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Kim D, Lee JH, Kim N, Lim DH, Song JH, Suh CO, Wee CW, Kim IA. Optimizing Recurrent Glioblastoma Salvage Treatment: A Multicenter Study Integrating Genetic Biomarkers From the Korean Radiation Oncology Group (21-02). Neurosurgery 2024; 95:584-595. [PMID: 38511935 DOI: 10.1227/neu.0000000000002903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/13/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Few studies have used real-world patient data to compare overall treatment patterns and survival outcomes for recurrent glioblastoma (rGBM). This study aimed to evaluate postprogression survival (PPS) according to the treatment strategy for rGBM by incorporating biomarker analysis. METHODS We assessed 468 adult patients with rGBM who underwent standard temozolomide-based chemoradiation. The impact of predictors on PPS was evaluated in patients with isocitrate dehydrogenase wild-type rGBM (n = 439) using survival probability analysis. We identified patients who would benefit from reirradiation (re-RT) during the first progression. RESULTS Median PPS was 3.4, 13.8, 6.6, and 10.0 months in the best supportive care (n = 82), surgery (with/without adjuvant therapy, n = 112), chemotherapy alone (n = 170), and re-RT (with/without chemotherapy, n = 75) groups, respectively. After propensity score matching analysis of the cohort, both the surgery and re-RT groups had a significantly better PPS than the chemotherapy-only group; however, no significant difference was observed in PPS between the surgery and re-RT groups. In the surgery subgroup, surgery with chemotherapy ( P = .024) and surgery with radio(chemo)therapy ( P = .039) showed significantly improved PPS compared with surgery alone. In the no-surgery subgroup, radio(chemo)therapy showed significantly improved PPS compared with chemotherapy alone ( P = .047). Homozygous deletion of cyclin-dependent kinase inhibitor 2A/B, along with other clinical factors (performance score and progression-free interval), was significantly associated with the re-RT survival benefit. CONCLUSION Surgery combined with radio(chemo)therapy resulted in the best survival outcomes for rGBM. re-RT should also be considered for patients with rGBM at first recurrence. Furthermore, this study identified a specific genetic biomarker and clinical factors that may enhance the survival benefit of re-RT.
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Affiliation(s)
- Dowook Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul , Korea
- Department of Radiation Oncology, Chungnam National University Hospital, Daejeon , Korea
| | - Joo Ho Lee
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul , Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul , Korea
| | - Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul , Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul , Korea
| | - Jin Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University, Seoul , Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Bundang CHA Medical Center, CHA University, Seongnam , Korea
| | - Chan Woo Wee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul , Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul , Korea
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam , Korea
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Tong E, Horsley P, Wheeler H, Wong M, Venkatesha V, Chan J, Kastelan M, Back M. Hypofractionated re-irradiation with bevacizumab for relapsed chemorefractory glioblastoma after prior high dose radiotherapy: a feasible option for patients with large-volume relapse. J Neurooncol 2024; 168:69-76. [PMID: 38551747 DOI: 10.1007/s11060-024-04643-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/11/2024] [Indexed: 05/15/2024]
Abstract
PURPOSE There remains no standard of care for patients with recurrent and chemorefractory glioblastoma. Re-irradiation (reRT) provides an additional management option. However, published series predominantly focus on small reRT volumes utilizing stereotactic hypofractionated regimens. Concerns regarding toxicity have limited utilisation of reRT for larger recurrences, however this may be mitigated with use of bevacizumab (BEV). METHODS AND MATERIALS A prospective database of patients managed with the EORTC-NCIC (Stupp) protocol 60 Gy chemoradiotherapy protocol for glioblastoma between 2007 and 2021 was reviewed for those patients receiving reRT for chemorefractory relapse. Serial MRI and PET were used to establish true progression and exclude patients with pseudoprogression or radionecrosis from reRT. The primary endpoint was overall survival (OS) from date of reRT. Prognostic factors were also assessed. RESULTS 447 patients managed for glioblastoma under the Stupp protocol were identified, of which 372 had relapsed and were thus eligible for reRT. 71 patients underwent reRT. Median relapse-free survival from diagnosis for the reRT and overall cohorts were similar at 11.6 months (95%CI:9.4-14.2) and 11.8 months (95%CI:9.4-14.2) respectively. 