Venous thromboembolism in malignant gliomas

Malignant gliomas are associated with a very high risk of venous thromboembolism (VTE). While many clinical risk factors have previously been described in brain tumor patients, the risk of VTE associated with newer anti-angiogenic therapies such as bevacizumab in these patients remains unclear. When VTE occurs in this patient population, concern regarding the potential for intracranial hemorrhage complicates management decisions regarding anticoagulation, and these patients have a worse prognosis than their VTE-free counterparts. Risk stratification models identifying patients at high risk of developing VTE along with predictive plasma biomarkers may guide the selection of eligible patients for primary prevention with pharmacologic thromboprophylaxis. Recent studies exploring disordered coagulation, such as increased expression of tissue factor (TF), and tumorigenic molecular signaling may help to explain the increased risk of VTE in patients with malignant gliomas.

Focal neuronal gigantism: a rare complication of therapeutic radiation

Radiation therapy, a mainstay in the treatment of many brain tumors, results in a variety of well-documented acute and chronic complications. Isolated cortical damage following irradiation represents an extremely rare delayed therapeutic complication, described only twice in the medical literature. We report this rare delayed complication in a patient following treatment of a right frontal anaplastic oligodendroglioma.

Phase I study of vandetanib with radiation therapy and temozolomide for newly diagnosed glioblastoma

2031

Background: There is increasing evidence that angiogenesis inhibition may potentiate the effects of radiation therapy (RT) and chemotherapy in patients with glioblastoma (GBM). In addition, inhibition of the epidermal growth factor receptor (EGFR) may be of therapeutic benefit, as EGFR is often upregulated in GBM and contributes to radiation resistance. We conducted a phase I study of vandetanib, an inhibitor of VEGFR2 and EGFR, in patients with newly-diagnosed GBM in combination with RT and temozolomide (TMZ). Methods: Using a standard 3 + 3 dose escalation design, 13 newly-diagnosed GBM patients received vandetanib with RT (60 Gy) and concurrent TMZ 75 mg/m2 daily, followed by adjuvant TMZ for up to 12 cycles (150–200 mg/m2 on days 1–5 of each 28 day cycle). The maximum tolerated dose (MTD) was defined as the dose with ≤1/6 dose-limiting toxicities (DLT). Eligible patients were adults with newly-diagnosed GBM or gliosarcoma, Karnofsky performance status of ≥60%, normal organ function, and not taking enzyme-inducing anti-epileptic drugs. MTD was determined by evaluation of DLTs during the first 12 weeks of therapy. Results: Six patients were treated with vandetanib at 200 mg daily. 2/6 patients developed DLTs (grade 5 gastrointestinal hemorrhage and grade 3 thrombocytopenia in one patient and grade 4 neutropenia in one patient). Seven patients were treated at 100 mg daily with no DLTs observed, establishing 100 mg daily as the MTD. Of 10 evaluable patients, one had a minor response (10%), defined as 25% to <50% reduction in enhancing area for 8 weeks; eight had stable disease (80%), defined as <25% increase or decrease; and one had progressive disease (10%). Conclusions: These data suggest that vandetanib may be combined with RT and TMZ in GBM patients. A randomized phase II study in which patients receive RT and TMZ with or without vandetanib 100 mg daily is underway.

[Table: see text]

Combination immunochemotherapy followed by reduced dose (rd) whole brain radiation therapy (WBRT) in an expanded cohort of patients with newly diagnosed primary central nervous system lymphoma (PCNSL)

2072

Background: High-dose methotrexate (M)-based chemotherapy combined with WBRT has improved survival in patients with PCNSL. However, disease recurrence and treatment-related neurotoxicity are significant problems. We conducted a prospective trial incorporating rituximab (R) and rdWBRT and previously demonstrated this was feasible. This study was extended to assess the long-term outcome of this approach in an expanded cohort. Methods: Patients were treated with R-MPV (d1 R 500mg/m2; d2 M 3.5gm/m2; vincristine 1.4mg/m2; d1–7 procarbazine 100 mg/m2/d on odd-cycles). Patients with a PR after five cycles received two additional cycles. Patients with a CR received rdWBRT (2340cGy), otherwise patients received standard WBRT (4500cGy). Patients then received two cycles of Ara-C 3gm/m2. Prospective neuropsychological evaluations were performed at baseline, before WBRT, and every 6 months thereafter. Results: From October 2002 to September 2008, 50 patients were enrolled (22 female, 28 male), median age 59.5 years (range 30–79 years). Due to neutropenia in two of the first five patients, all subsequent patients received G-CSF. 42 patients are assessable for response (4 patients died from progressive disease prior to completing the first cycle of treatment, 4 patients - treatment ongoing). 33 patients (79%) had a CR, of whom 29 received rdWBRT (3 refused, 1 died). At median follow-up of 3 years for survivors the median OS has not been reached and the estimated 2-year OS is 68%. Patients treated with rdWBRT have a median follow up of 38 months: 21 (72%) are alive with no evidence of disease, seven (24%) relapsed, and one died of unknown causes. Eight of 21 (38%) who are alive with no evidence of disease were age 60+ at diagnosis. The number of patients treated with rdWBRT alive with no evidence of disease at 3, 4, and 5 years is 12, 8, and 4 respectively. 9 patients have completed neuropsychological evaluations 24 months after rdWBRT with no significant cognitive decline detectable. Conclusions: Prolonged follow-up of an expanded cohort of patients treated with immunochemotherapy followed by rdWBRT for patients with an initial CR continues to support our initial conclusions that this approach results in excellent disease control with no observed treatment-related neurotoxicity.

