Re-irradiation For Recurrent Gliomas Research Articles

A Dosimetric Comparison of VMAT, IMRT, and 3DCRT in the Reirradiation of Recurrent Gliomas

A Dosimetric Comparison of VMAT, IMRT, and 3DCRT in the Reirradiation of Recurrent Gliomas

Reirradiation of Recurrent Gliomas

Reirradiation of Recurrent Gliomas

Generation and validation of a prognostic score to predict outcome after re-irradiation of recurrent glioma

Re-irradiation using high-precision radiation techniques has been established within the clinical routine for patients with recurrent gliomas. In the present work, we developed a practical prognostic score to predict survival outcome after re-irradiation. Patients and methods. Fractionated stereotactic radiotherapy (FSRT) was applied in 233 patients. Primary histology included glioblastoma (n = 89; 38%), WHO Grade III gliomas (n = 52; 22%) and low-grade glioma (n = 92; 40%). FSRT was applied with a median dose of 36 Gy in 2 Gy single fractions. We evaluated survival after re-irradiation as well as progression-free survival after re-irradiation; prognostic factors analyzed included age, tumor volume at re-irradiation, histology, time between initial radiotherapy and re-irradiation, age and Karnofsky Performance Score. Results. Median survival after FSRT was 8 months for glioblastoma, 20 months for anaplastic gliomas, and 24 months for recurrent low-grade patients. The strongest prognostic factors significantly impacting survival after re-irradiation were histology (p < 0.0001) and age (< 50 vs. ≥ 50, p < 0.0001) at diagnosis and the time between initial radiotherapy and re-irradiation ≤ 12 vs. > 12 months (p < 0.0001). We generated a four-class prognostic score to distinguish patients with excellent (0 points), good (1 point), moderate (2 points) and poor (3–4 points) survival after re-irradiation. The difference in outcome was highly significant (p < 0.0001). Conclusion. We generated a practical prognostic score index based on three clinically relevant factors to predict the benefit of patients from re-irradiation. This score index can be helpful in patient counseling, and for the design of further clinical trials. However, individual treatment decisions may include other patient-related factors not directly influencing outcome.

Repeat Irradiation for Recurrent Gliomas: The Johns Hopkins Experience

The prognosis of patients with recurrent glioma is poor. Management is controversial and responses to standard therapeutic options are modest. There is limited evidence regarding the role of re-irradiation in these patients. The purpose of this study was to evaluate the outcomes and prognostic factors for patients treated with re-irradiation for recurrent gliomas. One hundred eleven patients treated with re-irradiation at The Johns Hopkins Hospital for recurrent glioma between 1995 and 2010 were retrospectively reviewed. The median age of the cohort was 42 (range, 5 – 80) at re-irradiation. The median initial treatment dose was 60 Gy, 59.4 Gy, and 54 Gy for GBM, WHO Grade III, and low-grade gliomas, respectively. The median retreatment dose (interquartile range) was 36 Gy (26.6 – 45 Gy) for GBM and 45 Gy (41.4 – 45 Gy) for WHO Grade III and low-grade gliomas. Retreatment techniques included IMRT/3D-conformal (48%), LDR brachytherapy (31%), stereotactic radiosurgery (11%), and 2 – 4 conventional fields (10%). The median time interval (interquartile range) between radiation courses was 10.9 months (6.5 – 16.7 months) for GBM, 38.7 months (20.1 – 53.6 months) for WHO Grade III, and 80.3 months (52.4 – 134 months) for low-grade gliomas. Kaplan-Meier statistics were used for analysis. Median survival from primary diagnosis was 23 months for patients with GBM, 57 months for patients with WHO Grade III gliomas, and 108 months for patients with low-grade gliomas. However, there was no difference in survival following re-irradiation based on either pathologic grade at initial diagnosis or pathologic grade at the time of recurrence. Better performance status was significantly associated with prolonged survival following re-irradiation, irrespective of pathologic grade at the time of initial diagnosis or recurrence; patients with a KPS of >70 had a median survival of 9.9 months following re-irradiation compared to patients with KPS <60 who had a median survival of only 1.8 months (p < 0.0001). One-year survival following re-irradiation was 34% vs. 4%, respectively. Re-irradiation resulted in two significant pathologically confirmed complications: one case of radiation vasculopathy and one case of radiation necrosis. Our institutional experience suggests that performance status is the primary prognostic factor for survival following re-irradiation of recurrent glioma, irrespective of pathologic grade at diagnosis or recurrence. The incidence of necrosis with re-irradiation was similar to that expected for initial treatment, and the one year survival results suggest re-irradiation may be an appropriate treatment option for select patients. Prospective studies are warranted for further evaluation of the optimum treatment paradigm in these difficult cases.

Generation and Validation of a Prognostic Score to Predict Outcome after Re-irradiation of Recurrent Glioma

Re-irradiation has been established within the clinical routine for patients with recurrent gliomas. To date, no analysis has shown which patients benefit most from a second course of radiotherapy, and which prognostic factors should be taken into consideration for decision making. In the present work, we developed a prognostic score to predict outcome after re-irradiation and validated the scale in a group of patients with recurrent gliomas.

Radiotherapeutic alternatives for previously irradiated recurrent gliomas

Re-irradiation for recurrent gliomas has been discussed controversially in the past. This was mainly due to only marginal palliation while being associated with a high risk for side effects using conventional radiotherapy.With modern high-precision radiotherapy re-irradiation has become a more wide-spread, effective and well-tolerated treatment option. Besides external beam radiotherapy, a number of invasive and/or intraoperative radiation techniques have been evaluated in patients with recurrent gliomas.The present article is a review on the available methods in radiation oncology and summarizes results with respect to outcome and side effects in comparison to clinical results after neurosurgical resection or different chemotherapeutic approaches.

