[Advantages of studying the frontal plane of the uterine cavity in 3D ultrasound]

Recently, computer-assisted treatment of echographic images has permitted '3D' reconstruction in gynecology. This is achieved by scanning a given volume containing the organ of interest. Two practical options exist. Some ultrasound probes are equipped with an automatic scanning device while others use manual scanning, electronically normalized or not. Both approaches make possible of an electronic matrix, i.e., a pile of '2D' echographic images. Secondary cuts are possible through the electronic matrix, including plans not normally accessible to ultrasound scanning because of anatomical limitations. One of the secondary cuts most clinically useful is the frontal plan of the uterus. This enables one to visualize the organ lying flat as it is commonly drawn on medical sketches. Studying the frontal plan of the uterus acquired electronically from a 3D matrix improves the visualization of possible interactions between structures such as uterine fibroids and the endometrium. The frontal plan of the uterus also offers marked improvements for studying uterine malformations.

Correlates between hematopoiesis and neuropoiesis: neural stem cells

There are many parallels between the neuropoietic and lymphohematopoietic systems. The lymphohematopoietic stem/progenitor cell system has been extensively characterized, but there are still major questions relating to the definitive stem cell assay, the structure of the system (i.e., hierarchical versus cell cycle-based), and the nature of differentiation (i.e., stochastic versus deterministic). Recent data have established the existence of an epidermal growth factor (EGF)-responsive neural stem cell in adult mice. We have studied these neural progenitor/stem cells in fetal (day 15) and 2-day postnatal mice and established a single-cell progenitor assay and a variety of putative uni-, bi-, and tripotential stem cells that form in response to EGF. Neurospheres are the EGF-responsive neural units that grow in liquid culture, and we have found that cells derived from these neurospheres express a wide array of cytokines and their receptors. This will provide a window on the hemopoietic progenitor system analogous to that created by the description of in vitro growth of clonal hematopoietic progenitors.

Lymphohematopoietic stem cell engraftment

Traditional dogma has stated that space needs to be opened by cytoxic myeloablative therapy in order for marrow stem cells to engraft. Recent work in murine transplant models, however, indicates that engraftment is determined by the ratio of donor to host stem cells, i.e., stem cell competition. One hundred centigray whole body irradiation is stem cell toxic and nonmyelotoxic, thus allowing for higher donor chimerism in a murine syngeneic transplant setting. This nontoxic stem cell transplantation can be applied to allogeneic transplant with the addition of a tolerizing step; in this case presensitization with donor spleen cells and administration of CD40 ligand antibody to block costimulation. The stem cells that engraft in the nonmyeloablated are in G0, but are rapidly induced (by 12 hours) to enter the S phase after in vivo engraftment. Exposure of murine marrow to cytokines (IL-3, IL-6, IL-11 and steel factor) expands progenitor clones, induces stem cells into cell cycle, and causes a fluctuating engraftment phenotype tied to phase of cell cycle. These data indicate that the concepts of stem cell competition and fluctuation of stem cell phenotype with cell cycle transit should underlie any new stem cell engraftment strategy.

Prognostic factors derived from recursive partition analysis (RPA) of Radiation Therapy Oncology Group (RTOG) brain metastases trials applied to surgically resected and irradiated brain metastatic cases

PURPOSE

(a) To identify the prognostic factors that determine survival after surgical resection and irradiation of tumors metastatic to brain. (b) To determine if the prognostic factors used in the recursive partition analysis (RPA) of brain metastases cases from Radiation Therapy Oncology Group (RTOG) studies into three distinct survival classes is applicable to surgically resected and irradiated patients.

