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Ghaderi N, Jung J, Brüningk SC, Subramanian A, Nassour L, Peacock J. A Century of Fractionated Radiotherapy: How Mathematical Oncology Can Break the Rules. Int J Mol Sci 2022; 23:ijms23031316. [PMID: 35163240 PMCID: PMC8836217 DOI: 10.3390/ijms23031316] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
Radiotherapy is involved in 50% of all cancer treatments and 40% of cancer cures. Most of these treatments are delivered in fractions of equal doses of radiation (Fractional Equivalent Dosing (FED)) in days to weeks. This treatment paradigm has remained unchanged in the past century and does not account for the development of radioresistance during treatment. Even if under-optimized, deviating from a century of successful therapy delivered in FED can be difficult. One way of exploring the infinite space of fraction size and scheduling to identify optimal fractionation schedules is through mathematical oncology simulations that allow for in silico evaluation. This review article explores the evidence that current fractionation promotes the development of radioresistance, summarizes mathematical solutions to account for radioresistance, both in the curative and non-curative setting, and reviews current clinical data investigating non-FED fractionated radiotherapy.
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Affiliation(s)
- Nima Ghaderi
- Department of Biomedical Engineering, University of Minnesota Twin Cities, Minneapolis, MN 55455, USA; (N.G.); (J.J.)
| | - Joseph Jung
- Department of Biomedical Engineering, University of Minnesota Twin Cities, Minneapolis, MN 55455, USA; (N.G.); (J.J.)
| | - Sarah C. Brüningk
- Machine Learning & Computational Biology Lab, Department of Biosystems Science and Engineering, ETH Zurich, 4058 Basel, Switzerland;
- Swiss Institute for Bioinformatics (SIB), 1015 Lausanne, Switzerland
| | - Ajay Subramanian
- Department of Radiation Oncology, Stanford University, Stanford, CA 94305, USA;
| | - Lauren Nassour
- Department of Radiation Oncology, University of Alabama Birmingham, Birmingham, AL 35205, USA;
| | - Jeffrey Peacock
- Department of Radiation Oncology, University of Alabama Birmingham, Birmingham, AL 35205, USA;
- Correspondence:
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2
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Rao A, Ramani N, Stoppacher R, Coyle T. Complete response to temozolomide in chronic lymphocytic leukemia. Clin Case Rep 2017; 5:1130-1131. [PMID: 28680610 PMCID: PMC5494405 DOI: 10.1002/ccr3.978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 01/05/2017] [Accepted: 03/03/2017] [Indexed: 12/31/2022] Open
Abstract
We report a case of incidentally diagnosed chronic lymphocytic leukemia (CLL) in a patient with glioblastoma, which responded completely following standard treatment of the glioblastoma with temozolomide and cranial irradiation. The patient remained without an evidence of CLL until his death from recurrent glioblastoma. Further study of temozolomide for the treatment of CLL is indicated.
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Affiliation(s)
- Archana Rao
- Hematology Oncology Associates of CNY 5008 Brittonfield Parkway East Syracuse 13057 New York
| | - Nisha Ramani
- Department of Pathology SUNY Upstate Medical University 750 East Adams street Syracuse 13210 New York
| | - Robert Stoppacher
- Department of Pathology SUNY Upstate Medical University 750 East Adams street Syracuse 13210 New York
| | - Thomas Coyle
- Department of Benign Hematology TriHealth Cancer Institute 10506 Montgomery Rd Cincinnati 45242 Ohio
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3
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Álvarez de Eulate-Beramendi S, Álvarez-Vega MA, Balbin M, Sanchez-Pitiot A, Vallina-Alvarez A, Martino-González J. Prognostic factors and survival study in high-grade glioma in the elderly. Br J Neurosurg 2016; 30:330-6. [PMID: 26828095 DOI: 10.3109/02688697.2016.1139049] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Glioblastoma multiforme (GBM) is the most common and malignant primary brain tumour in adults. Due to the ageing of the population, diagnosis in the elderly is becoming more common. The aim of this study was to analyse different combinations of treatments and to identify preoperative factors, including O6-methylguanine-DNA methyltransferase status, that may be associated with decreased survival among patients older than 70 years. Methods and materials We retrospectively included all patients over 70 years of age, who underwent surgery at the Department of Neurosurgery (HUCA and HUMV) and were diagnosed of GBM by pathological criteria from January 2007 to September 2014. Results Eighty-one patients were analysed, whose mean age was 75 (SD 4) and 48 were male. Karnofsky performance status (KPS) was over 70 in 61 patients and 38.3% presented with motor deficit. Sixty-three patients underwent resection, and 18 had only a diagnostic biopsy. The complication rate was 17.28% and mortality rate was 7.4%. Survival was increased in patients who received radiotherapy (n = 41) or additional chemotherapy (n = 26) (p < 0.001). KPS < 70 was an independent factor associated with low-rate survival. Patients with optimal treatment had a median survival of 8 months compared to patients with suboptimal treatment who had a median survival of 4 months (p < 0.001). Conclusions This study suggests that KPS is the most important preoperative prognostic factor. Maximal safe resection followed by radical radiotherapy and temozolomide might be the optimal treatment of choice since glioblastoma-diagnosed patients over 70 years of age showed a statistically significant survival benefit.