[Table: see text]

Effects of riluzole (RZ) and ionizing radiation (IR) in metabotropic glutamate receptor-1 (GRM1) positive human melanoma

9083

Background: Melanoma has long been known to be relatively radio-resistant. GRM1 is a metabotropic glutamate receptor that has been detected in human melanoma cell lines and biopsies. Riluzole (RZ), a glutamate release inhibitor, has been shown to arrest GRM1 positive human melanoma cells in G2/M and sub-G1 phases of the cell cycle. The purpose of this study was to determine if RZ enhances the lethal effects of IR in human melanoma. Methods: ATP luminescence assays were performed. Clonogenic assays were performed and cell survival curves generated. Cell cycle analysis was performed utilizing flow cytometry. Western blot analysis was performed utilizing cleaved PARP and caspase-3 antibodies as markers of apoptosis. Results: Luminescence assays revealed 25uM Riluzole to be the necessary concentration for clonogenic assays. At 2Gy, there was a 48% reduction (p≤0.05) in cell survival in RZ-treated cells. At 4 Gy, there was a 19% reduction (p≤0.05) in cell survival in RZ-treated cells. No differences were seen at 6 and 8 Gy. Cell cycle analysis showed that the combination of IR and RZ was superior to IR alone in increasing the number of cells in sub-G1, which represents apoptotic death. Western blot analysis showed that the combination of IR and RZ showed yielded increased cleaved PARP and caspase-3 activity when compared to IR alone. Conclusions: Riluzole is a FDA approved drug that has long been used in ALS. It is relatively non-toxic and crosses the blood brain barrier. Our data shows that Riluzole in combination with radiation eliminates the radio-resistant shoulder of the C8161 survival curve. RZ and IR, as combination therapy are more lethal than IR or RZ alone in human melanoma, as demonstrated by flow cytometry and WB analysis. This data has promising implications for melanoma patients with brain metastases.

No significant financial relationships to disclose.

Primary CNS lymphoma with intraocular involvement: International PCNSL Collaborative Group Report

OBJECTIVE

To describe the demographics, diagnostic details, therapeutic management, and outcome in patients with primary CNS lymphoma (PCNSL) with ocular involvement.

METHODS

A retrospective study of 221 patients was assembled from 16 centers in seven countries. Only HIV-negative, immunocompetent patients with brain and ocular lymphoma were included; none had systemic lymphoma.

RESULTS

Median age at diagnosis was 60. Fifty-seven percent were women. Median Eastern Cooperative Oncology Group performance status was 2. Ocular disturbance and behavioral/cognitive changes were the most common presenting symptoms. Diagnosis of lymphoma was made by brain biopsy (147), vitrectomy (65), or CSF cytology (11). Diagnosis of intraocular lymphoma was made by vitrectomy/choroidal/retinal biopsy (90) or clinical ophthalmic examination (141). CSF cytology was positive in 23%. Treatment information was available for 176 patients. A total of 102 received dedicated ocular therapy (ocular radiotherapy 79, intravitreal methotrexate 22, and both 1) in addition to treatment for their brain lymphoma. Sixty-nine percent progressed at a median of 13 months; sites of progression included brain 52%, eyes 19%, brain and eyes 12%, and systemic 2%. Patients treated with local ocular therapy did not have a statistically significant decreased risk of failing in the eyes (p = 0.7). Median progression free survival and overall survival for the entire cohort were 18 and 31 months.

CONCLUSION

This is the largest reported series of primary CNS lymphoma (PCNSL) with intraocular involvement. Progression free and overall survival was similar to that reported with PCNSL. Dedicated ocular therapy improved disease control but did not affect overall survival.

Primary intraocular lymphoma: an International Primary Central Nervous System Lymphoma Collaborative Group Report

BACKGROUND

Primary intraocular lymphoma (PIOL) is an uncommon subset of primary central nervous system lymphoma. Because it is rare and difficult to diagnose, the natural history and optimal management are unknown.

PATIENTS AND METHODS

A retrospective study of 83 HIV negative, immunocompetent PIOL patients was assembled from 16 centers in seven countries.

RESULTS

Median age at diagnosis was 65. Median ECOG performance status was 0. Presenting symptoms included blurred vision, decreased visual acuity, and floaters. Median time to diagnosis was 6 months. Diagnosis was made by vitrectomy (74), choroidal/retinal biopsy (6) and ophthalmic exam (3). Eleven percent had positive CSF cytology. Initial treatment was categorized as focal in 23 (intra-ocular methotrexate, ocular radiotherapy) or extensive in 53 (systemic chemotherapy, whole brain radiotherapy). Six received none; details are unknown in one. Forty-seven relapsed: brain 47%, eyes 30%, brain and eyes 15%, and systemic 8%. Median time to relapse was 19 months. Focal therapy alone did not increase risk of brain relapse. Median progression free (PFS) and overall survival (OS) were 29.6 and 58 months, respectively, and unaffected by treatment type.

CONCLUSION

Treatment type did not affect relapse pattern, median PFS or OS. Focal therapy may minimize treatment toxicity without compromising disease control.

Cognitive functions in primary central nervous system lymphoma: literature review and assessment guidelines

BACKGROUND

Treatment-related neurotoxicity has been recognized as a significant problem in patients with primary central nervous system lymphoma (PCNSL) as effective treatment has increased survival rates. There is, however, a paucity of research on cognitive functions in this population.

DESIGN

In a review of the literature, a total of 17 articles that described cognitive outcome in adult PCNSL patients were identified.

RESULTS

The studies that assessed cognitive functions after whole-brain radiotherapy combined with chemotherapy reported cognitive impairment in most patients. Patients treated with chemotherapy alone had either stable or improved cognitive performance in most studies. Methodological problems, however, limited the ability to ascertain the specific contribution of disease and various treatment interventions to cognitive outcome. On the basis of the literature review, a battery of cognitive and quality-of-life (QoL) measures to be used in prospective clinical trials was proposed. The battery is composed of five standardized neuropsychological tests, covering four domains sensitive to disease and treatment effects (attention, executive functions, memory, psychomotor speed), and QoL questionnaires, and meets criteria for use in collaborative trials.

