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Initial and cumulative recurrence patterns of glioblastoma after temozolomide-based chemoradiotherapy and salvage treatment: a retrospective cohort study in a single institution.

Ogura K, Mizowaki T, Arakawa Y, Ogura M, Sakanaka K, Miyamoto S, Hiraoka M - Radiat Oncol (2013)

Bottom Line: Twenty-one patients with glioblastoma that recurred after concurrent temozolomide and localized radiotherapy were retrospectively analyzed (11 male, 10 female; median age, 57 years; range, 27-74).Disease progression was assessed by new response criteria proposed by the Response Assessment in Neuro-Oncology Working Group of the American Society of Clinical Oncology.The median follow-up of the recurrent patients was 501 (range, 217-1815) days after initial surgery.

View Article: PubMed Central - HTML - PubMed

Affiliation: Departments of Radiation Oncology and Image-applied Therapy, 54 Kawahara-cho, Shogoin Sakyo-ku, Kyoto 606-8507, Japan. mizo@kuhp.kyoto-u.ac.jp.

ABSTRACT

Purpose: To analyze initial recurrence patterns in patients with newly diagnosed glioblastoma after radiotherapy plus concurrent and adjuvant temozolomide, and to investigate cumulative recurrence patterns after salvage treatment, including surgery, stereotactic radiotherapy, and chemotherapy.

Methods: Twenty-one patients with glioblastoma that recurred after concurrent temozolomide and localized radiotherapy were retrospectively analyzed (11 male, 10 female; median age, 57 years; range, 27-74). Disease progression was assessed by new response criteria proposed by the Response Assessment in Neuro-Oncology Working Group of the American Society of Clinical Oncology. The pattern of recurrence was determined by relationships between locations of recurrent tumors and irradiated doses. Central, in-field, marginal, and out-field recurrences were defined relative to the prescribed isodose line. Distant recurrence was operationally defined as subependymal or disseminated disease. Initial and cumulative patterns of recurrence were evaluated in each patient.

Results: The median follow-up of the recurrent patients was 501 (range, 217-1815) days after initial surgery. Initial recurrences were central in 14 patients (66.7%), in-field in four patients (19.0%), marginal in no patient (0%), out-field in two patients (9.5%), and distant in four patients (19.0%). One patient had both central and in-field recurrences simultaneously, and two had both central and distant recurrences. In the analysis of cumulative recurrence patterns, five patients, who had no scans after initial recurrences, were excluded and the remaining 16 were included. Cumulative recurrences were central in 11 patients (68.8%), in-field in five patients (31.3%), marginal in three patients (18.8%), out-field in five patients (31.3%), and distant in 14 patients (87.5%). Regarding salvage treatments, 11 (52.4%), 11 (52.4%) and 17 (81.0%) patients underwent surgery, stereotactic radiotherapy and chemotherapy, respectively. Eighteen (85.7%) patients had died at the time of analysis, and 16 of them (88.9%) had suffered distant recurrences, which could have been the immediate causes of death.

Conclusions: Recurrence patterns of glioblastoma after radiotherapy plus concomitant and adjuvant temozolomide were mainly central at first, and distant recurrences were often detected during the clinical course. Much better local control and prevention of distant recurrence, including effective salvage treatment, seem to be important.

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The target delineation method used in our hospital. GTV = gross target volume, CTV = clinical target volume, FLAIR = fluid-attenuated inversion recovery, HIA = high intensity area.
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Figure 1: The target delineation method used in our hospital. GTV = gross target volume, CTV = clinical target volume, FLAIR = fluid-attenuated inversion recovery, HIA = high intensity area.

Mentions: Patients were immobilized with thermoplastic masks in the supine position and underwent CT simulation with a 0.25-cm slice thickness. Radiation treatment planning was performed with the Varian Eclipse Treatment Planning System. Preoperative and postoperative MRI images were fused with planning CT images. The gross target volume (GTV) was defined as the sum of the resection cavity and the residual tumor based on postoperative contrast-enhanced MRI. The clinical target volume (CTV) was classified into CTV1 and CTV2. CTV1 was defined by adding a 2-cm margin to the GTV and was modified to include high-intensity areas of T2 or fluid-attenuated inversion recovery (FLAIR) sequences based on pre- and postoperative MRI. CTV2 was identical to the GTV. These are depicted graphically in Figure 1. The CTV1 was manually edited according to the anatomic barriers to tumor spread such as bone, ventricles, cerebral falx, and cerebellar tentorium. The CTV1 was also modified if sparing of radiosensitive organs such as optic nerves, chiasm, and brain stem was needed. Then, the CTV1 and the CTV2 were expanded 0.5 cm to create planning target volume (PTV) in consideration of set-up error and patient motion, named as PTV1 and PTV2, respectively.