60/71 (85%) reRT patients had received BEV prior to reRT and continued concurrent BEV during reRT. Of the 11 patients not managed with BEV during reRT, 10 required subsequent salvage BEV. ReRT patients were younger (median 53 vs. 59 years, p < 0.001), had better performance status (86% vs. 69% ECOG 0-1, p = 0.002) and more commonly had MGMT promoter-methylated tumours (54% vs. 40%, p = 0.083) compared to non-reRT patients. Median reRT PTV volume was 135cm3 (IQR: 69-207cm3). Median OS from reRT to death was 7.1 months (95%CI:6.3-7.9). Patients aged < 50, 50-70 and > 70 years had post-reRT median OS of 7.7, 6.4 and 6.0 months respectively (p = 0.021). Median post-reRT survival was longer for patients with ECOG performance status 0-1 compared to 2-3 (8.1 vs. 6.3 months, p = 0.039). PTV volume, site of relapse, MGMT promoter-methylation status and extent of initial surgical resection were not associated with post-reRT survival. ReRT was well-tolerated. Out of the 6 patients (8%) admitted to hospital after reRT, only one was for reRT toxicity. This was a CTCAE grade 3 radiation necrosis event in a patient managed without prior BEV. CONCLUSION Patients with recurrent glioblastoma who have been previously treated with 60 Gy radiotherapy have a meaningful survival benefit from large volume re-irradiation which is well tolerated. ReRT should not be ignored as a salvage treatment option in patients with chemorefractory progressive disease.
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Affiliation(s)
- Elissa Tong
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia.
| | - Patrick Horsley
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Helen Wheeler
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
- The Brain Cancer Group, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Matthew Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia
| | - Venkatesha Venkatesha
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Joseph Chan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Marina Kastelan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
- The Brain Cancer Group, St Leonards, NSW, Australia
| | - Michael Back
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
- The Brain Cancer Group, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia
- GenesisCare, Sydney, NSW, Australia
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Fu M, Zhou Z, Huang X, Chen Z, Zhang L, Zhang J, Hua W, Mao Y. Use of Bevacizumab in recurrent glioblastoma: a scoping review and evidence map. BMC Cancer 2023; 23:544. [PMID: 37316802 DOI: 10.1186/s12885-023-11043-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Glioblastoma (GBM) is the most malignant primary tumor in the brain, with poor prognosis and limited effective therapies. Although Bevacizumab (BEV) has shown promise in extending progression-free survival (PFS) treating GBM, there is no evidence for its ability to prolong overall survival (OS). Given the uncertainty surrounding BEV treatment strategies, we aimed to provide an evidence map associated with BEV therapy for recurrent GBM (rGBM). METHODS PubMed, Embase, and the Cochrane Library were searched for the period from January 1, 1970, to March 1, 2022, for studies reporting the prognoses of patients with rGBM receiving BEV. The primary endpoints were overall survival (OS) and quality of life (QoL). The secondary endpoints were PFS, steroid use reduction, and risk of adverse effects. A scoping review and an evidence map were conducted to explore the optimal BEV treatment (including combination regimen, dosage, and window of opportunity). RESULTS Patients with rGBM could gain benefits in PFS, palliative, and cognitive advantages from BEV treatment, although the OS benefits could not be verified with high-quality evidence. Furthermore, BEV combined therapy (especially with lomustine and radiotherapy) showed higher efficacy than BEV monotherapy in the survival of patients with rGBM. Specific molecular alterations (IDH mutation status) and clinical features (large tumor burden and double-positive sign) could predict better responses to BEV administration. A low dosage of BEV showed equal efficacy to the recommended dose, but the optimal opportunity window for BEV administration remains unclear. CONCLUSIONS Although OS benefits from BEV-containing regimens could not be verified in this scoping review, the PFS benefits and side effects control supported BEV application in rGBM. Combining BEV with novel treatments like tumor-treating field (TTF) and administration at first recurrence may optimize the therapeutic efficacy. rGBM with a low apparent diffusion coefficient (ADCL), large tumor burden, or IDH mutation is more likely to benefit from BEV treatment. High-quality studies are warranted to explore the combination modality and identify BEV-response subpopulations to maximize benefits.