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Affiliation(s)
| | | | - Milagros Balbin
- b Molecular Oncology Department , Hospital Universitario Central De Asturias , Oviedo , Spain
| | - Ana Sanchez-Pitiot
- b Molecular Oncology Department , Hospital Universitario Central De Asturias , Oviedo , Spain
| | - Aitana Vallina-Alvarez
- c Banco De tumores - IUOPA , Hospital Universitario Central De Asturias , Oviedo , Spain
| | - Juan Martino-González
- d Neurosurgery Department , Hospital Universitario Marqués De Valdecilla , Santander , Spain
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4
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Redmond KJ, Mehta M. Stereotactic Radiosurgery for Glioblastoma. Cureus 2015; 7:e413. [PMID: 26848407 PMCID: PMC4725736 DOI: 10.7759/cureus.413] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/17/2015] [Indexed: 02/06/2023] Open
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults and one of the most aggressive of all human cancers. GBM tumors are highly infiltrative and relatively resistant to conventional therapies. Aggressive management of GBM using a combination of surgical resection, followed by fractionated radiotherapy and chemotherapy has been shown to improve overall survival; however, GBM tumors recur in the majority of patients and the disease is most often fatal. There is a need to develop new treatment regimens and technological innovations to improve the overall survival of GBM patients. The role of stereotactic radiosurgery (SRS) for the treatment of GBM has been explored and is controversial. SRS utilizes highly precise radiation techniques to allow dose escalation and delivery of ablative radiation doses to the tumor while minimizing dose to the adjacent normal structures. In some studies, SRS with concurrent chemotherapy has shown improved local control with acceptable toxicities in select GBM patients. However, because GBM is a highly infiltrative disease, skeptics argue that local therapies, such as SRS, do not improve overall survival. The purpose of this article is to review the literature regarding SRS in both newly diagnosed and recurrent GBM, to describe SRS techniques, potential eligible SRS candidates, and treatment-related toxicities. In addition, this article will propose promising areas for future research for SRS in the treatment of GBM.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Minesh Mehta
- Department of Radiation Oncology, University of Maryland
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5
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Chang-Halpenny CN, Yeh J, Lien WW. Elderly patients with glioblastoma multiforme treated with concurrent temozolomide and standard- versus abbreviated-course radiotherapy. Perm J 2015; 19:15-20. [PMID: 25663202 DOI: 10.7812/tpp/14-083] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONTEXT Glioblastoma multiforme (GBM) is an aggressive neoplasm, with controversy regarding treatment in elderly patients. OBJECTIVE To review outcomes of elderly patients aged ≥ 65 with newly diagnosed GBM treated with concurrent temozolomide and either standard-course radiotherapy (SRT) or abbreviated-course radiotherapy (ART). DESIGN Retrospective review from 2003 to 2012. MAIN OUTCOME MEASURE Survival, comparing treatment regimens. One hundred patients received SRT (median dose = 60 Gy), and 29 received ART (median dose = 35 Gy). O6- methylguanine-DNA methyltransferase (MGMT) status was available for 26 SRT and 13 ART recipients. RESULTS Median age was 70 years. Median follow-up was 11 months. At analysis, 3 patients were alive. Multivariate analysis of the entire cohort found SRT (hazard ratio [HR] = 0.421, p = 0.0001), Karnofsky Performance Score of 70 or higher (HR = 1.894, p = 0.0031), and more extensive surgery (HR = 0.466, p = 0.0023) were associated with longer survival time, but age was not. Median time to death with SRT was 13 months versus 5.4 months with ART, but the latter had worse prognostic factors, including lower Karnofsky Performance Scores, fewer gross total resections, and higher recursive partitioning analysis class. Recipients of SRT with methylated MGMT promoter had a trend toward longer survival compared with unmethylated MGMT (p = 0.06), but ART recipients had shorter survival with MGMT methylation (p = 0.02). CONCLUSION Elderly patients with multiple poor prognostic factors given ART had short survival times. Relative to other variables, MGMT status may not predict outcome for these patients.
