Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas. A cooperative clinical trial

A versatile permanent planar implant technique utilizing iodine-125 seeds imbedded in gelfoam

Tumors attached or adjacent to critical structures can often not be completely resected or resected with adequate surgical margins. Sites involving major blood vessels, the vertebral column or the brain with small residual tumors or suspicious margins often present technical difficulties for standard I-125 or Ir-192 implants. A relatively simple, accurate and inexpensive implant method is described using I-125 seeds imbedded in gelfoam to implant permanently into small residual tumors or suspicious margins where standard implant techniques may be unsatisfactory. A method for planning the treatment dose for such an implant is described. Cases involving paraspinal and brain tumors are reported to illustrate the technique.

Supratentorial malignant gliomas of childhood. Results of treatment with radiation therapy and chemotherapy

Twenty-seven patients aged 1 to 18 years harboring supratentorial (20 in the cerebrum and seven in the thalamus) malignant gliomas were treated between 1975 and 1982. There were four glioblastomas multiforme, 14 anaplastic astrocytomas, and nine malignant gliomas. All patients had a subtotal resection or biopsy as the initial procedure and received postoperative radiation therapy (RT). Fifteen of 27 patients were treated by RT alone; 14 had tumor progression with a median time to tumor progression (MTP) of 65 weeks. Twelve patients were treated with chemotherapy as an adjuvant to RT; only seven had tumor recurrence, with an MTP of 130 weeks. Of the 21 patients with recurrent tumors in both groups, 18 were treated with chemotherapy alone, or chemotherapy with a second surgical procedure or second course of RT. For all histological grades of tumor, the MTP for first recurrence was 75 weeks and the median survival time was 180 weeks. Age at initial diagnosis was found to be a statistically significant prognostic factor, with patients younger than 10 years of age surviving longer than patients aged over 10 years (p = 0.02).

Intracerebral transplantation of a human glioma line in immunosuppressed rats

A model was developed for in vivo study of the human glioma-derived D-54 MG cell line in the brains of immunosuppressed Fischer 344 rats. The rats were injected with horse anti-rat thymocyte serum before and after intracerebral inoculation with 5 or 10 microliters of a D-54 MG tumor cell suspension. Reproducible mortality distributions were obtained, with deaths occurring 18 to 34 days after intracerebral inoculation. Tumors grew as well circumscribed intracerebral masses with sheets of anaplastic cells, areas of necrosis bordered by concentrated nuclei, and minimal lymphocytic infiltration. Cytogenetic analysis revealed the same general chromosome distribution and markers in the heterotransplanted glioma cells as in the cultured line. Blood-brain barrier disruption was demonstrated by intracerebral tumor staining after intravenous injection of Evans blue dye. The in vivo growth of D-54 MG in immunosuppressed rats provides a reliable experimental model for the study of chemotherapy, immunodiagnosis, and immunotherapy of a human glioma-derived tumor in an animal sufficiently large to evaluate intracarotid or intratumoral injection of therapeutic agents.

Nutrition and the neurosurgical patient

There has been a rapid expansion of knowledge in the field of nutrition and metabolism with regard to the general surgical patient. However, only recently has there been greater appreciation of the benefits of adequate nutrition and appropriate metabolic care of the neurosurgical patient. In this review, the authors attempt to outline 1) the metabolic response to stress in general, and how it applies to the neurosurgical patient; 2) how best to provide adequate nutritional support for the neurosurgical patient; 3) the effects of nutrition on neurotransmitters; and 4) the effect of diet and nutrition on patients with malignant brain tumors.

Brachytherapy of recurrent malignant brain tumors with removable high-activity iodine-125 sources

Thirty-seven patients harboring recurrent malignant primary or metastatic brain tumors were treated by 40 implantations of high-activity iodine-125 (125I) sources. All patients had been treated with irradiation and most had been treated with chemotherapeutic agents, primarily nitrosoureas. Implantations were performed using computerized tomography (CT)-directed stereotaxy; 125I sources were held in one or more afterloaded catheters that were removed after the desired dose (minimum tumor dose of 3000 to 12,000 rads) had been delivered. Patients were followed with sequential neurological examinations and CT scans. Results of 34 implantation procedures were evaluable: 18 produced documented tumor regression (response) for 4 to 13+ months; five, performed in deteriorating patients, resulted in disease stability for 4 to 12 months. The overall response rate was 68%. In 11 patients, implantation did not halt clinical deterioration. At exploratory craniotomy 5 to 12 months after implantation, focal radiation necrosis was documented in two patients whose tumor had responded initially and then progressed, and in three patients whose disease had progressed initially (four glioblastomas, one anaplastic astrocytoma); histologically identifiable tumor was documented in two of these patients. All improved after resection of the focal necrotic mass and are still alive 10, 15, 19, 24, and 25 months after the initial implantation procedure; only one patient has evidence of tumor regrowth. The median follow-up period after implantation for the malignant glioma (anaplastic astrocytoma and glioblastoma multiforme) group is 9 months, with 48% of patients still surviving. While direct comparison with the results of chemotherapy is difficult, results obtained in this patient group with interstitial brachytherapy are probably superior to results obtained with chemotherapy.