CONCLUSION

The incorporation of formal and systematic cognitive evaluations in PCNSL studies will improve our understanding of treatment-related neurotoxicity in this population.

Phase IIa trial of cilengitide (EMD121974) single-agent therapy in patients (pts) with recurrent glioblastoma (GBM): EMD 121974-009

2002

Background: Our phase IIa study evaluated the safety, toxicity, and clinical activity of the cyclic RGD pentapeptide cilengitide (EMD121974), an inhibitor of integrins avβ3 and avβ5, as a single agent at doses of 500 and 2000 mg in pts with recurrent GBM. Methods: In this multicenter, open-label, randomized, uncontrolled study, pts with GBM and measurable disease that had relapsed after previous temozolomide and radiotherapy were randomized to receive cilengitide at either 500 mg or 2000 mg i.v., 2x/week, until progression. Neurologic exams were performed after every cycle (4 weeks) and MRIs were performed every other cycle. Central, blinded pathology and radiology reviews were performed. The primary endpoint was Progression Free Survival (PFS) at 6 months (6-mth PFS). Secondary endpoints included response, survival, time to disease progression, safety, tolerability and pharmacokinetics (PK). Results: 81 pts accrued (median Karnofsky Performance Status 80%; median age 57 yrs) at 15 sites including 41 at the 500 mg and 40 at the 2000 mg dose levels. Demographic and pretreatment variables were comparable between dose level cohorts. The median number of infusions was 16 [range, 4–179]. PK studies revealed significantly greater exposures among the 2000 mg cohort. Treatment related NCI CTC grade 3 adverse events (AEs) included elevated transaminases (at 500 mg), arthralgia/ myalgia (at 500 mg), and weight increase/ edema (at 2000 mg) in 1 patient, respectively. No grade 4 therapy related AEs were reported. One CTC grade 2 cerebral hemorrhage was reported in a pt at progression. The 6- mth PFS was 16.1% (n=13/81 pts). 10 pts (12.3 %, n=4 with 500 mg, n=6 with 2000 mg) received 12 or more cycles. Six pts (7.4%) remain progression-free and on treatment. Median Overall Survival (mOS) was 6.5 mths [95% CI: 5.2–9.3 mths] in the 500 mg arm and 9.9 mths [95% CI, 6.3–15.7 mths] in the 2000 mg arm. Although not statistically significant, there was a trend towards better tumor control in pts receiving 2000 mg 2x/week. Conclusions: Cilengitide was well tolerated and demonstrated single agent activity in recurrent GBM, with long term disease stabilization in a subset of pts.

[Table: see text]

Phase II study of antiangiogenic (metronomic) chemotherapy for recurrent malignant gliomas

1569

Background: There is preclinical evidence that continuous low-dose chemotherapy may inhibit tumor endothelial proliferation and prevent tumor growth (Browder et al Cancer Res 2000;60:1878). Methods: We conducted a phase II study of continuous low-dose etoposide (VP-16), alternating with cyclophosphamide (CP), in combination with thalidomide (T) and celecoxib (C) in adult patients with recurrent malignant gliomas. There was no limit on the number of prior therapies. Patients received VP-16 [35 mg/m2 (maximum 100 mg) daily for 21 days] alternating with CP [2 mg/kg (maximum 100 mg/day) for 21 days]. Thalidomide was started at 200 mg daily and increased by 100 mg weekly to a maximum of 1200 mg/day, as tolerated. Celecoxib was started at 200 mg twice daily and increased to 400 mg twice daily. MRIs were performed every 6 weeks. Patients were treated until tumor progression or development of unacceptable toxicity. Serum was collected for measurement of angiogenic peptides. Results: 48 patients were enrolled (15 female, 33 male). 28 had glioblastomas (GBM); 20 had anaplastic gliomas (AG). Median age was 53 years (range 33–74); median KPS was 70 (range 60–100). Patients had average of 2.1 prior chemotherapies; 33% had 3 or more prior chemotherapies. Toxicities included neutropenia (8 G3, 8 G4), leukopenia (13 G3, 8 G4), lymphopenia (26 G3), anemia (1 G3), thrombocytopenia (1 G3); nausea (1 G3), vomiting (3 G3), constipation (5 G3; 2 G4), colitis (2 G4), rash (1 G3), dizziness (1 G3); hypoxia (1 G3), and infection (2 G3). 2 patients had DVT and 6 had pulmonary emboli. There were no treatment related deaths. Fatigue was common but usually mild. 12% of patients had PR, 59% had SD, 29% progressed at their first scan. For GBM patients, median progression-free survival (PFS) was 11 weeks, 6 month-PFS was 9% and median survival was 21 weeks. For AG patients, median PFS was 14 weeks; 6 month-PFS was 26% and median survival was 41.5 weeks. Correlation of angiogenic peptide levels and response will be reported. Conclusions: Although there were some responders this regimen did not significantly improve survival in this heavily pretreated group of patients. However, further studies combining metronomic chemotherapy with more potent angiogenesis inhibitors such as lenalidomide or VEGFR inhibitors may be warranted.

