential utility of conventional MRI signs in diagnosing pseudoprogression in glioblastoma. Neurology 2011; 76:1918-24. [PMID: 21624991 DOI: 10.1212/wnl.0b013e31821d74e7] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the potential utility of conventional MRI signs in differentiating pseudoprogression (PsP) from early progression (EP). METHODS This retrospective study reviewed initial postradiotherapy MRI scans of 321 patients with glioblastoma undergoing chemotherapy and radiotherapy. A total of 93 patients were found to have new or increased enhancing mass lesions, raising the possibility of PsP. Final diagnosis of PsP or EP was established upon review of surgical specimens from a second resection or by clinical and radiologic follow-up. A total of 11 MRI signs potentially helpful in the differentiation between PsP and EP were examined on the initial post-RT MRI and were correlated with the final diagnosis through χ(2) or Fisher exact test. RESULTS Sixty-three (67.7%) of the 93 patients had EP, of which 22 (34.9%) were diagnosed by pathology. Thirty patients (32.3%) had PsP; 6 (16.7% of the 30) were diagnosed by pathology. Subependymal enhancement was predictive for EP (p = 0.001) with 38.1% sensitivity, 93.3% specificity, and 41.8% negative predictive value. The other 10 signs had no predictive value (p = 0.06-1.0). CONCLUSIONS Conventional MRI signs have limited utility in diagnosing PsP in patients with recently treated glioblastomas and worsening enhancing lesions. We did not find a sign with a high negative predictive value for PsP that would have been the most useful for the clinical physician. When present, subependymal spread of the enhancing lesion is a useful MRI marker in identifying EP rather than PsP.
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Affiliation(s)
- R J Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Sanghera P, Rampling R, Haylock B, Jefferies S, McBain C, Rees JH, Soh C, Whittle IR. The concepts, diagnosis and management of early imaging changes after therapy for glioblastomas. Clin Oncol (R Coll Radiol) 2011; 24:216-27. [PMID: 21783349 DOI: 10.1016/j.clon.2011.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/31/2011] [Accepted: 04/24/2011] [Indexed: 10/18/2022]
Abstract
Since postoperative radiotherapy plus concomitant temozolomide followed by adjuvant temozolomide has become standard treatment for glioblastoma, the phenomenon of early post-treatment enlargement of the imaged tumour volume, usually without clinical deterioration, has become widely recognised. The term pseudoprogression has been used to describe a poorly understood pathophysiological process. In this review, the pathophysiological concepts, relevance, diagnosis and management of patients with 'pseudoprogression' and 'pseudoresponse' are discussed. Guidelines are given with respect to radiological imaging modality, mode and frequency. Further biological and clinical insights into these phenomena require carefully designed prospective studies.
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Affiliation(s)
- P Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
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Leysalle A, Haberer S. Mise au point sur la pseudoprogression après chimioradiothérapie dans les glioblastomes. ONCOLOGIE 2010. [DOI: 10.1007/s10269-010-1927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Park KJ, Kang SH, Lee HK, Chung YG. Rapid progression of early delayed radiation effect in pleomorphic xanthoastrocytoma. J Korean Neurosurg Soc 2009; 46:564-7. [PMID: 20062573 DOI: 10.3340/jkns.2009.46.6.564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 03/23/2009] [Accepted: 10/26/2009] [Indexed: 11/27/2022] Open
Abstract
Early delayed radiation effects are known to occur within several months after completing radiotherapy for brain tumors. We present marked changes of magnetic resonance imaging (MRI) scan that occurred one month after radiotherapy in a patient with a pleomorphic xanthoastrocytoma, which was eventually diagnosed as an early delayed radiation effect. Such an early development of dramatic MRI change has not been reported in patients treated with radiotherapy for pleomorphic xanthoastrocytomas.
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Affiliation(s)
- Kyung Jae Park
- Department of Neurosurgery, Korea University College of Medicine, Seoul, Korea
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Yang I, Huh NG, Smith ZA, Han SJ, Parsa AT. Distinguishing glioma recurrence from treatment effect after radiochemotherapy and immunotherapy. Neurosurg Clin N Am 2009; 21:181-6. [PMID: 19944976 DOI: 10.1016/j.nec.2009.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Recent advancements have made radiation and chemotherapy the standard of care for newly diagnosed glioblastomas. The use of these therapies has resulted in an increased diagnosis of pseudoprogression and radiation-induced necrosis. Standard MRI techniques are inadequate in differentiating tumor recurrence from posttreatment effects. Diagnosis of a posttreatment lesion as glioma recurrence rather than radiochemotherapy or immunotherapy treatment effect is critical. This increase in accuracy plays a role as newer immunotherapies incurring posttreatment effects on MRI emerge. Advancements with magnetic resonance spectroscopy, diffusion-weighted imaging, and functional positron emission tomography scans have shown promising capabilities. Further investigations are necessary to assess the imaging algorithms and accuracy of these modalities to differentiate true glioma recurrence from radiotherapy or immunotherapy treatment effect.