METHOD

The medical records of 125 patients who had surgical resection and radiotherapy for brain metastases from 1985 to 1997 were reviewed. The patients' disease and treatment related factors were analyzed to identify factors that independently determine survival after diagnosis of brain metastasis. The patients were also grouped into three classes using the RPA-derived prognostic parameters which are: age, performance status, state of the primary disease, and presence or absence of extracranial metastases. Class 1: patients < or = 65 years of age, Karnofsky performance status (KPS) of > or =70, with controlled primary disease and no extracranial metastases; Class 3: patients with KPS < 70. Patients who do not qualify for Class 1 or 3 are grouped as Class 2. The survival of these patients was determined from the time of diagnosis of brain metastases to the time of death.

RESULTS

The median survival of the entire group was 9.5 months. The three classes of patients as grouped had median survivals of 14.8, 9.9, and 6.0 months respectively (p=0.0002). Age of < 65 years, KPS of > or = 70, controlled primary disease, absence of extracranial metastases, complete surgical resection of the brain lesion(s) were found to be independent prognostic factors for survival; the total dose of radiation was not.

CONCLUSION

Based on the results of this study, the patients and disease characteristics have significant impact on the survival of patients with brain metastases treated with a combination of surgical resection and radiotherapy. These parameters could be used in selecting patients who would benefit most from such treatment.

In vitro fertilization in women over 40 years of age. A study on retrospective data for eight years

A retrospective (1987-1995), single-center study was conducted to evaluate the IVF success rate in women who were 40 years and over. Controls were randomly selected patients who were 35 years or younger from the same center. The main evaluation criterion was the number of pregnancies initiated in each group and especially the number of full-term deliveries (take-home baby rate). Differences were considered as statistically significant for P < or = 0.05: A total of 194 IVF attempts in women 40 years or over were compared to 209 attempts in the control group. The mean ages of the two groups was 40.9 vs. 29.3 years (P < 0.001). The duration of follicle stimulation was 12.9 vs. 13.1 days (not significant, NS). The number of ampules was 29.6 vs. 29.2 (NS). Serum estradiol levels were 1435.8 vs. 2020.8 pg/ml (P < 0.001). Oocytes: 4.6 vs. 7.3 (P < 0.001). Embryos: 1.7 vs. 2.8 (P < 0.0001). Full-term deliveries: 3.6 vs. 13.4% (P < 0.05). Better oocyte retrieval was achieved (5.3 vs. 3.3; P = 0.001) in the group that was 40 years or over, but there were no differences in the rate of embryo transfer (1.9 vs. 1.3; NS) and full-term deliveries (4.2 vs. 2.9%) in a long protocol compared to a short one. The results of the study are similar to those found in the literature. Indications for standard IVF without oocyte donation should be carefully thought out and couples should be warned of the low success rate.

[Medical treatment exclusively for cervical pregnancy with in situ methotrexate]

We present a case report of cervical pregnancy with medical treatment. Medical treatment consisted in injection of methotrexate (50 mg) into the pregnancy, on the first, third and seventh day. Ultrasound and Doppler give important information for follow up. The pregnancy totally resolved and the patient did not need any further treatment.

Th2 cytokine mRNA expression in skin in cutaneous T-cell lymphoma

We have previously demonstrated that peripheral blood mononuclear cells from patients with Sézary syndrome, the leukemic form of cutaneous T-cell lymphoma which is accompanied by erythroderma and lymphadenopathy, have a Th2 cell cytokine [interleukin 4 (IL-4) and interleukin 5] production pattern. In this study, we extend these observations to demonstrate a correlation of the presence of a Th2 cytokine pattern with a malignant T-cell clone in different stages of cutaneous involvement among patients with cutaneous T-cell lymphoma (CTCL). Skin biopsies were obtained from 12 CTCL patients with various disease stages (three patch, three plaque, six tumor), three patients with parapsoriasis, four patients with inflammatory dermatoses, including two psoriasis and two lichen planus, and 12 normal controls. Total RNA was extracted, reverse transcribed, and PCR amplified with IL-2, IL-4, IL-5, interferon gamma (IFN-gamma), and beta-actin oligonucleotide primers. Although all skin specimens tested had detectable IL-2 and IFN-gamma mRNA, only specimens from patients with CTCL or parapsoriasis had demonstrable IL-4 and/or IL-5 mRNA. Specifically, IL-5 mRNA was detected in skin biopsies from five of six tumor-stage CTCL, two of three plaque-stage CTCL, one of three patch-stage CTCL, and 1 of 3 parapsoriasis patients, whereas IL-4 mRNA was demonstrated to be present in five of six tumor-stage, one of three plaque stage, none of three patch-stage CTCL, and none of three parapsoriasis patients. These results indicate that in all stages of cutaneous involvement of CTCL, encompassing patch stage through tumor stage, IL-4 and IL-5 mRNA is variably detectable. In tumor-stage skin lesions, typically characterized by a dense dermal infiltrate of malignant T cells, Th2 cytokine mRNA is virtually always detectable. The ability to detect Th2 cytokine mRNA in the skin of patients with CTCL supports our previous findings that the malignant T cells in CTCL possess a Th2-helper cell phenotype.

