Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery

Immunological and biochemical strategies for the identification of brain tumor-associated antigens

Various strategies have been used to identify and characterize the antigens associated with human brain tumors. These approaches have included the raising of polyclonal and monoclonal antibodies against tumor antigens and, more recently, efforts toward the direct biochemical identification of such proteins. This review summarizes the progress made in this area, suggests reasons for the broad antigenic cross-reactivity and heterogeneity revealed by these studies, and proposes additional methods for deciphering the complex antigenic composition of human brain tumors.

Chemotherapy for malignant gliomas

There continues to be an extensive effort to develop chemotherapeutic approaches to the treatment of malignant gliomas of the brain. In the past 5 years there have been literally hundreds of trials of new agents, combinations of old and new agents, and even new routes and approaches to the delivery of chemotherapy. In this review, the literature has been studied and the individual reports analyzed to evaluate the impact of the new findings on clinical management of the patient with malignant glioma of the brain. The major areas of progress include the addition of new drugs with varying modes of action, the use of combinations of drugs in a synergistic fashion, and the development of new routes of drug delivery. None of the advances has brought about the revolution in clinical care that is so eagerly sought, but clearly the amount of new knowledge gained by these studies helps in understanding how to use chemotherapy more effectively. Furthermore, the remarkable degree of interest and involvement in the use of chemotherapy promises that an even greater number of patients with malignant gliomas will be considered for vigorous and enthusiastic clinical management programs even if chemotherapy itself is not the key modality in the treatment of a specific patient.

Photodynamic therapy of malignant brain tumours: a phase I/II trial

Twenty patients bearing malignant brain tumours (18 glioblastoma multiforme, one malignant meningioma, one melanoma metastasis) were treated 25 times with photodynamic therapy (PDT)--the combination of Hematoporophyrin derivative and light at 630 nm (40-120 J/cm2). Sixteen times the PDT was followed immediately by a single dose radiation of 4 Gy of fast electrons. Conventional radiotherapy following PDT was performed in eight patients. The median survival of three patients with multiple recurrences of glioblastoma grade IV and various chemo- and radiotherapy was 5 months. Four out of 10 patients with one recurrence and prior treatment died with a median survival of 5 months, six are still living up to 12 months. Six patients with a primary glioblastoma are surviving now up to 22 months. Phototoxicity to the skin, the only side effect of PDT, was noted in five cases, but did not pose any threat to the patients. The treatment did not affect the quality of life of the patients. Our preliminary results with the photodynamic treatment of malignant gliomas indicate that PDT might be a valuable addition to our armament in the treatment of such tumours.

Neutron interstitial brachytherapy for malignant gliomas: a pilot study

Fifty-six patients with malignant glioma were treated with implantation of the neutron-emitting element californium-252 (252Cf) within 2 weeks after surgical debulking of the tumor. Implantation was performed using computerized tomography-guided placement of afterloading catheters, and the 252 Cf sources were removed after approximately 300 neutron rads were delivered. Patients then received 6000 to 7000 conventional photon rads by external beam. The total photon-equivalent dose to the tumor ranged from 8100 to 9100 rads. The median survival time was 10 months, with 18-and 24-month survival rates of 28% and 19%, respectively. The results of reoperation or autopsy showed that patients had recurrence of the tumor but that radiation necrosis was restricted to the area of the original tumor. Serious complications occurred in five patients (9%) and consisted of wound infections in three, cerebral edema in one, and radiation necrosis beyond the original tumor margin in one. Previous studies using external-beam neutron radiation have shown that neutrons are capable of totally eradicating malignant gliomas; however, in most cases, unacceptable widespread radiation necrosis has resulted. Neutron implants are a logical way to increase the dose to the tumor and decrease the dose to normal brain. Interstitial neutron radiation can be given safely with 252Cf, and the survival results achieved by radiation alone using relatively low doses of interstitial neutron radiation from 252Cf implants plus conventional photon radiation were equal to the results attained with any currently available conventional therapy.