[Table: see text]

Primary intraocular lymphoma (PIOL): An International Primary CNS Lymphoma Collaborative group report

1534

Background: PIOL is a hemopoietic tumor that arises in the retina, vitreous or optic nerve head, and carries a high risk of ocular and CNS relapse. The natural history and optimal management are unknown. Methods: A retrospective series of 81 patients with PIOL was assembled from 15 centers in 7 countries. Only patients with isolated ocular lymphoma were included; none had brain, spinal cord, or systemic lymphoma at diagnosis. Results: The median age at diagnosis was 65 (24–85). 58% were women. The median ECOG performance status was 0, and only three had a score > 1. The median latency from symptom onset to diagnosis was 6 months (0– 36). Slit lamp exam was positive in 51, negative in 6, and not reported in 24. Vitrectomy was positive in 72 and negative in 2. 6 had a positive choroidal or retinal biopsy and 1 had no ocular surgery. CSF cytology was positive in 10 (17%), negative in 48, and unknown in 23. 21 received local therapy at diagnosis: 6 intra-ocular methotrexate (400 ug), 14 ocular radiation (median 3600 cGy), and 1 both modalities. 52 received more extensive therapy including systemic chemotherapy alone in 20 and a combination of chemotherapy and radiotherapy in 32. 5 received no treatment and details are unknown in 3. 47 patients (58%) relapsed a median of 19 months (0.5–180) after initial therapy. Sites of relapse included brain 47%, eyes 30%, brain and eyes 15%, and systemic 8%. Patients treated with ocular therapy alone did not have an increased risk of failing in the brain (p = 0.6). Progression free survival (PFS) and overall survival (OS) were 29.6 and 57 months respectively and were unaffected by the choice of therapy. CNS disease was the cause of death in 19/33 (58%). Conclusions: In this series, treatment type did not affect sites of relapse, PFS or OS in patients with PIOL. To minimize toxicity, the best initial therapy should be limited to intraocular chemotherapy or focal radiotherapy. Prospective clinical trials are needed to improve our understanding and treatment of this disease.

No significant financial relationships to disclose.

Farnesylthiosalicylic acid induces caspase activation and apoptosis in glioblastoma cells

Primary glioblastomas (GBMs) commonly overexpress the oncogene epidermal growth factor receptor (EGFR), which leads to increased Ras activity. FTA, a novel Ras inhibitor, produced both time- and dose-dependent caspase-mediated apoptosis in GBM cell lines. EGFR-mediated increase in 3H-thymidine uptake was inhibited by FTA. FACS analysis was performed to determine the percent of apoptotic cells. The sub-Go population of GBM cells was increased from 4.5 to 13.8% (control) to over 45-53.6% in FTA-treated cells within 24 h. Furthermore, FTA also increased the activities of both caspase-3 and -9, and PARP cleavage. Treatment of GBMs with FTA before or after EGF addition to the cultures blocked phosphorylation of Akt and mitogen-activated protein kinases (MAPK). FTA also significantly reduced the amount of EGF-induced Ras-GTP as reflected by a decrease in the level of Ras bound to Raf-RBD-GST. This study demonstrates that inhibition of Ras methylation may provide a therapeutic target for the treatment of GBMs overexpressing EGFR.

Gliomas arising in organ transplant recipients: an unrecognized complication of transplantation?

Reported are six cases of glioma, diagnosed in the last 10 years, arising in organ transplant recipients. Five transplant recipients developed glioblastoma, and one developed oligodendroglioma. None had other risk factors for glioma. Gliomas must be considered in the differential diagnosis of space-occupying lesions in transplant recipients. Although these cases may represent coincidence, the putative HIV-glioma association suggests a pathogenetic link to immunosuppression.

The clinical utility of Doppler ultrasound prior to arteriovenous fistula creation

Arteriovenous fistula (AVF) is the preferred access for long-term hemodialysis, with superior long-term patency rates; however, early failure rates are significant. Recent evidence has brought into question the preferred site of AVF creation in many patient groups. A preoperative test that could reliably predict the outcome of a proposed AVF would be of great benefit. Doppler ultrasound has been the most extensively studied and widely used test to guide access creation. Accurate and validated measurements of internal vessel diameter, both arterial and venous, and blood flow in the upper extremity are obtainable by Doppler ultrasound. Studies evaluating the utility of Doppler ultrasound prior to AVF creation suggest that vessel size and blood flow are predictive of AVF outcome. An AVF created using a cephalic vein and/or radial artery smaller than 1.5-2.0 mm is likely to fail; such preoperative data may indicate that an upper arm AVF should be the primary access attempted. Further prospective studies are needed to evaluate the utility of Doppler ultrasound.

Intramedullary spinal cord metastasis (ISCM) in renal cell carcinoma: a series of six cases

Intramedullary spinal cord metastasis (ISCM) has been infrequently diagnosed during the clinical course of renal cell carcinoma (RCC). With the advent of more sensitive diagnostic procedures including magnetic resonance imaging (MRI), more cases of ISCM have been documented. The management of these cases is particularly challenging as lack of prompt intervention often results in irreversible progressive neurological deficits. We describe the management and clinical course in six patients with RCC who developed ISCM. Two of these patients were treated surgically while four were treated with radiation therapy (RT). Although no major improvements in neurological function were noted, stabilizations were common. This prolonged their ability to live independently, a matter of utmost importance in these terminally ill patients.

Preponderance of thiopurine S-methyltransferase deficiency and heterozygosity among patients intolerant to mercaptopurine or azathioprine

PURPOSE

To assess thiopurine S-methyltransferase (TPMT) phenotype and genotype in patients who were intolerant to treatment with mercaptopurine (MP) or azathioprine (AZA), and to evaluate their clinical management.

PATIENTS AND METHODS

TPMT phenotype and thiopurine metabolism were assessed in all patients referred between 1994 and 1999 for evaluation of excessive toxicity while receiving MP or AZA. TPMT activity was measured by radiochemical analysis, TPMT genotype was determined by mutation-specific polymerase chain reaction restriction fragment length polymorphism analyses for the TPMT*2, *3A, *3B, and *3C alleles, and thiopurine metabolites were measured by high-performance liquid chromatography.