Feasibility study of intraarterial vs intravenous cisplatin, BCNU, and teniposide combined with systemic cisplatin, teniposide, cytosine arabinoside, glycerol and mannitol in the treatment of primary and metastatic brain tumors

Sixteen patients with intracerebral tumors received intraarterial cisplatin, teniposide, and BCNU combined with intravenous cisplatin, teniposide, and cytosine arabinoside. Oral glycerol and intravenous mannitol were given along with the intravenous chemotherapy in an attempt to increase drug delivery to tumor by augmenting tumor blood flow. Thirteen additional patients were treated with the same regimen, but received all the chemotherapy intravenously. Of the 16 patients receiving intraarterial chemotherapy (median survival, 14 weeks), none responded, 5 (31%) were stable for > 8 weeks, 8 (50%) failed, and 3 (19%) were unevaluable due to early death. Of the 13 patients receiving all their treatment intravenously (median survival, 13 weeks), 3 (23%) responded, 1 (8%) was stable, 7 (54%) failed, and 2 (15%) were unevaluable due to early death. In the patients receiving intraarterial chemotherapy, toxicity included ipsilateral retinal toxicity (2 patients), ocular pain or headache (10), periorbital swelling and flushing (6), increased brain edema with focal neurological deficits and drowsiness (5), and catheter-related carotid artery thrombosis followed by fatal herniation (1). Myelosuppression was worse in patients who received all their treatment intravenously than in those receiving intraarterial chemotherapy (p < 0.05). Neutropenic sepsis developed in 4 patients on the intraarterial arm (1 fatal) and in 5 patients on the intravenous arm (2 fatal). Other toxic effects were similar whether or not patients received intraarterial treatment or only intravenous treatment. Overall, toxicity of this regimen was excessive, and response rates were lower than would have been expected with single agent therapy.

Development of immortalized human articular cartilage cell lines

Human articular cartilage cells were transfected with the t.-sensitive polyomavirus large T antigen of SV40. Several immortalized chondrocyte cell lines were obtained. The types of acidic polysaccharides and of collagen synthesized suggest dedifferentiation in the in vitro culture system used afterwards to obtain large numbers of cells.

Caudate nucleus pathology in Parkinson's disease: ultrastructural and biochemical findings in biopsy material

Ultrastructural and biochemical properties of caudate nucleus (CN) biopsies in two patients with advanced Parkinson's disease (PD) were compared with three CN specimens removed during surgery for intracranial tumors. An additional two specimens from neurologically intact patients (59 and 86 years old) were removed during autopsy (performed 3 and 4 h post mortem, respectively) for electron microscopic studies. Dopamine levels in PD were reduced to less than 15% of control values. Both PD patients showed frequent dystrophic neurites and transsynaptic degeneration of neurons and neuritic processes. These changes were not found in CN from the four control individuals. Only a few dystrophic neurites were noticed in one 67-year-old control patient. The development of neuroaxonal dystrophy in CN is consistent with a dying-back process, probably accompanying abnormalities of axonal transport in PD. Transsynaptic degeneration of neurons in CN very likely represents a morphological marker of disease severity. The occurrence of this change may account for the poor clinical response of patients with advanced PD to intracerebral implantation of dopaminergic tissues.

