Robert G. Selker

Survival of Patients with Well-Differentiated Astrocytomas Diagnosed in The Era of Computed Tomography

We report 25 verified cases of well-differentiated cerebral astrocytomas in adults treated between 1978 and 1988. All patients were diagnosed by computed tomographic (CT) scans, with 5 undergoing a craniotomy for debulking and 20 undergoing a biopsy alone. The median survival for the entire group was 8.2 years, the longest survival yet reported for a series of patients with these tumors. A review of the literature suggests that the longer survival observed in more recent series is the result of the earlier diagnosis of tumors afforded by modern brain imaging. Twenty of our patients presented with seizures in the absence of any other focal findings and would probably not have had a biopsy in the era before CT scans until their tumors had progressed. Only 8% of our patients had papilledema at the time of presentation, in contrast to almost half of the patients with low-grade astrocytomas reported before 1975, supporting the hypothesis that patients in the CT era are diagnosed earlier. None of our patients died from progressive low-grade disease. One patient died from a squamous cell cancer, and 7 died as a consequence of their tumors dedifferentiating into a more malignant astrocytoma or glioblastoma multiforme, with a median time of approximately 5 years after the diagnosis. Our findings, together with the available data in the literature, suggest that death from a focal low-grade astrocytoma, in the absence of malignant degeneration, may be a rare event. Consequently, future therapeutic efforts should be targeted at preventing dedifferentiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain stem and spinal metastases of supratentorial glioblastoma multiforme: a clinical series.

Although the spread of supratentorial glioblastoma multiforme to the brain stem and spine has been extensively described in published autopsy series, information on the diagnosis, treatment, and subsequent clinical course of patients manifesting symptoms of glioblastomatous dissemination ante mortem remains scant. We report a series of 11 patients having the signs and symptoms of neuraxis dissemination of supratentorial glioblastoma multiforme. All patients had radiographic documentation of metastases by either contrast-enhanced myelograms or enhanced magnetic resonance imaging scans. Ten presented with spinal involvement, whereas one presented with lower cranial neuropathies secondary to diffuse involvement of the basal cisterns. The mean age of the patients was 38.5 years, and the mean time interval between diagnosis of intracranial disease and diagnosis of metastases was 14.1 months. After diagnosis of tumor spread, subsequent mean survival time was 2.8 months. All patients received additional radiotherapy to the areas of metastasis, but the clinical response to radiotherapy was quite poor. This study confirms previous reports in the literature suggesting that metastases occur in younger patients and in patients with extended survival. The findings suggest that the relatively infrequent clinical incidence of the symptomatic spread of glioblastoma multiforme, as compared with the frequent incidental discovery of such spread at autopsy, may be the result of the limited survival of the affected patients, and not due to the biology of the tumor.

The Risk and Efficacy of Anticoagulant Therapy in the Treatment of Thromboembolic Complications in Patients with Primary Malignant Brain Tumors

Twenty-three patients with malignant glial neoplasms were treated with anticoagulant therapy for thromboembolic complications. Fifteen patients had deep vein thrombosis alone, and 8 patients had both deep vein thrombosis and pulmonary embolism. Serum prothrombin times were maintained at 1.25 times control for an average of 5.8 months per patient, for a total patient exposure to warfarin therapy of 132 patient-months (11 patient-years). Only 1 patient suffered a recurrent pulmonary embolism, and this occurred during an episode of gastrointestinal bleeding, when anticoagulant therapy had to be discontinued prematurely. All patients were followed with serial computed tomographic or magnetic resonance imaging scans, and no patient showed radiographic evidence of intratumoral hemorrhage either during or after warfarin therapy. One patient, who died from a large recurrent glioblastoma, was found at autopsy to have scattered foci of intratumoral hemorrhage. This series, together with a review of the available literature, suggests that oral anticoagulant therapy is both a safe and effective means of treating thromboembolic complications in patients with residual malignant glial tumors.

Intracranial pencil injuries

A case of delayed central nervous system manifestations of intracranial penetration by a pencil is presented. Twenty-one additional cases of cerebral injury by pencils are reviewed and discussed. A high index of suspicion, liberal use of the computed tomographic scan, and early operative intervention in cases with cranial perforation are important points in the management of these injuries.

