Edwin B. Boldrey

Radiation therapy in the treatment of partially resected meningiomas

To address the question of whether radiation therapy is beneficial in the management of partially resected meningiomas, we reviewed the records of all patients admitted to the University of California, San Francisco, between 1968 and 1978 who had a diagnosis of intracranial meningioma. The patients were divided into three groups: 51 patients had gross total resection and did not receive radiation therapy, 30 patients had subtotal resection and no radiation therapy, and 54 patients had subtotal resection followed by radiation therapy. The subtotal resection groups were similar in average age, male:female ratio, and tumor location, which allowed a valid comparison of the effects of irradiation. The recurrence rate in the total resection group was 4% (2 of 51 patients). Among patients in the subtotal resection groups, 60% of nonirradiated patients had a recurrence, compared with only 32% of the irradiated patients. The median time to recurrence was significantly longer in the irradiated group than in the nonirradiated group (125 vs. 66 months, P less than 0.05). There was no complication related to irradiation. These results provide convincing evidence that radiation therapy is beneficial in the treatment of partially resected meningiomas.

The role of radiation therapy in the treatment of astrocytomas

One hundred forty‐seven patients with astrocytoma were treated between 1942 and 1967. There were 25 postoperative deaths. The 14 patients in whom the tumor was thought to have been completely removed were not irradiated and all survived 5 years or longer. Seventy‐one of the 108 patients with incompletely excised lesions received radiation therapy. The 5‐year survival rate for those with incomplete resection alone was 19%, compared to 46% when irradiation was given. Based on observations up to 20 years, after incomplete removal postoperative irradiation significantly prolonged useful life and may have lead to permanent control in some. There was no evidence of radiation damage. Most of these tumors were fibrillary astrocytomas, and the results apply particularly to this histologic type. Only 1 of 11 patients with gemistocytic astrocytoma survived 5 years. The survival rate for Grade I tumors was appreciably greater than for Grade II lesions; in both grades, it was improved by irradiation.

Phase II study of procarbazine, CCNU, and vincristine combination chemotherapy in the treatment of malignant brain tumors

Forty‐eight patients with primary or metastatic malignant tumors of the central nervous system (CNS) were treated with combination chemotherapy, consisting of procarbazine (100 mg/m2 × 14 days), CCNU (75 mg/m2), and vincristine (1.4 mg/m2 × 2, 1 week apart) (PCV) every 4 weeks. Most patients had undergone initial resection of primary tumors, postoperative radiotherapy, and a post irradiation interval of 3 months or more. Other patients harbored unbiopsied, newly‐discovered primary or metastatic tumors. All patients were deteriorating neurologically when treatment began. Overall response rate for PCV combination therapy was 44%, no better than results obtained with single agent procarbazine or BCNU, the most effective drugs used alone in previous brain tumor chemotherapy studies.

Therapeutic Considerations in Tumors Affecting The Central Nervous System: Ependymomas

Ependymomas constitute a small but well defined group of the gliomas. The facts that all reported series are relatively small and that systems of classification differ probably account for the divergent opinions on therapy and prognosis. In Olivecronas surgically treated patients, the five-year survival rate was 15 per cent for supratentorial ependymomas and 33 per cent for infratentorial ependymomas (15). Ley and his co-workers (9), as recently as 1962, expressed the opinion that radiation therapy is apparently of no value in these lesions. On the other hand, Bouchard and Peirce (3) reported five- and ten-year survival rates of 58 and 50 per cent respectively after postoperative irradiation. The present report includes all intracranial ependymomas treated at the University of California Medical Center 1930 to 1961, inclusive. Since ependymomas arising in the spinal cord present different therapeutic problems and a different prognosis, these lesions have been excluded. Materials and Methods The records o...

THERAPEUTIC CONSIDERATIONS IN TUMORS AFFECTING THE CENTRAL NERVOUS SYSTEM: OLIGODENDROGLIOMAS.

The treatment of primary intracranial tumors gained the attention of the earliest pioneers in neurological surgery. Despite the efforts of more than three-quarters of a century, therapeutic results remain far from satisfactory. The principal methods of therapy available are still only surgery, radiation, or a combination of the two. Some probing with chemotherapy has been instituted and is of interest, but at present this is primarily investigative. Tissue immunity, as far as application to the treatment of brain tumors is concerned, has received practically no attention. This situation and the magnitude of the problem of brain tumors prompted an evaluation of results obtained with available therapeutic methods. This study includes all the patients who have come under the care of members of the Faculties in Neurological Surgery and in Radiation Therapy at the University of California School of Medicine. The first of these primary tumors to be evaluated is the oligodendroglioma. Material and Methods A revi...