Adjuvant high-dose photoradiation therapy in the treatment of cerebral glioma: a phase 1-2 study

A Phase 1-2 study of high-dose photoradiation therapy was performed in 23 patients with cerebral tumors. Twenty-two patients had high-grade gliomas (13 glioblastomas, six recurrent glioblastomas, two anaplastic astrocytomas, and one recurrent anaplastic astrocytoma) and one had a right frontal metastasis from a carcinoma of the lung. Hematoporphyrin derivative was administered to these patients in a dose of 5 mg/kg and, 24 hours later, they all underwent a craniotomy with radical excision of the tumor. The tumor bed was then irradiated with 630 nm of laser light from either an argon dye laser or a gold metal vapor laser for between 43 and 94 minutes, receiving total doses of 70 to 120 J/sq cm (six cases) or 120 to 230 J/sq cm (17 cases). The temperature of the tumor bed was kept below 37 degrees C by irrigation. Fifteen patients who developed new tumors underwent postoperative radiotherapy (45 Gy in 20 divided doses). There was no evidence of increased cerebral edema and no other toxicity from the therapy. All patients were discharged from the hospital within 18 days of surgery. Four of seven patients with gliomas have suffered a further recurrence at 12 to 16 weeks, and two of 15 patients with primarily treated gliomas experienced recurrence at 3 and 13 months following therapy. Fifteen patients have had no recurrence of their tumor and are alive and well at a median follow-up period of 7 months (range 1 to 16 months). It is concluded that photoradiation therapy using 5 mg/kg of hematoporphyrin derivative and 630 nm light at doses of up to 230 J/sq cm can be used as an adjuvant to surgery and radiotherapy with no additional complications.

Monitoring of 57Co-bleomycin delivery to brain metastases and their tumors of origin

The concentration of cobalt-57 (57Co)-labeled bleomycin delivered to three brain metastases and to their tumors of origin in the lungs was measured using a single-photon emission computerized tomography technique. In two brain metastases the 57Co-bleomycin concentration measured at different times after the intravenous injection was significantly lower than that in the originating lung tumors (p less than 0.01 and p less than 0.001). In these two patients, the tumor cumulative concentration (TCC) of drug in the brain neoplasm compared to the lung carcinoma was 12.92 versus 15.12 and 10.30 versus 19.74 micrograms/cc/min. In the third patient there was no significant difference in drug concentration between the tumor in the brain and in the lung (TCC 16.02 vs. 15.09 micrograms/cc/min). There was a significant difference in the drug TCC between the three brain metastases: the difference between the lowest and highest concentrations was more than 50% (10.3 vs. 16.02 micrograms/cc/min). When the concentration in the tumor over time (CT(t)) of the 57Co-bleomycin was compared in the brain and lung tumors, a good correlation was found in each of the three cases (r = 0.93, 0.99, and 0.97). This suggests that the difference in drug uptake between brain metastases and their originating lung tumor is a quantitative rather than a qualitative phenomenon. The results show that the amount of drug to which brain metastases are exposed varies and may be very low in some tumors; therefore, effectiveness of drug delivery may play a role in the nonresponsiveness of brain metastases to treatment.

Primary cerebellar glioblastoma multiforme

Glioblastoma multiforme in adults arising in the cerebellum is a rare tumor, well documented in only 13 cases in the literature. We report a fourteenth case, an 80-year-old female, and reassess the clinical and CT aspects of this tumor based on review of the world's literature. The median age of patients is 53 years with a median survival of three months, which is less than adult cerebral hemisphere malignant gliomas.

Intracarotid infusion of ACNU and BCNU as adjuvant therapy of malignant gliomas. Clinical aspects and critical considerations

Thirty patients with malignant gliomas were treated by operation, radiotherapy and additional intracarotid infusions of ACNU and BCNU. Positive results were obtained in the treatment of oligodendrogliomas and astrocytomas grade III and IV. On the contrary, the results in cases of glioblastoma multiforme were disappointing: neither survival time nor quality of life had been significantly improved. The protective effect of phenobarbitone against systemic toxicity by ACNU was not always confirmed in this study. Based on literature reports and our own experience the indications, technical aspects, unexpected complications and results of this therapeutic approach are discussed.

Contribution to the problem of giant cell astrocytomas

Histological, immunocytochemical, and biological features of 38 giant cell gliomas were investigated. The invasion of these tumors and its giant cells by histiocytes, lymphocytes, plasma cells, and especially by eosinophilic granulocytes is viewed as an immune response, which may explain a favorable clinical course. Fifty-three percent of the patients were younger than 45 years at the time of surgery. The average postoperative survival of 27.4 months was clearly longer than in glioblastoma. These biological features suggest a differentiation from glioblastoma multiforme. The classification of this entity as "monstrocellular astrocytoma" is proposed.