A Phase I study of intermittent intravenous bromodeoxyuridine (BUdR) with conventional fractionated irradiation

A Phase I trial of intravenous bromodeoxyuridine (BUdR) and conventional fractionated radiation therapy was performed in 14 patients with glioblastoma multiforme and 7 patients with other poorly radioresponsive tumors. The BUdR was given as a constant intravenous infusion for 12 hr/day for up to 14 days. Thirteen patients received a second 14 day infusion following a 10 to 14 day interruption for bone marrow recovery. Local toxicity (within the radiation field) was minor, with 7 of the 21 patients requiring a brief treatment break for moist skin desquamation. There was no significant CNS toxicity noted clinically nor by autopsy examination. Additionally, no significant enhancement of radiation injury was noted to bowel or liver. However, one patient treated for multiple pulmonary metastases experienced a clinical and radiographic pattern consistent with radiation pneumonitis. Dose-dependent systemic toxicity occurred in bone marrow and skin. Moderate myelosuppression, especially thrombocytopenia, was found following a 14 day cycle of BUdR at and above 650 mg/m2/12 hr infusion. Approximately one-third of patients developed a maculo-papular erythematous rash to the scalp, neck and upper chest. In two patients, the rash became generalized with evidence of epidermolysis on skin biopsy. Pharmacology studies revealed steady-state arterial plasma levels of 2 X 10(-6) M/1 during the 12 hr infusion of 650 to 700 mg/m2. Radiosensitization was measured by a change in the D0 of radiation survival curves of human bone marrow CFUc prior to and following the 14 day infusion in 4 patients. A trend of increasing radiosensitization was noted in most patients as the infusion rate of BUdR was increased from 500 to 870 mg/m2/12 hr. We conclude that the maximum tolerable dose of BUdR is 650 to 700 mg/m2/12 hrs when given as a 2 week intermittent intravenous infusion. Local toxicity is acceptable. The major systemic toxicities are myelosuppression and a maculopapular skin rash.

Intracerebral neutron brachytherapy for hemispheric glioblastoma multiforme. A pilot study

The University of Kentucky Brain Tumor Study and Research Group has developed a new treatment protocol of interstitial brain brachytherapy using Californium-252 neutron source implantation in 1980. Only patients with malignant gliomas were eligible for this pilot study. Nine patients entered the Phase I trial of the protocol study between November 1980 and October 1981. According to the design of the protocol, all patients who had a verified histologic diagnosis of glioblastoma multiforme underwent postoperative intracerebral Cf-252 neutron source implantation, followed by 6 000 cGy of external photon beam irradiation. The purpose of this pilot study was to test the feasibility of interstitial Cf-252 neutron source implantation and only one implant afterloading applicator was used for brachytherapy. The implant applicator was placed in the center of tumor and the procedure was performed under CT guidance. In the assessment of the procedure, Karnofsky functional performance status, intellectual status, neurological examination, CT scans, and complications were used. All patients tolerated the procedure well and no serious complications were encountered. Despite the quality of these early treatments, there was some evidence of short-term benefit in duration of survival of the patients. We believe that further technical improvement to achieve an adequate isodose distribution to cover the tumor volume might result in longer duration improvement in survival.

Superfractionation radiation therapy in the treatment of malignant astrocytoma

Superfractionation (SF) radiation therapy is the administration of three fractions per day. We have assessed the effect of SF in a prospective randomized clinical study of malignant astrocytomas from July 1978 to December 1980. Thirty-five patients were randomized to SF (4000 rad in 45 fractions in 3 weeks whole brain and 1000 rad in five fractions in one week local boost). Thirty-four patients were randomized to conventional fractions (3400 rad in 17 fractions whole brain in 3.5 weeks and 1600 rad in eight fractions in 1.5 weeks local boost). Both treatment arms received chemotherapy with CCNU. The 1- and 2-year actuarial survival rate is 54% and 21% for SF group and 32% and 10% for CF group. The other advantages of SF include shorter mean duration of steroid administration and improved performance status following radiation therapy.

Comparison of postoperative radiotherapy and combined postoperative radiotherapy and chemotherapy in the multidisciplinary management of malignant gliomas. A joint Radiation Therapy Oncology Group and Eastern Cooperative Oncology Group study

Recently, the RTOG and ECOG concluded a joint randomized study on malignant gliomas that was in progress for the past five years. A total of 626 patients entered this protocol. Sixty-seven percent of the 535 evaluable patients have died and thus this represents a preliminary report of a major joint clinical trial. The objective of this study was to evaluate the efficacy after neurosurgery of three new treatment options as compared with control treatment of radiotherapy alone. The four options were: (1) control radiation; 6000 rad/6-7 weeks to whole brain; (2) a higher radiation dose; Control dose plus a booster dose of 1000 rad/1-2 weeks to the tumor; (3) control radiation dose plus BCNU (80 mg/m2/day IV X 3 and repeat BCNU every 8 weeks); (4) Control radiation dose plus combination methyl-CCNU (125 mg/m2/day orally X 1 and repeat methyl-CCNU every 8 weeks), and DTIC (150 mg/m2/day IV X 5 and repeat DTIC every 4 weeks). All pertinent patient characteristics were studied and several important prognostic factors have been identified. Notably, age, histologic type (Astrocytoma with anaplastic foci, versus glioblastoma multiforme), initial performance status, time since first symptoms and presence or absence of seizure. At this time, it appeared that there was no treatment option which was significantly better than the control. The study identified that age was the most important prognostic factor. Patients who were younger than age 40 years had an 18-month survival of 64%, patients who were age 40-60 years had an 18-month survival of 20%, and patients who were older than age 60 had an 18-month survival of 8%. The study also demonstrated that a modified histologic classification of anaplastic astrocytoma versus glioblastoma provided better prognostic information than the astrocytoma grading system of Kernohan. Patients with anaplastic astrocytoma had a median survival of 27 months as compared to 8 months for patients with glioblastoma. In further evaluation of any beneficial effect of chemotherapy, it was identified that only among the 40-60-year-old groups, BCNU treated patients appeared to have significantly increased survival than patients in the control groups (P = 0.01, one-sided). Similarly, methyl-CCNU + DTIC was suggestively better than the control (P = 0.08, one-sided). The higher radiation dose, 7000 rad/8-9 weeks appeared to give no significantly better survival over the control dose option. Both BCNU and methyl-CCNU + DTIC produced some toxicity. The combination of methyl-CCNU + DTIC was more toxic than BCNU, producing severe or worse thrombocytopenia in 23% of the patients as compared to 6% on BCNU.