The treatment of meningiomas in childhood.

Thirteen cases of meningiomas in the pediatric age group seen at the University of California are reviewed. Four of these patients are alive; one had complete surgical resection of tumor and three had subtotal resection followed by irradiation, with total tumor doses of 4500 to 5500 rads. On the basis of these data, together with our total experience in the treatment of 188 patients with meningiomas, we conclude that patients who have complete surgical resection need no further treatment but patients who have subtotal removal may have recurrences delayed or prevented by the addition of postoperative irradiation to their therapeutic regimens.

SURGICAL PROCEDURES FOR MALIGNANT BRAIN TUMORS

The attention of the conference on Research in the Experimental and Clinical Aspects of Brain Tumors has centered on a wide variety of minutia related to brain tumors. These details are now only loosely interrelated and of a theoretical or restricted nature, but hopefully will soon be transformed into a final, happy solution to that devastating curse, the intrinsic cerebral neoplasm. It is my task to present to you the proposition that there is still a place for surgical procedures in dealing with this problem, that surgery can contribute to diagnosis, to treatment and to research. The present care of patients with brain tumors is largely surgically based. It is recognized that this care does indeed fall short of the ideal all of us have before us, and hence we all strongly support the investigation of all new developments in any field of biological sciences which may favorably affect our understanding of the underlying disease process or of methods leading to its reversal. One cannot conclude, though, that the present situation is complete chaos. For the foreseeable future, surgical procedures are necessary to the launching of any investigative effort in the study and management of the majority of the tumors of the brain, and of those unfortunate individuals who bear them. At this point, I would reemphasize the magnitude of the problem under discussion. It should be unnecessary to do this. However, in a current publication, “Progress against Cancer, 1967,”’ a report by the National Advisory Cancer Council, the statement is made: “Although very rare, brain tumors are an important cause of cancer deaths among young people.” (Italics are author’s.) It should be common knowledge that brain tumors account for approximately 2% of all deaths in the United States. It should also be common knowledge that the brain is among the first three organ systems affected by neoplasia in females up to the age of 20 years and in males up to the age of 40 years. Thus, brain tumors can hardly be considered “very rare.”2 The term “malignant brain tumor,” as used in this monograph, has been confined in general to those neoplasms commonly referred to with varying degrees of precision as glioblastoma multiforme. It would seem proper to emphasize that all gliomas-indeed all intracranial neoplasms-are malignant in the sense that, left untreated, they are fatal. Seldom can the intrinsic neoplasm be eliminated completely by surgery, or for that matter by any other presently available means. Today, with respect to brain tumors in general and to gliomas in particular, a surgical procedure is necessary for the final accurate premortem diagnosis of any of these lesions and may be helpful in the treatment of most. There is mounting evidence that in rare instances a histological diagnosis can be made through the study of the cellular content of the cerebrospinal fluid,3 or by culture of these cells.4 At the moment, however, this method is insufficiently developed to serve as a consistent basis for precise therapy, except under extraordinary circumstances. The information obtained must be regarded generally as inconclusive, requiring continued cross-checking against other methods of diagnosis, either through biopsy or at the postmortem examination table. There are situations in which making an accurate histological diagnosis carries

SIMULTANEOUS ANTERIOR AND POSTERIOR APPROACH TO THE CERVICAL SPINE. REDUCTION AND FIXATION OF AN OLD FRACTURE-DISLOCATION WITH CORD COMPROMISE.

Open reduction and fusion of dislocations arid fracture-dislocatiomms of the cervical spine are sometimes necessary ; it is generally recognized that certaiim types of dislocation of the cervical spine are irreducible by closed methods .8 Evemi mm situations in mvhich the dislocation might be reduced initially by closed methods, time possibility of successful reduction diminishes mvith the passage of time after iiijury 8,10 Furthermore, compression fractures with displacement of the vertebral bodies may be accompammied by disruption of the inmtervenming discs arid cause potemmtially hazardous permanent deformity of the cervical spine, despite adequate fixation .2 Finally, the presence of obvious compromise of the spinal cord is a cornpellinmg inmdication for stabilization of the spine, with or after decompression. Reported here is the case of a boy treated by open reduction and simultaneous anterior and posterior’ fusion for arm old, previously irreducible fracture-dislocation of time cervical spine.