Dsyembryoplastic neuroepithelial tumour with discrete bilateral multifocality: further evidence for a germinal origin

We report the case of a middle aged woman who developed refractory complex partial seizures in her early twenties. She had a right coloboma and neurological examination was normal. Neuropsychological assessments revealed mild impairments of non-verbal memory, and visuospatial and constructional difficulties. Serial CT and MRI showed multiple nodular abnormalities in her mid-brain, diencephalon, subependymal region and both mesial temporal lobes. EEG recording revealed a right medial temporal focus. She underwent en bloc temporal lobectomy. The surgical pathology revealed mesial temporal dysembryoplastic neuroepithelial tumour (DNET) in association with extensive, contiguous neocortical dysplasia. The proliferation marker MIB-1 revealed up to 2% labelling in tumour areas resembling conventional oligodendroglioma. In the two years since surgery she has been seizure free and the remaining MR brain abnormalities have not changed. The very unusual centripetal MRI pattern of discrete multifocal lesions with the characteristic T1 and T2 features of DNET would support the dysembyroplastic germinal origin that was proposed by Daumas-Duport et al. (1988) in their original description of the lesion. The neuroradiological, neuropathological and clinical features of this case are compared with the two previous cases of multifocal DNET.

Mood disorders in patients after treatment for primary intracranial tumours

The frequency of mood disorder was studied in a cohort of patients with treated intracranial glioma or meningioma, where psychological morbidity was related to physical and neuropsychological functioning and to the patients' knowledge of their disease. Forty patients were assessed on a range of physical, psychological and neuropsychological measures, with additional interview of a relative to obtain supplementary information regarding each patients' knowledge of their disease. Two (5%) of the 40 patients had clinically significant levels of anxiety, six (15%) clinically significant levels of depression and 92% full or intermediate knowledge about their prognosis. Psychological morbidity was associated with high levels of physical disability and also with cognitive dysfunction, but was not related to the grade of the patient's tumour or the extent to which the patient was aware of the nature of his or her disease. A proportion of patients with intracranial tumours suffer levels of psychological distress sufficient to warrant psychological and/or pharmacological intervention.

Tentative novel mechanism of the bystander effect in glioma gene therapy with HSV-TK/GCV system

Although many works support gap junctional intercellular communication (GJIC) having a close relation to bystander cell killing in herpes simplex virus thymidine kinase (HSV-TK) gene and ganciclovir (GCV) treatment, our previous work suggested that other factors involved in bystander effect besides GJIC exist. To confirm our primary work, we evaluated the mode of the bystander cell (C6) co-cultured with TK-positive cells (TF10.2) in our designed "insert plates" in which two cell lines could be separated but share the same medium. Another method that we used was adding the supernatant from the medium of GCV-treated TF10.2 cells to the wild type C6. Growth inhibition of the bystander cells was observed despite the absence of GJIC. In addition, apoptotic cell death of TK+ cells and bystander cells was obvious. These studies suggested that other pathways besides cell-cell contacts may play a role in bystander cell killing; the factors released from TK-positive cells could induce apoptosis of bystander cells.

The use of diffusion tensor imaging in quantifying the effect of dexamethasone on brain tumours

The role of dexamethasone in the treatment of patients with brain tumours remains poorly understood. In this study the self-diffusion parameters of extracellular water within primary intracranial tumours and peritumoural tissue, and their response to dexamethasone, have been measured using MR diffusion tensor imaging. Maps of the mean diffusivity <D> and two measures of diffusion anisotropy were obtained from six patients before, and typically 48-72h after, commencing dexamethasone treatment. A significant decrease in <D> of either tumour (p < 0.02) or oedematous brain (p < 0.04) was observed in three patients. No significant changes were noted in either of the two calculated diffusion anisotropy indices before and after steroid treatment in any of the six patients.

