The Epidemiological Characteristics and Prognostic Factors of Low-Grade Brainstem Glioma: A Real-World Study of Pediatric and Adult Patients

Prediction of H3K27M Alteration Status in Brainstem Glioma Using Multi-Shell Diffusion MRI Metrics

BACKGROUND

Multi-shell diffusion characteristics may help characterize brainstem gliomas (BSGs) and predict H3K27M status.

PURPOSE

To identify the diffusion characteristics of BSG patients and investigate the predictive values of various diffusion metrics for H3K27M status in BSG.

STUDY TYPE

Prospective.

POPULATION

Eighty-four BSG patients (median age 10.5 years [IQR 6.8-30.0 years]) were included, of whom 56 were pediatric and 28 were adult patients.

FIELD STRENGTH/SEQUENCE

3 T, multi-shell diffusion imaging.

ASSESSMENT

Diffusion kurtosis imaging and neurite orientation dispersion and density imaging analyses were performed. Age, gender, and diffusion metrics, including fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity, radial diffusivity (RD), mean kurtosis (MK), axial kurtosis (AK), radial kurtosis, intracellular volume fraction (ICVF), orientation dispersion index, and isotropic volume fraction (ISOVF), were compared between H3K27M-altered and wildtype BSG patients.

STATISTICAL TESTS

Chi-square test, Mann-Whitney U test, multivariate analysis of variance (MANOVA), step-wise multivariable logistic regression. P-values <0.05 were considered significant.

RESULTS

82.4% pediatric and 57.1% adult patients carried H3K27M alteration. In the whole group, the H3K27M-altered BSGs demonstrated higher FA, AK and lower RD, ISOVF. The combination of age and median ISOVF showed fair performance for H3K27M prediction (AUC = 0.78). In the pediatric group, H3K27M-altered BSGs showed higher FA, AK, MK, ICVF and lower RD, MD, ISOVF. The combinations of median ISOVF, 5th percentile of FA, median MK and median MD showed excellent predictive power (AUC = 0.91). In the adult group, H3K27M-altered BSGs showed higher ICVF and lower RD, MD. The 75th percentile of RD demonstrated fair performance for H3K27M status prediction (AUC = 0.75).

DATA CONCLUSION

Different alteration patterns of diffusion measures were identified between H3K27M-altered and wildtype BSGs, which collectively had fair to excellent predictive value for H3K27M alteration status, especially in pediatric patients.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 3.

Non-Invasive Prediction of Survival Time of Midline Glioma Patients Using Machine Learning on Multiparametric MRI Radiomics Features

Objectives

To explore the feasibility of predicting overall survival (OS) of patients with midline glioma using multi-parameter magnetic resonance imaging (MRI) features.

Methods

Data of 84 patients with midline gliomas were retrospectively collected, including 40 patients with OS > 12 months (28 cases were adults, 14 cases were H3 K27M-mutation) and 44 patients with OS < 12 months (29 cases were adults, 31 cases were H3 K27M-mutation). Features were extracted from the largest slice of tumors, which were manually segmented on T2-weighted (T2w), T2 fluid-attenuated inversion recovery (T2 FLAIR), and contrast-enhanced T1-weighted (T1c) images. Data were randomly divided into training (70%) and test cohorts (30%) and normalized and standardized using Z-scores. Feature dimensionality reduction was performed using the variance method and maximum relevance and minimum redundancy (mRMR) algorithm. We used the logistic regression algorithm to construct three models for T2w, T2 FLAIR, and T1c images as well as one combined model. The test cohort was used to evaluate the models, and receiver operating characteristic (ROC) curves, areas under the curve (AUCs), sensitivity, specificity, and accuracy were calculated. The nomogram of the combined model was built and evaluated using a calibration curve. Decision curve analysis (DCA) was used to evaluate the clinical application value of the four models.

Results

A total of 1,316 features were extracted from T2w, T2 FLAIR, and T1c images, respectively. And then the best non-redundant features were selected from the extracted features using the variance method and mRMR. Finally, five features were extracted each from T2w, T2 FLAIR, and T1c images, and 12 features were extracted for the combined model. Four models were established using the optimal features. In the test cohort, the combined model performed the best out of all models. The AUCs of the T2w, T2 FLAIR, T1c, and combined models were 0.73, 0.78, 0.74, and 0.87, respectively, and accuracies were 0.72, 0.76, 0.72, and 0.84, respectively. The ROC curves and DCA showed that the combined model had the highest efficiency and most favorable clinical benefits.

Conclusion

The combined radiomics model based on multi-parameter MRI features provided a reliable non-invasive method for the prognostic prediction of midline gliomas.

Management and outcome of pediatric brainstem and cerebellar peduncular low-grade gliomas: a retrospective analysis of 62 cases

PURPOSE

This study was designed to present our experience and recommendations regarding the management of pediatric brainstem and peduncular low-grade gliomas (LGGs).

