Retrospective and Randomized Analysis of Influence and Correlation of Clinical and Molecular Prognostic Factors in a Mono-Operative Series of 122 Patients with Glioblastoma Treated with STR or GTR

Prognostic Value of ATRX and p53 Status in High-Grade Glioma Patients in Morocco

INTRODUCTION

Glioblastoma and astrocytoma, grade 4, are the most common and aggressive brain tumors. Several biomarkers, such as the isocitrate dehydrogenase mutation (IDH-1), alpha-thalassemia/mental retardation, and the X-linked mutation (ATRX), enable more accurate glioma classification and facilitate patient management. This study aimed to determine the prognostic value of clinical and molecular factors (IDH, TP53, and ATRX mutations). We also studied the relationship between these molecular markers and the overall survival (OS) of 126 patients with grade 4 glioblastoma/astrocytoma.

METHODS

The immunohistochemical study was conducted using antibodies namely, IDH1, R132H, p53, and ATRX. Statistical tests were used to investigate factors that might influence overall survival using IBM SPSS Statistics, version 25.0 (IBM Corp., Armonk, NY).

RESULTS

The median age at diagnosis was 51.5 years. Patients with a Karnofsky performance score (KPS) <70 presented less favorable survival outcomes compared to those with a KPS ≥70. The median OS for patients was found to be 11.17 months. Expression of IDH1 R132H was found in 13.5% of patients, p53 overexpression was identified in 55.6% of cases, and loss of ATRX expression was detected in 11.9%. The group of patients with IDH mutant/ATRX mutant/p53 wild-type had the best prognosis (OS = 27.393 months; p = 0.015). Our results were in line with previous studies.

CONCLUSION

The clinical value of IDH and ATRX mutations in prognostic assessment was confirmed (p ≤0.05). The overexpression of p53 had no significant impact on OS (p = 0.726). Therefore, p53 alone cannot predict survival in glioblastoma patients. Based on the results, these biomarkers may be a potential therapeutic target to prolong patient survival, hence the need for further investigations.

The Impact of ioMRI on Glioblastoma Resection and Clinical Outcomes in a State-of-the-Art Neuro-Oncological Setup

Intraoperative magnetic resonance imaging (ioMRI) aims to improve gross total resection (GTR) in glioblastoma (GBM) patients. Despite some older randomized data on safety and feasibility, ioMRI's actual impact in a modern neurosurgical setting utilizing a larger armamentarium of techniques has not been sufficiently investigated to date. We therefore aimed to analyze its effects on residual tumor, patient outcome, and progression-free survival (PFS) in GBM patients in a modern high-volume center. Patients undergoing ioMRI for resection of supratentorial GBM were enrolled between March 2018 and June 2020. ioMRI was performed in all cases at the end of resection when surgeons expected complete macroscopic tumor removal. Extent of resection (EOR) was performed by volumetric analysis, with GTR defined as an EOR ≥ 95%, respectively. Progression-free survival (PFS) was analyzed through univariate and multivariate Cox proportional regression analyses. In total, we enrolled 172 patients. Mean EOR increased from 93.9% to 98.3% (p < 0.0001) due to ioMRI, equaling an increase in GTR rates from 78.5% to 93.0% (p = 0.0002). Residual tumor volume decreased from 1.3 ± 4.2 cm³ to 0.6 ± 2.5 cm³ (p = 0.0037). Logistic regression revealed recurrent GBM as a risk factor leading to subtotal resection (STR) (odds ratio (OR) = 3.047, 95% confidence interval (CI) 1.165-7.974, p = 0.023). Additional resection after ioMRI led to equally long PFS compared to patients with complete tumor removal before ioMRI (hazard ratio (HR) = 0.898, 95%-CI 0.543-1.483, p = 0.67). ioMRI considerably reduces residual tumor volume and helps to achieve comparable PFS, even in patients with unexpected residual tumor after initial resection before ioMRI.