Initial and cumulative recurrence patterns of glioblastoma after temozolomide-based chemoradiotherapy and salvage treatment: a retrospective cohort study in a single institution.

Ogura K, Mizowaki T, Arakawa Y, Ogura M, Sakanaka K, Miyamoto S, Hiraoka M - Radiat Oncol (2013)

The target delineation method used in our hospital. GTV = gross target volume, CTV = clinical target volume, FLAIR = fluid-attenuated inversion recovery, HIA = high intensity area.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3643853&req=5

Figure 1: The target delineation method used in our hospital. GTV = gross target volume, CTV = clinical target volume, FLAIR = fluid-attenuated inversion recovery, HIA = high intensity area.
Mentions: Patients were immobilized with thermoplastic masks in the supine position and underwent CT simulation with a 0.25-cm slice thickness. Radiation treatment planning was performed with the Varian Eclipse Treatment Planning System. Preoperative and postoperative MRI images were fused with planning CT images. The gross target volume (GTV) was defined as the sum of the resection cavity and the residual tumor based on postoperative contrast-enhanced MRI. The clinical target volume (CTV) was classified into CTV1 and CTV2. CTV1 was defined by adding a 2-cm margin to the GTV and was modified to include high-intensity areas of T2 or fluid-attenuated inversion recovery (FLAIR) sequences based on pre- and postoperative MRI. CTV2 was identical to the GTV. These are depicted graphically in Figure 1. The CTV1 was manually edited according to the anatomic barriers to tumor spread such as bone, ventricles, cerebral falx, and cerebellar tentorium. The CTV1 was also modified if sparing of radiosensitive organs such as optic nerves, chiasm, and brain stem was needed. Then, the CTV1 and the CTV2 were expanded 0.5 cm to create planning target volume (PTV) in consideration of set-up error and patient motion, named as PTV1 and PTV2, respectively.

Bottom Line: Twenty-one patients with glioblastoma that recurred after concurrent temozolomide and localized radiotherapy were retrospectively analyzed (11 male, 10 female; median age, 57 years; range, 27-74).Disease progression was assessed by new response criteria proposed by the Response Assessment in Neuro-Oncology Working Group of the American Society of Clinical Oncology.The median follow-up of the recurrent patients was 501 (range, 217-1815) days after initial surgery.

View Article: PubMed Central - HTML - PubMed

Affiliation: Departments of Radiation Oncology and Image-applied Therapy, 54 Kawahara-cho, Shogoin Sakyo-ku, Kyoto 606-8507, Japan. mizo@kuhp.kyoto-u.ac.jp.

ABSTRACT

Purpose: To analyze initial recurrence patterns in patients with newly diagnosed glioblastoma after radiotherapy plus concurrent and adjuvant temozolomide, and to investigate cumulative recurrence patterns after salvage treatment, including surgery, stereotactic radiotherapy, and chemotherapy.

Methods: Twenty-one patients with glioblastoma that recurred after concurrent temozolomide and localized radiotherapy were retrospectively analyzed (11 male, 10 female; median age, 57 years; range, 27-74). Disease progression was assessed by new response criteria proposed by the Response Assessment in Neuro-Oncology Working Group of the American Society of Clinical Oncology. The pattern of recurrence was determined by relationships between locations of recurrent tumors and irradiated doses. Central, in-field, marginal, and out-field recurrences were defined relative to the prescribed isodose line. Distant recurrence was operationally defined as subependymal or disseminated disease. Initial and cumulative patterns of recurrence were evaluated in each patient.

Results: The median follow-up of the recurrent patients was 501 (range, 217-1815) days after initial surgery. Initial recurrences were central in 14 patients (66.7%), in-field in four patients (19.0%), marginal in no patient (0%), out-field in two patients (9.5%), and distant in four patients (19.0%). One patient had both central and in-field recurrences simultaneously, and two had both central and distant recurrences. In the analysis of cumulative recurrence patterns, five patients, who had no scans after initial recurrences, were excluded and the remaining 16 were included. Cumulative recurrences were central in 11 patients (68.8%), in-field in five patients (31.3%), marginal in three patients (18.8%), out-field in five patients (31.3%), and distant in 14 patients (87.5%). Regarding salvage treatments, 11 (52.4%), 11 (52.4%) and 17 (81.0%) patients underwent surgery, stereotactic radiotherapy and chemotherapy, respectively. Eighteen (85.7%) patients had died at the time of analysis, and 16 of them (88.9%) had suffered distant recurrences, which could have been the immediate causes of death.

Conclusions: Recurrence patterns of glioblastoma after radiotherapy plus concomitant and adjuvant temozolomide were mainly central at first, and distant recurrences were often detected during the clinical course. Much better local control and prevention of distant recurrence, including effective salvage treatment, seem to be important.

Show MeSH
Related in: MedlinePlus