A randomized comparison of misonidazole sensitized radiotherapy plus BCNU and radiotherapy plus BCNU for treatment of malignant glioma after surgery; preliminary results of an RTOG study

A randomized prospective study was performed to evaluate misonidazole radiosensitized radiation therapy in the treatment of malignant glioma. The control arm, Group A, consisted of conventional radiation therapy (6000 cGy/6-7 weeks) to the whole brain plus BCNU (80 mg/m2 on day 3, 4, 5, and then repeated q 8 weeks for 2 years). The BCNU schedule was identical in both arms. In the experimental arm, Group B, misonidazole 2.5 gm/m2 was given once a week for six weeks, to a total dose of 15 gm/m2. It was given orally four hours prior to 400 cGy on Mondays. On Tuesdays, Thursdays and Fridays, 150 cGy was delivered to a total of 5100 cGy/6 weeks. An additional 900 cGy/5F/1 week was given without misonidazole. Patients were stratified according to the prognostic factors of age, performance status, and histology. Distribution of these characteristics among the treatment groups was comparable. As of March 1, 1982, 245 patients were randomized with follow-up information available on 202 patients. The median follow-up is 12 months (range 3-39 months). There is no significant difference in the survival of the two groups. The median survival for Group A was 12.6, and for Group B, 10.7 months. Misonidazole toxicity included an 11% peripheral neuropathy and a 3% central nervous system toxicity. BCNU toxicity included severe hematologic toxicity in 25%, including one death, and significant pulmonary toxicity in 6 out of 55 patients who received a minimum total dose of 960 mg/m2 of BCNU.

Two cases of acute leukemia following treatment of malignant glioma

Two female patients, 42 and 30 years old, respectively, died of acute nonlymphocytic leukemia 43 and 38 months, respectively, after a subsequent treatment: chemotherapy for one and irradiation and chemotherapy for the other, following excision of a malignant glioma. At the time of death, both seemed to be in complete remission of their brain tumor. Both had been treated with procarbazine and nitrosoureas. The latter were responsible for severe myelosuppressive episodes and seem to have played an essential role in the induction of the leukemia. In one case, a myelodysplasia was observed before the onset of the AL and the diagnosis of refractory anemia with excess of blasts seemed warranted. Secondary acute leukemias are rare in the evolution of malignant gliomas and the usefulness of subsequent radiochemotherapy cannot be questioned at the present time. The risks involved in this therapy are minor when compared to the short-term fatal prognosis of this type of tumor.

Combined radiotherapy and chemotherapy with dibromodulcitol and CCNU in the postoperative treatment of malignant gliomas

Within 4 weeks after definitive surgery, 91 patients with supratentorial glioblastomas and malignant astrocytomas were randomized to one of three treatment arms: Group 1 received radiotherapy alone; Group 2 received dibromodulcitol (DBD) during radiotherapy, and treatment was then continued with DBD; and Group 3 received DBD during radiotherapy, followed by combination chemotherapy of CCNU and DBD. No severe myelotoxicity occurred, but combined treatment with CCNU and DBD occasionally caused a transient myelosuppression. Statistical analysis of 84 evaluable patients showed a significantly longer survival period in those who received chemotherapy during and after irradiation. Median survival times in the three groups were 40, 57, and 60 weeks, respectively; the corresponding p value for Groups 2 and 3 was 0.025 and 0.0015. The ratio of patients surviving over 18 and 24 months was highest in Group 3. This study suggests that the administration of DBD during irradiation might have been the main factor in improving survival times.

Improved treatment of a brain-tumor model. Part 1: Advantages of single- over multiple-dose BCNU schedules

Clonogenic cell and animal survival studies were used to determine the most effective BCNU therapy schedule in the 9L rat brain-tumor model. Survival of tumor cells following a single LD10 dose of BCNU (13.3 mg/kg intraperitoneally) was compared to cell survival after one to four daily 0.5 X LD10 doses. The posttreatment kinetics of surviving clonogenic cells were investigated at various times after BCNU was given in single doses of 0.25 to 1 X LD10 and in two daily doses of 0.5 X LD10. The cell kill was greater, time to reinitiation of cell growth was later, posttreatment rate of clonogenic cell proliferation was slower, and the interval to total repopulation of the clonogenic cell pool was longer with a single LD10 dose as compared to the multiple-dose schedules. Animal survival studies confirmed that a single LD10 dose of BCNU was at least as effective as a cumulative level of up to 1 1/2 times that amount when treatment was administered in smaller doses, regardless of the fractionation schedule. Clinical experience with patients harboring malignant brain tumors has shown that a single BCNU dose of 185 to 200 mg/sq m is tolerated well. Results of these animal experiments suggest that this therapy should have anti-tumor activity at least equivalent to the more commonly employed schedule of 80 mg/sq m/day given for 3 days. Although direct comparison of treatment efficacy using the two schedules is not possible, no adverse clinical effects have been observed with the recently adopted single-dose schedule. Furthermore, the duration of patient hospitalization for chemotherapy has decreased.

Randomized comparisons of radiotherapy and CCNU versus radiotherapy, CCNU plus procarbazine for the treatment of malignant gliomas following surgery. A Southwest Oncology Group Report

One hundred and fifteen eligible patients with histologically verified malignant gliomas (astrocytoma grade III-IV) were randomized to receive either radiotherapy 6 000 rads/7 week plus CCNU 130 mg/M2 every 6 weeks (treatment 1) or radiotherapy 6 000 rads/7 weeks plus CCNU 75 mg/M2 day 1 plus procarbazine 100 Mg/m2 days 1-14 every 6 weeks (treatment 2) within 4 weeks following surgical resection. The response rates showed no statistically significant differences between treatment 1 CR/PR - 24/17% and treatment 2 CR/PR - 14/14% (P-value = 0.31). The median survival was also not significantly different: 55 and 50 weeks for treatments 1 and 2, respectively. The most important prognostic parameter identified was age with younger patients showing higher response rates and longer survival. Patients' performance status was also a useful prognostic parameter for response and survival. Neither the extent of surgical resection nor the tumor grade correlated significantly with the outcome. Further studies are needed to identify active chemotherapeutic agents for the treatment of brain tumors.

