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LETTER TO EDITOR
Year : 2019  |  Volume : 14  |  Issue : 2  |  Page : 616-617

Carmustine wafer implantation at the era of standardized chemoradiation protocol


1 Department of Neurosurgery, Sainte-Anne Hospital Center; Department of Neurosurgery, Paris Descartes University, Sorbonne Paris Cité; IMABRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France
2 Department of Neurosurgery, Sainte-Anne Hospital Center, Paris, France

Date of Web Publication26-Apr-2019

Correspondence Address:
Johan Pallud
Hôpital Sainte-Anne, 1, Rue Cabanis, 75674 Paris Cedex 14, Paris
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_297_18

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How to cite this article:
Rou A, Zanello M, Zah-Bi G, Pallud J. Carmustine wafer implantation at the era of standardized chemoradiation protocol. Asian J Neurosurg 2019;14:616-7

How to cite this URL:
Rou A, Zanello M, Zah-Bi G, Pallud J. Carmustine wafer implantation at the era of standardized chemoradiation protocol. Asian J Neurosurg [serial online] 2019 [cited 2019 Nov 18];14:616-7. Available from: http://www.asianjns.org/text.asp?2019/14/2/616/252971



Sir,

We read with great interest the recent paper by Salle et al., entitled (adverse event with the use of carmustine wafers and postoperative radiochemotherapy for the treatment of high-grade glioma).[1] The authors report a single-case experience about carmustine wafer implantation (CWI) in a newly diagnosed glioblastoma.

First, we have concerns about how the efficacy and indications of CWI have been presented as well as discussed. Here, the authors mix together different subtypes of high-grade gliomas under the generic name “high-grade gliomas,” but the current standard of care, they refer to actually differ between high-grade glioma subtypes. This should be detailed as is directly impacts the indication for CWI in high-grade gliomas, as recently proposed in French Neurosurgical Guidelines.[2]

Second, the case presentation lacks the information as whether corticosteroids were administered or not following surgical resection and at the beginning of chemoradiotherapy? This is of paramount importance since their administration in the early postoperative period is highly recommended to reduce CWI-related edema.[2] In addition, since the upper limb monoplegia occurred 4 weeks after surgery and 1 week after starting the chemoradiotherapy, this edema-related event can be hypothetically attributed equally to chemoradiotherapy and/or to CWI and no follow-up imaging, except the early postoperative computed tomography-scan, is available to document the timing of edema extension. As a consequence, the conclusions of this case report cannot be drawn at the light of the presented clinical data.

Third, the literature review of CWI-related adverse events is incomplete and the statement that “only small retrospective studies assess the risks of multimodal treatment strategies combining local and systemic chemotherapy with radiotherapy,” if possibly thoughtful in 2010 at the time of the Bock et al. study, is no longer true.[3] The current literature[4],[5],[6],[7] and the experience of the neuro-oncology club of the French Society of Neurosurgery[2],[8],[9],[10] adds significant data from large and prospective cohort studies. Recent systematic reviews, including studies performed at the standard radiochemotherapy era, did not show a significant increase of adverse effects related to CWI.[4],[5],[6],[7] In addition, a French, prospective, observational, cohort study including 92 high-grade gliomas patients treated with surgical resection plus CWI followed by the standard radiochemotherapy protocol showed interesting survival results without increased adverse events.[8] Last, a recent systematic review of the neuro-oncology club of the French Society of Neurosurgery analyzed the safety of CWI in 23 studies and suggested that the observed varying results about postoperative complications could be related to the experience of the surgeon who practices neurosurgical oncology procedures.[2] Last, in our own experience, the number of implanted wafers was not correlated with a higher risk of postoperative morbidity.[11] These results require a prospective evaluation, and no formal conclusion can be made.

As the authors stated that they choose a multimodal treatment, including CWI, whenever total resection of the tumor is possible, it will be of practical interest to the neuro-oncological community to report their whole experience rather than a single case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Salle F, Lahiani W, Spagnuolo E, Palfi S. Adverse event with the use of carmustine wafers and postoperative radiochemotherapy for the treatment of high-grade glioma. Asian J Neurosurg 2018;13:1171-4.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Roux A, Caire F, Guyotat J, Menei P, Metellus P, Pallud J, et al. Carmustine wafer implantation for high-grade gliomas: Evidence-based safety efficacy and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2017;63:433-43.  Back to cited text no. 2
    
3.
Bock HC, Puchner MJ, Lohmann F, Schütze M, Koll S, Ketter R, et al. First-line treatment of malignant glioma with carmustine implants followed by concomitant radiochemotherapy: A multicenter experience. Neurosurg Rev 2010;33:441-9.  Back to cited text no. 3
    
4.
Hart MG, Grant R, Garside R, Rogers G, Somerville M, Stein K, et al. Chemotherapeutic wafers for high grade glioma. Cochrane Database Syst Rev 2008;CD007294.  Back to cited text no. 4
    
5.
Hart MG, Grant R, Garside R, Rogers G, Somerville M, Stein K, et al. Chemotherapy wafers for high grade glioma. Cochrane Database Syst Rev 2011;CD007294.  Back to cited text no. 5
    
6.
Chowdhary SA, Ryken T, Newton HB. Survival outcomes and safety of carmustine wafers in the treatment of high-grade gliomas: A meta-analysis. J Neurooncol 2015;122:367-82.  Back to cited text no. 6
    
7.
Ashby LS, Smith KA, Stea B. Gliadel wafer implantation combined with standard radiotherapy and concurrent followed by adjuvant temozolomide for treatment of newly diagnosed high-grade glioma: A systematic literature review. World J Surg Oncol 2016;14:225.  Back to cited text no. 7
    
8.
Duntze J, Litré CF, Eap C, Théret E, Debreuve A, Jovenin N, et al. Implanted carmustine wafers followed by concomitant radiochemotherapy to treat newly diagnosed malignant gliomas: Prospective, observational, multicenter study on 92 cases. Ann Surg Oncol 2013;20:2065-72.  Back to cited text no. 8
    
9.
Menei P, Metellus P, Parot-Schinkel E, Loiseau H, Capelle L, Jacquet G, et al. Biodegradable carmustine wafers (Gliadel) alone or in combination with chemoradiotherapy: The French experience. Ann Surg Oncol 2010;17:1740-6.  Back to cited text no. 9
    
10.
Pallud J, Audureau E, Noel G, Corns R, Lechapt-Zalcman E, Duntze J, et al. Long-term results of carmustine wafer implantation for newly diagnosed glioblastomas: A controlled propensity-matched analysis of a French multicenter cohort. Neuro Oncol 2015;17:1609-19.  Back to cited text no. 10
    
11.
Pavlov V, Page P, Abi-Lahoud G, Nataf F, Dezamis E, Robin A, et al. Combining intraoperative carmustine wafers and stupp regimen in multimodal first-line treatment of primary glioblastomas. Br J Neurosurg 2015;29:524-31.  Back to cited text no. 11
    




 

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