Resection of Noncontrast-Enhancing Regions Deteriorated the Immunotherapeutic Efficacy of HSPPC-96 Vaccination in Treating Glioblastoma

Surgical resection remains a first-line therapy for glioblastoma multiforme (GBM). Increased extent of resection (EOR) of noncontrast-enhancing regions in T2-weighted MRI images (T2-EOR) provides a survival benefit for GBM patients receiving standard radio/chemotherapy. However, whether it also improves immunotherapeutic outcomes remains unclear. We calculated the T2-EOR by comparing the preoperative and postoperative MRI T2 hyperintensity outside the enhancing tumour and correlated the T2-EOR with immunological and clinical outcomes from our published early-phase trial of heat shock protein peptide complex-96 (HSPPC-96) vaccination in treating a cohort of 19 patients with newly diagnosed GBMs (NCT02122822). Patients with higher T2-EOR exhibited shorter progression-free survival (PFS) (HR 11.29, p=0.002) and overall survival (OS) (HR 6.5, p=0.003) times than patients with lower T2-EOR. T2-EOR was negatively correlated with the levels of tumour specific immune response (TSIR) post-vaccination (R=-0.725, p<0.001) and absolute TSIR increase from pre- to post-vaccination (R=-0.679, p=0.001). Multivariate Cox regression models revealed that higher T2-EOR represented an independent risk factor for PFS (HR 19.85, p=0.0068) and OS (HR 21.24, p=0.0185) in this patient cohort. Taken together, increased T2-EOR deteriorated immunotherapeutic outcomes by suppressing TSIR, suggesting the potential of T2-EOR as an early biomarker for predicting the immunotherapeutic efficacy of HSPPC-96 vaccination.

En Bloc Resection of Solitary Brain Metastasis: The Role of Perilesional Edema

BACKGROUND/AIM

The treatment of solitary brain metastasis is a challenging intervention since the incidence increases and prognosis is poor. This study investigated the role of perilesional edema in the overall mass effect of solitary brain metastasis.

PATIENTS AND METHODS

We conducted a retrospective analysis on 88 patients with single supratentorial brain metastasis and concomitant perilesional edema undergoing en bloc resection. Each patient was evaluated for perilesional brain edema grading. We stratified patients into three groups based on the size of the metastatic lesion and the extent of perilesional edema.

RESULTS

The grade of perilesional edema at 30 days after surgical removal did not correlate with the maximum diameter of the metastasis (Pearson's correlation 0.098, p=0.494). In patients with a maximal metastatic diameter ≤2 cm, the grade of perilesional edema before surgical treatment was 1.63 (STD 0.43), while 30 days after removal it was significantly reduced; 0.47 (STD 0.26), p<0.001.

CONCLUSION

The overall mass effect of solitary supratentorial brain metastases is not correlated to the size of the lesion and the grade of the associated perilesional edema should be considered. Surgical en bloc resection can be considered the first choice of treatment in the presence of solitary metastasis ≤2 cm in maximal diameter but with high-grade edema, since this treatment reduces the overall mass effect.

Prognostic significance of preoperative systemic inflammation response index in newly diagnosed glioblastoma patients underwent gross total resection: a propensity score matching analysis

Background

Glioblastoma (GBM) is the most frequent and lethal brain tumor, which possesses highly malignant characteristics and predominates in elder patients. Systemic inflammatory response index (SIRI) is a novel prognostic marker from peripheral blood, which is defined as neutrophil count × monocyte count/lymphocyte count. In the current research, we aim to explore the relationship between SIRI and newly diagnosed GBM underwent gross total resection (GTR).

Methods

A retrospective analysis was conducted on consecutive newly diagnosed GBM patients underwent operation at West China Hospital from March 2015 to January 2019. X-tile software was used to determine the optimal cut-off values of SIRI, and neutrophil to lymphocyte ratio (NLR). All statistical analyses were performed using SPSS software and R software. Propensity score matching (PSM) was conducted to adjust for imbalance of all potential confounding covariates.

Results

The current research included a total of 291 consecutive newly diagnosed GBM patients underwent gross total resection. Among them, 186 were male patients and 105 were female patients. In original cohort, only gender was evidently related to SIRI level. SIRI and NLR were independent prognostic indicators both in original cohort and PSM cohort. Prognostic models based on the independent prognostic factors were established, and prognostic capacity of Model SIRI was superior to Model NLR.

Conclusion

In the current research, SIRI was determined to be an independent prognostic indicator for GBM. And the prognostic predictive ability of SIRI was stronger than NLR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02588-0.