Results of a randomized trial comparing intra-arterial cisplatin and intravenous PCNU for the treatment of primary brain tumors in adults: Brain Tumor Cooperative Group trial 8420A

SummaryPurposeTo test the efficacy of intra-arterial (IA) cisplatin versus intravenous (IV) PCNU for treating primary brain tumors, in a randomized trial (Brain Tumor Cooperative Group [BTCG] Trial 8420A).Methods311 adult patients (ages 19–79 years; median 45) with supratentorial tumors (confirmed histologically) were randomized by nine participating institutions. Patients were required to have completed radiotherapy (4500–6020 cGy to the tumor bed) before randomization. Patients were stratified as either nonprogressive (clinically and radiologically stable) or progressive. Results were analyzed for the 311 patients in the randomized population (RP), and for the 281 patients in the Valid Study Group (VSG) meeting protocol eligibility requirements. 56% of patients in the VSG had glioblastoma multiforme, 33% had other malignant glioma, and 11% had low-grade glioma. 64% were stratified as progressive. 12% had received prior chemotherapy.ResultsThe group randomized to PCNU had the longer survival (p = 0.06 for the RP, p = 0.07 for the VSG). In the VSG, median survival was 10 months for the cisplatin group, 13 months for the PCNU group. The difference between treatment groups was significant (p ≤0.02) when adjusted for important prognostic factors. PCNU lead to greater hematotoxicity; cisplatin lead to greater renal toxicity and some ototoxicity. Some cisplatin patients experienced complications associated with IA administration, including six cases of encephalopathy.ConclusionThe trial showed a survival advantage to the group randomized to PCNU, although the difference was modest. Coupled with previous BTCG results, these trials suggest that PCNU is an active drug for brain tumors.

Pathological correlation of CT ring in recurrent, previously treated gliomas☆

The meaning of the enhancing ring commonly seen on computerized tomographic (CT) scans in patients with recurrent, treated glioblastoma has long been of concern. Does the ring represent radiation necrosis, pseudocapsule formation, compressed adjacent brain, or, in fact, a peripheral zone of viable tumor? We employed a multiple intratumoral biopsy technique at the time of reoperation to investigate this ring. Pathological evidence is presented documenting the content of the ring to the viable tumor. It is suggested that perhaps treatment failure may be determined on sequential CT examinations by comparing the volume and degree of contrast enhancement.

Carotid perfusion hypothermia for brain surgery using cardiac arrest without bypass

Abstract The technique of preferential cerebral hypothermia with elective cardiac arrest and balloon cardiac massage has been shown to be possible in the human patient. It involves the advantage of relative simplicity while avoiding some of the problems related to extracorporeal cardio-pulmonary bypass (such as anticoagulation). It can be adapted well to the requirements of neurosurgeons and neurosurgery. We believe that the utilization of a simple Ringers-like solution rather than cooled blood affords a better method of perfusion cooling and eliminates the adverse effects of increased viscosity and microvascular clotting.

On a method of dosimetry planning and implantation of 125I for interstitial irradiation of malignant gliomas.

Utilizing a treatment concept geared to the cell cycle of the glioma, a CT determined tumor volume and boundaries, 125I dosimetry data and a reference probe template system, it is now feasible to produce a volume implant of an intracranial mass based on prospective planning with accurate postimplant correspondence. The cell cycle oriented treatment plan is felt perhaps to be more beneficial in the treatment of the highly malignant glioblastoma, considering its wide range of cell cycle times, large irregular volumes and large dormant segment, than would be a similar isotope source delivering a high-dose rate, but short-term course irradiation. Seeds are contained within Lexan tubes, thereby allowing accurate assessment of postoperative dosimetry planning, negating seed migration and possible `cold spots within a volume implant as would be noted with unrestrained seeds. The implant described in this communication is designed to remain in place for approximately 20 months, a period of time well beyond the life expectancy of any group of failed glioma patients. Although ultimately the system may prove most beneficial in newly diagnosed glioblastomas, the current trial in patients having previously undergone 5–6000 rads of external beam therapy is not considered hazardous to surrounding brain.

Intracranial Abscess: Treatment by Continuous Catheter Drainage

15 children with brain abscesses were subjected to continuous catheter drainage as the procedure of choice for a solitary encapsulated abscess. Although many still advocate craniotomy and total excision, this series, coupled with the experience of others in the literature, leaves little doubt that catheter drainage alone is sufficient. The simplicity of creating a burr hole under local anesthesia, the ability to irrigate with antibiotics and then outline the cavity with contrast agents are but a few of the advantages of this method.

Effect of “elapsed time” and “insults” on mental development in hydrocephalics

Abstract Prompt closure of the meningocele decreases rate of infection, and permits an early placement of the shunt. The “elapsed time,” that is, the time between meningocele closure and placement of the valve, is important and produces an effect on ultimate performance. The optimum time for shunting would appear to be no later than the 7th–11th day, but it is believed that if the ventricular system is found to be enlarged earlier it should also be treated earlier so as to minimize the “elapsed time”-pressure relationship. Episodes of shunt blockage not promptly repaired do contribute to decreased future performance. Although malfunction of less than 24 hr does not in a statistically significant manner alter the performance, the duration of increased intracranial pressure may have a more significant correlation with future performance than does cortical mantle or serial head circumference measurement. Allowing time for spontaneous “arrest” in a patient with a surgically closed meningocele beyond a 20-day or more period may be detrimental to normal mental development.