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.

Immunobiology of primary intracranial tumors. Part 10: Therapeutic efficacy of interferon in the treatment of recurrent gliomas

Human lymphoblastoid alpha-interferon was administered intravenously or intramuscularly to 19 patients with recurrent gliomas. Each patient had previously undergone surgery and radiation therapy. The treatment course consisted of 8 weeks of therapy with an escalating daily dosage and number of days of treatment per week to a total dose of 900 X 10(6) U/sq m. Response to treatment was determined by serial computerized tomography (CT) scans. Seven of the 17 evaluable patients were determined to be treatment responders at 12 weeks (1 month after completion of treatment), and the other 10 patients exhibited tumor progression during this period. Median survival time was 511 days for the responders versus 147 days for the non-responding patients. Interferon appears to be efficacious in the treatment of recurrent anaplastic gliomas as defined by CT brain scan responses following therapy.

Effects of induced total-body hyperthermia on phosphorus metabolism in humans

The effects of total-body hyperthermia on phosphorus homeostasis are controversial. To evaluate the problem, 10 clearance studies were performed in seven patients undergoing total-body hyperthermia as an adjunct to the treatment of solid malignant tumors. Total-body hyperthermia was associated with significant reduction in plasma phosphorus concentration from a baseline value of 3.51 +/- 0.18 to 0.6 +/- 0.1 mg/dl (p less than 0.001), returning to baseline following cessation of total-body hyperthermia. The clearance of phosphorus increased from 15.2 +/- 2.5 to 26.1 +/- 3.1 ml per minute (p less than 0.01), and the fractional excretion of phosphorus increased from 11.37 +/- 2.2 to 47.68 +/- 9.7 percent (p less than 0.01). The reduction in plasma phosphorus during total-body hyperthermia was also associated with a significant reduction in the renal threshold phosphorus concentration from 3.17 +/- 0.16 to 0.38 +/- 0.08 (p less than 0.001). The changes in phosphorus homeostasis during total-body hyperthermia were independent of changes in circulating parathyroid hormone level, urinary cyclic AMP excretion, and arterial carbon dioxide tension.

Comparisons of carmustine, procarbazine, and high-dose methylprednisolone as additions to surgery and radiotherapy for the treatment of malignant glioma

Within 3 weeks of definitive surgery, 609 patients with histologically demonstrated, supratentorial malignant glioma were randomized to receive, in addition to 6000 rads of radiotherapy, one of four treatment regimens: carmustine (BCNU), high-dose methylprednisolone, procarbazine, or BCNU plus high-dose methylprednisolone. We analyzed the data for the total randomized population and for the 527 patients (87% with glioblastoma multiforme) in whom the initial protocol specifications were met (the valid study group). Significantly longer survival was experienced by patients receiving procarbazine or BCNU alone compared to those receiving only high-dose methylprednisolone. No other pairwise comparisons demonstrated differences significant at the 0.05 level. However, the combination of BCNU plus high-dose methylprednisolone tended to be less effective than BCNU alone in patients with poor prognosis. This study indicates that BCNU and procarbazine are moderately useful agents in conjunction with radiotherapy for patients with malignant glioma. In addition, future protocols may allow use of corticosteroids in conventional dosages for treating cerebral edema and controlling symptoms; conclusions based on survival as the endpoint are unlikely to be affected by administering steroids at somewhat greater than the usual dose. More effective regimens for the treatment of malignant glioma should be sought.

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.

Potentiation of carmustine-cranial irradiation-induced myelosuppression by cimetidine

In nine patients with glioblastomas, the histamine H2-receptor antagonist cimetidine was found to augment the myelosuppressive activities of carmustine and cranial irradiation. The nadir in neutrophil cell counts in this group averaged 650 +/- 220/microL. In a comparable series of 31 patients who did not receive cimetidine, the lowest neutrophil cell count averaged 2,160 +/0 240/microL. Further, marked suppression of these cells in the patients receiving cimetidine extended through day 42 of the treatment cycle. By contrast, the patients treated with carmustine and cranial irradiation alone did not experience significant neutropenia. This suggests that cimetidine may enhance the myelosuppressive effects of cytotoxic therapy.

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.

1,3-Bis(2-chloroethyl)-1-nitrosourea (BCNU)-induced pulmonary fibrosis

Clinical data are presented on 14 patients undergoing BCNU therapy for a primary intracranial glioma (11 biopsied, 3 suspected) in whom pulmonary fibrosis developed as a consequence of the therapy. Pulmonary diffusion abnormalities, dry hacking cough, and chest x-ray changes herald the onset of the process. Microscopic evaluation of lung specimens revealed a wide spectrum of change including hyaline membrane formation, alveolar septal thickening, interstitial fibrosis, and granuloma formation. It is concluded that BCNU causes pulmonary fibrosis that is primarily but not necessarily dose-related and may not be reversible.

