Prolonged administration of temozolomide in adult patients with anaplastic glioma

PURPOSE

Prolonged administration of temozolomide is widely used in patients with glioblastoma; whereas the treatment of anaplastic glioma differs between neurooncological centres. The safety, feasibility and efficacy of prolonged temozolomide administration in patients with anaplastic gliomas was evaluated.

PATIENTS AND METHODS

Forty-two patients with primary, recurrent or secondary anaplastic glioma were retrospectively analysed for the course of their disease. Treatment mostly consisted of surgery, followed by radiotherapy with concomitant and adjuvant temozolomide. In five patients with recurrence of primary anaplastic glioma, chemotherapy was initiated without previous surgery. Temozolomide was administered until evidence of tumour recurrence, appearance of serious side-effects or patients' wish to finish chemotherapy.

RESULTS

The median overall survival (OS) was 39 months with a median cycle number of 7.5 (1-42). Treatment with temozolomide was stopped in 12 patients due to side-effects in general, whereas in only three patients (7.1%) treatment had to be discontinued due to haematological side-effects. There was no evidence of treatment related infections or grade IV toxicity. Extent of surgery had a significant influence on OS in anaplastic gliomas, the number of adjuvant temozolomide cycles showed a positive influence as well on time to progression (TTP) and OS.

CONCLUSION

Prolonged administration of adjuvant temozolomide is safe and can be favorable for patients with anaplastic gliomas.

Management of patients with low-grade gliomas - a survey among German neurosurgical departments

BACKGROUND AND AIMS OF THE STUDY

The diagnosis and treatment of low-grade gliomas (LGG) are multimodal. Today, there is no defined standard in diagnosis and treatment. Controversies are, in general, about a "wait-and-see" strategy, diagnostic workup, surgical intervention, postoperative imaging, adjuvant treatment, and follow-up. The aim of this study is to gain an overview about management strategies of high-volume German neurosurgical departments treating these patients.

MATERIAL AND METHODS

A questionnaire including diagnostic, preoperative, perioperative, and postoperative parameters and 5 cases with magnetic resonance imaging data with questions to various treatment options in these patients was sent to all 34 German neurosurgical departments at university hospitals.

RESULTS

In total, 24 questionnaires were returned and analysed. Centres were divided into those who generally practice a "wait-and-see" strategy vs. those who do not or only in highly selected cases. Statistical analyses were performed with Fisher test and Chi (2)-test. Interestingly, 50% of all centres routinely follow a "wait-and-see" strategy.

CONCLUSION

Although the management of patients with LGG is complex and a simple questionnaire will not be able to define a standard in diagnosis and treatment, this study offers an overview on strategies at high-volume academic centres dealing with these patients. There is consensus to resect superficially located lobar and circumscribed low-grade lesions. However, the differences between centres become apparent with increasing complexity of the lesions.

Response to temozolomide in supratentorial multifocal recurrence of malignant ependymoma

Intracranial anaplastic ependymomas are a very rare entity within the group of adult CNS neoplasms. Thus, no standard adjuvant therapy after surgical resection has been defined so far. External radiotherapy is commonly administered, but the role of chemotherapy is still unclear in malignant ependymomas. The case of a 25-year-old female patient with multifocal recurrence of a supratentorial malignant ependymoma administered temozolomide as second-line therapy is reported. Currently, 5 months after initiation of temozolomide treatment, there is no evidence of radiographic progression. Temozolomide could constitute a promising approach to supratentorial recurrent and multifocal anaplastic ependymoma of adults.