Supratentorial malignant gliomas in childhood: a review of fifty cases

From 1977 to 1986, 50 children aged 15 months to 18 years were treated for supratentorial malignant gliomas at the Memorial Sloan-Kettering Cancer Center and the New York University Medical Center. Thirteen patients had glioblastoma multiforme, 29 had anaplastic astrocytomas, and 8 had malignant gliomas. In 10 patients the tumor evolved from a low-grade lesion. Seven patients, including 2 patients with neurofibromatosis, developed multiple primary malignant neoplasms. The median time to tumor progression after surgery was 31 weeks, with local recurrence representing the mode of treatment failure in nearly all patients. Notable clinical features included symptomatic leptomeningeal metastasis (13 patients) and intratumoral hemorrhage (9 patients). The estimated median survival time for all 50 patients was 98 weeks, with a 3-year survival rate of 32%. A trend toward longer survival was seen in patients 12 years of age or younger at diagnosis. There was no apparent correlation between survival and tumor histology or tumor location. Recommendations for management are presented.

Cell cycle perturbation of cultured C6 glioma cells following short-term contact with a low dose of ACNU

The purpose of this study was to investigate the cell cycle perturbation of cultured C6 rat glioma cells induced by 1-(4-amino-2-methyl-5-pyrimidyl)methyl-3-(2-chloroethyl)3-nitrosourea hydrochloride (ACNU) using simultaneous flow cytometric measurements of DNA and bromodeoxyuridine (BrdU) content. A new graphic computer program permitted the quantification of cell density in hexagonal subareas and allowed the fraction of BrdU-labeled cells with mid-S phase DNA content (FLS) to be defined in a narrow window. The cell kinetic parameters such as cell cycle time (Tc) and S phase time (Ts) were estimated from a manually plotted FLS curve at 18 and 6 hr, respectively. The major effect of ACNU on the cell cycle was an accumulation of the cells in the G2M phase 12 to 24 hr posttreatment when compared to G2M traverse of untreated cells. For the two-dimensional analysis, cells were labeled with BrdU and then treated with ACNU, or treated with ACNU and then labeled with BrdU. It was concluded that the cells in the S and G2M phases at the time of ACNU administration progressed to mitosis but that the G1 phase cells accumulated in the subsequent G2M phase. Two-dimensional FCM analysis using BrdU provided a useful tool in studying cell cycle perturbation.

Potent and specific killing of human malignant brain tumor cells by an anti-transferrin receptor antibody-ricin immunotoxin

Immunotoxins are hybrid molecules which combine the exquisite selectivity of monoclonal antibodies with the potent toxicity of protein toxins. An immunotoxin was constructed by linking a murine monoclonal antibody against the human transferrin receptor (TR) to the plant toxin, ricin. The cytotoxic activity of the anti-TR-ricin immunotoxin was tested in vitro and demonstrated highly potent and cell type-specific killing of cells derived from human glioblastoma, medulloblastoma, and leukemia. The anti-TR-ricin immunotoxin killed more than 50% of "target" cells at a concentration of 5.6 X 10(-13) M after an 18-hour incubation with the ionophore, monensin. This potency exceeds that of any other anti-TR immunotoxin reported in the literature. When the activity of the anti-TR-ricin immunotoxin against "target" tumor-derived cells was compared with the immunotoxin's activity against "non-target" cells, it could be predicted that a selective toxicity of anti-TR-ricin immunotoxin between tumor cells and normal brain was more than 150- to 1380-fold. Solid-phase indirect radioimmunoassay techniques were used to demonstrate significantly higher levels of TR in the glioblastoma- and medulloblastoma-derived cell lines, as well as in surgical tissue samples of medulloblastoma and glioblastoma, as compared to normal brain. Immunotoxins targeted to the TR may possess sufficient specificity to be of therapeutic importance, particularly to treat neoplastic disease of the central nervous system involving compartments (such as intrathecal, intraventricular, or cystic) where delivery of immunotoxins to tumor would not require transvascular transport.

Randomized phase III trial of single versus multiple chemotherapeutic treatment following surgery and during radiotherapy for patients with anaplastic gliomas

In 81 patients with anaplastic supratentorial gliomas, single versus multiple chemotherapeutic agents were selected for treatment following surgery and during radiotherapy in a prospective randomized study. Time to treatment failure and survival were not significantly enhanced by multiple agent chemotherapy, as administered in this study.