Multivariate analysis of associations between clinical sequencing and outcome in glioblastoma

BACKGROUND

Many factors impact survival in patients with glioblastoma, including age, Karnofsky Performance Status, postoperative chemoradiation, IDH1/2 mutation status, MGMT promoter methylation status, and extent of resection. High-throughput next-generation sequencing is a widely available diagnostic tool, but the independent impact of tumors harboring specific mutant genes on survival and the efficacy of extent of resection are not clear.

METHODS

We utilized a widely available diagnostic platform (FoundationOne CDx) to perform high-throughput next-generation sequencing on 185 patients with newly diagnosed glioblastoma in our tertiary care center. We performed multivariate analysis to control for clinical parameters with known impact on survival to elucidate the independent prognostic value of prevalent mutant genes and the independent impact of gross total resection.

RESULTS

When controlling for factors with known prognostic significance including IDH1/2 mutation and after multiple comparisons analysis, CDKN2B and EGFR mutations were associated with reduced overall survival while PTEN mutation was associated with improved overall survival. Gross total resection, compared to other extent of resection, was associated with improved overall survival in patients with tumors harboring mutations in CDKN2A, CDKN2B, EGFR, PTEN, TERT promoter, and TP53. All patients possessed at least one of these 6 mutant genes.

CONCLUSIONS

This study verifies the independent prognostic value of several mutant genes in glioblastoma. Six commonly found mutant genes were associated with improved survival when gross total resection was achieved. Thus, even when accounting for known predictors of survival and multiple mutant gene comparisons, extent of resection continues to be strongly associated with survival.

How about Levetiracetam in Glioblastoma? An Institutional Experience and Meta-Analysis

Simple Summary

To date, there is a discrepancy regarding the role of antiepileptic drugs on glioblastoma survival. In the present study, based on large institutional cohort and enhanced with a meta-analysis of seven previously published studies, we show a robust association between the perioperative start of levetiracetam treatment with increased overall and progression-free survival in glioblastoma. Our results encourage the initiation of a prospective clinical trial to analyze the antitumor effect of levetiracetam in glioblastoma patients.

Abstract

Despite multimodal treatment, the prognosis of patients with glioblastoma (GBM) remains poor. Previous studies showed conflicting results on the effect of antiepileptic drugs (AED) on GBM survival. We investigated the associations of different AED with overall survival (OS) and progression-free survival (PFS) in a large institutional GBM cohort (n = 872) treated January 2006 and December 2018. In addition, we performed a meta-analysis of previously published studies, including this study, to summarize the evidence on the value of AED for GBM prognosis. Of all perioperatively administered AED, only the use of levetiracetam (LEV) was associated with longer OS (median: 12.8 vs. 8.77 months, p < 0.0001) and PFS (7 vs. 4.5 months, p = 0.001). In the multivariable analysis, LEV was independently associated with longer OS (aHR = 0.74, p = 0.017) and PFS (aHR = 0.68, p = 0.008). In the meta-analysis with 5614 patients from the present and seven previously published studies, outcome benefit for OS (HR = 0.83, p = 0.02) and PFS (HR = 0.77, p = 0.02) in GBM individuals with LEV was confirmed. Perioperative treatment with LEV might improve the prognosis of GBM patients. We recommend a prospective randomized controlled trial addressing the efficacy of LEV in GBM treatment.

Impact of Immunohistochemical profiling of Glioblastoma multiforme on clinical outcomes: Real-world scenario in resource limited setting

OBJECTIVE

Intuition into the molecular pathways of glioblastoma multiforme (GBM) has changed the diagnostic, prognostic, and therapeutic approaches. We investigated the influence of various clinical and molecular prognostic factors on survival outcomes in radically treated GBM patients.

METHODS

Medical records of 160 GBM patients treated between January-2012 and December-2018 with surgery followed by post-operative external beam radiotherapy (EBRT) with/without temozolomide (TMZ) were reviewed. Immunohistochemical (IHC) assays were performed for IDH1mutation, ATRX loss, TP53 overexpression and Ki-67% index. Apart from disease and treatment-related factors' influence on clinical outcomes, the impact of IHC markers in prognostication was analyzed using appropriate statistical tests.