RESULTS

Of 23 patients evaluated, six had TPMT deficiency (activity < 5 U/mL of packed RBCs [pRBCs]; homozygous mutant), nine had intermediate TPMT activity (5 to 13 U/mL of pRBCs; heterozygotes), and eight had high TPMT activity (> 13.5 U/mL of pRBCs; homozygous wildtype). The 65.2% frequency of TPMT-deficient and heterozygous individuals among these toxic patients is significantly greater than the expected 10% frequency in the general population (P <.001, chi(2)). TPMT phenotype and genotype were concordant in all TPMT-deficient and all homozygous-wildtype patients, whereas five patients with heterozygous phenotypes did not have a TPMT mutation detected. Before thiopurine dosage adjustments, TPMT-deficient patients experienced more frequent hospitalization, more platelet transfusions, and more missed doses of chemotherapy. Hematologic toxicity occurred in more than 90% of patients, whereas hepatotoxicity occurred in six patients (26%). Both patients who presented with only hepatic toxicity had a homozygous-wildtype TPMT phenotype. After adjustment of thiopurine dosages, the TPMT-deficient and heterozygous patients tolerated therapy without acute toxicity.

CONCLUSION

There is a significant (> six-fold) overrepresentation of TPMT deficiency or heterozygosity among patients developing dose-limiting hematopoietic toxicity from therapy containing thiopurines. However, with appropriate dosage adjustments, TPMT-deficient and heterozygous patients can be treated with thiopurines, without acute dose-limiting toxicity.

Single Brain Metastasis

The management of single brain metastases has evolved substantially over the last decade. The advent of triple-dose contrast-enhanced MRI scans has improved the radiologists' capacity to resolve small tumors, and, thereby, has resulted in a declining percentage of brain metastases classified as single. Only 25% to 30% of brain metastases are single; single brain metastases in the absence of systemic metastases are termed solitary. Randomized trials suggest that patients not in imminent danger of herniation are best managed initially with dexamethasone 2 to 4 mg administered orally twice daily. The routine use of prophylactic anticonvulsants is discouraged. Patients with refractory progressive systemic tumor likely to prove fatal within 3 to 6 months should receive fractionated whole brain radiotherapy. Patients with highly radiosensitive primary tumors such as small cell lung cancer, lymphoma, and germinoma should also receive whole brain radiotherapy. Patients with inactive or controllable systemic cancer and good performance status benefit from the addition of local strategies like surgery or radiosurgery to whole brain radiotherapy. Although surgery and radiosurgery have not been compared in a randomized controlled trial, data suggest that results are similar. Consequently, for most metastases that fall within the size constraints of radiosurgery (3.5 cm or smaller in diameter), radiosurgery is preferred for its relatively noninvasive nature. Patients with larger or cystic tumors, with obstructive hydrocephalus, or neurologic instability despite corticosteroids are best treated with craniotomy. Fractionated whole brain radiation following surgical or radiosurgical management of single brain metastasis appears to decrease the risk of recurrent brain metastasis, although it has not been shown to improve survival. We recommend its use in most patients, although patients with tumors likely to be highly resistant to fractionated radiotherapy or at high risk of radiation neurotoxicity may reasonably defer its use.

Metastatic spinal cord compression in patients with colorectal cancer

BACKGROUND

A retrospective study was performed to examine the outcome of patients with colorectal cancer who had metastatic spinal cord compression (MSCC) and received radiation therapy (RT).

METHODS

Forty episodes of MSCC were treated with external beam RT in 34 patients with metastatic colorectal cancer. The median total dose was 3000 cGy (1800-4750 cGy), and the daily fraction size was 300 cGy (151-400 cGy). All patients were followed until death.

RESULTS

Median overall survival for the entire cohort was 4.1 months. Of 21 patients ambulatory before RT, 20 remained ambulatory after treatment, whereas only 2 of 9 patients who were nonambulatory regained full ambulatory status. Patients with rectal primary tumors had improved survival (median 7.9 months) compared with those who had colon primary tumors (2.7 months) (P = 0.002). Patients who received a total dose of more than 3000 cGy had a better survival (7 months) than those who received 3000 cGy or less (3.1 months) (P = 0.024). There was a trend for improved survival in patients fully ambulatory at diagnosis (P = 0.056) and after RT (P = 0.07). Unlike other primary sites in which approximately 70% of lesions are located in the thoracic spine, the location of epidural metastasis in colorectal primary tumors was most frequently in the lumbar spine (55% of lesions).

CONCLUSIONS

Prognostic features and outcomes for MSCC with primary colorectal cancer are similar to those for other primary sites. There is a suggestion that rectal primary tumors may be associated with an improved outcome compared with colon primary tumors. Patients who received more than 3000 cGy total dose had a longer survival than those who received lower total doses.

Morbidity and survival after 1,3-bis(2-chloroethyl)-1-nitrosourea wafer implantation for recurrent glioblastoma: a retrospective case-matched cohort series

OBJECTIVE

To determine the risks and survival benefit associated with implantation of an absorbable, 1,3-bis(2chloroethyl)-1-nitrosourea-impregnated polymer wafer, we prospectively studied patients with recurrent glioblastoma multiforme and compared them with a demographically matched cohort group.

METHODS

Over a 29-month period, 62 patients underwent operations. All had tumor growth despite standard treatment, a Karnofsky performance score of > or =70, and histopathological confirmation of glioblastoma. Seventeen patients underwent gross total resection with placement of 1,3-bis(2-chloroethyl)-1-nitrosourea wafers (wafer group) at a median 44 weeks from diagnosis (6 women, 11 men; median age, 56 years). A cohort group of 45 patients undergoing surgery for recurrent glioblastoma during the same time period, but not receiving wafers, was identified. Surgery was performed at a median 47 weeks from diagnosis (14 women, 31 men; median age, 54 years).