Differential temperature sensitivity of cultured cells from cartilaginous or bone origin

The effects of long-term exposure to hyperthermia were studied on several cell cultures of cartilaginous or bone origin after a 4-day treatment at 40 degrees C. Chondrocytes proliferation, as well as mitochondrial activity were not modified by these culture conditions (40 degrees C) but protein content and cell volume were increased. In contrast, the proliferative capacity of osteoblasts, MC3T3.E1 a and ROS 17/2.8 was decreased and their protein content, cell volume and mitochondrial activity were increased. Chondrocytes appeared to be thermoresistant, and osteoblastic cells thermosensitive. Furthermore, temperature sensitivity was greater for the continuous established osteoblastic cell line MC3T3.E1 and for the cancerous established osteoblastic cell line ROS 17/2.8 than for chondrocytes.

Atypical Subependymoma of the Spinal Cord: Ultrastructural and Immunohistochemical Studies

A 76-year-old woman with a 2-year history of progressive weakness of the left arm and leg underwent a laminectomy for an intradural, extramedullary, pedunculated subependymoma involving the meninges and spinal nerve roots at C7-T1. Eight months later, another operation was necessary for an intramedullary neoplasm at C3-T4. This latter tumor consisted of small. poorly developed cells, large atypical astrocytes, and ependymal cells. Neither ependymal rosettes nor papillary formations were present. Ultrastructural studies showed some features of ependymal differentiation of the large “astrocytic” cells. This case illustrates an unusual pattern of extramedullary and intramedullary presentations of subependymoma and a spectrum of cellular differentiation of neoplastic subependymal glia.

Atypical subependymoma of the spinal cord: ultrastructural and immunohistochemical studies

A 76-year-old woman with a 2-year history of progressive weakness of the left arm and leg underwent a laminectomy for an intradural, extramedullary, pedunculated subependymoma involving the meninges and spinal nerve roots at C7-T1. Eight months later, another operation was necessary for an intramedullary neoplasm at C3-T4. This latter tumor consisted of small, poorly developed cells, large atypical astrocytes, and ependymal cells. Neither ependymal rosettes nor papillary formations were present. Ultrastructural studies showed some features of ependymal differentiation of the large "astrocytic" cells. This case illustrates an unusual pattern of extramedullary and intramedullary presentations of subependymoma and a spectrum of cellular differentiation of neoplastic subependymal glia.

Intraparenchymal epithelial (enterogenous) cyst of the medulla oblongata

Intraparenchymal solitary cyst of the medulla oblongata was diagnosed on MRI examination in a 66-year-old woman with a nine year history of progressive brainstem dysfunction and three negative CT scan examinations. Craniotomy and drainage of the cyst to the IVth ventricle led to remarkable clinical recovery. Biopsy of the wall of the cyst revealed an epithelial lining with tonofilaments, desmosomes and surface coating on ultrastructural examination. Immunohistochemistry demonstrated positive reactions of epithelium for keratins, cytokeratins, epithelial membrane antigen and Ulex Europeus lectin, indicating endodermal origin of the cyst.

[Beta-mimetics and Pourcelot's index]

In a series of 20 patients presenting a threat of premature delivery, the vascular resistance index of Pourcelot, in the umbilical artery, was measured before, and then 24 hours after starting a continuous Salbutamol perfusion. A moderate but significant decreased placental vascular resistances is noted under betamimetic treatment. Relaxation of the myometrium obtained with a tocolytic treatment could be implicated in this alteration of placental resistances.

