Improved median survival for glioblastoma multiforme following introduction of adjuvant temozolomide chemotherapy

<p><b>INTRODUCTION</b>The use of adjuvant temozolomide (TMZ) in patients managed with surgery and adjuvant radiation therapy (RT) for glioblastoma multiforme (GBM) has been demonstrated to improve median and 2-year survival in a recent large international multicentre study. To confirm this result in routine clinical practice, an audit of the management and outcome of patients with GBM at The Cancer Institute Radiation Oncology was performed.</p><p><b>MATERIALS AND METHODS</b>All patients with GBM managed radically at The Cancer Institute Radiation Oncology from May 2002 to 2006 were entered into a prospective database. Patient, tumour and treatment factors were analysed for association with the outcome of median survival (MS). Survival was calculated using the Kaplan-Meier technique and correlation was assessed using Cox proportional hazards regression.</p><p><b>RESULTS</b>Forty-one patients with GBM were managed with radical intent over the 4- year period. The median age was 54 years and 66% were Eastern Cooperative Oncology Group (ECOG) 0-1 performance status. Macroscopic, subtotal and biopsy alone procedures were performed in 61%, 29% and 10% of patients, respectively. The median time from surgery to RT was 26 days. Adjuvant TMZ was used in 44% of patients (n = 18). The MS of the total group was 13.6 months, with a 24% 2-year overall survival. The use of TMZ was associated with improved MS (19.6 versus 12.8 months; P = 0.035) and improved 2-year survival (43% versus 0%). A requirement of dexamethasone dose greater than 4 mg at the end of RT (P = 0.012) was associated with worse survival, but there was no association of MS with age, ECOG, tumour size or extent of surgery.</p><p><b>CONCLUSION</b>The median and 2-year survival outcomes are comparable to the results of the European Multicentre Study and justify the continued use of TMZ in routine clinical practice.</p>

Salvage chemotherapy in progressive high-grade astrocytoma

<p><b>INTRODUCTION</b>Despite aggressive multidisciplinary interventions, patients with high-grade astrocytomas experience tumour progression or recurrence. Treatment for this group of patients remains a formidable challenge. We describe our experience of salvage chemotherapy for these patients.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of relevant clinical and radiographic information of patients who received at least one cycle of salvage chemotherapy for progressive high-grade astrocytoma at the National Cancer Center, Singapore, from March 2004 to September 2006, was conducted. Patients underwent regular assessment with clinical examination and magnetic resonance brain imaging to gauge response to salvage chemotherapy. Survival and progression free interval data were analysed via Kaplan-Meier method.</p><p><b>RESULTS</b>Twenty-four patients (13 glioblastomas, 11 anaplastic astrocytomas) had received chemotherapy as salvage treatment following progression of their high-grade astrocytoma. Among 20 patients assessable for tumour response, there were 4 patients with partial responses and 9 with stable responses. The 12-month survival rate for the entire group from time of onset of tumour progression was 49.6%. Eight patients had survived more than 12 months at the time of writing. Among patients with glioblastoma, the 12-month survival rate was 30% and the median survival was 11.2 months. For patients with anaplastic astrocytoma, the 12-month survival rate was 73%.</p><p><b>CONCLUSION</b>Durable disease control and prolonged survival were seen in a significant portion of selected patients with progressive high-grade astrocytoma who received salvage chemotherapy.</p>

Improvements in quality of care resulting from a formal multidisciplinary tumour clinic in the management of high-grade glioma

<p><b>INTRODUCTION</b>There is increasing belief that a formal protocol-based multidisciplinary care model should be adopted as an optimal care model in oncology. However, there is minimal outcome evidence to demonstrate an improvement in patient care. The aim of this study was to compare clinical quality outcomes between patients with high-grade glioma managed at one hospital using a formal neuro-oncology multidisciplinary tumour clinic (MTC) and a second hospital with a traditional on-call referral pattern (non-MTC).</p><p><b>MATERIALS AND METHODS</b>Patients with high-grade glioma managed radically with radiation therapy at 2 Singapore hospitals from May 2002 to May 2006 were entered into a prospective database. Patients were grouped into management via MTC or non-MTC. Four clinical quality indicators were chosen retrospectively to assess the variation in practice: a) Use of computed tomography (CT) or magnetic resonance (MR) imaging post-resection (POI) for assessment of residual disease; b) Commencement of radiation therapy (RT) within 28 days of surgery; c) Adjuvant chemotherapy use for glioblastoma multiforme (CTGBM) and d) Median survival.</p><p><b>RESULTS</b>Sixty-seven patients were managed radically, with 47 by MTC and by 20 by non-MTC. MTC patients were more likely to have POI (P = 0.042), and CTGBM (P = 0.025). Although the RT start time was similar for the whole cohort (60% versus 45%: P = 0.296); for GBM patients, the RT start was earlier (63% vs 33% P = 0.024). The median survival for the MTC group was 18.7 months versus 11.9 months for the non-MTC group (P = 0.11).</p><p><b>CONCLUSION</b>Clinical quality outcomes were significantly improved in patients with high-grade glioma managed in this neuro-oncology MTC.</p>

Chemotherapy in adults with gliomas

Treating patients with gliomas requires a multidisciplinary approach, which often includes surgery, radiation and chemotherapy. Recent developments have demonstrated the efficacy of chemotherapeutic agents in patients with newly diagnosed or recurrent gliomas. Large clinical studies have provided important information on the impact of chemotherapy for anaplastic oligodendrogliomas in the upfront setting. Randomised trials have demonstrated the benefit of chemoradiation for patients with glioblastoma. Investigations are also under way to clarify the role of chemotherapy for low-grade gliomas. This review article summarises the recent developments and approaches in the use of chemotherapy to treat adult patients with astrocytomas and oligodendrogliomas.

Application of the McDonald MRI criteria in multiple sclerosis

<p><b>INTRODUCTION</b>The aim of this study was to assess the sensitivity of McDonald's magnetic resonance imaging (MRI) criteria for the diagnosis of multiple sclerosis (MS) in a group of Asian patients diagnosed with clinically definite MS, based on lesion characterisation on MRI scans.</p><p><b>MATERIALS AND METHODS</b>Forty-nine patients from 3 major neurological institutions were classified as having Asian- or Western-type MS based on clinical assessment. Each MRI scan was reviewed by 2 neuroradiologists for the presence and characteristics of brain and spinal lesions. The McDonald's MRI criteria were then applied and its sensitivity evaluated.</p><p><b>RESULTS</b>Nine patients were excluded, leaving 34 females and 6 males who were dominantly Chinese (90%), with a mean age of 36.2 years. The MRI brain and spinal findings were detailed and tabulated. Statistically significant differences (P <0.01) in MRI brain findings and sensitivity of McDonald's MRI criteria were found between our Asian- and Western-type MS patients. The diagnostic yield of McDonald's MRI criteria increased by 20% when we substituted a cord for a brain lesion, and applied the substitution for enhancing cord lesions as well.</p><p><b>CONCLUSION</b>The diagnosis is more likely to be made when using McDonald MRI criteria based on brain findings, in a patient who presents clinically with Western-type MS. The provision for substitution of "one brain for a spinal lesion" is helpful in Asian-type MS, where there is preponderance of spinal lesion load. Our findings suggest that minor modifications in the interpretation of McDonald's MRI criteria have significant impact on the diagnosis in patients clinically presenting as Asian-type MS, with potential bearing on their subsequent management.</p>