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Affiliation(s)
- Minjie Fu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, #12 Middle Urumqi Road, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Zhirui Zhou
- Radiation Oncology Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao Huang
- Department of General Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhenchao Chen
- Department of General Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Licheng Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, #12 Middle Urumqi Road, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jinsen Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, #12 Middle Urumqi Road, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Hua
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, #12 Middle Urumqi Road, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.
- Neurosurgical Institute of Fudan University, Shanghai, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, #12 Middle Urumqi Road, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.
- Neurosurgical Institute of Fudan University, Shanghai, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.
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Value of a 18F-FDG PET/CT Semi-quantitative Parameter (SUVmax) in Predicting the Survival of Patients with Esophageal Cancer Subtypes. IRANIAN JOURNAL OF RADIOLOGY 2022. [DOI: 10.5812/iranjradiol-128737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan is employed for initial staging and restaging of esophageal cancer patients. Objectives: The present study aimed to assess the value of a semi-quantitative parameter of 18F-FDG PET/CT scan, that is, maximum standardized uptake value (SUVmax), to determine its correlation with patient survival in two subtypes of esophageal cancer, including squamous cell carcinoma (SCC) and adenocarcinoma. Patients and Methods: This cross-sectional study was performed on patients with esophageal SCC and adenocarcinoma, undergoing 18F-FDG PET/CT scan for initial staging before any treatment. The 18F-FDG PET/CT semi-quantitative parameter (SUVmax) was determined by reviewing the PET/CT images. The patients were reevaluated using 18F-FDG PET/CT scan for restaging within 12 - 24 months. Results: No significant difference was observed in the SUVmax values of the primary tumor, metastatic lymph nodes, or distant metastasis between the adenocarcinoma and SCC groups, regardless of response to treatment. Similarly, no significant association was found between the short-term survival of patients with adenocarcinoma and the SUVmax values of the primary tumor, metastatic lymph nodes, or distant metastasis. Based on the survival curve, one- and two-year survival rates were estimated at 75% and 63.9% in patients with SCC and at 80% and 60% in patients with adenocarcinoma, respectively. In the SCC group, a significantly higher SUVmax was detected in deceased patients with distant metastatic lesions compared to cancer survivors. According to the area under the ROC curve, the SUVmax of metastatic lesions showed high potential for predicting the mortality of SCC patients. Conclusion: The assessment of SUVmax in distant metastatic lesions by 18F-FDG-PET/CT may help predict the survival of patients with esophageal SCC. However, 18F-FDG-PET/CT findings were not associated with the survival of esophageal adenocarcinoma; therefore, further evaluations on a larger sample size and a longer follow-up are required.
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Impact of fractionated stereotactic radiotherapy on activity of daily living and performance status in progressive/recurrent glioblastoma: a retrospective study. Radiat Oncol 2022; 17:201. [PMID: 36474245 PMCID: PMC9727986 DOI: 10.1186/s13014-022-02169-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The prognosis of recurrent glioblastoma (GBM) is poor, with limited options of palliative localized or systemic treatments. Survival can be improved by a second localized treatment; however, it is not currently possible to identify which patients would benefit from this approach. This study aims to evaluate which factors lead to a lower Karnofsky performance status (KPS) score after fractionated stereotactic RT (fSRT). METHODS We retrospectively collected data from patients treated with fSRT for recurrent GBM at the Institut de Cancérologie de Lorraine between October 2010 and November 2017 and analyzed which factors were associated with a lower KPS score. RESULTS 59 patients received a dose of 25 Gy in 5 sessions spread over 5-7 days (80% isodose). The median time from the end of primary radiotherapy to the initiation of fSRT was 10.7 months. The median follow-up after fSRT initiation was 8.8 months. The incidence of KPS and ADL impairment in all patients were 51.9% and 37.8% respectively with an adverse impact of PTV size on KPS (HR = 1.57 [95% CI 1.19-2.08], p = 0.028). Only two patients showed early grade 3 toxicity and none showed grade 4 or late toxicity. The median overall survival time, median overall survival time after fSRT, median progression-free survival and institutionalization-free survival times were 25.8, 8.8, 3.9 and 7.7 months, respectively. Initial surgery was associated with better progression-free survival (Hazard ratio (HR) = 0.48 [95% CI 0.27-0.86], p = 0.013). CONCLUSIONS A larger PTV should predicts lower KPS in the treatment of recurrent GBM using fSRT.