METHODS

Retrospective analysis was performed for pathologically proven brainstem or cerebellar peduncular LGGs in patients admitted between 2014 and 2019. These lesions were classified into the dorsal exophytic, focal brainstem, cervicomedullary, lower peduncular, and upper peduncular groups, and this classification was the basis for the surgical approach for the lesions.

RESULTS

Sixty-two pediatric patients were included, and their distribution among the aforementioned groups were as follows: 12, 12, 3, 16, and 19 cases in the dorsal exophytic, focal brainstem, cervicomedullary, upper peduncular, and lower peduncular groups, respectively. Stereotactic biopsy was performed for all cases in the focal brainstem group, whereas other groups underwent open excision. Gross total resection (GTR) was achieved in 20 cases (40%), near-total resection (NTR) was achieved in 17 cases (34%), and subtotal resection (STR) was achieved in 13 cases (26%). The extent of GTR and NTR for the upper peduncular, lower peduncular, dorsal exophytic, and cervicomedullary groups were 81.2%, 68.4%,75%, and 66.6%, respectively. Then, 32 cases received chemotherapy. The 3- and 5-year progression-free survival rates were 95% (95% confidence interval (CI) 89.5-100%) and 90.3% (95% CI 79.9-100%), respectively. A significant difference in the 3-year progression-free survival rate was observed between the GTR and NTR groups (p = 0.06; 100% vs. 88.2% (95% CI 72.9-100%)).

CONCLUSION

Surgery plays a definitive curative role in grossly resected cases. Additionally, the role of surgical debulking should be considered, even if GTR is impossible. Meanwhile, chemotherapy showed a beneficial role in patients with focal brainstem lesions and progressive lesions, those with STR, and some patients with NTR.

Nomograms for predicting the overall survival of patients with cerebellar glioma: an analysis of the surveillance epidemiology and end results (SEER) database

At present, our understanding of cerebellar glioma is still insufficient. This study collected information on patients in the SEER database to identify the predictive factors for patients with cerebellar glioma. Data from patients with cerebellar glioma diagnosed from 1975 to 2018 were retrieved from the Surveillance Epidemiology and End Results Database. We randomly divided the patients into a training group and a validation group, established a nomogram based on the training group, and used the validation group data to verify the clinical value of the model. A total of 508 patients were included in this study. Multivariate analysis was performed based on the data before randomization, and the results showed that the patient's age, WHO grade, histological type, and extent were significantly correlated with the survival rate. The C-index of the OS nomograms of the training cohort was 0.909 (95% CI, (0.880–0.938)) and 0.932 (95% CI, (0.889–0.975)) in the validation group. The calibration curve of OS for 3 and 5 years showed that there was good consistency between the actual survival probability and the predicted survival probability. For patients with cerebellar glioma, the age at diagnosis, WHO grade of the glioma, histological type, and extension are the four factors that most strongly affect the overall survival outcomes. Furthermore, our model may be a useful tool for predicting OS in these patients.

Epidemiology and Survival of Patients With Brainstem Gliomas: A Population-Based Study Using the SEER Database

Background

Brainstem glioma is a primary glial tumor that arises from the midbrain, pons, and medulla. The objective of this study was to determine the population-based epidemiology, incidence, and outcomes of brainstem gliomas.

Methods

The data pertaining to patients with brainstem gliomas diagnosed between 2004 and 2016 were extracted from the SEER database. Descriptive analyses were conducted to evaluate the distribution and tumor-related characteristics of patients with brainstem gliomas. The possible prognostic indicators were analyzed by Kaplan-Meier curves and a Cox proportional hazards model.

Results

The age-adjusted incidence rate was 0.311 cases per 100,000 person-years between 2004 and 2016. A total of 3387 cases of brainstem gliomas were included in our study. Most of the patients were white and diagnosed at 5-9 years of age. The most common diagnosis confirmed by histological review was ependymoma/anaplastic ependymoma. The median survival time was 24 months. Patients with tumors less than 3 cm in size had a better prognosis. Surgery was effective at improving overall survival. There was no evidence that radiotherapy and chemotherapy improved overall survival.

Conclusion

Brainstem gliomas can be diagnosed at any age. Ependymoma/anaplastic ependymoma is the most common pathological diagnosis. The prognosis is poor, and timely diagnosis and surgery are effective at improving the prognosis. We suggest that more attention should be given to the treatment of patients with brainstem gliomas.

The Survival Benefits of Surgical Resection and Adjuvant Therapy for Patients With Brainstem Glioma

Purpose

The role of surgical resection in the treatment of brainstem glioma (BSG) is poorly understood. For pediatric low-grade (LGBSG) group, several monocentric small-scale retrospective studies reported contradictory conclusions. And there was no clinical study focused on surgical resection for adult or pediatric high-grade (HG) patient groups. This study aims to illustrate whether surgical resection and adjuvant therapy provide survival benefits for patients with histologically confirmed BSG.