Hemorrhagic encephalitis produced by selective non-occlusive intracarotid BCNU injection in dogs

A selective non-occlusive technique was developed for administration of BCNU (1,3-bis(2-chloroethyl)-1-nitrosourea) into the internal carotid artery of the dog, and the neuropathological effects in the brain were studied. One out of three dogs showed ipsilateral hemorrhagic necrotizing encephalitis at doses of 102 mg/sq m, and all of three dogs showed similar but more severe pathology at doses of 215 to 232 mg/sq m. This study and previous studies in the dog and monkey suggest definite thresholds above which cerebral toxicity occurs when BCNU is administered via the intracarotid route. Greater dilution of drug in the larger territory of supply of the human internal carotid artery allows somewhat higher doses in man. The pathology of the lesion induced by BCNU suggests a primary vascular injury as a pathogenic mechanism, consonant with similar findings following high-dose systemic BCNU administration in man. Investigators conducting ongoing and future trials of intracarotid BCNU in the human for the treatment of intracranial neoplasms should be especially vigilant for a similar toxic effect.

Toxicity of very high dose nitrosourea administration

We report a case of inadvertent administration of over twice the usual dose of methyl-CCNU. The patient exhibited an early onset of bone marrow suppression. Profound pancytopenia, including lymphopenia, persisted for over seven weeks, Although early recovery started at about five weeks. Permanent marrow damage was indicated by persistent thrombocytopenia and abnormal megakaryocyte morphology at autopsy, some six months after the single exposure to methyl-CCNU. There was no discernible toxicity to lung, liver, or kidneys. The case suggests that the cummulative bone marrow toxicity seen with nitrosoureas is not dose-schedule sensitive. There is also evidence suggesting that high dose nitrosourea therapy affects a bone marrow target population other than the early stem cell target affected by usual doses of these drugs.

Superfractionation in glioblastoma multiforme--results of a phase II study

A sequential series of 30 patients who were referred to a cancer treatment hospital with glioblastoma multiforme were treated with superfractionated cobalt 60 gamma radiation, three treatments per day, 100 rad per fraction. Their survival was compared to that of a historical group of 90 patients who had been referred for the same disease. Survival of the study patients was significantly longer than the historical patients, both for those who underwent resection (48.6 weeks median survival vs. 35.1 weeks), and for those who did not (35.1 weeks vs. 11.7 weeks). A retrospective survey of the historical group led to the following conclusions about this group: 1. Survival for patients who were well enough to be referred was unchanged after steroids came into general use; 2. Younger patients (under 50 years) did not have a longer survival than older patients; 3. The size of the dose of irradiation did not affect survival over the range of doses employed; 4. The size of the treatment volume employed did not affect survival over the range of treatment volumes employed.

Mechanisms by which human gliomas may escape cellular immune attack

Whereas substantial evidence indicates that the majority of glioma patients make humoral immune responses to their own tumours, the evidence that glioma patients make significant cellular immune responses is more tenuous and controversial. In order to study those properties of human gliomas that might contribute to their ability to escape cell-mediated immune attack, we have examined the ability of cultured human glioma cells to elicit allogeneic cytolytic lymphocyte responses in vitro. Five of ten glioma lines were unable to elicit allogeneic cytolytic lymphocyte responses in mixed lymphocyte-tumour cultures, despite the presence of serologically detectable alloantigens on the surface of the glioma cells. Analysis of the reasons why certain glioma lines failed to stimulate cytolytic lymphocyte responses revealed three distinct mechanisms by which human gliomas may escape cellular immune attack: 1. a defect in immunogenicity which can be overcome by "help" from an allogeneic mixed lymphocyte reaction, 2. the secretion of a protective mucopolysaccharide coat, and 3. the production of macromolecular immunosuppressive substance(s). The implications of these findings for the immunotherapy of human gliomas are discussed.

Complications after combination of chemotherapy and radiation for malignant brain tumours

The combination of chemotherapy and irradiation for the treatment of malignant intracerebral tumours is increasing, and survival times longer than those after monotherapy are reported. The suitability of simultaneous radio-chemotherapy using BCNU-Bleomycin, a regimen in which has been followed 38 patients of this hospital (up to 31 December 1981) is critically discussed. Statistics of 30 patients with treatment ended by 31 December 1980 and case histories of two patients with fatal complications, aspergillosis in the one and necrotizing colitis in the other, are presented. The value of the various agents used for chemotherapy is discussed with respect to the survival rates and observed side effects in all the patients. The use of Bleomycin is questioned.

A potpourri of RCT topics

(1. Randomization of the first patient. At least six examples are known to the author, and there are undoubtedly others. (2. Factorially structured treatments. The advantages of conducting two trials in the same patients when there is no suggestion of interaction, and documenting interaction if it exists must be weighed against the potential loss of power and the inconvenience of missing values. (3. RCT control groups as a source of unnatural history. Such a small percentage of apparently suitable patients are actually randomized in most clinical trials that be control group can never the considered representative of that disease seen by practicing physicians. (4. Bias in random and nonrandom treatment assignments. Differences in risk factors documented before randomization can be as much responsible for differences in outcome as the treatments under study. (5. Time lags between innovation, RCTs, and practice. These have varied from a very few years (coronary bypass operations) to 154 years (treatment of scurvy).