Simultaneous radio- and chemotherapy of inoperable brain tumours

Between January 1980 and May 1985, 102 patients (68 men, 34 women, median age 47 years) with malignant brain tumours (35% glioblastoma multiforme, 30% astrocytoma grade III, 21% oligodendroglioma grade III) have been treated in our clinic. All tumours were inoperable because of their size and/or location. The diagnosis was confirmed histopathologically (stereotactic biopsy or subtotal resection). Seventy-five patients without previous radiotherapy received three courses of a concomitant radio- and chemotherapy with free intervals of 5 weeks between the courses of the therapy. Using lateral opposing fields the whole brain was irradiated with 60Co in daily fractions of 1.5 Gy up to 15 Gy per course of the treatment. Simultaneously, all patients received ifosfamide on five consecutive days in a dosage of 1.2 g/sqm body surface each day i.v. On days 1, 3 and 5, BCNU was given additionally in a daily dosage of 30 mg/sqm body surface i.v. After three courses, a total radiation dose of 45 Gy was administered to the whole brain. Directly after the last cycle of the combined treatment the primary tumour was boosted up to 50-60 Gy using smaller portals. Seventy-one of the 75 patients were amenable to statistical analysis. The overall tolerance was good. No severe haematological or gastrointestinal complications occurred. According to the criteria of the UICC, 12 complete remissions (CR) (i.e. 16.9%) and 35 partial remissions (PR) (i.e. 49.3%) were achieved. In 21 cases (i.e. 29.6%), the progression of the tumour could be stopped. Depending on the histopathological classification of the malignancies survival rates between 64.3% and 87.5% were achieved for one year.(ABSTRACT TRUNCATED AT 250 WORDS)

Vidarabin-monophosphate, BCNU, VM26--an in vitro comparative study of active agents in the treatment of malignant human brain tumours

BCNU (carmustine), VM26 (teniposide) and ARA-A5'P (vidarabin-monophosphate) were compared in their activity against 30 cell lines of primary (N = 21) and metastatic (N = 9) human brain tumours, which were characterized in tissue culture by cytochemical, immunological and cytogenetic criteria. In vivo achievable concentration-time products c X t were correlated with in vitro pharmacokinetic data in order to evaluate in vitro drug sensitivity at relevant exposure doses. A microcytotoxicity assay was employed to screen for drug toxicity in individual tumour cell lines. Following drug exposure and 5 to 8 population doubling times of untreated controls, RNA-synthesis - as a parameter of cell metabolism and proliferation - was determined by incorporation of [5,6-3H]-uridine into cellular RNA (liquid scintillation counting protocol). The cytotoxic effect of each drug on individual cell lines was expressed in terms of a sensitivity index (SI); by these means effects of different drugs on individual tumour cell lines could be compared. Mean sensitivity indices of ARA-A5'P, BCNU and VM26 for primary brain tumour cell lines were 0.59, 0.82 and 0.54. ARA-A5'P and VM26 had almost similar activities against brain tumour cell lines, whereas BCNU was significantly (P less than 0.001) less active. High grade gliomas were less sensitive to all three agents than low grade and infratentorial gliomas. ARA-A5'P was also able to effectively reduce colony formation in brain tumour cell lines. A cross-resistance of ARA-A5'P to either BCNU or VM26 could not be observed. Clearly, ARA-A5'P is an effective drug in treatment of brain tumour cells in vitro.

Pharmacokinetics of recombinant interferon-alpha 2 following intralesional administration in malignant glioma patients

Pharmacokinetics of recombinant interferon-alpha 2 (rIFN-alpha 2) following intralesional administration into patients with malignant gliomas was investigated. A dose of 5 X 10(6) IU of rIFN-alpha 2 was injected locally postoperatively for 2 weeks each day, and the same dose was then given once a week for 10 additional weeks. During the daily and weekly administration, the IFN was consistently present in the fluid of the postsurgical cavity. Not until 5 weeks after the end of the IFN administration was the IFN undetectable. The decay of IFN injected was minimal.

Radiation treatment with twice a day fractionation versus conventional fractionation in high grade astrocytoma. A retrospective study

A consecutive series of 73 patients with high grade astrocytoma treated by surgery and postoperative radiotherapy was analysed. A total tumour dose of 60 Gy was delivered with either 2 Gy daily fractions (24 patients) or twice a day 1.5 Gy fractions, with a 4-hour-interval (49 patients). The analysis of survival with respect to patient variables showed that age and performance status were significant prognostic factors. As the type of fractionation was not randomly assigned, the comparison between the conventional schedule (CF) and the multifractionated schedule (MFD) was performed by means of a multivariate analysis adjusting for basic prognostic factors; CF proved to be significantly superior to MFD. The possible reasons for the disagreement between our results and the theoretical expectations in favour of MFD are discussed.