Patients and Methods

This retrospective cohort study included 529 patients with histologically confirmed BSG in Surveillance Epidemiology and End Results (SEER) database from 2006-2015. Patients were divided into four groups by age and World Health Organization (WHO) grade. Kaplan-Meier curves of CSS were plotted by different treatment options to compare the survival probability. Univariate and multivariable analyses were then conducted to determine the prognosis effects of surgical resection and adjuvant therapy on cancer specific survival (CSS). All analyses were done in four different groups separately.

Results

The final sample included 529 patients. The entire study population was divided into groups of pediatric LG (n=236, 44.6%), pediatric HG (n=37, 7.0%), adult LG (n=204, 38.6%) and adult HG (n=52, 9.8%). 52.7% (n=144) of pediatric patients had pilocytic astrocytoma and 45.3% (n=116) of adult patients had ependymoma. Pediatric LGBSG group had the highest gross total resection (GTR) rate (61.4%) and 5-year CSS rate (88.6%). Kaplan-Meier curves of pediatric LGBSG group revealed that patients treated with GTR had significantly better survival probability (P=0.033). Multivariable analysis identified GTR as independently significant predictor for prolonged CSS in pediatric LGBSG group (HR0.29, 95%CI 0.11-0.78, P=0.015); Surgical resection showed no relation to CSS in other patient groups. Kaplan-Meier curves of adult HGBSG group showed that patients treated with both RT and CT in adult HGBSG group had the best survival probability (P=0.02). However, multivariable analysis showed the combination of radiotherapy (RT) and chemotherapy (CT) was not significantly related to better CSS in adult HGBSG group (HR0.35, 95%CI 0.11-1.09, P=0.070). Adjuvant therapy didn’t associate with better CSS in other patient groups.

Conclusion

Pediatric LGBSG group had the highest GTR rate and the most favorable clinical outcome. GTR can provide significant survival benefits for pediatric LGBSG group.

Hsa_circ_0110757 upregulates ITGA1 to facilitate temozolomide resistance in glioma by suppressing hsa-miR-1298-5p

Temozolomide (TMZ) is the internationally recognized and preferred drug for glioma chemotherapy treatment. However, TMZ resistance in glioma appears after long-term use and is an urgent problem that needs to be solved. Circular RNAs (circRNAs) are noncoding RNAs and play an important role in the pathogenesis and progression of tumors. Hsa_circ_0110757 was identified in TMZ-resistant glioma cells by high-throughput sequencing analysis and was derived from reverse splicing of myeloid cell leukemia-1 (Mcl-1) exons. The role of hsa_circ_0110757 in TMZ-resistant glioma was evaluated both in vitro and in vivo. It was found that hsa_circ_0110757 and ITGA1 are more highly expressed in TMZ-resistant glioma than in TMZ-sensitive glioma. The overexpression of hsa_circ_0110757 in glioma patients treated with TMZ was obviously associated with tumor invasion. This study indicates that hsa_circ_0110757 inhibits glioma cell apoptosis by sponging hsa-miR-1298-5p to promote ITGA1 expression. Thus, hsa_circ_0110757/hsa-miR-1298-5p/ITGA could be a potential therapeutic target for reversing the resistance of glioma to TMZ.

Racial/Ethnic Disparities and Survival in Pediatrics with Gliomas Based on the Surveillance, Epidemiology, and End Results Database in the United States

BACKGROUND

Gliomas are the most common type of primary central nervous system tumor for both children and adults. However, the influence of racial/ethnic disparities on the survival of children with gliomas has not been fully evaluated yet.

METHODS

Baseline characteristics of patients, including sex, year of diagnosis, surgery, grade, radiation, histology, and races, were collected. Univariate and multivariate analyses for overall survival (OS) were performed using Cox proportional hazards regression model. Survival curves were plotted using Kaplan-Meier methods.

RESULTS

A total of 4400 childhood patients were enrolled, including 2516 non-Hispanic whites (NHWs), 1050 Hispanic whites (HWs), 519 blacks, 282 Asians or Pacific Islanders (APIs), and 33 American Indian/Alaska Natives. NHWs had the longest overall survival (OS), whereas blacks had the shortest OS (P = 0.003). Stratified by histologic type, OS of children with astrocytoma was better among NHWs and HWs than among blacks and APIs (P = 0.004). OS of children with ependymoma was better among NHWs and APIs than among HWs and blacks (P = 0.008). However, no significant difference was observed in OS for children with medulloblastoma (P = 0.854).

CONCLUSIONS

Survival outcomes varied significantly by race/ethnicity among childhood gliomas. Better management of childhood gliomas is warranted to close the survival gap between race/ethnicity.