Prediction of BCNU pulmonary toxicity in patients with malignant gliomas: an assessment of risk factors

Symptomatic pulmonary disease occurred in 20 per cent of 93 patients with anaplastic gliomas being treated with carmustine (BCNU). An analysis of the variables has revealed a relation between the occurrence of pulmonary toxicity on the one hand, and the total cumulative dose of BCNU, the number of cycles over which the BCNU was administered, the history of lung disease, the patient's age, and the platelet-count nadir after the first course of BCNU on the other. An equation has been generated that allows prediction of pulmonary toxicity during the course of therapy with BCNU with 80 per cent accuracy. Pretreatment analysis of individual cases should allow safe use of BCNU and prevention of most of the serious pulmonary complications caused by this drug.

Prolonged cerebral "luxury perfusion" after removal of a convexity meningioma

Following total removal of a convexity meningioma, serial computerized tomographic scans disclosed massive hemispheric contrast enhancement compatible with "luxury perfusion". Maximum enhancement occurred one month following the operation and resolved two months postoperatively. Luxury perfusion appeared to be associated with slowly resolving cerebral edema.

Effect of total body temperature on toxicity of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU)

One hundred eighty-two rats were divided into groups to test the effect of three different total body temperature levels on the toxic effect of three different dose levels of 1,3-bis(2-chlorethyl)-1-nitrosourea (BCNU) and to assess the effect of delayed total body temperature elevation on BCNU breakdown products. Results were tabulated on the basis of life survival figures. At depressed total body temperatures (28 degrees C), normally expected toxicity was avoided. Elevated body temperatures, on the other hand, enhanced the toxic effect of BCNU. Delayed total body temperature elevation (3 and 6 days after BCNU administration) created similar toxicity. This finding was not observed when total body temperature elevation was delayed 10 days. The results point toward an interesting interaction between BCNU and heat (immediate and delayed) on the basis of an elevated metabolic rate of tissue, a synergistic effect of two therapeutic modalities, interference with normal reparative processes by the combination, or an enhancement of retained serum protein-bound breakdown products of BCNU.

Preliminary observations on the use of Corynebacterium parvum in patients with primary intracranial tumors: effect on intracranial pressure

It has been observed that patients with metastatic brain lesions developed neurologic symptoms when given Corynebacterium parvum. To obtain more information in patients with intracranial mass lesions, intracranial pressures (ICP) were measured or observed in six patients undergoing C. parvum therapy. All patients except two (one previously shunted, one recently operated) demonstrated a profound increase in ICP. It is presumed that either edema is formed within brain and tumor tissue (inasmuch as neurologic deterioration has not been observed in patients without an intracranial lesion) or transient increases in cerebral blood flow adversely alter an already compromised intracranial volume. Surgical decompression of tumor volume or use of Lasix may abort this response to C. parvum infusion.

Preferential cerebral hypothermia with elective cardiac arrest: resection of "giant" aneurysm

The technique of preferential cerebral hypothermia is reported in its application to a patient with a "giant" anterior communicating artery aneurysm. The method utilizes elective ventricular fibrillation and differential or "preferential" hypothermia induced by a combination of external skin cooling and perfusion of core organs with 0 degree buffered electrolyte solution. The value of the technique lies in its provision of a period of safe circulatory arrest approaching one hour without the need for anticoagulation, heart-lung bypass, open chest resuscitation or major vessel clamping. Because of the absence of blood flow and because of the clear fluid washout of the cerebral vessels, it was possible to open the aneurysm, evacuate its contents and resect it in several sections. It was not necessary to clip the feeding arteries until all dissection and total removal of the aneurysm were completed. The application of the technique to neurosurgery and cardiovascular surgery is discussed.

Materials for selective tissue heating in a radiofrequency electromagnetic field for the combined chemothermal treatment of brain tumors

A technique of creating localized heating by implanting metallic materials in the brain and inserting the head into a radiofrequency electromagnetic field is described. The heating properties of various materials for implantation were studied, and the two best materials were carbon steel rods and Hysterloy (1000 and 655 cal/g-min, respectively). Heating of these materials was done primarily by eddy current since their heating rates were significantly affected by their shapes and orientation in the field, rods oriented parallel to the field producing the most heat. There is evidence that warmer cells have a greater uptake of chemotherapeutic agents. This suggests a combined therapeutic approach employing localized brain heating in conjunction with systemic or intrathecal chemotherapy. In this way, large doses of chemotherapeutic drugs might be concentrated in a warmed brain tumor while toxicity is prevented by keeping the rest of the brain and body hypothermic.

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.

Osteomyelitis of the skull in chronic granulomatous disease of childhood. Case report

✓ A case of osteomyelitis of the skull in a child with chronic granulomatous disease is presented and the diagnosis and treatment discussed.