- •No hard data links radiotherapy with cognitive decline in LGG patients.
- •Quality of evidence is low, with confounders still incompletely addressed.
- •The main confounder is that of tumour location.
- •Currently withholding RT from high risk LGG patients is not advisable.
- •High quality evidence from an ongoing prospective study is expected.
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|Search terms||(astrocytoma or glioma or oligodendroglioma or astrocytic or oligodendroglial)|
(radiotherapy or radiation or cranial irradiation or irradiation or XRT)
(cognition or cognitive or dementia or functional or emotion or psychological or emotional or memory or mental or mental disorders or attention or mood)
|Inclusion Criteria||Exclusion Criteria|
|Patients||Patients of any age with hemispheric diffuse grade II gliomas (astrocytomas, oligodentrogliomas).||High grade gliomas, metastases, optic nerve gliomas, infratentorial tumors|
|Intervention||Any radiotherapeutic treatment. (Intensity-modulated radiation therapy – IMRT), (Stereotactic-radiosurgery), (Three-Dimensional conformal radiation therapy – 3D-CRT) (Brachytherapy), (Proton Beam Therapy), (photon based RT)||Patients receiving both chemo- and radiotherapy|
|Comparisons||Patients receiving radiotherapy VS patients not-receiving radiotherapy or none|
|Outcomes||Primary outcome measures: Effect of treatment on cognitive function|
|Study Design||Randomized controlled trials, Non-randomized controlled trials, retrospective, prospective, concurrent cohort studies, at least10 patients. Published in English||Expert Opinions, Comments, letters to the editor, case reports, animal studies, conference reports, studies with no outcomes reported, reviews|
|Author||Study type||Sample||Tumor type||Intervention||Intervention Dose/Duration||Neurocognitive examination time|
|Yavas et al. 2011||Prospective study||43 pts, >18 yo (median 36 yo), No control||LGG (4 Grade I, 35 Grade II; oligodendroglioma, astrocytoma, oligoastrocytoma), 4 not LG||Conformal external beam radiotherapy||Total dose 54 Gy in 2 Gy daily fractions||Baseline, 3rd, 6th, 12th, 18th, 24th, 30th, 36th mos|
|Taphoorn et al. 1994||Case-control Retrospective Study||35/41 hemispheric LGG [two groups with LGGs cases (17/20 pts had hemιspheric LGG RT+, 18/21 pts had hemispheric LGG RT−)], One control group (19 pts 35–71 yo with mean age 53.3 ys) with NHL/CLL||LGG (astrocytomas & oligodendrogliomas)||External beam radiation, 4–6 MeV photons||Total dose ranged from 45 to 63 Gy; the number of fractions (1.8–2.0 Gy) varied between 25 and 35, given in 30 to 55 days||Neuropsychological/QoL assessment to long term LGG survivors, surgery/RT took place at least one year ago, mean interval between histological diagnosis and test was 3.5 ys|
|Taphoorn et al. 1992||Retrospective study||11 pts (11/12 neuropsychologically assessed), 26–66 yo||5 oligodendrogliomas (4/5 were able to participate in cognitive tests), 7 astrocytomas)||Focal brain radiotherapy (4 or 6 MeV photons)||Total dose ranged from 4500 to 6120 cGy; the number of fractions varied between 25 and 34, given in 30 and 54 days||NM exactly; the enrolled pts had surgery/RT at least one year previously|
|Surma-aho et al. 2001||Retrospective cohort study||49/51 pts (26 LGG/RT+, 23 LGG/RT−) *2 pts from LGG/RT + group excluded as they received both radio + chemo*||11/23 LGG/RT – Gr I, all LGG/RT+Gr II||Whole brain radiotherapy (WBRT) (17 pts), Focal brain radiotherapy (FBRT) (9 pts)||WBRT; 40 Gy from two opposing fields, and a 20 to 28 Gy booster to the tumor bed FBRT; median total dose of 60 Gy (range, 56–66) in 28–34 fractions.||Mean follow-up of 7 ys for the RT+ group and 10 ys for the RT− group|
|Shih et al. 2015||Prospective study||20 pts, 22–56 yo (mean age 37.5 yo). No control||WHO GrII LGGs (7 astrocytomas, 4 oligodendrogliomas, 9 oligoastrocytomas)||Fractionated proton therapy||Total dose 54 Gy at 1.8 Gy per fraction over 6 wks.||Baseline (= within 8 wks of initiating RT), 3, 6, 12, 24, 36, 48 & 60 mo after the completion of RT. Median follow-up at data cut-off time was 3.2 ys for progressed pts (11/20) and 5.1 ys for stable ones (9/20)|