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Affiliation(s)
| | - Jekwon Yeh
- Radiation Oncologist at the Cancer Center of Irvine in CA.
| | - Winston W Lien
- Radiation Oncologist at the Sunset Medical Center in Los Angeles, CA.
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6
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Kralik SF, Ho CY, Finke W, Buchsbaum JC, Haskins CP, Shih CS. Radiation Necrosis in Pediatric Patients with Brain Tumors Treated with Proton Radiotherapy. AJNR Am J Neuroradiol 2015; 36:1572-8. [PMID: 26138138 DOI: 10.3174/ajnr.a4333] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/15/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Proton radiotherapy has been increasingly utilized to treat pediatric brain tumors, however, limited information exists regarding radiation necrosis among these patients. Our aim was to evaluate the incidence, timing, clinical significance, risk factors, and imaging patterns of radiation necrosis in pediatric patients with brain tumors treated with proton radiation therapy. MATERIALS AND METHODS A retrospective study was performed on 60 consecutive pediatric patients with primary brain tumors treated with proton radiation therapy. Radiation necrosis was assessed by examining serial MRIs and clinical records to determine the incidence, timing, risk factors, imaging patterns, and clinical significance associated with the development of radiation necrosis in these patients. Radiation necrosis was defined as areas of new enhancement within an anatomic region with previous exposure to proton beam therapy with subsequent decrease on follow-up imaging without changes in chemotherapy. RESULTS Thirty-one percent of patients developed radiation necrosis with a median time to development of 5.0 months (range, 3-11 months). Risk factors included multiple chemotherapy agents (>3 cytotoxic agents) and atypical teratoid rhabdoid tumor pathology (P = .03 and P = .03, respectively). The most common imaging patterns were small (median, 0.9 cm) and multifocal (63% of patients) areas of parenchymal enhancement remote from the surgical site. The median time to complete resolution on imaging was 5.3 months (range, 3-12 months). Among patients with imaging findings of radiation necrosis, 25% demonstrated severe symptoms with medical intervention indicated. CONCLUSIONS Pediatric patients with brain tumors treated with proton radiation therapy demonstrate a high incidence of radiation necrosis and a short time to development of necrosis. Multiple small areas of necrosis are frequently identified on imaging. Exposure to multiple chemotherapy agents was a significant risk factor associated with radiation necrosis in these patients.
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Affiliation(s)
- S F Kralik
- From the Departments of Radiology and Imaging Sciences (S.F.K., C.Y.H., W.F.)
| | - C Y Ho
- From the Departments of Radiology and Imaging Sciences (S.F.K., C.Y.H., W.F.)
| | - W Finke
- From the Departments of Radiology and Imaging Sciences (S.F.K., C.Y.H., W.F.)
| | | | - C P Haskins
- Indiana University School of Medicine (C.P.H.), Indianapolis, Indiana
| | - C-S Shih
- Pediatrics, Hematology/Oncology Section (C.-S.S.)
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Kumthekar PU, Macrie BD, Singh SK, Kaur G, Chandler JP, Sejpal SV. A review of management strategies of malignant gliomas in the elderly population. Am J Cancer Res 2014; 4:436-444. [PMID: 25232486 PMCID: PMC4163609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/16/2014] [Indexed: 06/03/2023] Open
Abstract
Glioblastoma Multiforme (GBM) is the most frequent primary malignant brain tumor in adults. It is an aggressive primary brain neoplasm, associated with a poor prognosis and median survival of less than 1 year. Approximately 50% of patients diagnosed with malignant gliomas in the United States are over the age of 65. Advancing age and poor performance status are two variables that have found to negatively affect prognosis. When compared to younger patients, not only is the treatment of elderly patients associated with decreased efficacy but also greater toxicity. As a result, elderly patients often receive less aggressive treatment and are excluded from clinical trials. There are many challenges in the treatment of elderly patients with GBM including increased surgical morbidity and mortality as well as increased toxicity to radiation and chemotherapy. As such, the optimal therapy remains unclear and controversial for the elderly malignant glioma population.