Platinum distribution in malignant glioma following intraoperative intravenous infusion of carboplatin

The objective of this paper was to determine the time course and extent of platinum uptake into human malignant glioma tissue. An intraoperative, intravenous infusion of carboplatin was given to nine patients (seven glioblastoma and two anaplastic glioma) undergoing tumour excision. Carboplatin dosage was calculated individually to achieve a target systemic free carboplatin exposure. Tumour and peritumoural tissue was harvested at timed intervals following carboplatin administration. Plasma and tumour platinum concentrations were measured by graphite furnace flameless atomic absorption spectrophotometry. Histological examination was also performed on a piece of each tissue sample. The mean carboplatin dose administered was 783, SEM 56 mg (range 485-903). Plasma pharmacokinetics showed a typical elimination curve. The mean peak plasma platinum concentration was 44, SEM 5 micrograms/ml (range 27-74). The mean total elemental plasma platinum area under the curve (AUC) was 9.0, SEM 1.4 mg/ml/min. Platinum was detected in 61 tumour samples, the mean peak concentration being 13 SEM 2 micrograms/g (range 5-21). Platinum was also detected in peritumoural brain and necrotic tumour. No correlation was apparent between the degree of necrosis in each tumour specimen and tumour platinum concentration. Platinum concentrations achieved in tumour were similar to levels that would be cytotoxic for glioma cells in vitro. The results of this study have implications for future studies using capillary permeability modifying agents as adjuncts to brain tumour chemotherapy.

Dynamics of reactive oxygen intermediate production in human glioma: n-6 essential fatty acid effects

BACKGROUND

Reactive oxygen intermediates (ROIs) are important signals controlling cell growth and cell death. Local essential fatty acid (EFA) deficiencies in tumour cells may limit tumour ROI generation. This deficiency may be rectified by the addition of exogenous EFA.

MATERIALS AND METHODS

The n-6 EFA effects on tumour ROIs were analysed in terms of kinetics, dose-response and individual cell type responses using flow cytometry of intracellular 2',7'-dichlorofluorescin oxidation. ROI formation in 30 gliomas and five paired samples of normal brain tissue, > 500 000 cells per specimen, was analysed every 10 s for 0-25 min.

RESULTS

Tumour cell basal ROI was lower than normal brain tissue ROI from the same subjects (P < 0.00002). Normal and tumour cell ROIs were stimulated by 4-40 micromol L-1 n-6 EFAs, arachidonic acid (AA) and gamma-linolenic acid (GLA). The stimulated ROI rate was exponential, with the maximum dependent on EFA concentration and tumour grade.

CONCLUSIONS

EFAs stimulated tumour cells more than normal cells (P < 0.0000017, n = 71) and increased ROIs in glial fibrillary acidic protein-positive cells in tumours. This indicated high sensitivity of glioma cell ROIs to n-6 EFAs.

Anxiety and depression in patients with an intracranial neoplasm before and after tumour surgery

The aims of this prospective study were to investigate levels of anxiety and depression in patients with a solitary intracranial neoplasm before and after surgery, and to determine if relationships exist between high levels of anxiety or depression and the hemispheric location of the tumour, the tumour type or patient gender. Patients aged between 17 and 79 years with a solitary intracranial neoplasm completed the Hospital Anxiety and Depression Scale (HAD) before and after biopsy or resective tumour surgery. A control group of non-brain-damaged subjects also completed the HAD before and after lumbar spinal surgery. Of the 109 patients with a brain tumour 30 and 16% demonstrated the likely presence of anxiety and depression, respectively, according to HAD scoring criteria. A greater proportion of females with a left hemisphere tumour reported higher levels of emotional disturbance than any other group of patients; relationships between dysphasia and levels of anxiety or depression were not significant. Patients with a meningioma had higher levels of anxiety and depression as measured by the HAD than those with any other tumour types. Levels of both anxiety and depression were significantly lower after tumour surgery according to the HAD. There were no significant differences in HAD scores between (a) left and right hemispheric tumour groups, and (b) the tumour and control (n = 20) groups. This study has found that anxiety and depression as measured by the HAD are relatively uncommon in patients with an intracranial neoplasm, and that levels of mood disturbance do not differ significantly from those in patients undergoing lumbar spinal surgery. Levels of anxiety and depression become lower after surgery in patients with a brain tumour. Patterns of anxiety and depression in patients with a brain tumour appear to differ from those reported in stroke.