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She L, Su L, Liu C. Bevacizumab combined with re-irradiation in recurrent glioblastoma. Front Oncol 2022; 12:961014. [PMID: 36046037 PMCID: PMC9423039 DOI: 10.3389/fonc.2022.961014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background Glioblastoma is characterized by rich vasculature and abnormal vascular structure and function. Currently, there is no standard treatment for recurrent glioblastoma (rGBM). Bevacizumab (BEV) has established role of inhibiting neovascularization, alleviating hypoxia in the tumor area and activating the immune microenvironment. BEV may exert synergistic effects with re-irradiation (re-RT) to improve the tumor microenvironment for rGBM. Purpose The purpose of this study was to evaluate the safety, tolerability, and efficacy of a combination of BEV and re-RT for rGBM treatment. Methods In this retrospective study, a total of 26 rGBM patients with surgical pathologically confirmed glioblastoma and at least one event of recurrence were enrolled. All patients were treated with re-RT in combination with BEV. BEV was administered until progression or serious adverse events. Results Median follow-up was 21.9 months for all patients, whereas median progression-free survival (PFS) was 8.0 months (95% confidence interval [CI]: 6.5–9.5 months). In addition, the 6-month and 1-year PFS rates were 65.4% and 28.2%, respectively. The median overall survival (OS), 6-month OS rate, and 1-year OS rate were 13.6 months (95% CI: 10.2–17.0 months), 92.3%, and 67.5%, respectively. The patient showed good tolerance during the treatment with no grade > 3 grade side event and radiation necrosis occurrence rate of 0%. Combined treatment of gross total resection (GTR) before re-RT and concurrent temozolomide during re-RT was an independent prognostic factor that affected both OS and PFS in the whole cohort (OS: 0.067, 95% CI: 0.009–0.521, p = 0.010; PFS: 0.238, 95% CI: 0.076–0.744, p = 0.038). Conclusion In this study, re-RT combined with concurrent and maintenance BEV treatment was safe, tolerable, and effective in rGBM patients. Moreover, GTR before re-RT and selective concurrent temozolomide could further improve patient PFS and OS.
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Affiliation(s)
- Lei She
- Department of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Engineering Research Center for Applied Technology of Pharmacogenomics of Ministry of Education, Central South University, Changsha, China.,Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Su
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
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Tian Y, Ge Z, Xu M, Ge X, Zhao M, Ding F, Yin J, Wang X, You Y, Shi Z, Qian X. Diallyl trisulfide sensitizes radiation therapy on glioblastoma through directly targeting thioredoxin 1. Free Radic Biol Med 2022; 189:157-168. [PMID: 35921994 DOI: 10.1016/j.freeradbiomed.2022.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022]
Abstract
Radiotherapy is a standard-of-care treatment approach for glioblastoma (GBM) patients, but therapeutic resistance to radiotherapy remains a major challenge. Here we demonstrate that diallyl trisulfide (DATS) directly conjugates with cysteine (C) 32 and C35 (C32/35) residues of thioredoxin 1 (Trx1) through Michael addition reactions. Due to localizing in activity center of Trx1, the conjugation between DATS and C32/35 results in inhibition of Trx1 activity, therefore disturbing thioredoxin system and leading to accumulated levels of reactive oxygen species (ROS). High levels of Trx1 expression are correlated with poor prognosis of glioma patients. Notably, we reveal that DATS synergistically enhances irradiation (IR)-induced ROS accumulation, apoptosis, DNA damage, as well as inhibition of tumor growth of GBM cells. These findings highlight the potential benefits of DATS in sensitizing radiotherapy of GBM patients.