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Affiliation(s)
- Priya U Kumthekar
- Department of Neurology, Northwestern University, Feinberg School of MedicineChicago, IL, USA
| | - Bryan D Macrie
- Department of Radiation Oncology, Northwestern University, Feinberg School of MedicineChicago, IL, USA
| | - Simran K Singh
- Department of Neurology, Northwestern University, Feinberg School of MedicineChicago, IL, USA
| | - Gurvinder Kaur
- Department of Neurosurgery, Northwestern University, Feinberg School of MedicineChicago, IL, USA
| | - James P Chandler
- Department of Neurosurgery, Northwestern University, Feinberg School of MedicineChicago, IL, USA
| | - Samir V Sejpal
- Department of Radiation Oncology, Northwestern University, Feinberg School of MedicineChicago, IL, USA
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8
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Omuro A, Beal K, Gutin P, Karimi S, Correa DD, Kaley TJ, DeAngelis LM, Chan TA, Gavrilovic IT, Nolan C, Hormigo A, Lassman AB, Mellinghoff I, Grommes C, Reiner AS, Panageas KS, Baser RE, Tabar V, Pentsova E, Sanchez J, Barradas-Panchal R, Zhang J, Faivre G, Brennan CW, Abrey LE, Huse JT. Phase II study of bevacizumab, temozolomide, and hypofractionated stereotactic radiotherapy for newly diagnosed glioblastoma. Clin Cancer Res 2014; 20:5023-31. [PMID: 25107913 DOI: 10.1158/1078-0432.ccr-14-0822] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Bevacizumab is associated with decreased vascular permeability that allows for more aggressive radiotherapy schedules. We conducted a phase II trial in newly diagnosed glioblastoma utilizing a novel hypofractionated stereotactic radiotherapy (HFSRT) schedule combined with temozolomide and bevacizumab. EXPERIMENTAL DESIGN Patients with tumor volume ≤60 cc were treated with HFSRT (6 × 6 Gy to contrast enhancement and 6 × 4 Gy to FLAIR hyperintensity with dose painting) combined with concomitant/adjuvant temozolomide and bevacizumab at standard doses. Primary endpoint was 1-year overall survival (OS): promising = 70%; nonpromising = 50%; α = 0.1; β = 0.1. RESULTS Forty patients were enrolled (median age: 55 years; methylated MGMT promoter: 23%; unmethylated: 70%). The 1-year OS was 93% [95% confidence interval (CI), 84-100] and median OS was 19 months. The median PFS was 10 months, with no pseudo-progression observed. The objective response rate (ORR) was 57%. Analysis of The Cancer Genome Atlas glioblastoma transcriptional subclasses (Nanostring assay) suggested patients with a proneural phenotype (26%) fared worse (ORR = 14%, vs. 77% for other subclasses; P = 0.009). Dynamic susceptibility-contrast perfusion MRI showed marked decreases in relative cerebral blood volume over time (P < 0.0001) but had no prognostic value, whereas higher baseline apparent diffusion coefficient (ADC) ratios and persistent hypermetabolism at the 6-month FDG-PET predicted poor OS (P = 0.05 and 0.0001, respectively). Quality-of-life (FACT-BR-4) and neuropsychological test scores were stable over time, although some domains displayed transient decreases following HFSRT. CONCLUSIONS This aggressive radiotherapy schedule was safe and more convenient for patients, achieving an OS that is comparable with historical controls. Analysis of advanced neuroimaging parameters suggests ADC and FDG-PET as potentially useful biomarkers, whereas tissue correlatives uncovered the poor prognosis associated with the proneural signature in non-IDH-1-mutated glioblastoma.