Apoptosis in human primary brain tumours

Apoptosis, or programmed cell death, has been recognized for nearly three decades as occurring in many organs in response to different pathophysiological stimuli. It is now recognized as one of the fundamental cellular biological processes. In human glioma it was initially identified as 'shrinkage necrosis'. This review outlines the characteristics of apoptosis in the various types of primary human brain tumours. The significance of apoptosis is reviewed in relation to normal and tumour cell dynamics, cellular susceptibility to normal and oncogenic signals and to potential therapeutic advances. On a practical level, methods which are currently used to analyse different aspects of the apoptotic process are introduced. These techniques for analysing apoptosis are critically evaluated and compared. Current developments elucidating the diverse pathways of apoptosis signalling are also reviewed. The potential of pro-apoptotic therapy for the treatment of gliomas is discussed.

Assessment of communication impairment and the effects of resective surgery in solitary, right-sided supratentorial intracranial tumours: a prospective study

To assess the effects of solitary, right-sided supratentorial intracranial tumours on language and communication function patients were assessed preoperatively using the Western Aphasia Battery (WAB) and Boston Naming Test (BNT). The impact of resective tumour surgery was evaluated prospectively by a comparison of test scores obtained at pre- and postoperative assessments. The WAB scores in 33 patients revealed that 21% were by definition dysphasic (i.e. Aphasia Quotient < 93.8) and 35% obtained an abnormal Language Quotient. Performance was particularly variable on the written picture description and word fluency WAB subtests. Using the BNT 21% of 47 patients were anomic. The tumours were evenly distributed throughout the frontal, temporal and parietal lobes, but none were in the occipital lobe. Reassessment approximately 6 days after excisional tumour surgery showed that mean scores for the BNT, Aphasia Quotient, and the WAB spontaneous speech and comprehension subtests had improved significantly despite a significant reduction in dexamethasone therapy. This study has demonstrated that right-sided intracranial tumours produce subtle, but specific language deficits of a type more usually associated with left-sided brain dysfunction. The pathophysiological basis of these deficits is unclear, but they are not attributable to either limited education or pre-existing dyslexia. Further studies using a discriminating and comprehensive assessment of language in the right hemisphere are required.

Rater reliability of Fahn's tremor rating scale in patients with multiple sclerosis

OBJECTIVE

Assessment of movement disorders in patients with multiple sclerosis (MS) is difficult because of the complex nature of the movement disorders. The aim of this study was to determine the reliability of Fahn's Tremor Rating Scale (FTRS) in assessing movement disorders in patients with MS.

METHOD

Videos were made of 10 patients with MS showing their rest, postural, action/intention, and goal-related movement disorders as well as their performance of spirometry, a volumetric task, and timed functional tasks. Ratings of tremor were carried out by one rater on two occasions 3 months apart and by 8 raters on one occasion using FTRS.

RESULTS

Intrarater reliability was generally very good, with no significant "drift" in ratings over time. Interrater reliability was generally good, with some variation in interpretation of scoring criteria that may reflect raters' backgrounds.

CONCLUSION

The FTRS is a reliable and potentially useful tool with which to assess movement disorders in patients with MS.

Neuropathological findings after intracerebral implantation of microdialysis catheters

The neuropathological and immunocytochemical changes in the sheep forebrain following 7 days of microdialysis, using a catheter approved for human use, are described. There was no behavioural dysfunction and light microscopy revealed mild astrogliosis and patchy macrophage infiltration immediately adjacent to the catheter track. The surrounding neuropil was normal. There was one small subcortical haemorrhage (10 x 1.5 mm). These findings are similar to those following microdialysis in rodents and suggest that the risk of significant damage to the human brain is low, that neuropathological changes in the brain around the catheter should not interfere with local brain metabolism, and that the catheter should be affixed in such a way as to minimize movement-induced damage to the brain.