RESULTS

Within 6 weeks of surgery, 13 complications were identified in 8 patients in the wafer group. In the cohort group, 6 patients sustained 8 complications. We were unable to identify any survival advantage using Kaplan-Meier analysis. In the wafer group, median survival was 58 weeks from diagnosis and 14 weeks from wafer implantation. In the cohort group, median survival was 97 weeks from diagnosis and 50 weeks from operation.

CONCLUSION

1,3-bis(2-chloroethyl)-1-Nitrosourea wafer implantation for recurrent glioblastoma was associated with a higher risk of postoperative complications, particularly those related to infection and wound healing. No clear survival benefit associated with wafer implantation was identified.

Phase II study of phenylacetate in patients with recurrent malignant glioma: a North American Brain Tumor Consortium report

PURPOSE

To determine the response rate, time to treatment failure, and toxicity of phenylacetate in patients with recurrent malignant glioma and to identify plasma concentrations achieved during repeated continuous infusion of this agent.

PATIENTS AND METHODS

Adult patients with recurrent malignant glioma were treated with phenylacetate. The schedule consisted of a 2-week continuous, intravenous infusion followed by a 2-week rest period (14 days on, 14 days off). A starting dose of 400 mg/kg total body weight per day of phenylacetate was initially used and subsequently changed to 400 mg/kg/d based on ideal body weight. Intrapatient dose escalations were allowed to a maximum of 450 mg/kg ideal body weight/d. Tumor response was assessed every 8 weeks. The National Cancer Institute common toxicity criteria were used to assess toxicity. Plasma concentrations achieved during the patients' first two 14-day infusions were assessed.

RESULTS

Forty-three patients were enrolled between December 1994 and December 1996. Of these, 40 patients were assessable for toxicity and response to therapy. Reversible symptoms of fatigue and somnolence were the primary toxicities, with only mild hematologic toxicity. Thirty (75%) of the 40 patients failed treatment within 2 months, seven (17.5%) had stable disease, and three (7.5%) had a response defined as more than 50% reduction in the tumor. Median time to treatment failure was 2 months. Thirty-five patients have died, with a median survival of 8 months. Pharmacokinetic data for this dose schedule showed no difference in the mean plasma concentrations of phenylacetate between weeks 1 and 2 or between weeks 5 and 6.

CONCLUSION

Phenylacetate has little activity at this dose schedule in patients with recurrent malignant glioma. Further studies with this drug would necessitate an evaluation of a different dose schedule.

Risk of injury to cranial nerves after gamma knife radiosurgery for skull base meningiomas: experience in 88 patients

OBJECT

In this study the authors sought to determine the neurological risks and potential clinical benefits of gamma knife radiosurgery for skull base meningiomas.

METHODS

A consecutive series of 88 patients harboring skull base meningiomas were treated between 1990 and 1996 by using the Leksell gamma knife in a prospective clinical study that included a strict dose-volume protocol. Forty-nine patients had previously undergone surgery, and six had received external-beam radiotherapy. The median treatment volume was 10 cm3, and the median dose to the tumor margin was 16 Gy. The radiosurgical dosage to the optic nerve, the cavernous sinus, and Meckel's cave was calculated and correlated with clinical outcome. The median patient follow-up time was 35 months (range 12-83 months). Two tumors (2.3%) progressed after radiosurgery; the progression-free 5-year survival rate was 95%. At last follow-up review, 60 (68%) tumors were smaller and 26 (29.5%) remained unchanged. Clinical improvement (in vision, trigeminal pain, or other cranial nerve symptoms) occurred in 15 patients. Functioning optic nerves received a median dose of 10 Gy (range 1-16 Gy), and no treatment-induced visual loss occurred. Among nine patients with new trigeminal neuropathy, six received doses of more than 19 Gy to Meckel's cave.

CONCLUSIONS

Gamma knife radiosurgery appeared to be an effective method to control the growth of most skull base meningiomas in this intermediate-term study. The risk of trigeminal neuropathy seemed to be associated with doses of more than 19 Gy, and the optic apparatus appeared to tolerate doses greater than 10 Gy. Considering the risks to cranial nerves associated with open surgery for comparable tumors, the authors believe that gamma knife radiosurgery is a useful method for the management of properly selected recurrent, residual, or newly diagnosed skull base meningiomas.

CD8(+), radiosensitive T cells of parental origin, oppose cells capable of down-regulating cytotoxicity in murine acute lethal graft-versus-host disease

Murine graft-versus-host (GVH) disease takes two forms depending upon the parental/F1 strain combination employed. Anemia, lymphopenia, hypogammaglobulinemia, profound anti-F1 cytotoxicity, and the loss of cytotoxic potential against third party alloantigen is seen in acute lethal GVH disease. In contrast to this, in chronic GVH disease there is polyclonal B cell activation, auto-antibody production, no anti-F1 cytotoxicity, and retained cytotoxicity against allotargets. We have previously reported that this marked disparity in disease expression results from a radiosensitive host veto cell which protects the F1 mouse from parental anti-F1 cytotoxicity in mice undergoing CGVH disease. This cell could be induced in vitro or in vivo in CGVH disease. Using an in vitro system, we now demonstrate that a CD4(+), radiation-sensitive, T cell does emerge in acute lethal GVH disease which is capable of down-regulating cytotoxicity. The cell does not appear to be a veto cell in that it attenuates cytotoxicity directed against nonself alloantigen. The function of this cell does not appear to be influenced by minor lymphocyte stimulatory gene products. We further report that, in ALGVH disease, regulation by this cell is not readily apparent due to the emergence of a CD8(+) T cell of parental (B6) origin, which opposes its action.

Neuroimaging and treatment implications of patients with multiple epidural spinal metastases

BACKGROUND

Although multiple spinal epidural metastases (MEMs) commonly occur in cancer patients, their clinical significance remains uncertain. The authors attempted to ascertain the incidence of MEMs and their association with the completeness of spinal imaging by magnetic resonance (MR) scanning versus myelography to determine how often they are missed because of incomplete spinal imaging and to assess their prognostic and treatment implications.