Cellular blue nevus ("melanocytoma") of the spinal meninges: electron microscopic and immunohistochemical features

A primary cellular blue nevus (melanocytoma) of the spinal canal in a 21-year-old woman is reported. Light microscopic examination revealed a melanotic neoplasm with histological patterns resembling schwannoma, dermal nevi, and neuroblastic-like tumor. The ultrastructural features of the neoplastic cells were similar to those in dermal blue nevi and melanomas. There was no evidence of arachnoidal cell differentiation. Immunohistochemistry revealed positive reactions for S-100 protein and neuron-specific enolase in many cells and no reactions for glial fibrillary acidic protein, cytokeratins, epithelial membrane antigen, 70-kD neurofilament protein, or Leu-7. Vimentin was strongly positive in the melanocytic cells as well as in the arachnoidal cells of involved meninges. The ultrastructural and immunohistochemical features support the nevoid nature of this tumor, which is frequently mislabeled as "melanotic meningioma."

Gangliocytoma of the cerebellum: ultrastructure and immunohistochemistry

A 31-year-old man presenting with a cerebellopontine angle syndrome underwent subtotal resection of a gangliocytoma of the left middle cerebellar peduncle. The tumor was positive for 68-kD neurofilament protein and vasoactive intestinal peptide. No glial cells were identified on immunohistochemical or ultrastructural examination. Electron microscopic study of neoplastic ganglionic cells revealed the presence of dense core vesicles, synaptic junctions, Hirano bodies, and marked dystrophic changes in the neuritic processes. The nosology of this lesion is discussed. Similarities between the morphological changes shown by mature neoplastic ganglion cells and comparable structural alterations seen in the physiological senescence of nonneoplastic neurons are stressed.

Intravascular papillary endothelial hyperplasia in an intracranial cavernous hemangioma

A novel presentation of intravascular papillary endothelial hyperplasia within a cerebral cavernous angioma in an adult is described. The pathogenesis of the lesion and its histological differentiation from malignant angiosarcoma are stressed.

Combined intraommaya methotrexate, cytosine arabinoside, hydrocortisone and thio-TEPA for meningeal involvement by malignancies

Twenty-three adult patients with meningeal involvement by a variety of malignancies were treated with the intra-Ommaya combination of methotrexate, hydrocortisone, cytosine arabinoside, and thio-TEPA. Whole brain irradiation was also administered to most patients who had not previously received it. Most patients demonstrated improvement of cerebrospinal fluid parameters, but only 50% of the patients experienced neurological improvement. Patients who did not receive cranial irradiation and performance status 4 patients were less likely to respond than were patients who did receive cranial irradiation as part of their treatment and patients who were performance status 0-3. Four patients developed possible and 2 patients developed probable or definite serious neurological complications. Another 4 patients developed less severe, reversible neurological toxicity. It is possible (but still uncertain) that this regimen is more toxic than other less intensive regimens, and further studies should be undertaken cautiously.

Combined intraarterial and systemic chemotherapy for intracerebral tumors

Twenty-six patients with intracerebral tumors (predominantly gliomas) were treated with intraarterial BCNU, VM-26, and cisplatin combined with the systemic administration of VM-26, methotrexate, vincristine, bleomycin, and procarbazine. Oral glycerol was given before i.v. VM-26. Twelve patients responded (46% of all patients and 63% of the fully evaluable patients). The response rate for gliomas was 50% if all patients were considered and 71% if only fully evaluable patients were considered. The response rate did not seem to be affected by glioma grade, prior chemotherapy, or pretreatment performance status. Median time to tumor progression for responders was 19 weeks. Median survival from initiation of treatment was 21 weeks for evaluable patients and 17 weeks for all patients. Median survival from initial diagnosis was 55 weeks. Myelosuppression was dose-limiting for the systemic chemotherapy. Reversible neurological toxicity was common, but tolerable. One patient developed ipsilateral blindness, and two patients developed prolonged neurological toxicity. Pulmonary toxicity was also seen. Vertebral artery infusions proved feasible, although difficult and more toxic than carotid infusions. Overall, this regimen was not more active than the intraarterial combination of BCNU, VM-26, and cisplatin without the systemic chemotherapy. Further studies of more intensive intracarotid therapy combined with different systemic drugs are being initiated.