Radiation and nitroimidazoles in supratentorial high grade gliomas: a second clinical trial

As a continuation of a previous controlled trial using "high-dose" metronidazole as a specific sensitizer of hypoxic cells, we used a more efficient nitroimidazole derivative (misonidazole, MISO) in combination with higher doses of radiation in patients with supratentorial high-grade astrocytomas. Sixty-six patients were stratified according to functional level and histological grading, and randomly allocated within 2 weeks of operation of 1 of 3 therapeutic groups: 1, conventional radiation alone; 2, large fractions of radiation with high-dose metronidazole; and 3, radiation as in Group 2 but with equitoxic doses of MISO. We examined survival as the principal end-point of the study. Neither by increasing the dose of radiation over the previous study, nor by using a more efficient sensitizer, were we able to improve survival over the current conventional daily fractionated radiation.

Experimental allergic encephalomyelitis in Lewis rats bearing avian sarcoma virus-induced brain tumors

Lewis rats bearing avian sarcoma virus (ASV)-induced brain tumors were injected with guinea pig spinal cord emulsion and complete Freund's Adjuvant to determine if they remained susceptible to induction of experimental allergic encephalomyelitis (EAE). The incidence of EAE among rats with small, and moderate sized gliomas was similar to non-tumor-bearing controls (P less than 0.5; P less than 0.9) while 18 of 24 (75%) animals with large gliomas developed EAE as compared to 31 of 33 (93%) controls (P less than 0.05). The histologic features and geographical distribution of "ordinary' EAE were seen in controls and were maintained in tumor-bearing rats. The presence of an intracranial tumor did not significantly alter the ability of Lewis rats to develop EAE.

Age-related chemosensitivity of stem cells from human malignant brain tumours

After radiation therapy and chemotherapy for malignant glioma, patients aged 50 or under survive longer than patients over 50. Data from Brain Tumor Study Group trials show that, without treatment, these age groups have similar survival; therefore unperturbed tumour growth does not account for the difference. Sixteen consecutive patients with malignant glioma were studied, half of whom were less than or equal to 50 years of age; none had been treated before initial surgery, and all were subsequently treated with radiation and chemotherapeutic agents (in all but two patients, with nitrosoureas). Median survival of those aged greater than 50 was less than or equal to 50 years was 54 + weeks whereas that of those aged greater than 50 was 37 weeks. The longer survival for younger patients could not be attributed to tumour type, size, or location, pretreatment Karnofsky status, or mode of treatment. In-vitro sensitivity testing of clonogenic cells obtained from biopsy specimens showed that tumour cells from seven of eight patients aged less than or equal to 50 years were sensitive to 1,3-bis (2-chloroethyl)-1-nitrosourea (greater than 40% cell kill at clinically achievable concentrations) compared with only one patient with sensitive cells out of eight older patients. Patient age was inversely correlated with in-vitro cell kill, and patients with sensitive cells were significantly younger than those with resistant cells. Therefore influence of age on survival after treatment of malignant gliomas is probably due to inherent differences in the sensitivity of clonogenic cells to radiation and/or chemotherapeutic agents.

Glioblastoma multiforme: treatment by large dose fraction irradiation and metronidazole

In an attempt to overcome the possible radioresistance of glioblastoma multiforme related to the large shoulder on the in vitro survival curves and to sensitize hypoxic tumor cells, a treatment protocol was instituted at Yale University Medical Center and affiliated hospitals, using large dose fraction irradiation therapy in conjunction with the hypoxic cell sensitizer metronidazole. Nineteen patients with biopsy-confirmed, previously untreated, cerebral grade IV glioblastoma multiforme were, following surgery, irradiated once a week at 600 rad per fraction, 3.5 to 4 hours after ingestion of metronidazole, 6 gm/m2. A total of 7 treatments were employed, with all patients maintained on antiseizure medications and corticosteroids. Metronidazole levels were determined prior to each treatment and patients were followed closely clinically and with serial computerized tomography (CT) scans. The treatment was well tolerated, in general, with no untoward side effects related to the high dose fraction irradiation. The majority of the patients experienced varying degrees of gastrointestinal upset lasting up to several hours following metronidazole administration. Three patients died of pulmonary emboli. One patient experienced moderately severe ototoxicity. A median survival of 9.4 months was obtained for all 19 patients, suggestive of a prolongation of survival compared to historical controls treated with conventionally fractionated radiation or with unconventional radiation fractionation schemes and metronidazole or misonidazole.

Immunological monitoring of patients affected by anaplastic glioma concerning in effects of surgery, radio-, and chemotherapy. A preliminary report

The authors studied 24 patients affected by anaplastic gliomas, as regards immunology. In all of them the authors evaluated the lymphocyte subpopulation (B and T), firstly by simple lymphocyte count, secondly by studying the rosettes E-total and EAC, thirdly by stimulating the lymphocytes with mitogens phyto-haemoagglutinin-P (PHA), concanavalin A (Con A), and pokeweed mitogen (PWM), and lastly by counting the release of Cr51 in Chang liver cells culture in order to obtain antibody dependent cellular cytotoxicity (ADCC). The parameters were also evaluated after surgery and during conventional radio-chemotherapy with BCNU. Whereas the so-called B-pool seems to be unaffected, the preliminary results show that the T-pool (identified by the E-t rosettes and by responses to PHA, PWM, and ConA) is depressed to a statistically significant degree, if compared with a control group. This depression seems to be related to the tumoral mass, and it is not increased by radio-chemotherapy. In addition, ADCC also seems to be depressed in our glioma patients in comparison with a control group and witha group of bladder cancer patients.

Reoperation for glioblastoma

The results of a second operation for tumor removal in 24 adult patients with supratentorial glioblastoma multiforme or anaplastic astrocytoma were analyzed. The median survival time after reoperation was 14 weeks. Five of the 24 patients lived 6 months or longer after reoperation. Only three of these patients maintained a Karnofsky rating (KR) of at least 60 for 6 months or longer after reoperation. Preoperative neurological status (KR) is the most significant determinant of survival after reoperation (p = 0.02). When the KR is at least 60, median survival after reoperation is 22 weeks. When the KR prior to reoperation is less than 60, median survival is 9 weeks. Only one of 13 patients with a KR of less than 60 prior to reoperation survived longer than 6 months after the second operation. The interval between first and second operation is significantly related to survival (p = 0.03), but when adjustment is made for the KR the interoperative interval is no longer significantly related to survival after the second operation (p = 0.39). Age, sex, and location of tumor were not significantly related to duration of survival. This study suggests that reoperation is most likely to produce the best result when the KR is at least 60 and the interval between operations is longer than 6 months. Using these criteria, one-third of the patients could be expected to survive with a KR of at least 60 for 6 months. The study indicates that reoperation should not be carried out when the KR is less than 60.