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Affiliation(s)
- Yangyang Tian
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China
| | - Zehe Ge
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China
| | - Miao Xu
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China
| | - Xin Ge
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China
| | - Mengjie Zhao
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Department of Neuro-Psychiatric Institute, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210029, China
| | - Fangshu Ding
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China
| | - Jianxing Yin
- Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210029, China
| | - Xiuxing Wang
- Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; National Health Commission Key Laboratory of Antibody Technologies, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Department of Cell Biology, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, Jiangsu, 211166, China
| | - Yongping You
- Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210029, China
| | - Zhumei Shi
- Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210029, China.
| | - Xu Qian
- Department of Nutrition and Food Hygiene, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, 211166, China; Institute for Brain Tumors, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, Jiangsu, 211166, China.
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Park SY, Choi N, Jang NY. Frameless immobilization system with roll correction for stereotactic radiosurgery of intracranial brain metastases. JOURNAL OF RADIATION RESEARCH 2021:rrab071. [PMID: 34373910 DOI: 10.1093/jrr/rrab071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/13/2021] [Accepted: 08/02/2021] [Indexed: 06/13/2023]
Abstract
The objectives of this study were to develop a frameless immobilization system that allows roll rotation corrections and to investigate the performance of this system for stereotactic radiosurgery (SRS) treatment. We designed the support frame of a frameless immobilization system based on the commercial Brainlab immobilization system. The support frame consisted of a fixed component and a rotating component. With rack and pinion gears and guide holes installed in the system, the rotating component was configured to be rotated along the longitudinal axis of the patient with respect to the fixed component. To evaluate the performance of the system, the six degree-of-freedom (6D) positioning corrections (translational and rotational corrections) were assessed by image verification between planning computed tomography (CT) and cone-beam computed tomography (CBCT) images. The commercial immobilization system was evaluated in the same manner for comparison. The mean translational shifts for the commercial system were 0.68 ± 0.19 mm, 0.73 ± 0.24 mm and 0.78 ± 0.19 mm, while those for the developed system were 0.44 ± 0.31 mm, 0.43 ± 0.25 mm and 0.60 ± 0.14 mm in the lateral, longitudinal and vertical directions, respectively. The mean rotational shifts for the commercial system were 0.37° ± 0.12°, 0.32° ± 0.16° and 0.38° ± 0.14°, while those for the developed system were 0.04° ± 0.04°, 0.11° ± 0.06° and 0.15° ± 0.12° along the lateral, vertical and longitudinal axes of the patient, respectively. For institutions that do not have 6D robotic couches installed, the use of the developed immobilization system can provide 6D corrections, resulting in shorter treatment times and higher patient positioning accuracy.