[Value of ultrasonics in acute pelvic infections]

Sonograms performed in 228 women admitted for acute pelvic infection has enabled to find a normal image in 39.9% of the cases. In order of frequency, the abnormalities include: endometrial alterations (31.1%), one (or several) pelvic masses (25.9%) and a collection in the Douglas cul-de-sac (22.8%). The main advantage of the examination in the acute phase is the diagnosis and the study of the mass structure: most of the time, it concerns a "mixed" or heterogeneous aspect, for all of the images of a mass, as well as for images corresponding to a tubo-adnexal collection. The major critic of this examination is the lack of specificity of the images which are very diversified. The risk of confusion with another pathology (gynecological or, exceptionally gastro-intestinal) must be decreased with an examination of good quality and comparison with the clinical context. The presumption of a tubo-adnexal collection cannot, in most cases, be established with certainty. However, the Echography guides the diagnosis by showing an anechogenous image or a particular aspect (Douglas abscess, huge septated images of sequelae) and remains more reliable than clinic to detect the mass (44% of false negative, clinically) and follow the evolution of the disease. The therapeutic advantage is also mentioned, but the tap of an abscess under sonogram guidance is seldom performed.

[Thanatophoric nanism: a case of early ultrasonic diagnosis]

The diagnosis of a thanatophorous nanism is evoked in the presence of an abnormality of the size of the long bones. This study records the symptoms which, on sonograms, permit to recognize this fatal form of nanism among other forms of metaphysis chondrodysplasia, in order to establish a diagnosis before deciding to interrupt the pregnancy.

Cytosine arabinoside plus cisplatin and other drugs as chemotherapy for gliomas

Twenty-five evaluable patients with gliomas were treated with a combination of cytosine arabinoside plus cisplatin administered intravenously (IV). Ten of the 25 patients (40%) responded, including three of 13 patients (23%) with prior cranial radiation, and seven of 12 patients (58%) without prior cranial radiation. In a second study, intramuscular (IM) and oral caffeine were added to IV cytosine arabinoside plus cisplatin. Caffeine-induced seizures prevented escalation of the dose of caffeine to a level that would have been anticipated to potentiate the cytotoxicity of the cytosine arabinoside plus cisplatin. Twelve of 25 treated patients (48%) responded. Most of the patients had not received prior cranial radiation. In a third study, IV cytosine arabinoside was administered in combination with intracarotid and IV cisplatin, plus BCNU and tenoposide (VM-26). This study is continuing to accrue patients. Myelosuppression has been pronounced, but has generally been rapidly reversible. It is too early to comment on efficacy of this combination. Our results to date permit us to conclude that the combination of cytosine arabinoside plus cisplatin is capable of inducing regression of gliomas in some patients. We feel that further studies are warranted.

Intracarotid chemotherapy with a combination of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), cis-diaminedichloroplatinum (cisplatin), and 4'-O-demethyl-1-O-(4,6-O-2-thenylidene-beta-D-glucopyranosyl) epipodophyllotoxin (VM-26) in the treatment of primary and metastatic brain tumors

Thirty-seven patients with intracranial primary or metastatic tumors were treated with an intraarterial combination of BCNU, cisplatin, and VM-26 to determine the efficacy, toxicity, and maximal tolerated doses for the combination. A transfemoral fluoroscopic approach was used to catheterize temporarily the internal carotid or vertebral artery. Thirteen of 19 (68%) evaluable primary brain tumors and 9 of 16 (56%) evaluable brain metastases responded. The response rate was lower in patients previously treated with both cranial irradiation and i.v. chemotherapy than in patients less heavily pretreated (54% vs. 82%), although even patients previously treated i.v. with all three of the study drugs responded. All five patients with both extracranial and intracranial evaluable tumor deposits experienced a greater response of their intracranial than of their extracranial tumor. Ipsilateral retinal and neurological toxicity were dose-limiting, with major toxicity (permanent decreased vision or hemiparesis) occurring in five of nine (56%) patients receiving doses of BCNU greater than or equal to 100 mg/m2 plus cisplatin, 60 mg/m2 plus cisplatin, 60 mg/m2, plus VM-26, 175 mg/m2. Only 9% of the patients treated with a lower VM-26 dose developed permanent severe toxicity, and the doses that we now recommend are: BCNU, 100 mg/m2; cisplatin, 60 mg/m2; and VM-26, 150 mg/m2. The response rate was also dose-related (100% at the highest doses tested vs. 57% at the lower doses).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of acute subdural hematomas from aneurysmal rupture