Potentials and possible pitfalls of human stem cell analysis

A clonogenic cell assay for malignant brain tumors that permits the evaluation of tumor cell sensitivity to BCNU and that correlates with patient response to BCNU has been developed. The potential for a stem cell analysis of human tumors has been demonstrated by studies of the reasons for clinical drug failure, tumor heterogeneity, and age-response relationships. The basic requirements of a stem cell assay include the ability to dissociate representative single cells from solid tumors, to optimize culture conditions, and to characterize the growth of colonies. Exposure of cells to a drug in vitro must be comparable to the in situ situation; possible significant differences between short-term and "continuous" treatment methods are emphasized. Also discussed are criteria for in vitro sensitivity of cells, problems inherent in the "early" evaluation of cultures (at the cell "cluster" stage), and the effects of system errors, which if overcome should lead to the development of analytic methods with a maximum sensitivity and predictive value.

Efficacy of continuous treatment with radiation in a rat brain-tumor model

Rats bearing intracerebral 9L/Ro tumors were treated with 10 daily fractions of cesium-137 gamma-rays, BCNU, or combinations of these to agents beginning on either Day 10 or Day 12 after implantation. The treatments were administered either 5 days/week for 2 weeks, with the weekend off, or 10 consecutive days. The median day of death for untreated tumor-bearing rats was Day 15, so Day 12 tumors can be considered late tumors and Day 10 tumors can be considered moderately early. Although all single- and multiple-agent treatments significantly (p less than 0.05) increased the lifespan of tumor-bearing rats over that of the untreated controls, and all multiple-agent schedules significantly (p less than 0.05) increased the lifespan over that of the single-agent therapies, none of the 10 consecutive day schedules increased the lifespan of tumor-bearing rats significantly (p less than 0.2) over that obtained with the 5-day/week schedules. Thus, the evidence from this tumor model suggests that no significant improvement in lifespan would be expected if malignant brain tumors were treated with radiation 7 days a week, either alone or in combination with chemotherapeutic agents such as BCNU.

Induction of lethal experimental allergic encephalomyelitis in nonhuman primates and guinea pigs with human glioblastoma multiforme tissue

✓ The introduction of active specific immunotherapy as an adjunct to conventional therapy of the brain-tumor patient creates the risk of the concomitant induction of experimental allergic encephalomyelitis (EAE). The lack of resolution concerning the total group of central nervous system (CNS) antigens which may be encephalitogenic, and the lack of definition of the necessary conditions for the induction of an anti-CNS myelin response complicate the design of an immunotherapeutic regimen for brain-tumor patients. We report here the ready induction of EAE in four of four guinea pigs and both of two nonhuman primates (Macaca fascicularis) with human glioblastoma multiforme (GBM) tissue injected with either complete or incomplete Freund's adjuvant (CFA, IFA). Immunization protocols utilizing encephalitogenic GBM tissue and adjuvant which did not result in EAE induction were established in both of two macaques, and the production of significant levels of antibodies specifically reactive with immunizing GBM-derived cultured cell lines in all of 12 macaques without EAE induction was demonstrated. As the lower detection limit of the sodium dodecyl sulfate-polyacrylimide gel electrophoresis (SDS-PAGE) assay for human myelin basic protein (HBP) was 0.6 µg HBP/gel, and an extract prepared from WR-GBM tumor tissue contained less than 0.6 µg of detectable HBP/25 µg of pH 3 extractable protein, and as 100 to 1000 µg of purified human basic protein (HBP) failed to induce EAE in three of three macaques, it was hypothesized that 1) GBM tissue may act as an adjuvant and markedly lower myelin basic protein (MBP) threshold doses for EAE induction, that 2) MBP encephalitogenic fragments capable of EAE induction may be present in GBM tissue but difficult to quantitate in precipitates by in vitro methods, or that 3) secondary encephalitogenic antigens unrelated to MBP may be present in GBM tissue. The threat of EAE induction and the potential difficulty of its detection in the deteriorating brain-tumor patient receiving active specific immunotherapy warrants a biological screen in immunizing CNS material in experimental animals prior to administration to patients in immunotherapy protocols.

Pharmacokinetics of a new water-soluble nitrosourea derivative (ACNU) in human gliomas

The pharmacokinetics of a newly developed water-soluble nitrosourea derivative (ACNU) following a single intravenous injection was investigated in 11 patients with gliomas. A major portion of ACNU was excreted within 2 hours. The distribution rate was very fast, and the elimination rate tended to be slow. More than 50% of ACNU moves into the tissue compartment. ACNU tended to move into glioma tissue well. The ACNU level in glioma tissue was above 1.0 microgram/gm 30 to 60 minutes ater injections. ACNU was detected at a higher concentration in malignant gliomas than in benign gliomas. These results suggest that ACNU is taken up by tumor tissue relatively rapidly and eliminated slowly, which leads to effective manifestation of its antitumor activity.

