Use of high dose corticosteroids in patients with inoperable brain tumours

Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic syndrome

Neurologic symptoms commonly occur in oncology patients, and in some cases they may be the presenting symptom of malignancy. Cancer-related neurologic syndromes are rarely pathognomonic and must be differentiated from other benign or serious conditions. This article reviews common neuro-oncologic syndromes that may lead to urgent evaluation in the emergency department, including cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic neurologic syndromes.

Supportive Care of Brain Tumor Patients

The supportive care of patients who have brain tumors consists mainly of the treatment of brain edema, seizures, venous thromboembolism, and cognitive dysfunction. Each of these complications may occur in patients who have primary or metastatic brain tumors. The development of any of these complications significantly increases the morbidity and mortality associated with brain tumors. Effective treatment is usually possible, however, and can result in an improved quality of life for these patients.

Treating gliomas with glucocorticoids: from bedside to bench

Glucocorticoids are used in the treatment of gliomas to decrease tumour-associated oedema and to reduce the risk of acute encephalopathy associated with radiotherapy. However, the mechanisms by which glucocorticoids work are still largely unknown. In this paper, we survey the experimental and clinical evidence for the effects of glucocorticoids on tumour cell proliferation, apoptosis and sensitivity to chemotherapy, angiogenesis and vascular permeability. We then review current guidelines on the choice of molecule, dose and duration of glucocorticoid treatment for gliomas.

Medical decompressive therapy for primary and metastatic intracranial tumours

Medical decompressive therapy (MDT) with corticosteroids and mannitol is often used in patients with primary or metastatic brain tumours. This review highlights the lack of sound evidence regarding the indications and dosage schedule of steroids, prolonged use of which may cause debilitating complications. The available evidence supports the short-term use of MDT for raised intracranial pressure or progressive neurological deficits, but in the absence of these symptoms, MDT is not recommended for stable focal deficits, abnormal higher mental functions, seizures, or as prophylaxis during cranial irradiation. A practical stepladder guideline (based on symptom severity) is proposed with a starting daily dexamethasone dose of 6 mg for non-severe headache and or vomiting; 12 mg for progressive focal neurological deficit with or without non-severe headache or vomiting; and 24 mg dexamethasone with mannitol for severe headache, vomiting, or altered consciousness. Depending on the clinical response, dose can be increased to the next step(s) or tapered every 48 h (more slowly in patients who are dependent on steroids). A scheme for the assessment of efficacy and toxicity prevention is also proposed. The proposed guidelines may be used as a template for further clinical research.

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.

Glucocorticoid dependency as a prognostic factor in radiotherapy for cerebral gliomas

Records of 76 consecutive patients treated with radiotherapy for cerebral gliomas were reviewed. Eleven patients had no tissue diagnosis, and their outcome was comparable to that of patients with glioblastoma. Patients with other histologic diagnoses had much better results. Among the entire study population, the most important prognostic factors included age and histologic grade. Even with stratification by histologic grade and age, glucocorticoid (steroid) dependency was a reliable prognostic indicator in terms of survival. Fifteen of the 47 patients (32%) who were less steroid dependant are still alive with a median survival time of 29 months. Among the 29 patients who were heavily dependant on steroids during the course of radiotherapy, the median survival time was 5 months with only 2 patients (7%) still alive.

Effect of methylprednisolone on radiotherapy of F344 rats with avian sarcoma virus induced gliomas

We have examined the impact of methylprednisolone acetate (MPA) on survival of F344 rats that were bearing avian sarcoma virus (ASV)-induced gliomas and that were treated optimally with radiotherapy. Toxicity of MPA (dose range of 0.2-5.0 mg/kg X 7 over 3 weeks) was first established in non-tumor bearing rats as assessed by their relative failure to gain weight. Doses of 2.0 or 5.0 mg/kg X 7 caused animals to be 21.8 or 43.9%, respectively, underweight compared with vehicle controls. In rats bearing ASV-induced gliomas, treatment with 3,000 cGY (nine fractions over a 3-week period) alone or with 0.2 or 1.0 mg MPA/kg (X 6 during the 3-week radiotherapy course) produced a significantly prolonged survival compared with that of untreated, tumor bearing rats. However, MPA did not enhance survival when given concurrently with radiotherapy; indeed, at the higher of these two doses, median survival of tumor-bearers was slightly less than with radiotherapy alone. This trend towards interference with the beneficial effects of radiotherapy was more pronounced with the highest dose of MPA studied, 5.0 mg/kg body weight X 6. These animals had a median survival time that was significantly less than that of tumor-bearers receiving radiotherapy alone, but not significantly different from untreated rats with gliomas. The possible significance of these observations is discussed.

