Malignant gliomas treated after surgery by combination chemotherapy and delayed irradiation. Part I: Analysis of results

A phase II study of preradiation chemotherapy followed by external beam radiotherapy for the treatment of patients with newly diagnosed glioblastoma multiforme: an Eastern Cooperative Oncology Group study (E2393)

Recent publications support the use of preradiation chemotherapy in the treatment of selected primary brain tumors. In the pediatric population, this treatment strategy often delays radiotherapy and may improve the outcome in patients. This manuscript describes the use of a preradiation chemotherapy approach for adult patients with newly diagnosed glioblastoma multiforme. The main objective of this trial was to determine the feasibility of delivering up to 3 monthly cycles of a 72 h continuous simultaneous intravenous infusion of BCNU (40 mg/m2/day) and cisplatin (40 mg/m2/day). Patients were evaluated for tumor response or progression after each cycle. Following the completion of the chemotherapy treatments or evidence of tumor progression, patients underwent external beam radiotherapy. A dose of 45 Gy was delivered to the pretreatment tumor volume plus surrounding edema and a margin of 3.0 cm. An additional 14.4 Gy was delivered to the preoperative volume plus a 2 cm margin. Fifty patients were enrolled, 47 were eligible and analyzable. Overall, 79% of patients were able to complete at least 2 cycles of treatment, exceeding the predefined measure of feasibility. One patient achieved a complete response, 10 patients a partial response and 18 patients had stable disease at completion of the chemotherapy treatments. Twenty-four patients experienced grade 4 toxicity, mostly hematologic. All patients were able to undergo radiotherapy following chemotherapy. These results indicate that a preradiation strategy is feasible. Although responses to the chemotherapy were seen, a phase III trial is needed to determine whether this approach provides an advantage over standard treatment; such a phase III trial has been undertaken by ECOG.

The role of chemotherapy in the treatment of gliomas in adults

Glioblastomas and previously irradiated recurrent gliomas remain incurable. Chemotherapy is able to palliate patients by shrinking tumors, thereby improving neurological status and quality of life. Chemotherapy may also be capable of prolonging survival in some instances. The effectiveness of chemotherapy against gliomas is comparable to the efficacy of chemotherapy against many other solid tumors. When given in an adjuvant setting along with radiation postoperatively, studies suggest that the nitrosoureas, dibromodulcitol, dianhydrogalactitol, procarbazine, teniposide, dacarbazine, and cisplatin may possibly be useful, although results for many of these drugs are inconclusive. Some chemotherapy combinations also appear to be useful in an adjuvant setting, particularly BCNU plus ifosfamide, BCNU plus cisplatin, CCNU plus dibromodulcitol, and CCNU plus lonidamine. However, there is not yet conclusive evidence that combination chemotherapy is superior to single agent adjuvant chemotherapy in the treatment of gliomas. While the use of chemotherapy prior to postoperative cranial radiation is worthy of further study, it has not to date proven to be more effective than chemotherapy combined with radiation. In patients whose tumors have recurred following radiation, palliation may be achieved with the nitrosoureas, procarbazine, teniposide, and diaziquone. Cisplatin, high dose methotrexate, the interferons, and a variety of other medications also may be of use. As in the case of adjuvant chemotherapy, chemotherapy combinations for recurrent tumor have not been conclusively demonstrated to be superior to single agent treatment, although some CCNU-based combinations are of interest. Many different chemotherapy drugs have been administered by intracarotid infusion. There is a moderately high risk of serious local retinal and neurological toxicity using this approach, and efficacy has not been proven to be improved by this approach. However, further studies of intraarterial administration of chemotherapy are warranted in light of theoretical considerations, pharmacological observations of enhanced local drug concentrations, and the observation that patients who have failed the same drugs intravenously may respond when lower doses of the drug are administered intraarterially. In addition, some patients have had tumor shrinkage in the area infused while tumor has grown in other areas. Thus, while intracarotid chemotherapy must be regarded as still investigational and potentially quite toxic, further studies are indicated. High dose chemotherapy has been administered in combination with autologous bone marrow rescue. High response rates and prolonged survival durations have been reported in some instances, justifying further study despite substantial toxicity.(ABSTRACT TRUNCATED AT 400 WORDS)

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.

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.

Cerebral space-occupying cysts following radiation and chemotherapy of malignant gliomas

Eight cases of cerebral cyst formation among 50 patients (= 16%) with malignant supratentorial gliomas treated by surgery, megavoltage radiation, and multiple-agent chemotherapy are reported. Five of them developed signs of intracranial hypertension or progressive neurological deficit, while in three patients cerebral cysts were detected by CT without clinical deterioration. At operation or autopsy, or both, the large fluid-filled, smooth-walled cysts were lined by glio-mesenchymal scar tissue with no or little tumour recurrence in five, while three patients showed large recurrent tumour masses associated with necrosis and cyst formation. Clinical signs or CT evidence, or both, of cerebral cysts developed 4 to 12 months (average 10 months) after the first craniotomy, and 3 to 9 months after termination of radiotherapy, usually after the second to fourth course of polychemotherapy. The cystic cavities which are attributed to increased necrosis and other effects of radiation and cytostatic treatment, may mimic tumour progression or recurrence, and cerebral abscess, but are usually recognized by CT. Surgical treatment produced transient clinical improvement in 5 patients, but usually did not prevent the fatal outcome of the disease, which in these paticrosis and other effects of radiation and cytostatic treatment, may mimic tumour progression or recurrence, and cerebral abscess, but are usually recognized by CT. Surgical treatment produced transient clinical improvement in 5 patients, but usually did not prevent the fatal outcome of the disease, which in these paticrosis and other effects of radiation and cytostatic treatment, may mimic tumour progression or recurrence, and cerebral abscess, but are usually recognized by CT. Surgical treatment produced transient clinical improvement in 5 patients, but usually did not prevent the fatal outcome of the disease, which in these patients occurred 3 weeks to 6 months after surgical treatment of cyst formation, their life span ranging from 9 to 22 months. The pathogenesis and clinical problems related to cerebral cysts arising following multimodality treatment of malignant brain tumours are discussed.

Malignant gliomas treated after surgery by combination chemotherapy and delayed radiation therapy. Part II. Tolerance to irradiation after chemotherapy

34 patients operated on for malignant gliomas were successively treated by combination chemotherapy with VM26 and CCNU and conventional radiation therapy with an average dosage of 5,800 Rads, six months after surgery. The general and haematological tolerance of delayed irradiation after chemotherapy was satisfactory. Twelve patients developed neurological complications during or after irradiation. The complications were early in 10 cases, and delayed in 2. They were probably due to tumour growth in five cases, and secondary to irradiation in seven. In four of the seven cases the preradiation chemotherapy seemed to potentiate the radiation effect on the central nervous system.