Effects of nitric oxide modulation on tumour blood flow and microvascular permeability in C6 glioma

C6 glioma strongly express nitric oxide synthase. Rats bearing C6 tumours were pre-treated with i.v. Ng-nitro-L-arginine methyl ester (L-NAME), 3-morpholinosydnonimine (SIN-1) or saline before local cerebral blood flow (LCBF) or tumour capillary permeability (TCP) was measured by the [14C]iodoantipyrine autoradiographic or [14C]alpha-amino-isobutyric acid techniques. L-NAME and SIN-1 caused significant TBF alterations (-44% and +136%, respectively) with less marked (-15% and +33%) alterations in normal brain. Calculated cerebrovascular resistance changes within tumour were indeed selective. Baseline TCP was increased compared with normal brain (20-fold). L-NAME and SIN-1 administration did not alter TCP. These effects have significant implications for human malignant glioma management. Selective i.v. manipulation of LCBF, without significant changes in TCP, could increase the efficacy of chemotherapy, radiotherapy or provide better peritumoural oedema control.

Application of the MRC brain tumour prognostic index to patients with malignant glioma not managed in randomised control trial

OBJECTIVES

The MRC brain tumour prognostic index, which uses clinical variables to place patients in different outcome categories, has not been evaluated on a cohort outside a randomised controlled trial. The aims of this study were to (a) determine in a large cohort of patients, derived solely from one centre and not in a clinical trial, whether the MRC prognostic index stratified patients for outcome; (b) compare actual outcomes with those obtained in the original studies; and (c) examine whether neuropathological diagnosis was an independent prognostic variable.

METHODS

The MRC prognostic index was calculated for 236 patients with either glioblastoma or anaplastic astrocytoma managed at a dedicated neuro-oncology clinic in Edinburgh between 1989 and 1995.

RESULTS

For this mixed population of malignant glioma the median survival was 8.6 months. Two year survival was 72.2% for patients with an MRC index score of 1-10; 36.3% for those with an index score of 11-15; 25.1% for those scoring 16-20; 20.4% with those scoring 21-25; 4.8% with those scoring 26-33; and 0% for those scoring 34-38. Exclusion of 79 patients who would not have been eligible for the MRC studies from which the index was derived, because they were either too old or did not receive radiotherapy, still resulted in a similar pattern of stratification but with significantly improved median survival times for the lowest two categories. Multivariate analysis of prognostic variables in the Edinburgh cohort showed that patients with anaplastic astrocytoma did significantly better than those with glioblastoma (p<0.001).

CONCLUSIONS

Although there were some differences in median survival times between the patients in the original MRC studies and the Edinburgh cohort in similar prognostic categories and a tendency to improved two year survivorship in the Edinburgh cohort these differences have arisen because (a) the Edinburgh cohort was accrued about 10 years later than the study has shown that even outside the setting of a prospective controlled trial and with relaxed inclusion criteria the Medical Research Council (MRC) prognostic index is a robust predictor of outcome in patients with malignant glioma. Survival clearly declines as the prognostic index increases. Moreover, the prognostic model can be substantially improved by the addition of histology data, although there is some evidence that this will require complex modelling procedures.

Pineal apoplexy: an occurrence with no diagnostic clinicopathological features

Symptomatic pineal apoplexy unlike pituitary apoplexy is uncommon. A patient with an apoplectic pineal cyst, identified preoperatively using MRI and confirmed histologically presented with episodic syncope, and features of raised intracranial pressure, but no localizing neuro-ophthalmological signs. This case prompted a review of the clinicopathological features of pineal apoplexy. There are no diagnostic clinical features and the neuropathological associations of pineal region haemorrhage are diverse. There is no consistent clinicopathological syndrome of pineal apoplexy.