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Affiliation(s)
- So-Yeon Park
- Department of Radiation Oncology, Veterans Health Service Medical Center, Seoul, 05368, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, 03080, Republic of Korea
| | - Noorie Choi
- Department of Radiation Oncology, Veterans Health Service Medical Center, Seoul, 05368, Republic of Korea
| | - Na Young Jang
- Department of Radiation Oncology, Veterans Health Service Medical Center, Seoul, 05368, Republic of Korea
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McBain C, Lawrie TA, Rogozińska E, Kernohan A, Robinson T, Jefferies S. Treatment options for progression or recurrence of glioblastoma: a network meta-analysis. Cochrane Database Syst Rev 2021; 5:CD013579. [PMID: 34559423 PMCID: PMC8121043 DOI: 10.1002/14651858.cd013579.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Glioblastoma (GBM) is a highly malignant brain tumour that almost inevitably progresses or recurs after first line standard of care. There is no consensus regarding the best treatment/s to offer people upon disease progression or recurrence. For the purposes of this review, progression and recurrence are considered as one entity. OBJECTIVES To evaluate the effectiveness of further treatment/s for first and subsequent progression or recurrence of glioblastoma (GBM) among people who have received the standard of care (Stupp protocol) for primary treatment of the disease; and to prepare a brief economic commentary on the available evidence. SEARCH METHODS We searched MEDLINE and Embase electronic databases from 2005 to December 2019 and the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library; Issue 12, 2019). Economic searches included the National Health Service Economic Evaluation Database (NHS EED) up to 2015 (database closure) and MEDLINE and Embase from 2015 to December 2019. SELECTION CRITERIA Randomised controlled trials (RCTs) and comparative non-randomised studies (NRSs) evaluating effectiveness of treatments for progressive/recurrent GBM. Eligible studies included people with progressive or recurrent GBM who had received first line radiotherapy with concomitant and adjuvant temozolomide (TMZ). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data to a pre-designed data extraction form. We conducted network meta-analyses (NMA) and ranked treatments according to effectiveness for each outcome using the random-effects model and Stata software (version 15). We rated the certainty of evidence using the GRADE approach. MAIN RESULTS We included 42 studies: these comprised 34 randomised controlled trials (RCTs) and 8 non-randomised studies (NRSs) involving 5236 participants. We judged most RCTs to be at a low risk of bias and NRSs at high risk of bias. Interventions included chemotherapy, re-operation, re-irradiation and novel therapies either used alone or in combination. For first recurrence, we included 11 interventions in the network meta-analysis (NMA) for overall survival (OS), and eight in the NMA for progression-free survival (PFS). Lomustine (LOM; also known as CCNU) was the most common comparator and was used as the reference treatment. No studies in the NMA evaluated surgery, re-irradiation, PCV (procarbazine, lomustine, vincristine), TMZ re-challenge or best supportive care. We could not perform NMA for second or later recurrence due to insufficient data. Quality-of-life data were sparse. First recurrence (NMA findings) Median OS across included studies in the NMA ranged from 5.5 to 12.6 months and median progression-free survival (PFS) ranged from 1.5 months to 4.2 months. We found no high-certainty evidence that any treatments tested were better than lomustine. These treatments included the following. Bevacizumab plus lomustine: Evidence suggested probably little or no difference in OS between bevacizumab (BEV) combined with lomustine (LOM) and LOM monotherapy (hazard ratio (HR) 0.91, 0.75 to 1.10; moderate-certainty evidence), although BEV + LOM may improve PFS (HR 0.57, 95% confidence interval (CI) 0.44 to 0.74; low-certainty evidence). Bevacizumab monotherapy: Low-certainty evidence suggested there may be little or no difference in OS (HR 1.22, 95% CI 0.84 to 1.76) and PFS (HR 0.90, 95% CI 0.58 to 1.38; low-certainty evidence) between BEV and LOM monotherapies; more evidence on BEV is needed. Regorafenib (REG): REG may improve OS compared with LOM (HR 0.50, 95% CI 0.33 to 0.76; low-certainty evidence). Evidence on PFS was very low certainty and more evidence on REG is needed. Temozolomide (TMZ) plus Depatux-M (ABT414): For OS, low-certainty evidence suggested that TMZ plus ABT414 may be more effective than LOM (HR 0.66, 95% CI 0.47 to 0.92) and may be more effective than BEV (HR 0.54, 95% CI 0.33 to 0.89; low-certainty evidence). This may be due to the TMZ component only and more evidence is needed. Fotemustine (FOM): FOM and LOM may have similar effects on OS (HR 0.89, 95% CI 