Early Toxicities After High Dose Rate Proton Therapy in Cancer Treatments

Background: The conventional dose rate of radiation therapy is 0.01-0.05 Gy per second. According to preclinical studies, an increased dose rate may offer similar anti-tumoral effect while dramatically improving normal tissue protection. This study aims at evaluating the early toxicities for patients irradiated with high dose rate pulsed proton therapy (PT). Materials and methods: A single institution retrospective chart review was performed for patients treated with high dose rate (10 Gy per second) pulsed proton therapy, from September 2016 to April 2020. This included both benign and malignant tumors with ≥3 months follow-up, evaluated for acute (≤2 months) and subacute (>2 months) toxicity after the completion of PT. Results: There were 127 patients identified, with a median follow up of 14.8 months (3-42.9 months). The median age was 55 years (1.6-89). The cohort most commonly consisted of benign disease (55.1%), cranial targets (95.1%), and were treated with surgery prior to PT (56.7%). There was a median total PT dose of 56 Gy (30-74 Gy), dose per fraction of 2 Gy (1-3 Gy), and CTV size of 47.6 ml (5.6-2,106.1 ml). Maximum acute grade ≥2 toxicity were observed in 49 (38.6%) patients, of which 8 (6.3%) experienced grade 3 toxicity. No acute grade 4 or 5 toxicity was observed. Maximum subacute grade 2, 3, and 4 toxicity were discovered in 25 (19.7%), 12 (9.4%), and 1 (0.8%) patient(s), respectively. Conclusion: In this cohort, utilizing high dose rate proton therapy (10 Gy per second) did not result in a major decrease in acute and subacute toxicity. Longer follow-up and comparative studies with conventional dose rate are required to evaluate whether this approach offers a toxicity benefit

Imaging practice in low-grade gliomas among European specialized centers and proposal for a minimum core of imaging

Objective: Imaging studies in diffuse low-grade gliomas (DLGG) vary across centers. In order to establish a minimal core of imaging necessary for further investigations and clinical trials in the field of DLGG, we aimed to establish the status quo within specialized European centers. Methods: An online survey composed of 46 items was sent out to members of the European Low-Grade Glioma Network, the European Association of Neurosurgical Societies, the German Society of Neurosurgery and the Austrian Society of Neurosurgery. Results: A total of 128 fully completed surveys were received and analyzed. Most centers (n=96, 75%) were academic and half of the centers (n=64, 50%) adhered to a dedicated treatment program for DLGG. There were national differences regarding the sequences enclosed in MRI imaging and use of PET, however most included T1 (without and with contrast, 100%), T2 (100%) and TIRM or FLAIR (20, 98%). DWI is performed by 80% of centers and 61% of centers regularly performed PWI.ConclusionA minimal core of imaging composed of T1 (w/wo contrast), T2, TIRM/FLAIR, PWI and DWI could be identified. All morphologic images should be obtained in a slice thickness of 3mm. No common standard could be obtained regarding advanced MRI protocols and PET. Importance of the study: We believe that our study makes a significant contribution to the literature because we were able to determine similarities in numerous aspects of LGG imaging. Using the proposed minimal core of imaging in clinical routine will facilitate future cooperative studies

Imaging practice in low-grade gliomas among European specialized centers and proposal for a minimum core of imaging.

OBJECTIVE: Imaging studies in diffuse low-grade gliomas (DLGG) vary across centers. In order to establish a minimal core of imaging necessary for further investigations and clinical trials in the field of DLGG, we aimed to establish the status quo within specialized European centers. METHODS: An online survey composed of 46 items was sent out to members of the European Low-Grade Glioma Network, the European Association of Neurosurgical Societies, the German Society of Neurosurgery and the Austrian Society of Neurosurgery. RESULTS: A total of 128 fully completed surveys were received and analyzed. Most centers (n = 96, 75%) were academic and half of the centers (n = 64, 50%) adhered to a dedicated treatment program for DLGG. There were national differences regarding the sequences enclosed in MRI imaging and use of PET, however most included T1 (without and with contrast, 100%), T2 (100%) and TIRM or FLAIR (20, 98%). DWI is performed by 80% of centers and 61% of centers regularly performed PWI. CONCLUSION: A minimal core of imaging composed of T1 (w/wo contrast), T2, TIRM/FLAIR, PWI and DWI could be identified. All morphologic images should be obtained in a slice thickness of ≤ 3 mm. No common standard could be obtained regarding advanced MRI protocols and PET. IMPORTANCE OF THE STUDY: We believe that our study makes a significant contribution to the literature because we were able to determine similarities in numerous aspects of LGG imaging. Using the proposed "minimal core of imaging" in clinical routine will facilitate future cooperative studies