Experimental cerebral and plasma pharmacokinetic studies of TCNU: implications for brain tumour chemotherapy

This study of the pharmacokinetics of TCNU, a new nitrosourea, in the rodent has shown that TCNU concentrations in the plasma (ng/ml) and brain (ng/g) are equivalent from 15 min to 4 hours after drug administration. The absolute levels of TCNU obtained with a dose of 100 mg TCNU/kg bodyweight were at most time points, three to four times those obtained with dosage of 25 mg TCNU/kg. The profile of rodent plasma TCNU levels following drug administration is similar to that recorded in humans, with peak TCNU concentrations occurring around 45 min. Since TCNU crosses an intact blood brain barrier (BBB), and clinical Phase I trials have shown it to possess potent antitumour properties. It may be a useful agent in the management of primary and secondary cerebral neoplasia.

Radiation therapy for neoplasms of the brain

The effectiveness and complications of radiation therapy for brain neoplasms are reviewed. While the available data suggest a favorable influence and outcome, randomized studies are needed to further optimize radiation therapy techniques and to integrate new therapeutic modalities.

Lymphokine activated killer (LAK) cell mediated killing of human glioma: effect of pretreating glioma with various membrane modifying agents

The killing of human glioma by lymphokine activated killer (LAK) cells was studied. LAK cells generated by culturing recombinant interleukin-2 (IL-2) with human peripheral blood lymphocytes (PBL) obtained from normal volunteers markedly lysed allogeneic glioma grown in tissue culture. Susceptibility of glioma to lysis by LAK cells was abrogated by pretreating the glioma cells with trypsin or chymotrypsin, but was unaffected by pretreatment with hydrocortisone, neuraminidase, glycosidases or sodium periodate. These results suggest that the cell surface determinant on human glioma cells responsible for its tumor selective lysis by LAK is a protein sensitive to trypsin and chymotrypsin.

Therapy of malignant brain tumors: comparison of the in vitro activities of vidarabin-monophosphate, BCNU and 5-fluorouracil

BCNU (carmustine), 5-Fluorouracil (5-FU) and Vidarabin-monophosphate (ARA-A5'P) were compared in their activities against 30 cell lines of primary (n = 21) and metastatic (n = 9) brain tumors, which were characterized in tissue culture by cytochemical, immunological and cytogenetic criteria. In vivo achievable concentration-time products were correlated with in vitro pharmacokinetic data. A micro assay was employed to screen for drug toxicity in individual tumor cell lines; cells were exposed to the drugs at exposure doses relevant to in vivo pharmacokinetics. After 5-8 population doubling times of untreated controls, RNA-synthesis, as a parameter of cell metabolism and proliferation, was determined by incorporation of (5, 6-3H)-uridine into cellular RNA (liquid scintillation counting protocol). A tumor stem cell assay was performed under similar conditions. The cytotoxic effect of each drug on individual cell lines was expressed in terms of a sensitivity index SI (SI = 1 indicating complete resistance) to compare effects of different drugs on the individual tumor cell lines. Mean sensitivity indices for ARA-A5'P, BCNU and 5-FU in brain tumor cell lines (in brackets: primary CNS-tumors) were 0.64 (0.59), 0.89 (0.82) and 0.35 (0.33) respectively. 5-FU was significantly more active than BCNU and ARA-A5'P (P less than 0.001), whereas BCNU was significantly less active than ARA-A5'P (P less than 0.001). ARA-A5'P had a suppressive effect on formation of brain tumor stem cell colonies. There was no cross-resistance of ARA-A5'P to either BCNU or 5-FU. We conclude that ARA-A5'P and 5-FU are potent agents in experimental therapy of human brain tumors, compared with BCNU.

Central neurotoxicity following intracarotid BCNU chemotherapy for malignant gliomas

Central neurotoxicity is reported in 5 of 16 patients with recently diagnosed anaplastic gliomas, who received intra-arterial BCNU (200 mg/M2/course) and also 2 in a series of 26 patients with recurrent gliomas similarly treated. Neurotoxicity was usually delayed, commencing several weeks following the second or third course. CT scans during central neurotoxicity represented 1 or more of 3 patterns: no change; increased low density area(s); and/or ipsilateral gyral enhancement and punctate calcification in the middle cerebral artery territory. In one clinicopathological correlation, coagulative necrosis of the white matter was observed, identical histologically to those changes recognized as delayed vascular events following radiotherapy. Cautious exploration of the various clinical factors that may contribute to this toxicity seems appropriate, as exploration of the potential benefits of regional chemotherapeutic infusions is undertaken.