Re-irradiation using high precision radiotherapy and concomitant temozolomide in patients with recurrent glioma: Re- challenge with radio-chemotherapy

12517 Background: This study was aimed to assess the toxicity and efficacy of radiochemotherapy (RCHT) with temozolomide performed as re-irradiation in patients with recurrent glioma. Patients and Methods: We treated 17 patients with RCHT for recurrent glioma between July 2005 and December 2006. Nine patients were female, eight were male. Pathology evaluation revealed WHO grade II astrocytoma in 5, anaplastic astrocytoma in 4 and glioblastoma multiforme (GBM) in 7 patients. One patient suffered from gliosarcoma. Median age at primary diagnosis was 33 years (range, 6–60 years). In 4 patients surgery had been performed as total resection, subtotal resection in 9 and as a biopsy in 4 patients. Median doses of radiotherapy (RT) of 60 Gy had been applied. Prior treatment with temozolomide either as RCHT or as chemotherapy alone for tumor progression had been performed in 8 patients. The median time interval between primary RT and re-irradiation was 29.5 months (range 5–180 months). Re-irradiation was performed as high precision radiotherapy using fractionated stereotactic radiotherapy (FSRT) in 16 patients with a median total dose of 36 Gy (range, 28–36 Gy); in one patients stereotactic radiosurgery (SRS) was applied for a very small lesion with a single dose of 18Gy/80% isodose. The target volume was defined as the area of contrast enhancement on T1-weighed MRI-scans including a safety margin of 0.5 to 1 cm. Chemotherapy was applied concomitantly in a median dose of 50 mg/m2 per day (median of 100mg TMZ qd); in 14 patients RCHT was followed by adjuvant cycles of temozolomide. Results: Treatment could be completed in all patients without interruptions due to side effects; no severe acute or long-term toxicities were observed. One patient with recurrent GBM showed tumor progression during therapy and treatment was stopped at 32 Gy out of 36 Gy. Progression-free survival was 56% at 6 months after FSRT; survival after FSRT was 75% at 6 months. Median overall survival was 39 months, with 92% at 1 and 2 years. Conclusions: High-precision RT and concomitant temozolomide is safe and effective when performed as re-irradiation in recurrent glioma. The data demonstrate that re-challenge with temozolomide justifies further evaluation. No significant financial relationships to disclose.

Efficacy of Fractionated Stereotactic Reirradiation in Recurrent Gliomas: Long-Term Results in 172 Patients Treated in a Single Institution

To evaluate the efficacy of fractionated stereotactic radiotherapy (FSRT) performed as reirradiation in 172 patients with recurrent low- and high-grade gliomas. Between 1990 and 2004, 172 patients with recurrent gliomas were treated with FSRT as reirradiation in a single institution. Seventy-one patients suffered from WHO grade 2 gliomas. WHO grade 3 gliomas were diagnosed in 42 patients, and 59 patients were diagnosed with glioblastoma multiforme (GBM). The median time between primary radiotherapy and reirradiation was 10 months for GBM, 32 months for WHO grade 3 tumors, and 48 months for grade 2 astrocytomas. FSRT was performed with a median dose of 36 Gy in a median fractionation of 5 x 2 Gy/wk. Median overall survival after primary diagnosis was 21 months for patients with GBM, 50 months for patients with WHO grade 3 gliomas, and 111 months for patients with WHO grade 2 gliomas. Histologic grading was the strongest predictor for overall survival, together with the extent of neurosurgical resection and age at primary diagnosis. Median survival after reirradiation was 8 months for patients with GBM, 16 months for patients with grade 3 tumors, and 22 months for patients with low-grade gliomas. Only time to progression and histology were significant in influencing survival after reirradiation. Progression-free survival after FSRT was 5 months for GBM, 8 months for WHO grade 3 tumors, and 12 months for low-grade gliomas. FSRT is well tolerated and may be effective in patients with recurrent gliomas. Prospective studies are warranted for further evaluation.

Recurrent low-grade gliomas: the role of fractionated stereotactic re-irradiation

To assess the effectiveness of re-irradiation in recurrent low-grade gliomas (LGG). Sixty-three patients were treated with fractionated stereotactic re-irradiation in the case of recurrent gliomas. At primary diagnosis of the tumor, the histology was grade II astrocytoma, oligodendroglioma or oligoastrocytoma. Fifty-two (82.5%) recurrences were in-field, three (4.8%) were localized at the field border, and eight (12.7%) tumors were localized completely out-field of the former RT field, respectively. Using three to four irregular non-coplanar fields formed with a multi-leaf-collimator, we applied a median total dose of 36 Gy (range 15-62 Gy)with a weekly fractionation of 5 x 2 Gy/week depending on the size and the location of the lesion. No concomitant chemotherapy was applied. Radiation was well tolerated by all patients. No severe side effects occurred. Median overall survival was 111 months (range 12-240 months). Extent of neurosurgical resection significantly influenced overall survival (P = 0.02). Median interval between the first radiation therapy and re-irradiation was 50 months (range 5-204 months). From the time point of re-irradiation, median survival was 23 months. Median progression-free survival from the time point of re-irradiation was 12 months (range 2-63 months). No prognosticators could be identified for survival from re-irradiation and progression free survival. Our retrospective data suggest that stereotactically guided fractionated re-irradiation in recurrent glioma represents an effective treatment option with good results and few complications. However, further investigation is warranted to consolidate these results and to combine radiation with chemotherapy in the case of recurrent LGG.