EGF/EGFR pathway is sufficient to induce aggressiveness and expression of pluripotency markers of patient-derived glioblastoma cells

L’objectif de ce travail était de démontrer que les cellules de glioblastomes sont capables de se différencier et de se dédifférencier en fonction de leur environnement, d’explorer les mécanismes biologiques qui sous-tendent ces transitions, et d’évaluer in vivo les capacités de différenciation à distance des CIG par les CIG-miR-302-367 via la sécrétion de microvésicules. A partir de plusieurs glioblastomes fraichement réséqués, nous avons caractérisé les cellules tumorales sur le plan phénotypique et fonctionnel pour l’état souche et différencié. Nous avons extraits et analysés les microvésicules des milieux de culture de 2 lignées de CIG-miR-302-367. Selon les principes de la thérapie cellulaire, des co-injections de CIG+CIG-miR-302-367 ont été réalisées dans le cerveau des souris. La majorité des cellules tumorales avaient un phénotype et étaient fonctionnellement différenciées. Après 48 heures de culture en milieu EGF, elles acquéraient les propriétés souches phénotypiques et fonctionnelles. Ce processus de dédifférenciation était réversible en 4 jours de culture en milieu sérum et inhibé par l’adjonction dans le milieu EGF d’un anti-EGFR (cétuximab), suggérant un rôle primordial de la voie EGF/EGFR/ERK. Les microvésicules produites par les CIG-miR-302-367 ont permis une baisse significative de la tumorigénicité des CIG in vivo, et une augmentation de la survie des souris. Le concept de plasticité cellulaire remet en cause les dogmes établis sur la hiérarchie tumorale unidirectionnelle. La déplétion tumorale en CIG, en les forçant à se différencier, est une stratégie thérapeutique innovante, qui peut s’envisager par une approche de thérapie cellulaire.There is great interest but little understanding in how cancer stem cells arise. Here we show that tumor cells exhibiting stem-like properties and expression of stemness(CD133) and pluripotency markers (SOX2, NANOG, OCT4), can arise from differentiated tumor cells that are isolated from human glioblastomas. These cells could transit from a more differentiated state that cannot self-renew to a self-renewing stem-like state upon EGF/EGFR signaling. This dedifferentiation process induced expression of pluripotency markers, and restored clonal and tumorigenic properties as well as resistance to temozolomide, the chemotherapy of reference. EGF/EGFR signaling including ERK activation was crucial for this cellular reprogramming. Interestingly, expression of pluripotency markers occurred before the cells re-entered the cell cycle, demonstrating that the cells have the capacity to change and reprogram before the cell division starts. Our findings support a model of tumor homeostasis in which tumor cells driven by environmental cues such as EGF, can spontaneously acquire stem-like properties contributing thus to the enrichment in tumor propagating cells

Contralesional macrostructural plasticity of the insular cortex in patients with glioma: A VBM study

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Motor cortex neurovascular coupling: inputs from ultra–high-frequency ultrasound imaging in humans