Computerized tomography in the prognosis of malignant cerebral gliomas

Ninety-seven patients with supratentorial malignant gliomas who received postoperative radiation therapy and chemotherapy at the University of California, San Francisco, from 1977 through 1984 showed improvement in their follow-up computerized tomography (CT) scans. Twenty-one of these 97 "CT responders" were designated "complete responders" because on serial CT scans they had complete disappearance of the tumor mass and contrast enhancement, which had been present postoperatively. In the remaining 76 patients, CT scans showed reduction in the size, but not disappearance, of the lesions, and these were designated "partial responders." Fifty-eight partial responders had glioblastoma multiforme (GM); their median survival time was 72 weeks. The median survival time for the 11 complete responders with GM has not yet been achieved, but survival at the 53rd percentile is 172 weeks. Among patients with highly anaplastic astrocytoma, the median survival time was 211 weeks for the 10 complete responders and 125 weeks for the 18 partial responders. Eleven of the 21 complete responders are alive at a median postoperative follow-up time of 163 weeks (range 114 to 470 weeks). Eighteen of these patients had subtotal resection of tumor; three patients had gross total tumor resections, but postoperative CT scans showed evidence of residual or possibly recurrent tumor within 1.5 to 4.5 months. Resolution of the tumor mass and contrast enhancement took 9 to 151 weeks; the time to resolution did not depend upon the configuration of the remaining tumor mass and contrast enhancement after surgery. In this study, patients with malignant gliomas whose CT scans eventually showed sustained complete disappearance of the tumor mass and contrast enhancement had a more favorable prognosis than did patients whose CT scans showed improvement, but not complete disappearance, of the tumor. These CT findings may prove useful in determining the prognosis of patients with malignant gliomas.

Prevention of ocular toxicity of carmustine (BCNU) with supraophthalmic intracarotid infusion

Intracarotid administration of carmustine (BCNU) is an increasingly accepted therapeutic modality for primary brain tumors. Its beneficial effect on prolonging survival, however, is countered by its frequent delayed complication of retinal toxicity and severe visual loss, which reportedly occurs in approximately 70% of the patients. Since this complication probably results from increased flow of the drug into the ophthalmic artery, the authors have attempted to infuse BCNU via a small intracarotid catheter advanced beyond the origin of the ophthalmic artery. In a series of nine patients (average follow-ups, 10.7 months), the authors were successful in treating six patients with exclusively supraophthalmic infusions. None of these patients developed any ocular toxicity. From the remaining three patients, two patients received one infraophthalmic infusion with no retinal toxicity. The third patient, however, who received three infraophthalmic infusions, developed ipsilateral retinopathy. These results suggest that retinopathic complications of intracarotid BCNU can be avoided if the infusion catheter is advanced beyond the origin of the ophthalmic artery.

Effect of difluoromethylornithine on the antiglioma therapeutic efficacy of intra-arterial BCNU

In an attempt to improve glioma management, an animal model was developed to evaluate the therapeutic efficacy of intra-arterial 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). Furthermore, the model was used to study the antitumor activity of D,L-alpha-difluoromethylornithine (DFMO), a polyamine-biosynthesis inhibitor, used both as a single agent and in combination with intra-arterial BCNU. An N-methylnitrosourea-induced gliosarcoma (T9) was transplanted stereotaxically into the right caudate nucleus of male Fischer 344 rats. Animals receiving a single low-dose (5 mg/kg) intracarotid injection of BCNU 9 days following tumor implantation had a 57% increase in life span compared with untreated control rats (p less than 0.001). Intracarotid drug delivery was more effective than systemic (intraperitoneal) administration of the same dose of BCNU. When given as a single agent, DFMO demonstrated dose-dependent effectiveness. As part of a combined regimen, DFMO enhanced the antitumor therapeutic activity of both systemic (intraperitoneal) and intra-arterial BCNU. Survival times of animals receiving combined DFMO and intra-arterial BCNU were almost double those of untreated controls, and were significantly better than survival times of animals receiving combined DFMO and intraperitoneal BCNU. These findings suggest methods to optimize current clinical chemotherapy for glioma.