Subdural hematomas (SDH) from ruptured aneurysm (RA) are much less common than intracerebral (ICH) hematomas or subarachnoid (SAH) or intraventricular hemorrhage (IVH). With computerized tomography, preoperative diagnosis is now made more often. The authors have collected 18 such cases from a review of 897 cases of RA admitted to eleven medical centers in 1980 and 1981. Nine (50%) of these patients died prior to discharge from hospital. Four (22%) had surgery and died postoperatively and 9 (50%) were operated upon and survived. Thirteen (72%) of the patients showed anisocoria, decreased consciousness and unilateral weakness prior to surgery. Eight (89%) of the fatalities had shown preoperative herniation as opposed to only 5 (56%) of the survivors. The overall incidence of delayed ischemia due to vasospasm was 11% (2 cases). Those who died had greater midline shift and larger SDH on the admission CT scan. Sixteen (89%) of these patients were female. Thirteen (72%) had ruptured aneurysms on the internal carotid artery. All of these hematomas were unilateral and uniformly hyperdense, and the convexity hematomas were crescentic in shape. Seventeen (94%) had evidence of blood in locations other than the subdural space. If the patient is potentially salvageable and has a midline shift, the SDH should probably be evacuated immediately and the aneurysm clipped at the same operation since the development of a tentorial herniation has such an adverse effect on outcome.

Cisplatin plus cytosine arabinoside in adults with malignant gliomas

A combination of cisplatin and cytosine arabinoside was used to treat 21 patients with glioblastomas and 5 patients with recurrent grade II gliomas. Cisplatin 60-100 mg/m2 was given I.V. in 250 ml 0.45% saline and preceded by 500 ml dextrose 5% in 0.45% saline. Mannitol 50 g was given I.V. concurrently with the cisplatin. Cytosine arabinoside 500-1000 mg/m2 was given by rapid I.V. infusion immediately after the cisplatin. Of 25 evaluable patients, 10 (40%) experienced objective tumor shrinkage on CT scan, and 6 (24%) stabilized. There were 2 complete remissions. Patients who had had no prior treatment had a higher response rate (58%) than those previously treated (23%). Myelosuppression occurred in some patients 2-3 weeks after treatment. Gastrointestinal toxicity (vomiting and diarrhea) was dose-limiting. Two patients had possible neurological toxicity. Recommended doses for further studies are cisplatin 90 mg/m2 and cytosine arabinoside 900 mg/m2.

Treatment of malignant gliomas in adults with BCNU plus metronidazole

Twenty-six adult patients with astrocytomas were treated with BCNU (1,3-bis(2-chloroethyl)-1-nitrosourea) 180-240 mg/m2 I.V. every 6-9 weeks, with metronidazole 1.5 g/m2 p.o. 12 h and 1 h before BCNU and again 6 h and 24 h after BCNU. Of twenty-two evaluable patients, 9 (41%) responded with evidence of reduced tumor size on CT scan, 3 (14%) stabilized and 10 (45%) failed. Patients with no prior chemotherapy or radiotherapy, good performance status, low grade tumors, and age less than or equal to 50 years had the highest response rates, although differences were not statistically significant. Median survival and duration of response have not been reached with a median follow-up time of ten months. Hematological toxicity was dose-limiting and was probably not augmented by the metronidazole. There was one death from infection that was possibly drug-related. Gastrointestinal toxicity was substantial, and was probably increased by the metronidazole. While the combination of BCNU and metronidazole were tolerable, the response rate seen was no higher than that noted for BCNU alone, and further studies using this dose-schedule are not recommended in astrocytomas.