International audienceTo ensure appropriate blood supply through the brain, the cerebral blood vessels, neurons, and as-trocyte glial cells must interact according to complex mechanisms. This interaction, named "neurovascular coupling" (NVC), describes the link between neuronal activity and cerebral blood flow (CBF) changes. 25 Several methods have been developed to assess the NVC in humans by exploring either cerebral tissue oxygenation using functional MRI, near-infrared spectrosco-py, or positron emission tomography, or CBF changes using transcranial Doppler (TCD) ultrasonography. 9,21 TCD ultrasonography is the ultrasound (US) imaging technique mostly used in the clinic to explore CBF because of its high temporal resolution and noninvasive nature. For example, sensorimotor or cognitive stimulatory effects on cerebral blood velocity have been studied using low-frequency (≤ 2-MHz) transducers. 4 In healthy individuals, this response leads to an average 10%-20% increase in CBF in the posterior cerebral artery during visual stimulation, 1 and a 5%-8% increase in the middle cerebral artery during a cognitive task. 22 However, despite good spatiotemporal resolution, TCD US imaging is limited to the exploration of large cerebral vessels and is not able to detect subtle changes of low blood flow in cortical vessels that may occur during a task. Recently, very high frame rate US imaging (> 10,000 frames per second) was shown to enable high-resolution and high-sensitivity power Doppler imaging, 2,29 allowing ABBREVIATIONS BOLD = blood oxygen level-dependent; CBF = cerebral blood flow; DES = direct electrostimulation; fUS = functional US; mSA = median surface area; NVC = neurovascular coupling; TCD = transcranial Doppler; UHF-US = ultra-high-frequency US; US = ultrasound. OBJECTIVE : Neurovascular coupling reflects the link between neural activity and changes in cerebral blood flow. Despite many technical advances in functional exploration of the brain, including functional MRI, there are only a few reports of direct evidence of neurovascular coupling in humans. The authors aimed to explore, for the first time in humans, the local cerebral blood flow of the primary motor cortex using ultra-high-frequency ultrasound (UHF-US) Doppler imaging to detect low blood flow velocity (1 mm/sec).METHODS : Four consecutive patients underwent awake craniotomy for glioma resection using cortical direct electro-stimulation for brain mapping. The primary motor cortical area eliciting flexion of the contralateral forearm was identified. UHF-US color Doppler imaging of this cortical area was acquired at rest, during repeated spontaneous forearm flexion, and immediately after the movement's termination. In each condition, the surface areas of the detectable vessels were measured after extraction of non-zero-velocity colored pixels and summed. RESULTS : During movement, local cerebral blood flow increased significantly by 14.4% (range 5%-30%) compared with baseline. Immediately after the termination of movements, the local hyperemia decreased significantly by 8.6% (range 1.9%-15.7%). CONCLUSIONS : To the authors' knowledge, this study is the first to provide a real-time demonstration of the neurovas-cular coupling in the human cortex by ultrasound imaging. They assume that UHF-US may be used to gather original and advanced data on brain functioning, which could be used to help in the identification of functional cortical areas during brain surgery. Clinical trial registration no.: NCT03179176 (clinicaltrials.gov) https://thejns.org/doi/abs/10.3171/2018.5.JNS1875

Disrupting the right pars opercularis with electrical stimulation frees the song: case report

International audienceThe authors report the first case of a strikingly unusual speech impairment evoked by intraoperative electrostimulation in a 36-year-old right-handed patient, a well-trained singer, who underwent awake surgery for a right fronto-temporoinsular low-grade glioma. Functionally disrupting the pars opercularis of the right inferior frontal gyrus led the patient to automatically switch from a speaking to a singing mode of language production. Given the central role of the right pars opercularis in the inhibitory control network, the authors propose that this finding may be interpreted as possible evidence for a competitive and independent neurocognitive subnetwork devoted to the melodically intoned articulation of words (normal language-based vs singing-based) in subjects with high expertise. From a more clinical perspective, such data may have implications for awake neurosurgery, especially to preserve the quality of life for singers

The left inferior fronto-occipital fasciculus subserves language semantics: a multilevel lesion study

International audienceConsequential works in cognitive neuroscience have led to the formulation of an interactive dual-stream model of language processing: the dorsal stream may process the phonological aspects of language, whereas the ventral stream may process the semantic aspects of language. While it is well-accepted that the dorsal route is subserved by the arcuate fasciculus, the structural connectivity of the semantic ventral stream is a matter of dispute. Here we designed a longitudinal study to gain new insights into this central but controversial question. Thirty-one patients harboring a left diffuse low-grade glioma—a rare neurological condition that infiltrates preferentially white matter associative pathways—were assessed with a prototypical task of language (i.e. verbal fluency) before and after surgery. All were operated under local anesthesia with a cortical and subcortical brain mapping—enabling to identify and preserve eloquent structures for language. We performed voxel-based lesion-symptom (VLSM) analyses on pre- and postoperative behavioral data. Preoperatively, we found a significant relationship between semantic fluency scores and the white matter fibers shaping the ventro-lateral connectivity (P < 0.05 corrected). The statistical map was found to substantially overlap with the spatial position of the inferior fronto-occipital fasciculus (IFOF) (37.7%). Furthermore, a negative correlation was observed between semantic fluency scores and the infiltration volumes in this fasciculus (r = -0.4, P = 0.029). Postoperatively, VLSM analyses were inconclusive. Taken as a whole and when combined with the literature data, our findings strengthen the view that the IFOF plays an essential role in semantic processing and may subserve the direct ventral pathway of language

Dural and pial pain-sensitive structures in humans: new inputs from awake craniotomies

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