Norbert Roosen

Adjuvant intraarterial chemotherapy with nimustine in the management of world health organization grade IV gliomas of the brain. Experience at the department of neurosurgery of Düsseldorf university

A protocol with postoperative adjuvant intraarterial (ia) chemotherapy using nimustine (ACNU) was followed at the University of Düsseldorf (Federal Republic of Germany) after histologic confirmation of malignant glioma of the brain. The first iaACNU procedure was performed within 10 days of surgery, and immediately before postoperative irradiation. After radiotherapy further iaACNU courses were given. The study population consisted of 35 primarily treated malignant gliomas World Health Organization (WHO) Grade IV, i.e., glioblastomas (NIV). Of these tumors 11 showed early progressive disease (PD) (NIVprimPD), whereas 24 had stable or responsive disease (NIVsd&rd). Seven patients with recurrent malignant gliomas WHO Grade IV (NIV recurrent) were also treated plus six patients with malignant gliomas WHO Grade III (NIII). Experience with 50 treated patients resulted from this study. The median survival time (MST) for the group NIV was 14.2 months; 41.0% of patients were long‐term survivors. The MST for the group NIV primPD was 7.8 months; 9.1% of patients were long‐term survivors. For the group NIVsd&rd a MST of 18.3 months and 66.7% of long‐term survivors were determined. Patients with recurrent tumors on this treatment protocol had an additional MST of 6.1 months. The total MST after first surgery was 16.2 months. The incidence of complications was low. Systemic complications were infrequent or rare. Retinal disturbances were seen in two patients; leukoencephalopathy was not seen in our patients. In 10% of patients cerebral complications were found, which were irreversible in 2% of patients. Complications could not be assigned unequivocally to the nitrosourea. These results compare favorably with what is reported in the literature, demonstrate the potential value of iaACNU in the treatment of malignant gliomas WHO Grade IV, and should encourage the initiation of a randomized clinical trial of adjuvant iaACNU in the therapy of these tumors. The authors propose iaACNU as a valuable approach in the management of primarily diagnosed malignant gliomas WHO Grade IV, but cannot recommend the delay of iaACNU until the recurrence of a brain tumor.

Tomographic studies of rCBF with [99mTc]-HM-PAO SPECT in patients with brain tumors: comparison with C15O2 continuous inhalation technique and PET

In 10 patients with malignant gliomas, the intracerebral distribution of [99mTc]–hexamethylpropyleneamine oxime ([99mTc]–HM-PAO) was studied with single photon emission computed tomography (SPECT) in comparison with C15O2 steady-state inhalation technique to measure cerebral blood flow using positron emission tomography (PET). In all instances, the cerebral [99mTc]–HM-PAO distribution was comparable with the regional pattern of cerebral blood flow (rCBF) observed with PET. This was confirmed by a significant correlation of tumor to cortex and tumor to white matter ratios between these two experimental methods. However, the contrast between high and low activity regions in the SPECT scans was significantly less than that in the PET scans. Contrast enhancement of the SPECT scans was accomplished using a correction formula proposed by Lassen.

Immunohistochemical demonstration of proliferating cell nuclear antigen in glioblastomas : pronounced heterogeneity and lack of prognostic significance

SummaryIn order to evaluate a possible significance of the expression of proliferating cell nuclear antigen (PCNA) as clinically useful prognostic parameter, we retrospectively investigated a series of 40 glioblastomas by means of immunohistochemistry and compared the results to patient survival. All glioblastomas included in the study had been treated by operation, radiotherapy and intraarterial ACNU [3-(4-amino-2-methyl-5-pyrimidinylmethyl)-1-(2-chloroethyl)-1-nitrosourea] chemotherapy. Patient survival ranged from 2 months to 42 months (mean: 14.2 months). PCNA values varied widely, ranging from 0.5% to 75% (mean: 24.9%). Statistical analysis revealed no significant correlation between PCNA index and patient survival. Our study thus indicates that the expression of PCNA appears not to be a useful prognostic parameter for glioblastoma patients.

MR imaging of calcified herniated thoracic disk.

The magnetic resonance findings in a 48-year-old woman with a calcified, herniated thoracic intervertebral disk at the T5-T6 level are reported. This patient had an 18 year history of spinal cord symptoms and signs, previously thought to be caused by multiple sclerosis (MS). Magnetic resonance was obtained for further evaluation of MS.

Magnetic resonance imaging of colloid cysts of the third ventricle

SummaryTwo cases of colloid cyst of the third ventricle are reported. Their computed tomographic (CT), magnetic resonance (MR) and neuropathological features are presented. The MR findings were different in the two cases for reasons not yet fully explained, full biochemical and biophysical analyses of the cyst contents not being available. Neuropathologically, the only significant difference was the abundant presence of cholesterin crystals in the colloid of case 1 and their absence in case 2. One of our cases is also peculiar from a CT point of view, since it was primarily hypodense and did not enhance on intravenous contrast administration.

Tomographic studies of rCBF with 99mTc-HM-PAO SPECT in comparison with PET in patients with primary brain tumors.

Abstract99mTc-hexamethyl-propyleneamine-oxime (HM-PAO) was developed as a radiotracer of regional cerebral blood flow (rCBF) with SPECT. THe purpose of this study was to investigate if HM-PAO is able to trace rCBF in primary brain tumors. In 10 patients with glioblastoma grade IV the intracerebral distribution of HM-PAO was studied in comparison with C15O2 steady state inhalation technique and PET for rCBF evaluation. In all instances the cerebral HMPAO distribution was comparable with rCBF pattern as confirmed by a significant correlation of tumor to cortex ratios. The results indicate the clinical usefulness of HMPAO for tracing rCBF in brain tumors.

Completely reversible, severe, acute neurological deterioration with an otherwise asymptomatic, huge intradiploic calvarial epidermal cyst

A huge, intradiploic, right temporoparietal epidermal cyst was known to be present, unchanged in extent, for over 14 years in a 55-year-old man. Although extreme mass effect was demonstrated by computed tomography scans, results of the neurological examination were within normal limits. Treatment of nausea and vomiting after vestibular testing caused somnolence and an acute diencephalic-mesencephalic syndrome of tentorial herniation. However, only moderate amounts of analgesics and sedatives were given. These symptoms disappeared as the pharmacological sedative effect diminished. Thereafter the tumor was resected radically. Neuropathological examination confirmed an epidermal cyst. Results of the postoperative neurological examination were within normal limits.

The influence of magnetic resonance tomography on diagnosis and therapy in patients with intracranial manifestation of neurofibromatosis (Recklinghausen disease)

Recent research into the natural course of neurofibromatosis has revealed an outstandingly high proportion of central nervous system malignancies as well as cancers of various other organs. Due to the lack of ionizing radiation, the extraordinary reconstruction in the frontal and parasaggital planes as well as the diagnosis of intracanalicular acoustic neurinomas and intraorbital tumors, magnetic resonance tomography (MRT) is indicated for control of patients with neurofibromatosis.