Effects of resective surgery for left-sided intracranial tumours on language function: a prospective study

BACKGROUND

Although language disorders occur in about 50% of patients with a left hemispheric tumour and are a significant cause of morbidity, the effects of resective neurosurgery and their relation to tumour pathology are unclear. We report the immediate effects of resective surgery on language functions in a heterogeneous group of patients with left-sided intracranial tumours.

METHODS

40 patients were studied. The Western Aphasia Battery (WAB) and Boston Naming Test (BNT) were administered preoperatively and before discharge following resective neurosurgery. Dexamethasone dose at time of testing was recorded, as was time taken to complete the tests, and tumour neuropathology.

FINDINGS

15 patients with normal aphasia quotients and language quotients before resective surgery all had normal quotients postoperatively. 25 who were dysphasic (ie, aphasia quotient <93.8) preoperatively showed significant postoperative improvements in both their mean aphasia quotient (from 81.8 to 89.1, p=0.004) and their mean language quotient (from 73.4 to 85.4, p=0.001), though 13 remained dysphasic. Two of the 25 dysphasic patients had their WAB scores lowered by tumour resection. The findings and postoperative changes in BNT scores were almost identical to the pattern of those in WAB scores. At second assessment, dexamethasone therapy was significantly (p<0.01) lower than preoperative dose (reduction from mean 10.3 mg/day to 0.7 mg/day in the dysphasic group). Patients with glioblastoma were more likely to have lower aphasia quotients, language quotients, and BNT scores than patients with anaplastic glioma, metastasis, or meningioma. Although the glioblastoma group had the greatest improvements in WAB operative scores, 57% remained dysphasic after resective surgery. Two additional patients declined postoperative assessment.

INTERPRETATION

Resective surgery for left-sided intracranial tumours significantly improves language function in dysphasic patients, and is unlikely to impair language functions in non-dysphasic patients. Dysphasia and its response to resective surgery are related to the tumour neuropathology.

The costs of managing patients with malignant glioma at a neuro-oncology clinic

Malignant glioma (glioblastoma and anaplastic astrocytoma) remain incurable despite extensive resection, radiotherapy, chemotherapy and experimental therapies. Few studies have addressed either the costs of various treatments for malignant glioma or their cost effectiveness. The aims of this study were to identify direct hospital costs of treating patients with biopsy proven malignant glioma. The study was carried out within the setting of a dedicated neuro-oncology clinic at a university teaching hospital and included 236 patients treated between 1989 and 1995. The study used the unit costing of each item of treatment according to NHS National Costing Project. The cost of treatment was broken down into its various components: bed days, investigations, surgery, radiotherapy, chemotherapy and neuro-oncology out-patient follow-ups. The mean costs for each of the items based on 1995 figures for the 157 patients having surgery followed by radiotherapy were neuroradiological investigations (442 Pounds), neurosurgical bed days (2407 Pounds), neurosurgery (2068 Pounds), neuropathology (434 Pounds), radiotherapy (8832 Pounds), out-patients (1078 Pounds) and chemotherapy (440 Pounds). Total treatment costs per patient ranged from 1978 Pounds to 26,980 Pounds. Median costs of care decreased sequentially with worsening MRC Brain Tumour prognostic group. Management of patients with the best prognosis (MRC index score of 1-10) cost a median of 16,550 Pounds (range 4572-26,090 Pounds) whilst the median management cost of those in the worst prognostic group (MRC score 34-38) was 6514 Pounds (range 1978-18,360 Pounds). The median cost of each week of survival in the patients with the best outcome (MRC score 1-10) was < 150 Pounds compared to 232 Pounds for each week of survival for patients in the worst prognostic group (MRC score 34-38). This study made no attempt to collect costs of supportive or community-based care. Prospective studies are required to collect such data, as well as assessing the costs effectiveness of alternative treatment strategies.