Intraventricular hemorrhage from ruptured aneurysm. Retrospective analysis of 91 cases

Intraventricular hemorrhage (IVH) from aneurysm rupture is generally considered to be of grave prognostic significance. Ninety-one cases have been studied retrospectively from seven medical centers. The overall mortality rate was 64%. The dramatically poor condition of these patients leads to their rapid admission to the hospital. Eighty-seven percent were admitted on Day 0 or 1, and more than half were classified neurologically as Grade 4 or 5. A multiple regression analysis explained 56% of the variance in survival, using the variables of ventriculocranial ratio (VCR), day of admission, diastolic blood pressure, location of aneurysm, associated intracerebral hematoma, age, grade on admission, sex, and systolic blood pressure. No patient with a VCR of more than 0.25, as calculated from the initial computerized tomography (CT) scan, survived. No patient whose smallest VCR was 0.23 or more survived. This ratio can be simply measured with a millimeter ruler from the CT scan. Patients with IVH usually had enlarged ventricles, even initially. The overall results suggest that early management of intracranial hypertension should be more generally considered, although even when this was done the prognosis was still guarded. The timing of surgery was not an important determinant of outcome, although a significant number of patients died awaiting surgery.

Timing of surgery for intracerebral hematomas due to aneurysm rupture

✓ Intracerebral hematomas (ICH) from aneurysm rupture are not rare and can now be diagnosed easily and accurately by computerized tomography. The authors have collected 132 such cases from 11 medical centers. Of these patients, 38% died prior to discharge from the hospital. Seventy-eight percent of cases were admitted to the neurosurgical services on Day 0 or 1 after rupture of the aneurysm; of these patients, 15% died without surgery, 28% had surgery and died postoperatively, and 57% were operated on and survived. Mortality rates were increased in patients who were hypertensive, had poor neurological grades, showed evidence of brain herniation, or had larger clots. If the patient lived beyond the first few days and did not have brain herniation, the timing of surgery was not of great consequence, although there was a tendency toward lower morbidity in earlier surgery. This was true despite the fact that earlier operations were carried out on an initially sicker group of patients. Ischemic deterioration attributed to vasospasm occurred in 26% of cases; even when deaths at the acute stage were excluded, it was no more common in patients with early than in those with late surgery. Morbidity and mortality rates were prohibitively high in operations consisting solely of evacuation of ICH without clipping of the aneurysm. Parietal hematomas were particularly dangerous, while those in the temporal lobe were associated with the best outcome. Since it is impossible to predict survival with a high degree of reliability, even when the prognostic indicators are known, the authors recommend that patients with a significant ICH have it removed as soon as possible and that their ruptured aneurysm be clipped at the same time.

Cyanide toxicity following nitroprusside induced hypotension

Several recently reported deaths following the use of sodium nitroprusside have been attributed to the accumulation of the nitroprusside metabolite, cyanide. In this study, brief nitroprusside infusions (mean = 36 minutes) were administered in currently recommended doses during intracranial surgery. The peak blood cyanide following the infusions was 65.2 +/- 17.5 microgram per cent (mean +/- SE) (n = 13). It occurred within 45 minutes after infusion. The highest cyanide level detected was 205 microgram per cent, which is within the range of reported lethal blood cyanide levels. Metabolic acidosis developed in the four patients with the highest blood cyanide levels (range 90-205 microgram per cent). This occurred between 45 and 180 minutes following the cyanide peak. Blood ATP levels were depressed in the same patients. These findings are indicative of disturbed aerobic metabolism. We conclude that there is evidence of cyanide toxicity when nitroprusside is infused into patients using currently recommended doses. We recommend that for short infusions the dose of sodium nitroprusside should not exceed 0.5 mg/kg.