METHODS

A review of 337 epidural spinal cord compression (ESCC) cases seen at the Mayo Clinic between 1985 and 1993 was conducted.

RESULTS

ESCC patients undergoing myelography only were significantly more likely to undergo complete spinal imaging (CSI)than patients undergoing either MR scan only or both imaging modalities (P < 0.0001). MEMs were detected in 32% of patients undergoing CSI and 18% of patients with incomplete spinal imaging (P=0.02). Failure to image the cervical spine in patients with symptomatic thoracic or lumbar epidural lesions would have missed secondary epidural lesions in only 1% of patients; however, this figure increased to 21% for failure to image either the thoracic or lumbosacral spine when symptomatic disease was located elsewhere. Radiation oncologists included secondary epidural deposits in treatment ports in 93% of MEM cases. In a multivariate model, the presence of MEMs was an independent prognostic factor for poorer survival.

CONCLUSION

The incidence of MEMs in patients with ESCC is approximately 30%, and their presence frequently alters treatment plans. It appears safe to forgo cervical spine MR scanning in patients with radiographically verified thoracic or lumbar ESCC; however, careful imaging of the thoracic and lumbar spine should be considered in all ESCC patients to detect MEMs.

Neurologic perspectives of Crigler-Najjar syndrome type I

Limited information exists on the neurologic sequelae of Crigler-Najjar syndrome type I despite this being the major morbidity of this rare autosomal recessive disorder of bilirubin conjugation that results in chronic unconjugated hyperbilirubinemia. Two patients with identical underlying genetic mutations resulting in Crigler-Najjar syndrome type I were assessed from a neurodevelopmental perspective in late childhood using age appropriate standardized measures. In addition, the English language literature of case reports and series describing the outcomes of patients with this disorder was reviewed (descriptive meta-analysis) and summarized with particular reference to neurologic symptomatology, pattern of neurologic disability, age of onset of symptoms, and therapeutic interventions. Despite radically different therapeutic interventions, our two patients did not differ in outcome measures. Review of the literature reveals distinct, often age-related, patterns of neurologic sequelae reflecting injury to basal ganglia, cerebellar, and likely hippocampal structures. Definitive prevention of the neurologic sequelae that often occur within the context of Crigler-Najjar syndrome type I requires that curative treatment (hepatic transplantation, presently, and gene therapy in the future) be applied prior to the possible onset of neurologic symptoms in adolescence.

Neurologic emergencies in cancer patients

Neurologic emergencies are common among cancer patients and their incidence is increasing as patients live longer as a result of improved antineoplastic therapy. This article reviews acute neurologic complications in cancer patients. Among those complications reviewed are brain metastases, epidural spinal cord compression, leptomeningeal metastases, cerebrovascular disorders, complications of antineoplastic therapy, and paraneoplastic syndromes.

Herpes simplex encephalitis (HSE) and the immunocompromised: a clinical and autopsy study of HSE in the settings of cancer and human immunodeficiency virus-type 1 infection

Although herpes simplex encephalitis (HSE) is not regarded as an opportunistic infection, the occurrence of HSE in immunocompromised patients has been documented and the suggestion made that unusual clinical and neuropathologic features characterize the disorder in this population. To further characterize HSE as it affects the immunodeficient, the authors reviewed the clinical and pathological findings in three immunocompromised patients with autopsy-proven HSE. Two patients had cancer (one with lymphoma and another with glioblastoma multiforme), one was known to be human immunodeficiency virus-type 1 (HIV-1)-seropositive and a second was suspected of harboring underlying HIV-1 infection. Two were receiving dexamethasone at onset of HSE. All had fever, mental status changes and new, focal neurological deficits or worsening of established deficits. Cerebrospinal fluid (CSF) pleocytosis was absent or minimal and head computerized tomographic (CT) scans, performed in all cases, were unrevealing. No patient was clinically suspected of having HSE, only one received acyclovir (for concurrent mucocutaneous herpes) and HSE played a major role in all deaths. Autopsy revealed an unusual form of HSE characterized by a noninflammatory, pseudoischemic histological presentation and the unexpected persistence of viral antigens in abundance despite survival beyond the clinical stage during which inflammatory responses usually peak and productive brain infection wanes. The incidence of HSE in the immunocompromised may be underestimated. Preexistent neurological disease, a noninflammatory CSF profile and negative CT scan may confound the diagnosis in this population, a typical clinical presentation notwithstanding. Increased clinical suspicion, the use of magnetic resonance imaging and polymerase chain reaction analysis of CSF for herpes simplex virus nucleic acid sequences may permit more rapid diagnosis and treatment. The absence of inflammatory infiltrates in some fatal cases of HSE suggests that an intact immune response is not requisite to the devastating neurological injury characteristic of this disorder.

Risk factors for primary central nervous system lymphoma: a case-control study

BACKGROUND

The incidence of primary central nervous system lymphoma (PCNSL) has increased over time in both immunocompetent and immunodeficient individuals. The reasons for the increase among immunocompetent patients are unclear.

METHODS

The authors conducted a case-control study of PCNSL at the Mayo Clinic based on cases from local community and referral practices. Cases were all PCNSL patients without immunodeficiency diagnosed between 1975 and 1994 (n = 109). Two groups of controls were selected from the same referral practice, namely, patients with other cancer (cancer controls; n = 101), and patients with a different neurologic disease (neurologic controls; n = 109) seen at our institution during the same time period.