0.51 to 1.57, low-certainty evidence). Bevacizumab and irinotecan (IRI): Evidence on BEV + irinotecan (IRI) versus LOM for both OS and PFS is very uncertain and there is probably little or no difference between BEV + IRI versus BEV monotherapy (OS: HR 0.95, 95% CI 0.70 to 1.30; moderate-certainty evidence). When treatments were ranked for OS, FOM ranked first, BEV + LOM second, LOM third, BEV + IRI fourth, and BEV fifth. Ranking does not take into account the certainty of the evidence, which also suggests there may be little or no difference between FOM and LOM. Other treatments Three studies evaluated re-operation versus no re-operation, with or without re-irradiation and chemotherapy, and these suggested possible survival advantages with re-operation within the context of being able to select suitable candidates for re-operation. A cannabinoid treatment in the early stages of evaluation, in combination with TMZ, merits further evaluation. Second or later recurrence Limited evidence from three heterogeneous studies suggested that radiotherapy with or without BEV may have a beneficial effect on survival but more evidence is needed. Evidence was insufficient to draw conclusions about the best radiotherapy dosage. Other evidence suggested that there may be little difference in survival with tumour-treating fields compared with physician's best choice of treatment. We found no reliable evidence on best supportive care. Severe adverse events (SAEs) The BEV+LOM combination was associated with significantly greater risk of SAEs than LOM monotherapy (RR 2.51, 95% CI 1.72 to 3.66, high-certainty evidence), and ranked joint worst with cediranib + LOM (RR 2.51, 95% CI 1.29 to 4.90; high-certainty evidence). LOM ranked best and REG ranked second best. Adding novel treatments to BEV was generally associated with a higher risk of severe adverse events compared with BEV alone. AUTHORS' CONCLUSIONS For treatment of first recurrence of GBM, among people previously treated with surgery and standard chemoradiotherapy, the combination treatments evaluated did not improve overall survival compared with LOM monotherapy and were often associated with a higher risk of severe adverse events. Limited evidence suggested that re-operation with or without re-irradiation and chemotherapy may be suitable for selected candidates. Evidence on second recurrence is sparse. Re-irradiation with or without bevacizumab may be of value in selected individuals, but more evidence is needed.
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Affiliation(s)
- Catherine McBain
- Clinical Oncology, The Christie NHS FT, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
| | | | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
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10
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Arpa D, Parisi E, Ghigi G, Cortesi A, Longobardi P, Cenni P, Pieri M, Tontini L, Neri E, Micheletti S, Ghetti F, Monti M, Foca F, Tesei A, Arienti C, Sarnelli A, Martinelli G, Romeo A. Role of Hyperbaric Oxygenation Plus Hypofractionated Stereotactic Radiotherapy in Recurrent High-Grade Glioma. Front Oncol 2021; 11:643469. [PMID: 33859944 PMCID: PMC8042328 DOI: 10.3389/fonc.2021.643469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/09/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The presence of hypoxic cells in high-grade glioma (HGG) is one of major reasons for failure of local tumour control with radiotherapy (RT). The use of hyperbaric oxygen therapy (HBO) could help to overcome the problem of oxygen deficiency in poorly oxygenated regions of the tumour. We propose an innovative approach to improve the efficacy of hypofractionated stereotactic radiotherapy (HSRT) after HBO (HBO-RT) for the treatment of recurrent HGG (rHGG) and herein report the results of an ad interim analysis. METHODS We enrolled a preliminary cohort of 9 adult patients (aged >18 years) with a diagnosis of rHGG. HSRT was administered in daily 5-Gy fractions for 3-5 consecutive days a week. Each fraction was delivered up to maximum of 60 minutes after HBO. RESULTS Median follow-up from re-irradiation was 11.6 months (range: 3.2-11.6 months). The disease control rate (DCR) 3 months after HBO-RT was 55.5% (5 patients). Median progression-free survival (mPFS) for all patients was 5.2 months (95%CI: 1.34-NE), while 3-month and 6-month PFS was 55.5% (95%CI: 20.4-80.4) and 27.7% (95%CI: 4.4-59.1), respectively. Median overall survival (mOS) of HBO-RT was 10.7 months (95% CI: 7.7-NE). No acute or late neurologic toxicity >grade (G)2 was observed in 88.88% of patients. One patient developed G3 radionecrosis. CONCLUSIONS HSRT delivered after HBO appears to be effective for the treatment of rHGG, it could represent an alternative, with low toxicity, to systemic therapies for patients who cannot or refuse to undergo such treatments. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier NCT03411408.