|Sherman et al. 2016||Prospective study||20 pts, 22–56 yo (mean age 37.5 yo)||WHO GrII LGGs (7 astrocytomas, 4 oligodendrogliomas, 9 oligoastrocytomas), 12 right hemisphere, 8 left (no control some full some partial others no resection||Fractionated proton therapy||Total dose 54 Gy at 1.8 Gy per fraction over 6 wks||Baseline (=within 8 wks of initiating RT), 3, 6, 12, 24, 36, 48 and 60 mo after the completion of RT. Median follow-up at data cut-off time was 4.9 ys for progressed pts (8/17 alive) and 5.1 ys for stable ones (9/17 alive)|
|Laack et al. 2005||Prospective study||20 pts, 9 pts 18–40 yo and 11 pts >40 yo, no controls||LGGs GrI or II; 2 astrocytomas, 9 oligodendrogliomas, 9 oligoastrocytomas||Focal Radiotherapy||Low dose group’; Total dose 50.4 Gy in 28 fractions of 1.8 Gy 'High dose group'; Total dose 64.8 Gy (extra 14.4 Gy boost dose)||Baseline (before RT), at 18 mos intervals for 59 mos after completing RT (mean follow-up 3 ys, every pt underwent at least two evaluations)|
|Brown et al. 2003||Prospective randomized clinical trial||203 pts >18 yo with LGG; 187 pts had baseline neurocognitive assessment, 101 pts who were still alive, had median follow-up 7.4 ys. No controls||LGG WHO GrII (astrocytomas, oligodendrogliomas, oligoastrocytomas)||Focal conventional/ conformal Radiotherapy||Lower-arm dose group’; Total dose 50.4 Gy in 28 fractions 'Higher-arm dose group'; Total dose 64.8 Gy (extra 14.4 Gy to the preoperative tumor volume in 8 fractions)||Baseline, 1, 2, 5 yrs after radiotherapy|
|Douw et al. 09||Retrospective study||65 (no controls)||LGG (astocytoma 72%, oligodendroglioma 12%, oligoastocytoma 9%)||Focal Radiotherapy||<2Gy per dose (29/32). Mean 56.6 Gy, sd 7, mean 30.6 fractions of 16–2.5 Gy per fraction.||1st and second assessment (33 no RT, 32 RT) at 12 sd 3.9 range 6–28|
|Klein et al. 2002||Retrospective study||195 (91 of them, control group)||LGG (73 astrocytoma, 24 oligo dentrogliomas 7 oligoastrocytoma)||Focal Radiotherapy||55.6+ −6.1, fraction 2 (18% >2 gy fraction)||Testing 1 year post primary treatment with no recurrence within the last 3 months|
|Prabhu et al. 2014||Prospective study||126 RT (no control, 125 received RT & PCVl)||LGG (23 astrocytoma, 4 oligodentroglioma, 32 mixed astrocytoma/oligodendroglioma)||Focal Radiotherapy||54 Gy, 30 fractions of 1.8 Gy over 6 weeks||Baseline, 1, 2, 3, 5 ys|
|Author||Cognitive functions studied||Primary outcome (Cognitive function)|
|Yavas et al. 2011||MMSE, EORTC QLQ-C30 (contains one cognitive domain)||Among MMSE scores, the only factor that was significantly different (increased) during follow-up period was recall score. Pts taking anti-epileptic drugs had lower cognitive function in 3rd year of follow-up|
|Taphoorn et al. 1994||Stroop Color word test; language & executive functions, Wechler Intelligence Scale for Children (WISC); planning & foresight, Rey-Auditory Verbal Learning Test (AVLT); global memory & specifically verbal functions, Categoric fluency task, Concentration endurance test (d2-test); sustained attention in series of speed & connectness, Benton Facial Recognition & Judgment of Line Orientation; Non-verbal (right hemispheric) processes evaluation tests||LGG/RT+ & LGG/RT− groups did not differ significantly in any of Neuropsychological assessment scores. Only pts with left hemisphere LGGs yielded a significant difference in the speed scores of the Stroop word card and the WISC mazes, both in favor of the LGG/RT+ group. In LGG/RT+ group, no differences found neither in mean test scores between pts with the radiation dose above and those with the dose below the median (56 Gy) nor in the interval from diagnosis|
|Taphoorn et al. 1992||A Total Cognitive Problem Score (TGPS) calculated by performances on 8 tests: d2- Test; selective concentration, Stroop- Color Word Task; exclusive concentration, Rey- Auditory Verbal Learning Test; immediate & delayed recall, Visual Association Test; episodic memory, Categoric word retrieval; verbal fluency, Judgment of Line Orientation; spatial insight, Facial recognition test; gestalt recognition, WISC Maze test; foresight & planning. The TGPS was divided into a 3 point scale from 0 (normal), 1 (lowered) to 2 (disturbed)||5 cases TGPS range was 0.69–1.21 (high cognitive impairment), 6 cases was 0–0.55 (low cognitive impairment)|