RESULTS

PCNSL was significantly associated with lower education when cases were compared with cancer controls but only suggestively when cases were compared with neurologic controls. PCNSL cases were less likely to have had a history of tonsillectomy or oral contraceptive use compared with both control groups. The findings regarding autoimmune disorders and cardiovascular diseases were inconsistent for the two control groups. Neither farming nor prior personal or family history of cancer appeared to be risk factors for PCNSL.

CONCLUSIONS

The findings of this study warrant further investigation of tonsillectomy and oral contraceptives as possible factors for PCNSL.

Pneumonic tularemia in a patient with chronic granulomatous disease

We report the case of a 14-year-old boy with granulomatous pneumonia caused by Francisella tularensis. In addition, an autosomal recessive form of chronic granulomatous disease was diagnosed. Both F. tularensis and chronic granulomatous disease are associated with pulmonary granulomas. To our knowledge, this is the first report of F. tularensis infection in a patient with chronic granulomatous disease. The relationship between these two processes is discussed.

Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach

The objective of our study was to delineate clinical features and specific diagnostic and therapeutic implications of spinal epidural metastasis (SEM) occurring as the initial manifestation of malignancy (IMM)-a less common event than SEM in the setting of previously established malignancy (PEM). We performed a retrospective review of the clinical histories of 337 patients seen at Mayo Clinic with a radiographically verified diagnosis of SEM between January 1, 1985, and December 31, 1993. Twenty percent of all cases of SEM occurred as SEM-IMM. Carcinoma of the lung, cancer of unknown primary site, multiple myeloma, and non-Hodgkin's lymphoma were disproportionately represented in SEM-IMM, together accounting for 78% of SEM-IMM patients and only 26% of SEM-PEM patients. Inversely, breast and prostate carcinoma contributed only 12% of SEM-IMM patients but 51% of SEM-PEM patients. Only 27% of patients with SEM-IMM had nonspecific symptoms suggesting malignancy, and in only 24% did the history or physical examination suggest the primary site of malignancy. Percutaneous needle biopsy of the vertebral lesion was diagnostic of malignancy in 18 of 19 patients (95%), and no complications ensued. Fifteen patients underwent diagnostic laminectomy with biopsy, and one had a fatal complication. Survival after the diagnosis of SEM did not differ between patients with SEM-IMM and those with SEM-PEM; the median survival was 6.6 months. SEM not uncommonly occurs as the presentation of malignancy, and often it produces the only symptoms or signs of malignancy. The great majority of neoplasms presenting with SEM are carcinomas of the lung, unknown primary lesions, and hematologic malignancies. Computed tomography-guided needle biopsy is a safe, efficacious means of diagnosing malignancy, allowing for rational diagnostic workup and staging. In most patients it obviates a diagnostic spinal surgical procedure.

Central neurocytomas

BACKGROUND

This analysis was performed to examine the outcome of patients with histologically confirmed central neurocytomas.

METHODS

Thirty-two patients with histologically confirmed central neurocytomas were evaluated retrospectively. Patients were treated with various combinations of surgery, chemotherapy, and radiotherapy (RT). Follow-up ranged from 2.3 to 15.3 years (median, 4.7 years).

RESULTS

The overall 5-year survival and local control rates were 81% and 79%, respectively. No patient developed metastases. The 5-year local control rate was 70% for patients undergoing subtotal resection (STR) and 100% for those undergoing gross total resection (GTR) (P = 0.08). The 5-year survival rate was 77% for patients undergoing STR and 90% for those undergoing GTR (P = 0.44). The effect of RT was evaluated for patients undergoing STR. The 5-year local control rate was 100% for patients who received RT after STR compared with 50% for those who did not (P = 0.02). The 5-year survival rate was 88% for patients who received RT after STR compared with 71% for those who did not (P = 0.3). Three patients received salvage RT for local progression after resection. All were alive and free of disease 1 to 6 years after RT.

CONCLUSIONS

GTR results in a very high likelihood of local control and survival. Postoperative RT appears to improve local control rates significantly for patients who have undergone STR. The overall prognosis of patients with central neurocytomas is quite favorable, with an actuarial 5-year survival rate of 81%.

Intramedullary spinal cord metastases: clinical features and treatment outcome

Our objective was to delineate clinical features and treatment outcome of patients with intramedullary spinal cord metastasis (ISCM). There are no reports of a large experience with this rare cancer complication. We reviewed records retrospectively from 1980 to 1993 to identify patients with histologically confirmed systemic cancer, clinical features of myelopathy, and either tissue-proven ISCM or abnormal neuroimaging findings consistent with ISCM. We identified 40 patients who fulfilled these criteria. In nine, ISCM was the initial presentation of cancer. Nineteen patients had lung primaries (small cell in 12). Twenty-one patients had pain, 35 had demonstrable sensory loss, 37 had weakness, and 25 had urinary incontinence at presentation. Nine patients had true Brown-Séquard syndrome and nine others had pseudo-Brown-Séquard syndrome. Median duration of symptoms at diagnosis was 28 days (range 3 days to 18 months). Thirteen patients had prior brain metastasis, nine had brain metastasis simultaneous with ISCM, and one had brain metastasis after ISCM; 11 had concomitant leptomeningeal metastases. Spinal magnetic resonance findings were abnormal in 30/30 patients, myelographic results were abnormal in 16/20, and eight had pathologic confirmation of ISCM. Thirty-five patients had radiotherapy and five had surgery; four were untreated or treated elsewhere. Median survival was 4 months for patients receiving radiotherapy and 2 months for patients not receiving radiotherapy. Eleven patients survived > 6 months. Twenty-three were ambulatory at ISCM diagnosis, and 21 were ambulatory at letest follow-up. We conclude that ISCM as the initial presentation of malignancy is not rare, and hemicord syndromes occur frequently. Although long-term survival is poor, treatment preserves ambulation in most patients still ambulatory at diagnosis. Focal radiotherapy is indicated in most patients.