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Affiliation(s)
- Donatella Arpa
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Elisabetta Parisi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Annalisa Cortesi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | | | - Patrizia Cenni
- Neuroradiology Unit, “Santa Maria delle Croci” Hospital, Ravenna, Italy
| | - Martina Pieri
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Simona Micheletti
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Francesca Ghetti
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Manuela Monti
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Anna Tesei
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Chiara Arienti
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Anna Sarnelli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giovanni Martinelli
- Scientific Directorate, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Antonio Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
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11
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Schelin ME, Liu H, Ali A, Shi W, Yu Y, Mooney KE. Dosimetric comparison of Gamma Knife® Icon TM and linear accelerator-based fractionated stereotactic radiotherapy (FSRT) plans for the re-irradiation of large (>14 cm 3) recurrent glioblastomas. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:233-243. [PMID: 33898087 PMCID: PMC8055238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
Our objective is to investigate dosimetric differences between clinically deliverable Gamma Knife® (GK) Icon™ and linac-based FSRT plans on the basis of normal brain dose sparing for large (>14 cm3) recurrent glioblastomas (GBM). Sixteen patients with large, recurrent GBM were treated using re-irradiation via linac-based FSRT, 35 Gy in 10 fractions. For each patient, a new GK FSRT plan was created in Leksell GammaPlan® V11 (LGP). To maintain clinical deliverability, the LGP optimization included a planning goal of treatment time <20 minutes per fraction. Dosimetric comparison of coverage and normal brain dose between the linac and GK treatment plans was performed in MIM. The GK FSRT plans had significantly (p < 0.05) lower mean normal brain dose values (-8.85%), mean values of normal brain V20 (-32.4%) and V12 (-25.9%), and a lower mean V4 (-10.0%). GK FSRT plans have the potential to reduce the risk of radiation-related toxicities.
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Affiliation(s)
- Matthew E Schelin
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Haisong Liu
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Ayesha Ali
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Yan Yu
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Karen E Mooney
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
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12
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Dobi Á, Darázs B, Fodor E, Cserháti A, Együd Z, Maráz A, László S, Dodd L, Reisz Z, Barzó P, Oláh J, Hideghéty K. Low Fraction Size Re-irradiation for Large Volume Recurrence of Glial Tumours. Pathol Oncol Res 2020; 26:2651-2658. [PMID: 32648211 PMCID: PMC7471107 DOI: 10.1007/s12253-020-00868-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
The aim of the present study was to evaluate the efficacy of re-irradiation (re-RT) in patients with advanced local relapses of glial tumours and to define the factors influencing the result of the hyper-fractionated external beam therapy on progression after primary management. We have analysed the data of 55 patients with brain tumours (GBM: 28) on progression, who were re-irradiated between January 2007 and December 2018. The mean volume of the recurrent tumour was 118 cm3, and the mean planning target volume (PTV) was 316 cm3, to which 32 Gy was delivered in 20 fractions at least 7.7 months after the first radiotherapy, using 3D conformal radiotherapy (CRT) or intensity modulated radiotherapy (IMRT). The median overall survival (mOS) from the re-RT was 8.4 months, and the 6-month and the 12-month OS rate was 64% and 31%, respectively. The most important factors by univariate analysis, which significantly improved the outcome of re-RT were the longer time interval between the diagnosis and second radiotherapy (p = 0.029), the lower histology grade (p = 0.034), volume of the recurrent tumour (p = 0.006) and Karnofsky performance status (KPS) (p = 0.009) at the re-irradiation. Our low fraction size re-irradiation ≥ 8 months after the first radiotherapy proved to be safe and beneficial for patients with large volume recurrent glial tumours.
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Affiliation(s)
- Ágnes Dobi
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary.
| | - Barbara Darázs
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Emese Fodor
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Adrienne Cserháti
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zsófia Együd
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Anikó Maráz
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Szilvia László
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Leopold Dodd
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zita Reisz
- Department of Pathology, University of Szeged, Állomás utca 1, Szeged, H-6725, Hungary
| | - Pál Barzó
- Department of Neurosurgery, University of Szeged, Semmelweis utca 6, Szeged, H-6725, Hungary
| | - Judit Oláh
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Katalin Hideghéty
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
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