Chemotherapy of pediatric brain-stem tumors

Forty-five children harboring brain-stem tumors were treated at the University of California, San Francisco, between 1969 and 1979. Pathological diagnoses were made in 19 patients. All patients received radiation therapy (RT). Thirteen patients received chemotherapy before, during, or immediately after RT. Twenty-four patients were treated with chemotherapy at the time of tumor progression, after initial treatment with RT alone. No statistically significant difference in time to tumor progression or survival was found for treatment with chemotherapy as an adjuvant to RT compared to treatment with RT alone followed by chemotherapy administered at the time of tumor progression. There were, however, more long-term survivors in the group that was first treated with chemotherapy at the time of tumor progression. There was no statistically significant correlation between survival and tumor pathology or location, although there were more long-term survivors among patients harboring low-grade gliomas and among patients with tumors confined to the midbrain. The authors documented the response of some brain-stem tumors to chemotherapy; however, cooperative controlled studies will be required to determine the optimum treatment for this disease.

High-dose BCNU with autologous bone marrow rescue for recurrent glioblastoma multiforme

Eleven patients with recurrent malignant glioma were treated with single high doses of BCNU ranging from 600 to 1400 mg/sq m. To prevent the characteristic late myelosuppression observed after conventional doses of BCNU, autologous bone marrow harvested just before drug treatment was infused 24 to 36 hours after therapy. Higher doses of BCNU causes earlier and more profound myelosuppression; one patient died on pancytopenia, breakdown of the gut epithelium, and Clostridium septicemia 10 days after receiving 1400 mg/sq m of BCNU. All patients experienced transient emesis; four developed transient elevation of hepatic enzymes, two reversible interstitial pulmonary infiltrates, and two who received 1400 mg/sq m BCNU suffered irreversible cortical damage. Eight patients receiving 600 to 1200 mg/sq m demonstrated reconstitution of polymorphonuclear leukocytes an platelets within at least 30 days after treatment. With a follow-up time of up to 19 months, four patients improved, three stabilized, and three deteriorated and died. The median survival time was 7 months. Computerized tomography performed on patients receiving constant corticosteroids showed diminished contrast enhancement and mass effect in eight patients. High-dose BCNU at doses up to 1200 mg/sq m with marrow rescue is a feasible approach to the treatment of patients with glioblastoma.

Combined cyclotron fast-neutron and BCNU therapy in a rat brain-tumor model

The combination of cyclotron fast-neutron radiotherapy with BCNU chemotherapy was compared to 137Cs gamma photon radiotherapy combined with BCNU in the 36B-10, F-344 rat-transplanted glioma model. Radiation and drug treatments were administered 7 to 8 days after intracerebral tumor implantation. Increase in animal survival time was used as the measure of the effectiveness of various treatment schedules. Single-dose neutron or gamma radiotherapy was tested on Day 7 over the ranges 0 to 900 rads and 0 to 2000 rads, respectively. This therapy produced increases in mean survival times up to 70% at the highest radiation doses. When BCNU (10 mg/kg body weight) was administered intravenously on Day 8, 1 day following radiotherapy, mean survival times were increased by an additional 35% to 50%, irrespective of the dose or type of irradiation. In contrast, by using the same radiation and drug doses but scheduling combined therapy trials so that BCNU was administered 1 hour before either neutron or gamma irradiation on Day 7, there was enhancement of the radiation effect by BCNU. Under these conditions, the maximum enhancement of the mean survival time was 70% to 75% in neutron-treated animals and 120% to 150% in gamma-treated animals. Treatment with BCNU 1 hour before or 1 day after neutron irradiation proved to be no more effective in proving the survival time of tumor-bearing animals than the drug similarly combined with conventional gamma irradiation.

Combined modality therapy of operated astrocytomas grade III and IV. Confirmation of the value of postoperative irradiation and lack of potentiation of bleomycin on survival time: a prospective multicenter trial of the Scandinavian Glioblastoma Study Group

In a controlled, prospective, randomized investigation, started in 1974, 118 patients with supratentorial astrocytoma Grade III--IV were divided into three groups. Groups 1 and 2 received 45 Gy postoperatively to the whole supratentorial brain. Bleomycin in 15-mg doses and a total dose of 180 mg or placebo was given intravenously three times a week, one hour prior to radiotherapy, during weeks 1, 2, 4 and 5. Group 3 received conventional care but no radiotherapy or chemotherapy. Median survival rates of patients were 10.8 months in Groups 1 and 2, and 5.2 months in Groups 3, a statistically significant difference. With regard to performance, the patients in Group 3 deteriorated faster than patients in Groups 1 and 2. Bleomycin had no positive or negative influence on survival.

Immunobiology of primary intracranial tumors. Part 4: levamisole as an immune stimulant in patients and in the ASV glioma model

Levamisole was evaluated as an immune stimulant in a randomized controlled study of patients with anaplastic gliomas, who had undergone surgical resection and who were also treated with radiotherapy and BCNU chemotherapy. Of 102 patients placed into the study, 85 were determined to comprise the adequately treated group (ATG): a full course of radiotherapy and two cycles of BCNU chemotherapy. Within the ATG, those patients who received levamisole did not demonstrate significantly different serial delayed hypersensitivity reactions, peripheral blood lymphocyte and T-cell counts, or serum IgM levels, compared to those patients not receiving levamisole. There was no significant difference in survival times of the two groups. Studies utilizing the avian sarcoma virus-induced glioma in rats also showed no improvement in survival with levamisole stimulation as the only immune agent, but the combination of active immunization and adjuvant stimulation with bacillus Calmette-Guerin plus levamisole was found to be therapeutically effective in this model and will be used in future pilot studies of active immunization in patients.

Response of cultured human brain tumors to nitrosoureas: correlation with clinical data

An in vitro microcytotoxicity assay was utilized to determine the sensitivity of 58 cultured human malignant gliomas to the chemotherapy agent 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). Of 58 such tumors, 42 (72%) showed a statistically significant cytotoxic response to BCNU in this assay. For those responding tumor lines, the cytotoxic index ranged from 0.25 to 0.76, with most clustered at the 0.40 level. To determine the therapeutic predictive relevance of such microcytotoxicity testing, the clinical course of patients receiving postoperative radiation therapy plus two or more doses of nitrosourea chemotherapy, as well as two or more computerized tomographic scans, was evaluated. In the 14 patients meeting all these criteria, tumor size increased in all five patients whose tumors did not respond to BCNU in the microcytotoxicity test. Six of the nine patients whose tumors in culture showed significant sensitivity to BCNU in vitro showed a clear decrease in tumor size over periods ranging from 17 to 48 months. Tumors in two patients increased in size, and one remained unchanged over the interval studied. These data support the concept that in vitro microcytotoxicity testing can be predictive of clinical response. Further study of this correlation seems warranted.

Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery

Within three weeks of definitive surgical intervention, 467 patients with histologically proved malignant glioma were randomized to receive one of four treatment regimens: semustine (MeCCNU), radiotherapy, carmustine (BCNU) plus radiotherapy, or semustine plus radiotherapy. We analyzed the data for the total randomized population and for the 358 patients in whom the initial protocol specifications were met (the valid study group). Observed toxicity included acceptable skin reactions secondary to radiotherapy and reversible leukopenia and thrombocytopenia due to chemotherapy. Radiotherapy used alone or in combination with a nitrosourea significantly improved survival in comparison with semustine alone. The group receiving carmustine plus radiotherapy had the best survival, but the difference in survival between the groups receiving carmustine plus radiotherapy and semustine plus radiotherapy was not statistically significant. The combination of carmustine plus radiotherapy produced a modest benefit in long-term (18-month) survival as compared with radiotherapy alone, although the difference between survival curves was not significiant at the 0.05 level. This study suggests that it is best to use radiotherapy in the post-surgical treatment of malignant glioma and to continue the search for an effective chemotherapeutic regimen to use in addition to radiotherapy.

Pathology of human malignant gliomas after radiation and chemotherapy

The pathological effects of radio- and chemotherapy have been studied in 31 malignant gliomas. The brains have been examined by means of the complete study technique. Many histological features have been related to surgery, localization, preoperative duration, postoperative survival, irradiation, and chemotherapy. No specific alterations have been found, but some positive correlations have been established: decrease of mitoses, occurrence of macrophages and vessel degeneration after radiation, increase of monstrous cells after chemotherapy.

CCNU chemotherapy in adult patients with tumors of the basal ganglia and brain stem

The present investigation evaluates those few patients of our series with basal ganglia and brain-stem tumor who refused either surgical decompression and biopsy or radiation therapy. Four patients were suffering from tumors of the basal ganglia and three from brain-stem tumors; all the tumors were diagnosed by classical neuroradiological investigations and computerized tomography. The patients were given CCNU by mouth, 13 mg/sq m every 6 weeks. No toxicity was recorded. Mean survival was 19 weeks for patients with basal ganglia tumors and 48 weeks for those with brain-stem tumors. All patients were evaluated with respect to the quality of survival. Results were compared with those obtained in a control group of patients who received methylprednisolone therapy only.

Histologic factors of prognostic significance in the glioblastoma multiforme

The pretreatment biopsy specimens from 184 cases of malignant gliomas from The National Brain Tumor Study Group were reviewed in order to determine which, if any, of nine histologic factors were useful in subdividing the glioblastoma multiforme. In the smaller group of cases treated with surgery and supportive care only, there was a strong negative correlation between cellularity and survival. For those cases treated with surgery and radiation only, and for the study as a whole, there was a positive relationship between survival and the presence of a giant cell neoplasm. We have concluded, on the basis of this limited sample of this select group of patients, that this latter features offers a potential basis of subclassification of the glioblastoma multiforme.

Treatment of autochthonous rat brain tumors with fractionated radiotherapy. The effects of graded radiation doses and of combined therapy with BCNU or steroids

The avian sarcoma virus-induced glioma model in rats was used to evaluate radiation dose response (survival curves), giving fractionated treatments to the whole head. Groups of 14 to 20 rats received total doses of 2300, 4600, or 5750 rads over 2, 4, or 5 weeks, respectively. Median group survival times were compared to controls and to each other. All doses of radiation significantly prolonged survival with reference to control. The 4600- and 5750-rad doses were significantly more effective than the 2300-rad dose. In another series of experiments, BCNU chemotherapy (10 mg/kg) was combined with 2300 and 4600 rads radiation therapy. Synergism of therapies was demonstrated. Methylprednisolone acetate (2 mg/kg twice weekly over 4 weeks) alone did not affect survival curves, and its combination with 4600 rads radiation therapy negated the prolongation of survival achieved with 4600 rads alone.

Glioblastoma multiforme

Glioblastoma multiforme is the most common primary brain tumor of adults, as well as the most malignant. Its etiology is unknown, but the tumor is thought to arise through dedifferentiation of adult astrocytes. It occurs most frequently between the ages of 40 and 60, in men more often than in women (1.5:1). Important early symptoms include subtle personality change, headache, weakness, and intellectual impairment; specific complaints and physical findings depend on the location of the lesion. The initial diagnostic test should be a CT-scan; it will detect more than 90% of malignant astrocytomas. Surgery remains the cornerstone of treatment; patients receiving radical debulking have a median survival of 8 months compared to the 3 month survival of unoperated cases. Modern neurosurgical technique, neuroanesthesia, mannitol, and corticosteroids have reduced the surgical mortality to 3%. Most patients also receive 4500 rads of whole-brain irradiation and 1800 rads to the operative site; radiotherapy increases the median survival of operated patients by 2 to 3 months. An additional small increment in survival time and some improvement in quality of survival can be achieved by nitrosourea chemotherapy; the latter is usually given as 100 mg/m2/day x 3 days of BCNU every eight to ten weeks. Experimental treatments under study include the use of radiosensitizers, the role of immunotherapy and the application of microwave-induced hyperthermia. Two-year survival remains 10% to 20%, and there are virtually no five-year survivors. An optimal combined modality treatment plan, one in which each cellular compartment of this truly multiforme tumor is effectively addressed, remains to be designated.