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Affiliation(s)
- Isaac Yang
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
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Yang I, Aghi MK. New advances that enable identification of glioblastoma recurrence. Nat Rev Clin Oncol 2009; 6:648-57. [DOI: 10.1038/nrclinonc.2009.150] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Miyatake SI, Kawabata S, Nonoguchi N, Yokoyama K, Kuroiwa T, Matsui H, Ono K. Pseudoprogression in boron neutron capture therapy for malignant gliomas and meningiomas. Neuro Oncol 2009; 11:430-6. [PMID: 19289492 DOI: 10.1215/15228517-2008-107] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Pseudoprogression has been recognized and widely accepted in the treatment of malignant gliomas, as transient increases in the volume of the enhanced area just after chemoradiotherapy, especially using temozolomide. We experienced a similar phenomenon in the treatment of malignant gliomas and meningiomas using boron neutron capture therapy (BNCT), a cell-selective form of particle radiation. Here, we introduce representative cases and analyze the pathogenesis. Fifty-two cases of malignant glioma and 13 cases of malignant meningioma who were treated by BNCT were reviewed retrospectively mainly via MR images. Eleven of 52 malignant gliomas and 3 of 13 malignant meningiomas showed transient increases of enhanced volume in MR images within 3 months after BNCT. Among these cases, five patients with glioma underwent surgery because of suspicion of relapse. In histology, most of the specimens showed necrosis with small amounts of residual tumor cells. Ki-67 labeling showed decreased positivity compared with previous samples from the individuals. Fluoride-labeled boronophenylalanine PET was applied in four and two cases of malignant gliomas and meningiomas, respectively, at the time of transient increase of lesions. These PET scans showed decreased lesion:normal brain ratios in all cases compared with scans obtained prior to BNCT. With or without surgery, all lesions were decreased or stable in size during observation. Transient increases in enhanced volume in malignant gliomas and meningiomas immediately after BNCT seemed to be pseudoprogression. This pathogenesis was considered as treatment-related intratumoral necrosis in the subacute phase after BNCT.
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Affiliation(s)
- Shin-Ichi Miyatake
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka 569-8686, Japan.
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Peca C, Pacelli R, Elefante A, Del Basso De Caro ML, Vergara P, Mariniello G, Giamundo A, Maiuri F. Early clinical and neuroradiological worsening after radiotherapy and concomitant temozolomide in patients with glioblastoma: tumour progression or radionecrosis? Clin Neurol Neurosurg 2008; 111:331-4. [PMID: 19117668 DOI: 10.1016/j.clineuro.2008.11.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 09/17/2008] [Accepted: 11/07/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study investigates the diagnosis and management of patients with resected brain glioblastomas who presented early clinical and neuroradiological worsening after the completion of the Stupp protocol. Its aim is to discuss the occurrence of early radionecrosis. METHODS Fifty patients with brain glioblastoma treated by surgical resection and Stupp protocol were reviewed; 15 among them (30%) had early clinical and neuroradiological worsening at the 6-month follow-up. The MR spectroscopy and surgical findings of these patients are reviewed. RESULTS MR spectroscopy was in favour of tumour recurrence in 14 among 15 patients and showed radionecrosis in one. Among 10 patients who were reoperated on, 7 had histologically verified tumour recurrence or regrowth, whereas in 3 histopathology showed necrosis without evidence of tumour. The 7 patients with tumour progression had prevalence of focal neuroradiological signs (6/7) and a survival of 7.5-12 months (median survival 10 months). The 4 patients with early radionecrosis (including one patient who was not reoperated on) had clinical worsening with mental deterioration, confusion and ataxia, and MR spectroscopy positive for tumour recurrence in 3. Three were alive 24-30 months after the end of the radiotherapy, whereas one died at 40 months. CONCLUSION Early radionecrosis after the Stupp protocol is not a rare event due to the radiosensitization effect of temozolomide. This phenomenon may predict a durable response to radiotherapy. MR spectroscopy may simulate tumour recurrence. A correct diagnosis is necessary to avoid useless reoperations and incorrect withdrawal of temozolomide.