Myelofibrosis following treatment with a nitrosourea for malignant glioma

Nitrosoureas are alkylating agents that have been associated with the development of a preleukemic syndrome, secondary acute nonlymphocytic leukemia and a variety of acute and delayed toxicities. Nitrosoureas have activity in the treatment of primary malignant brain tumors. The authors report a patient who developed bone marrow myelofibrosis three years following treatment with radiation therapy and oral CCNU. This is the first case of marrow fibrosis associated with the use of a nitrosourea. Bone marrow myelofibrosis may be another delayed treatment effect of this class of drugs.

Malignant gliomas of the brain. A retrospective study

A retrospective study of 72 consecutive and nonrandomized patients with malignant glial tumors is presented. The influence of age, sex, location of tumor, initial presenting symptoms, symptomatic preoperative interval, reoperation, extent of tumor removal, histological subtype of tumor, lymphocyte infiltration, and different treatments upon survival time has been evaluated and statistically analyzed. Age was inversely associated with survival with a strong statistical significance (p = 0.0001). Headache was the most common (67%) initial symptom; aphasia and seizure were both present in 45.3% of patients. Initial presenting symptoms had no effect upon survival. Parietal lobe and lymphocyte infiltration had marginally negative effects upon survival (p = 0.097 and p = 0.10 respectively). The amount of tumor removal was marginally associated with an improved survival (p = 0.07). Radiation therapy was strongly associated with an improved survival time (p = 0.0007). The addition of chemotherapy did not affect the survival (perhaps reflecting the small number of patients and inadequate chemotherapy). There was an obvious beneficial effect of reoperation upon survival time, if the patient lived and underwent reoperation later than 16 months after the initial operation (slow-growing tumor). Although median and mean survival times (10 and 20.34 months respectively, SD 7.45 months) were similar to most series reported, our rates of survival (20%, 12.5%, and 7.5% at 2, 3, and 5 years, respectively) were notably higher.

Lymphokine activated killer (LAK) cell-mediated lysis of murine glioma: trypsin-chymotrypsin-sensitive glioma protein is responsible for tumor-selective recognition by LAK cells

The killing of Fischer rat 9L glioma in vitro by lymphokine-activated killer (LAK) cells was studied. LAK cells generated by culturing Fischer spleen cells with recombinant interleukin 2 markedly lysed glioma cells but did not kill syngeneic normal brain tissue in a chromium release microcytotoxicity assay. Susceptibility of glioma to lysis by LAK cells was markedly diminished by pretreating the glioma cells with trypsin or chymotrypsin but was unaffected by pretreatment with neuraminidase, glycosidases, or sodium periodate. These results suggest that LAK cell killing of glioma is probably tumor-selective and that a crucial cell surface determinant on glioma cells responsible for its tumor-selective lysis by LAK is a protein sensitive to trypsin and chymotrypsin.

Interleukin-2 and autologous lymphokine-activated killer cells in the treatment of malignant glioma. Preliminary report

Nine patients with malignant glioma were treated with the lymphokine interleukin-2 (IL-2) or with lymphokine-activated killer (LAK) cells, and one patient received combination therapy with both LAK cells and IL-2. The LAK cells were generated by culturing recombinant IL-2 with peripheral blood lymphocytes obtained from brain-tumor patients. Escalating doses of LAK cells (10(8) to 10(10] or IL-2 (10(4) to 10(6) U) were administered intraoperatively by direct injection into the brain tissue surrounding the cavity left by debulking the tumor. There were no signs of systemic or neural toxicity following treatment. The selective killing of the tumor by LAK cells used for these treatments was demonstrated by a chromium release microcytotoxicity assay which showed in vitro the ability of the LAK cells to lyse glioma cells but not normal cells.

Induction of human glioma-specific cytotoxic T-lymphocyte lines by autologous tumor stimulation and interleukin 2

Two human glioma-specific cytotoxic T-lymphocyte (G-S-CTL) lines were established by autologous tumor stimulation (ATS) with the aid of lectin free interleukin 2 (IL 2). Coculture of patient's peripheral blood lymphocytes and autologous irradiated glioma cells and subsequent addition of partially purified IL 2 enhanced the tumoricidal activity of the lymphocytes. These CTL lines possessed cross-cytotoxic activity against autologous allogeneic glioma cells and exhibited low cytotoxic activity against non-glial tumor cells. They did not lyse autologous lymphoblasts. This phenomenon suggested the existence of a common glioma-specific antigen recognized by the CTL lines. T-cell subset depletion test revealed that the major surface phenotype of G-S-CTL line, responsible for cytotoxic activity was OKT 3 positive, OKT 4 negative and OKT 8 positive. G-S-CTL lines were composed of a low proportion of OKT 8 positive subpopulation after primary ATS and successive propagation with IL 2. The proportion of OKT 8 positive subpopulation was increased by secondary ATS, which enhanced the cytotoxic activity to glioma cells more effectively.