Effect of high-dose corticosteroid therapy on blood flow, evoked potentials, and extracellular calcium in experimental spinal injury

High-dose methylprednisolone (15 to 30 mg/kg), administered 45 minutes after severe contusion injury (400 gm-cm) to cat spinal cords, rapidly reverses the typical posttraumatic ischemia that occurs in spinal injuries. White matter blood flow improves despite the systemic hypotension associated with bolus intravenous injections of such massive corticosteroid doses. In addition, this treatment facilitates extracellular calcium ionic recovery in contused spinal cords, and salvages evoked potential activity that is lost in untreated cats. These data suggest that high-dose corticosteroid treatment causes local vasodilation of spinal cord blood vessels. The consequent blood flow increase may account for the beneficial effects of high-dose corticosteroid treatment on both functional recovery and histopathological appearance of injured spinal cords.

Effect of methylprednisolone in compression trauma to the feline spinal cord

The purpose of this study was to determine the effect of methylprednisolone sodium succinate on clincal recovery and tissue preservation following compression trauma of feline spinal cord. Cats were anesthetized with pentobarbital and injured by placing a 170-gm weight on the spinal cord for 5 minutes. One hour after injury, the animals were given intravenous steroid (15 mg/kg/day) for 2 days in three devided doses, 15 mg/kg/day for 1 day intramuscularly, 7.5 mg/kg/day intramuscularly for 3 days, and 3.75 mg/kg/day intramuscularly for 3 days, for a total of 9 days. In a control group, the animals were injured but untreated. At 60 days after injury, the animals were sacrifieced by perfusion fixation with 10% formalin. The spinal cord was removed and evaluated for a number of morphometric parameters, including percentage of spinal cord cross-sectional area containing the cavity (%area) and percentage of spinal cord volume occupied by the cavity (%volume). A clinical recovery score (recovery index) was devised to evaluate neurological recovery. Steroid-treated cats showed significantly greater recovery than the untreated controls (p less than 0.001). Moreover, the spinal cord of treated cats displayed greater tissue preservation as measured by %area (p leass than 0.005) and %volume (p less than 0.004). Correlation coefficients comparing the recovery index with morphometric parameters revealed a negative correlation between cavity size and recovery. These data provide evidence for a beneficial effect of methylprednisolone in promoting recovery and preserving spinal cord tissue following blunt injury to the feline spinal cord.

In vitro sensitivity of human ovarian tumours to chemotherapeutic agents

The in vitro chemosensitivity of primary monolayer cultures of human ovarian tumours to a wide range of chemotherapeutic agents has been determined using 3H-leucine incorporation as an index of cytotoxicity. Of 67 specimens received, 35 have been successfully cultured and tested for chemosensitivity. Drugs tested included alkylating agents, antibiotics, antimitotics, antimetabolites and progestogens. The overall incidence of efficacy of the drugs corresponded with the incidence which might be expected from data on the clinical response rates produced by the various drugs. Cultures from the tumour cells of treated patients generally showed greater resistance than tumours of untreated patients. Correlation between in vitro results and in vivo response was positive in all 8 patients receiving first-line chemotherapy and in 57% (4/7) patients receiving second-line 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.

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.

Massive doses of steroids in cryogenic cerebral injury and edema

Cryogenic lesions were produced in the brains of rhesus monkeys and the accompanying edema measured by quantitative chemical methods. No effect on this type of edema could be demonstrated in animals treated with massive doses of steroids.