|Surma-aho et al. 2001||5 test variables: Digit Span Similarities subtests; verbal IQ & verbal memory and free recall (similarities), Block Design and Digit Symbol subtests (Wechsler Adult Intelligence Scale); performance IQ, Modified Benton Visual Retention Test (MBVRT first reproduction and percentage forgotten); visual memory & attention||Significantly worse tests results found in RT+ group than in RT−, especially in the MBVRT forgetting percentage. No significant differences found in any 5 test variables between whole/focal irradiation pts. The severity of leukoencephalopathy both in resected & non-resected hemispheres was significantly relates to poor memory performance in the RT+ group but not in the RT− group|
|Shih et al. 2015||Wechsler Adult Intelligence Scale (WAIS)- III Full scale IQ; Intellectual Functioning, WAIS-III Perceptual Organization Index; Visuospatial ability, WAIS-III Verbal Comprehension Index, Boston Naming Test, Auditory Naming Test; Language, WAIS-III Working Memory Index and Spatial Span; Continuous Performance Test: Inattention Score and Vigilance Score; Attention & working memory, WAIS-III Processing Speed Index; Trail Making Test A; Processing speed, Trail Making Test B; Controlled Oral Word Association Test F-A-S; Wisconsin Card Sorting Test; Continuous Performance Test Impulsivity Score; Executive function, Hopkins Verbal Learning Test-R (HVLT-R): Total Recall, Delayed Recall, and Retention; Verbal memory, Brief Visual Memory Test-R (BVMT-R): Total Recall and Delayed Recall; Visual memory, HVLT-R Total Recall; WMS-III Trails A and Trails B; Controlled Oral Word Association Test F-A-S; Clinical trials battery||8 pts exhibited baseline impairment before radiation in 1 or more of the language, visual or verbal memory, or processing speed domains. Performances in all neurocognitive domains remained stable or improved marginally over time for all pts|
|Sherman et al. 2016||WAIS-III Full Scale IQ; Intellectual functioning, WAIS-III Perceptual Organization; Visuospatial ability, WAIS-III Verbal Comprehension, Boston Naming Test, Auditory Naming Test; Language, WAIS-III Working Memory, WMS-III Spatial Span, Conners' continuous Performance Test (CPT-II) Inattention, CPT-II Vigilance; Attention & working memory, WAIS-III Processing Speed, Trail Making Test Part A; Processing speed, Trail Making Test part B, Controlled oral word association test (COWAT) F-A-S, Wisconsin card sorting test (WCST) Errors, CPT-II Impulsivity; Executive function, HVLT-R Total Recall, HVLT-R Delayed Recall, HVLT-R Retention; Verbal memory, BVMT-R Total Recall, BVMT-R Delayed Recall; Visual memory, HVLT-R Total Recall, Trail Making Test Part A, Trail Making Test Part B, COWAT F-A-S; Clinical trials battery||Pts at baseline were not significantly impaired compared to normative data in any assessed cognitive domain. At baseline, pts with left-sided tumors performed significantly worse than those with right-sided tumors on measures of verbal memory. Cognitive functioning of entire group remained largely stable over time, but the left-sided tumor pts had greater improvement in verbal memory performances & Clinical Trial Battery. No significant cognitive differences were found according to tumor size|
|Laack et al. 2005||Cognitive functions; verbal and visual- spatial intelligence, immediate verbal & visual memory, long term verbal memory, cognitive flexibility, psychomotor skills, alertness & concentration, language were tested by Folstein MMSE, WAIS-R (Revised), AVLT, Benton Visual Retention Test (BVRT), Trail-Making Test (TMT), Stroop Color-Word Test, COWAT. Furthermore, the performance in the aforementioned cognitive functions was graded clinically on a scale ranged from −4 to +1 [(−4 = severe impairment), (−3 = moderate impairment), (−2 = mild impairment), (−1 = borderline impairment), (0 = normal), (+1 = above average)], in which, any 2-point change in these ratings was considered clinically significant||No statistically significant declines in cognitive function after RT. More precisely, Baseline: Lower overall cognitive performance was found in both