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Affiliation(s)
- C Peca
- Department of Neurological Sciences, Neurosurgical Clinic, University Federico II, Naples, Italy
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Brandsma D, Stalpers L, Taal W, Sminia P, van den Bent MJ. Clinical features, mechanisms, and management of pseudoprogression in malignant gliomas. Lancet Oncol 2008; 9:453-61. [PMID: 18452856 DOI: 10.1016/s1470-2045(08)70125-6] [Citation(s) in RCA: 784] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Dieta Brandsma
- Department of Neuro-oncology, Daniel den Hoed Cancer Centre, Erasmus Medical Centre, Rotterdam, Netherlands
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Armstrong CL, Hunter JV, Hackney D, Shabbout M, Lustig RW, Goldstein B, Werner-Wasik M, Curran WJ. MRI changes due to early-delayed conformal radiotherapy and postsurgical effects in patients with brain tumors. Int J Radiat Oncol Biol Phys 2005; 63:56-63. [PMID: 16111572 DOI: 10.1016/j.ijrobp.2004.12.073] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2004] [Revised: 12/21/2004] [Accepted: 12/22/2004] [Indexed: 11/20/2022]
Abstract
PURPOSE Discernment of radiotherapy (XRT) effects vs. tumor activity is difficult in brain tumor patients during the months after XRT when white matter hyperintensities sometimes emerge. We examined brain scans in XRT-treated vs. untreated patients for early-delayed post-XRT effects. METHODS AND MATERIALS Brain regions susceptible to XRT injury were examined on magnetic resonance imaging (MRI) for T2-weighted hyperintensities and atrophy in 37 adults with low-grade primary brain tumors (13 nonirradiated and 24 irradiated). Cases evidencing recurrence/growth over the study period were censored. Interactions with age, mood, fatigue, medications, tumor type and grade, extent of resection, and laterality of MRI changes were examined. RESULTS Hyperintensity and atrophy ratings over time for the treated and untreated groups were not significantly different. White matter atrophy increased unrelated to XRT. In all patients combined, white matter atrophy and hyperintensities were greater at all time points and more lateralized in surgically treated patients. CONCLUSIONS Radiotherapy status was not related to changes in MRI ratings during the weeks/months after XRT. Findings contradict assumptions about radiographically evidenced early-delayed XRT effects. Increases in T2-weighted hyperintensities during the 1-6-month period post-conformal radiotherapy for low-grade tumors are likely not related to early-delayed XRT effects.
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Affiliation(s)
- Carol L Armstrong
- Department of Neurology, University of Pennsylvania Medical School, Philadelphia, PA, USA.
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22
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Cicciarello R, d'Avella D, Gagliardi ME, Albiero F, Vega J, Angileri FF, D'Aquino A, Tomasello F. Time-related Ultrastructural Changes in an Experimental Model of Whole Brain Irradiation. Neurosurgery 1996. [DOI: 10.1227/00006123-199604000-00028] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Rocco Cicciarello
- Institute of Oncology, University of Messina Medical School, Messina, Italyn
| | - Domenico d'Avella
- Neurosurgical Clinic, University of Messina Medical School, Messina, Italyn
| | | | - Francesca Albiero
- Institute of Oncology, University of Messina Medical School, Messina, Italyn
| | - José Vega
- Department of Morphology, University of Oviedo, Oviedo, Spain
| | | | - Antonio D'Aquino
- Neurosurgical Clinic, University of Messina Medical School, Messina, Italyn
| | - Francesco Tomasello
- Institute of Oncology, University of Messina Medical School, Messina, Italyn
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23
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Thajeb P. Progressive late delayed postirradiation encephalopathy with Klüver-Bucy syndrome. Serial MRI and clinico-pathological studies. Clin Neurol Neurosurg 1995; 97:264-8. [PMID: 7586863 DOI: 10.1016/0303-8467(95)00049-p] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The first pathologically documented case of progressive late delayed postirradiation encephalopathy in a 37-year-old man with Klüver-Bucy syndrome (KBS) is reported here. The pathological findings and clinical course of KBS with recurrent stroke-like episodes and partial epilepsy within a 7-year period following a 'safe dose' radiation therapy for pituitary tumor are presented. Serial magnetic resonance imaging shows, at different stages of the disease, a pontine infarct, enlarged temporal lobes with serpentine hyperintense signal at cortical gyri on T2-weighted and proton density MRI, and progressive brain calcification which appears hyperintense on T1-weighted images and hypointense on T2-weighted images.
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Affiliation(s)
- P Thajeb
- Section of Neurology, Cathay General Hospital, Taipei, Taiwan
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Radiotherapy for Pediatric Brain Stem Glioma. Neurosurgery 1992. [DOI: 10.1097/00006123-199210000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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25
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Hibi T, Shitara N, Genka S, Fuchinoue T, Hayakawa I, Tsuchida T, Nomura K, Kondo T, Takakura K. Radiotherapy for pediatric brain stem glioma: radiation dose, response, and survival. Neurosurgery 1992; 31:643-50; discussion 650-1. [PMID: 1407449 DOI: 10.1227/00006123-199210000-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
An analysis of 39 patients under 20 years of age with brain stem glioma treated with radiotherapy between 1977 and 1991 was undertaken. Twenty-eight (71.2%) of the patients responded well to initial radiotherapy, and 11 (28.8%) responded poorly. Median survival for the total patient population was 10 months. Response rates and median survivals were influenced by radiation dose: 45.5% and 9 months at doses less than 4499 cGy (n = 11), 83.3% and 13 months at doses between 4500 and 5499 cGy (n = 12), 66.7% and 11.5 months at doses between 5500 and 6499 cGy (n = 9), and 100% and 10 months at doses more than 6500 cGy (n = 7). Multivariate analysis revealed the response to initial radiotherapy was the only predictor of survival with radiation doses up to 6499 cGy. Four of the patients who responded well demonstrated radiological and/or histological calcification within or around the tumor at the time of clinical deterioration. Radiation injury was confirmed in two autopsy cases. The possibility that intratumoral radiation injury causes clinical deterioration is suggested.
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Affiliation(s)
- T Hibi
- Department of Neurosurgery, Tokyo Metropolitan Toshima Hospital, Japan
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