Connelly Jennifer, Hormigo Adília, Mohilie Nimish, Hu Jethro, Chaudhry Aafia, Blondin Nicholas
Froedtert Hospital and the Medical College of Wisconsin, Milwaukee, WI, USA.
Department of Neurology, Medicine and Neurosurgery, The Icahn School of Medicine at Mount Sinai and The Tisch Cancer Institute, New York, NY, USA.
BMC Cancer. 2016 Nov 4;16(1):842. doi: 10.1186/s12885-016-2890-0.
Gliomas are the most common primary brain tumors in adults and invariably carry a poor prognosis. Recent clinical studies have demonstrated the safety and compelling survival benefit when tumor treating fields (TTFields) are added to temozolomide for patients with newly diagnosed glioblastoma. TTFields are low-intensity, intermediate frequency (200 kHz) alternating electric fields, delivered directly to a patient's brain through the local application of non-invasive transducer arrays. Experimental simulations have demonstrated that TTFields distribute in a non-uniform manner within the brain. To ensure patients receive the maximal therapeutic level of TTFields at the site of their tumor, tumor burden is mapped and an optimal array layout is personalized using the NovoTAL software. The NovoTAL software utilizes magnetic resonance imaging (MRI) measurements for head size and tumor location obtained from axial and coronal T1 postcontrast sequences to determine the optimal paired transducer array configuration that will deliver the maximal field intensity at the site of the tumor. In clinical practice, physicians planning treatment with TTFields may determine that disease activity is more accurately represented in noncontrast-enhancing sequences. Here we present and discuss a series of 8 cases where a treating physician has utilized non-contrast enhancement and advanced imaging to inform TTFields treatment planning based on a clinical evaluation of where a patient is believed to have active tumor. This case series is, to our knowledge, the first report of this kind in the literature.
All patients presented with gliomas (grades 2-4) and ranged in age from 49 to 65 years; 5 were male and 3, female. Each patient had previously received standard therapy including surgery, radiation therapy and/or chemotherapy prior to initiation of TTFields. The majority had progressed on prior therapy. A standard pre- and postcontrast MRI scan was acquired and used for TTFields treatment planning.
This paper details important approaches for integrating clinical considerations, nonmeasurable disease and advanced imaging into the treatment planning workflow for TTFields. As TTFields become integrated into standard care pathways for glioblastoma, this case series demonstrates that treatment planning beyond the extent of contrast enhancement is clinically feasible and should be prospectively compared to standard treatment planning in a clinical trial setting, in order to determine the impact on patient outcomes.
胶质瘤是成人中最常见的原发性脑肿瘤，预后通常较差。最近的临床研究表明，对于新诊断的胶质母细胞瘤患者，在替莫唑胺基础上加用肿瘤治疗电场（TTFields）具有安全性且能显著延长生存期。TTFields是低强度、中频（200kHz）的交变电场，通过局部应用非侵入性换能器阵列直接作用于患者脑部。实验模拟表明，TTFields在脑内的分布并不均匀。为确保患者在肿瘤部位获得最大治疗剂量的TTFields，需使用NovoTAL软件对肿瘤负荷进行映射并个性化定制最佳阵列布局。NovoTAL软件利用从轴位和冠状位T1增强序列获得的头部尺寸和肿瘤位置的磁共振成像（MRI）测量值，来确定能在肿瘤部位提供最大场强的最佳配对换能器阵列配置。在临床实践中，计划使用TTFields进行治疗的医生可能会认为，非增强序列能更准确地反映疾病活动情况。在此，我们展示并讨论了8例病例，治疗医生根据对患者疑似活跃肿瘤部位的临床评估，利用非增强成像和先进影像技术为TTFields治疗计划提供参考。据我们所知，该病例系列是文献中此类报告的首例。
所有患者均患有胶质瘤（2 - 4级），年龄在49至65岁之间；5例为男性，3例为女性。每位患者在开始TTFields治疗前均已接受包括手术、放疗和/或化疗在内的标准治疗。大多数患者在先前治疗后病情进展。进行了标准的增强前和增强后MRI扫描，并用于TTFields治疗计划。
本文详细介绍了将临床考量、不可测量疾病和先进影像技术纳入TTFields治疗计划工作流程的重要方法。随着TTFields被纳入胶质母细胞瘤的标准治疗路径，该病例系列表明，超出增强范围的治疗计划在临床上是可行的，应在临床试验环境中与标准治疗计划进行前瞻性比较，以确定对患者预后的影响。