Efficacy of different regimens of adjuvant radiochemotherapy for glioblastoma

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Background: Purpose/Objective(s): We retrospectively analyzed the impact of different temozolomide (TEM) regimens in a group of patients treated for glioblastoma compared to patients only receiving postoperative radiotherapy. Methods: Between 01/2000 and 12/2003, 75 consecutive patients underwent radiotherapy. 52 patients received exclusively radiotherapy, 17 patients radio-chemotherapy with low-dose TEM (20 mg/m2) given in 2 daily single doses in combination with an inhibition of cyclooxygenase-2, 6 patients radio-chemotherapy with high-dose TEM (50mg/m2) followed by adjuvant TEM (150–200mg/m2) for 5 days during each 28-day cycle up to 6 cycles. Patients were monitored with MRI every 8 weeks. Aggressive treatment for recurrent disease consisted of re-operation, re-irradiation (fractionated stereotactic radiotherapy 12 x 3 Gy) and/or chemotherapy. Results: The groups treated with high-dose TEM and low dose TEM showed the longest overall survival (OS) (median OS 21 months and 17 months, respectively). Median OS of 9 months for the radiation alone group was condiserably shorter. The same positive trend on prolonged OS was confirmed when either only patients submitted to maximally radical resection or for patients with KPS>70 were considered. No statistically significant difference was observed in terms of progression free survival (PFS). Conclusions: Patients treated with adjuvant TEM either inside or outside study protocols had survival times similar to other reports or randomized studies. The absence of influence of TEM on PFS could either depend on the unavoidable drawbacks and bias of retrospective investigations or on the definition of relapse used. Aggressive and early treatment for recurrent disease results in median survival times approaching 2 years.

No significant financial relationships to disclose.

Angiogenesis in malignant glioma--a target for antitumor therapy?

The prognosis of malignant gliomas is still dismal despite aggressive treatment attempts. Thus, alternative therapy strategies are needed. Malignant gliomas are upon the best vascularized tumors in humans and their proliferation is hallmarked by a distinct proliferative vascular component. Hence it seems to be a logical consequence to apply anti-angiogenic treatment strategies to malignant gliomas. These treatment strategies have shown promising effects in animal models and some experimental clinical studies. This review gives a short introduction into the molecules involved in angiogenesis of malignant gliomas, it provides an overview of the latest experimental developments of glioma angiogenesis inhibition and discusses the results of clinical anti-angiogenic trials in patients with high grade glioma. Additionally the problem of monitoring the treatment success of an anti-angiogenic therapy is addressed.

[Septic thrombosis of the cavernous sinus due to folliculitis]

Sinus thrombosis is an acute life-threatening disease. While cavernous sinus thrombosis secondary to facial infections is described in the literature, it is uncommon. The key clinical characteristics are a facial infection, headache, chemosis and edema of the eyelid. The main differential diagnostic consideration is meningoencephalitis. Early diagnosis by angiography, magnetic resonance imaging and examination of CSF is important as treatment should be initiated as soon as possible in order to decrease morbidity and mortality. The mainstays of therapy are heparinization and appropriate intravenous antibiotic therapy.

Nitric oxide modulates cerebral blood flow stimulation by acetazolamide in the rat cortex: a laser Doppler scanning study

The involvement of nitric oxide (NO) in cerebral blood flow (CBF) stimulation by acetazolamide was studied in anaesthetised, mechanically ventilated Wistar rats. CBF was monitored by laser Doppler scanning. Acetazolamide induced a long-lasting significant rCBF-increase. Application of NG-Nitro-L-arginine (L-NNA), an inhibitor of all NO synthetases (NOS), prevented CBF stimulation by acetazolamide. Continuous infusion of the exogenous NO donor SIN-1 (3-morpholinosydnonimine) suppressed L-NNA induced increases of mean arterial blood pressure without effect on rCBF in comparison to baseline. Additional acetazolamide injection then again caused a significant increase of rCBF in spite of NOS-inhibition. We thus conclude that NO is involved in acetazolamide-induced CBF stimulation. The mere continuous presence of NO is sufficient to re-establish the acetazolamide-response in spite of NOS-inhibition. These data suggest that NO acts rather as a modulator than as a mediator of the acetazolamide-induced CBF response.