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Affiliation(s)
- Antonio Omuro
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Philip Gutin
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Denise D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Thomas J Kaley
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York. Department of Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Igor T Gavrilovic
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Craig Nolan
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Adilia Hormigo
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew B Lassman
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ingo Mellinghoff
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York. Department of Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Christian Grommes
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Raymond E Baser
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Juan Sanchez
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | - Jianan Zhang
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Geraldine Faivre
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York. Department of Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lauren E Abrey
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jason T Huse
- Department of Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York. Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
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Fiorentino A, Balducci M, Chiesa S. Which therapeutic approach is feasible for elderly people with glioblastoma? CNS Oncol 2014; 3:9-11. [DOI: 10.2217/cns.13.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Alba Fiorentino
- Radiation Oncology Department, Sacro Cuore-Don Calabria Hospital, Negrar-Verona, Italy
| | - Mario Balducci
- Radiation Oncology Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Silvia Chiesa
- Radiation Oncology Department, Catholic University of the Sacred Heart, Rome, Italy
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Tabouret E, Tassy L, Chinot O, Crétel E, Retornaz F, Rousseau F. High-grade glioma in elderly patients: can the oncogeriatrician help? Clin Interv Aging 2013; 8:1617-24. [PMID: 24353408 PMCID: PMC3861296 DOI: 10.2147/cia.s35941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Gliomas are the most frequent primary brain tumors in adults. As the population ages in Western countries, the number of people being diagnosed with glioblastoma is expected to increase. Clinical management of elderly patients with primary brain tumors is difficult, owing to multiple comorbidities, polypharmacy, decreased tolerance to chemotherapy, and an increased risk of radiation-induced neurotoxicity. A few specific randomized studies have shown a benefit for radiotherapy in elderly patients with good performance status. For patients with poor performance status, chemotherapy (temozolomide) has been shown to be associated with prolonged duration of response. Patients with methylated O6-alkylguanine deoxyribonucleic acid alkyltransferase promoter seem to have better outcomes. Oncogeriatrics proposes the geriatric evaluation of elderly patients to improve therapeutic choices and optimize the management of treatment toxicities and comorbidities.
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Affiliation(s)
- Emeline Tabouret
- Department of Neuro-oncology, Timone Hospital, Marseille, France
| | - Louis Tassy
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Olivier Chinot
- Department of Neuro-oncology, Timone Hospital, Marseille, France
| | - Elodie Crétel
- Transveral Oncogeriatric Unit, University Hospital Timone, Marseille, France
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Pontes LDB, Loureiro LVM, Koch LO, Karnakis T, Guendelmann RAK, Weltman E, Malheiros SMF. Patterns of care and outcomes in elderly patients with glioblastoma in Sao Paulo, Brazil: A retrospective study. J Geriatr Oncol 2013; 4:388-93. [DOI: 10.1016/j.jgo.2013.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 05/02/2013] [Accepted: 07/23/2013] [Indexed: 12/27/2022]
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12
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Radiotherapy plus concurrent or sequential temozolomide for glioblastoma in the elderly: a meta-analysis. PLoS One 2013; 8:e74242. [PMID: 24086323 PMCID: PMC3782499 DOI: 10.1371/journal.pone.0074242] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/31/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Many physicians are reluctant to treat elderly glioblastoma (GBM) patients as aggressively as younger patients, which is not evidence based due to the absence of validated data from primary studies. We conducted a meta-analysis to provide valid evidence for the use of the aggressive combination of radiotherapy (RT) and temozolomide (TMZ) in elderly GBM patients. METHODS A systematic literature search was conducted using the PubMed, EMBASE and Cochrane databases. Studies comparing combined RT/TMZ with RT alone in elderly patients (≥65 years) with newly diagnosed GBM were eligible for inclusion. RESULTS No eligible randomized trials were identified. Alternatively, a meta-analysis of nonrandomized studies (NRSs) was performed, with 16 studies eligible for overall survival (OS) analysis and nine for progression-free survival (PFS) analysis. Combined RT/TMZ was shown to reduce the risk of death and progression in elderly GBM patients compared with RT alone (OS hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.48-0.72; PFS: HR 0.58, 95% CI 0.41-0.84). Evaluable patients were reported to tolerate combined treatment but certain toxicities, and especially hematological toxicities, were more frequently observed. Limited data on O6-methylguanine-DNA methyltransferase (MGMT) promoter status and quality of life were reported. CONCLUSION The meta-analysis of NRSs provided level 2a evidence (Oxford Centre for Evidence-Based Medicine) that combined RT/TMZ conferred a clear survival benefit on a selection of elderly GBM patients who had a favorable prognosis (e.g., extensive resection, favorable KPS). Toxicities were more frequent but acceptable. Future randomized trials are warranted to justify a definitive conclusion.