RESULTS

The median overall survival (OS) was 14 months. EBRT with concurrent TMZ was given to 60% of patients and 42.5% completed the standard Stupp-protocol. Significant improvements in OS was observed in patients aged ≤ 50years (2-year OS: 22.1% vs. 12.5%, p = 0.001), those who underwent gross total resection (2-year OS: 21.8% vs. 12.8%, p = 0.002), received concurrent TMZ (21.9% vs. 12.5%, p = 0.005), completed the entire Stupp-protocol (2-year OS: 23.4% vs. 6.5%, p = 0.000), and with Ki-67 index <20% (2-year OS: 23.3% vs. 11.6%, p = 0.015). On multivariate analysis, IDH1 mutation, ATRX loss, TP53 expression, and Ki-67 ≤ 20% were significant prognosticators of outcomes.

CONCLUSION

GBM patients treated with concurrent chemoradiation and those who completed the full Stupp-protocol experienced better survival outcomes. Molecular biology significantly impacts clinical outcomes and plays a key deterministic role in newer management strategies.

Historical Perspective on Surgery and Survival with Glioblastoma: How Far Have We Come?

BACKGROUND

Glioblastoma multiforme remains a therapeutic challenge. We offer a historical review of the outcomes of patients with glioblastoma from the earliest report of surgery for this lesion through the introduction of modern chemotherapeutics and aggressive approaches to tumor resection.

METHODS

We reviewed all major surgical series of patients with glioblastoma from the introduction of craniotomy for glioma (1884) to 2020.

RESULTS

The earliest reported craniotomy for glioblastoma resulted in the patient's death less than a month after surgery. Improved intracranial pressure management resulted in improved outcomes, reducing early postoperative mortality from 50% to 6% in Harvey Cushing's series. In the first major surgical series (1912), the mean survival was 10.1 months. This figure did not improve until the introduction of radiotherapy in the 1950s, which doubled survival relative to those who had surgery alone. The most recent significant advance, chemotherapy with the alkylating agent temozolomide, extended survival by 2.5 months compared with surgery and radiotherapy alone (14.6 and 12.1 months, respectively). This protocol remains the standard regimen for newly diagnosed glioblastoma. The innovative treatments being investigated have yet to show a survival benefit.

CONCLUSIONS

With advancements in localization, imaging, anesthesia, surgical technique, control of cerebral edema, and adjuvant therapies, outcomes in glioblastoma improved incrementally from Cushing's time until the introduction of magnetic resonance imaging enabled better degrees of resection in the 1990s. Modest improvements came with the advent of biomarker-driven targeted chemotherapy in the first decade of the current century.

Preoperative and early postoperative seizures in patients with glioblastoma-two sides of the same coin?

Background

Symptomatic epilepsy is a common symptom of glioblastoma, which may occur in different stages of disease. There are discrepant reports on association between early seizures and glioblastoma survival, even less is known about the background of these seizures. We aimed at analyzing the risk factors and clinical impact of perioperative seizures in glioblastoma.

Methods

All consecutive cases with de-novo glioblastoma treated at our institution between 01/2006 and 12/2018 were eligible for this study. Perioperative seizures were stratified into seizures at onset (SAO) and early postoperative seizures (EPS, ≤21days after surgery). Associations between patients characteristics and overall survival (OS) with SAO and EPS were addressed.

Results

In the final cohort (n = 867), SAO and EPS occurred in 236 (27.2%) and 67 (7.7%) patients, respectively. SAO were independently predicted by younger age (P = .009), higher KPS score (P = .002), tumor location (parietal lobe, P = .001), GFAP expression (≥35%, P = .045), and serum chloride at admission (>102 mmol/L, P = .004). In turn, EPS were independently associated with tumor location (frontal or temporal lobe, P = .013) and pathologic laboratory values at admission (hemoglobin < 12 g/dL, [P = .044], CRP > 1.0 mg/dL [P = 0.036], and GGT > 55 U/L [P = 0.025]). Finally, SAO were associated with gross-total resection (P = .006) and longer OS (P = .030), whereas EPS were related to incomplete resection (P = .005) and poorer OS (P = .009).

Conclusions

In glioblastoma patients, SAO and EPS seem to have quite different triggers and contrary impact on treatment success and OS. The clinical characteristics of SAO and EPS patients might contribute to the observed survival differences.