RT groups, with no statistical difference between them. Tumor/pts variables were not found to be associated with cognitive functioning. Second evaluation: Higher scores in all psychometric measures; only WAIS-R (index for non-verbal problem-solving ability) scores meet statistically significant increase. No statistically significant changes between to RT groups. Third & more evaluations (10/20 pts had): Stable cognitive performance of pts. No statistically significant difference of 2nd evaluation cognitive performance among pts underwent two evaluations vs those with 3. Pts that respond to RT had a median of 1 point improvement on their MMSE score than non-responders (p = 0.02). Clinically significant change in cognitive function according to the clinical scale created: 11/20 pts were stable. 5/20 pts had improvement in the domains of immediate verbal memory, learning, long-term verbal memory, cognitive flexibility & spatial problem solving. Complex reasoning skills of one pt (1/5) improved from −2 to 0 after 18mo, but declined back to baseline after 3ys. 4/20 had decline in one or more domains of immediate verbal memory, learning, spatial problem solving. All declined pts were from high RT dose group|
|Brown et al. 2003||Folstein MMSE over time; clinically significant change was considered a 3-point change on MMSE from baseline||Baseline: 36 pts had abnormal MMSE (0–26), 151 pts had normal MMSE (27–30) Year 1, 2, 5: Only 8%, 5% & 5% of pts assessed on year 1, 2 & 3 respectively, with available baseline MMSE had clinically significant decrease in score. 8%, 4% & 6% of pts assessed on year 1,2 &3 respectively, with normal baseline MMSE had clinically significant decrease in score whereas 92%, 96% & 94& were stable. 12%, 12% & 0% of pts assessed on year 1, 2&3 respectively, with abnormal baseline MMSE had clinically significant decrease in score, whereas 29%, 38% & 33% were stable and 59%, 50% & 67% had clinically significant increase. Among the three cognitive different groups (clinically significant increase in score, stable score, clinically significant decrease in score) no significant differences were found at any key evaluations in the distributions of age, sex, tumor size, tumor location, tumor histologic type, NFS, seizures, seizure medication, radiation dose, conventional versus conformal radiotherapy (conventional defined as two or fewer fields, conformal defined as three or more fields), and number of radiation fields|
|Douw et al. 09||Letter-digit substitution test, Concept-shifting test, Stroop test, visual verbal learning test, memory comparison test, categoric word fluency||Significantly worse on executive functioning, information processing speed and attention, between groups. Attention (significant decline in repeated measures)|
|Klein et al 2002||Intelligence (Dutch adult reading test) perception (line bisection, facial recognition, judgement of line orientation, LDST), memory (VVLT, WMT) attention & executive function (Stroop, categoric word fluency, concept shifting test) one year post diagnosis, no radiological recurrence before testing within 3 months||Both irradiated and non-irradiated patients exhibited worse cognitive results. Cognitive decline attributed to the tumor itself|
|Prabhu et al 2014||MMSE||No decline in MMSE score|
|Cognitive Domain||Tests||Impaired out of total tested||Studies (Studies with statistically significant findings are marked in bold with asterisk)|
|Full scale IQ test||0/1|
|Executive function||Trail making test||0/2|
|Concept Shifting Test|
|Wisconsin Card Sorting Test (WCST)||0/2|
|Controlled Oral Word Association Test|
(COWAT), Categoric fluency
|Letter Digit Substitution Test (LDST)||1/2||* |
|Memory||Benton Visual Retention Test (BVRT)||1/3||* |
|Visual association test (VAT)||0/1|
|Working Memory test||1/1||* |
|Rey Auditory Verbal Learning Test (AVLT)||1/2||* |
|Hopkins Verbal Learning Test (HVLT)||0/1|
|Language||Visuo Verbal Learning Task (VVLT||1/2||* |
|COWAT, Categoric fluency||1/4||* |
|Visuospatial||Various tests||1/9||* |
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Conflict of Interest
Consent to participate
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