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13
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Graus F, Bruna J, Pardo J, Escudero D, Vilas D, Barceló I, Brell M, Pascual C, Crespo JA, Erro E, García-Romero JC, Estela J, Martino J, García-Castaño A, Mata E, Lema M, Gelabert M, Fuentes R, Pérez P, Manzano A, Aguas J, Belenguer A, Simón A, Henríquez I, Murcia M, Vivanco R, Rojas-Marcos I, Muñoz-Carmona D, Navas I, de Andrés P, Mas G, Gil M, Verger E. Patterns of care and outcome for patients with glioblastoma diagnosed during 2008-2010 in Spain. Neuro Oncol 2013; 15:797-805. [PMID: 23460319 DOI: 10.1093/neuonc/not013] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND To assess management patterns and outcome in patients with glioblastoma multiforme (GBM) treated during 2008-2010 in Spain. METHODS Retrospective analysis of clinical, therapeutic, and survival data collected through filled questionnaires from patients with histologically confirmed GBM diagnosed in 19 Spanish hospitals. RESULTS We identified 834 patients (23% aged >70 years). Surgical resection was achieved in 66% of patients, although the extent of surgery was confirmed by postoperative MRI in only 41%. There were major postoperative complications in 14% of patients, and age was the only independent predictor (Odds ratio [OR], 1.03; 95% confidence interval [CI],1.01-1.05; P = .006). After surgery, 57% received radiotherapy (RT) with concomitant and adjuvant temozolomide, 21% received other regimens, and 22% were not further treated. In patients treated with surgical resection, RT, and chemotherapy (n = 396), initiation of RT ≤42 days was associated with longer progression-free survival (hazard ratio [HR], 0.8; 95% CI, 0.64-0.99; P = .042) but not with overall survival (HR, 0.79; 95% CI, 0.62-1.00; P = .055). Only 32% of patients older than 70 years received RT with concomitant and adjuvant temozolomide. The median survival in this group was 10.8 months (95% CI, 6.8-14.9 months), compared with 17.0 months (95% CI, 15.5-18.4 months; P = .034) among younger patients with GBM treated with the same regimen. CONCLUSIONS In a community setting, 57% of all patients with GBM and only 32% of older patients received RT with concomitant and adjuvant temozolomide. In patients with surgical resection who were eligible for chemoradiation, initiation of RT ≤42 days was associated with better progression-free survival.
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Affiliation(s)
- Francesc Graus
- Service of Neurology, Hospital Clínic, Villarroel 170, Barcelona 08036, Spain.
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Ciammella P, Galeandro M, D'Abbiero N, Podgornii A, Pisanello A, Botti A, Cagni E, Iori M, Iotti C. Hypo-fractionated IMRT for patients with newly diagnosed glioblastoma multiforme: a 6 year single institutional experience. Clin Neurol Neurosurg 2013; 115:1609-14. [PMID: 23453151 DOI: 10.1016/j.clineuro.2013.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/01/2013] [Accepted: 02/03/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Glioblastoma (GBM) is the most common malignant primary brain tumour in adults. Surgery and radiotherapy constitute the cornerstones for the therapeutic management of GBM. The standard treatment today is maximal surgical resection followed by concomitant chemo-radiation therapy followed by adjuvant TMZ according to Stupp protocol. Despite the progress in neurosurgery, radiotherapy and oncology, the prognosis still results poor. In order to reduce the long time of standard treatment, maintaining or improving the clinical results, in our institute we have investigated the effects of hypo-fractionated radiation therapy for patients with GBM. PATIENTS AND METHODS Sixty-seven patients affected by GBM who had previously undergone surgical resection (total, subtotal or biopsy) were enrolled between October 2005 and December 2011 in a single institutional study of hypo-fractionated intensity modulated radiation therapy (IMRT) followed or not by adjuvant chemotherapy with TMZ (6-12 cycles). The most important eligibility criteria were: biopsy-proven GBM, KPS ≥ 60, age ≥ 18 years, no previous brain irradiation, informed consensus. Hypo-fractionated IMRT was delivered to a total dose of 25 Gy in 5 fractions prescribed to 70% isodose. Response to treatment, OS, PFS, toxicity and patterns of recurrence were evaluated, and sex, age, type of surgery, Karnofsky performance status, Recursive Partitioning Analysis (RPA) classification, time between surgery and initiation of radiotherapy were evaluated as potential prognostic factors for survival. RESULTS All patients have completed the treatment protocol. Median age was 64.5 years (range 41-82 years) with 31 females (46%) and 36 males (54%). Median KPS at time of treatment was 80. The surgery was gross total in 38 patients and subtotal in 14 patients; 15 patients underwent only biopsy. No grade 3-4 acute or late neurotoxicity was observed. With median follow-up of 14.9 months, the median OS and PFS were 13.4 and 7.9 months, respectively. CONCLUSIONS The hypo-fractionated radiation therapy can be used for patients with GBM, resulting in favourable overall survival, low rates of toxicity and satisfying QoL. Future investigations are needed to determine the optimal fractionation for GBM.
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Affiliation(s)
- Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy.
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