Dibromodulcitol-based combined postoperative chemotherapy of malignant astrocytomas and glioblastomas

Continuing our earlier studies with dibromodulcitol (DBD), in a series of 38 evaluable consecutive patients who were operated on for malignant supratentorial gliomas, radiotherapy with smaller daily but higher total doses of DBD has been started 3-5 weeks after surgery. This was followed alternately by a combination chemotherapy of CCNU and DBD or CCNU and Procarbazine. No severe myelotoxicity occurred. Survivals were compared with a group of patients who got irradiation alone. Statistical analysis showed a significantly better survival in the presently treated group: median survival was 55 weeks, p = 0.02. These values were very similar to those groups which were treated by intermittent DBD schedule during irradiation. This study seems to confirm our previous suggestion that the concurrent use of DBD during irradiation might be an important factor in improving survival times.

Computer-assisted stereotaxic laser resection of intra-axial brain neoplasms

Computer interpolation of stereotaxic computerized tomography (CT) scanning data allows the transposition of a tumor volume in stereotaxic space. A stereotaxically directed and computer-monitored CO2 laser is then utilized to vaporize that volume as the surgeon monitors the position of a cursor representing the laser beam against planar contours of the tumor displayed on an operating room computer monitor. Computer-assisted stereotaxic laser microsurgery provides precise three-dimensional control for aggressive resection of deep-seated tumors from neurologically important areas with acceptable postoperative results. Thus, a significant cytoreduction can be achieved in addition to providing a tissue diagnosis and internal decompression. The authors report 83 computer-assisted stereotaxic laser procedures for tumor excision in 78 patients. The tumors were located in the thalamus/basal ganglia in 15 patients, ventricular system in five, corpus callosum in four, brain stem in three, and deep and centrally in the hemispheres in 51. Histologically, there were 26 glioblastomas, seven grade III astrocytomas, 14 grade II astrocytomas, 14 metastatic tumors, nine vascular lesions, and eight miscellaneous lesions. Resection of these subcortical lesions was confirmed by postoperative contrast-enhanced CT scanning. Neurological examinations performed 1 week after the 83 procedures revealed that 48 patients had improved from their preoperative level and 23 were unchanged (12 were neurologically normal preoperatively). Twelve patients had an increase in a preoperative neurological deficit, three of whom died in the postoperative period: one from infection, one from pulmonary emboli, and one from brain-stem edema. The average survival period (37.6 weeks) of patients having glioblastomas treated by this technique and irradiation was no different from that of patients having glioblastomas in more favorable locations treated by conventional surgery and irradiation. Patients with circumscribed lower-grade astrocytomas did better in terms of morbidity and completeness of resection than those with infiltrative neoplasms. Other circumscribed lesions, such as metastatic tumors, vascular lesions, and intraventricular tumors, were easily resected by the technique described.

High dose chemotherapy in solid tumours in adults

The available evidence suggests that if benefit is to be obtained from high dose chemotherapy regimens, it will be in patients whose tumours are either untreated or still responding to conventional therapy. In each of the diseases discussed in this chapter the optimum timing of the treatment regimen has still to be determined. Effective regimens have been found but it is probable that further improvements can be made. In small cell lung cancer initial high dose therapy followed by non-cross-resistant regimens may prove effective. In glioma studies with high dose therapy before irradiation are awaited and may offer the best means of exploiting this approach to treatment. In breast cancer some impressive responses have occurred but the category of patient likely to benefit has not yet been defined. In melanoma high dose treatment is likely to benefit only those patients with probable minimal disease after surgery.

Brain tumours in man

Brain tumours occur at all ages but they differ in type depending upon the age of the patient. In adults, probably more than 50% of tumours in the brain are metastatic carcinomas or melanomas. The pathological classification of primary brain tumours depends largely upon the cell type involved. Recently, immunocytochemical identification of cell-specific proteins by the use of polyclonal or monoclonal antibodies has greatly enhanced the accuracy of cell identification within tumours. Primary brain tumours in children arise mainly in the brain stem and cerebellum and are astrocytomas, primitive neuroectodermal tumours (medulloblastomas) and ependymomas. Gliomas form the largest group of primary brain tumours in adults, with an annual incidence of 3.94/100,000 in Southern England. In young adults, well differentiated astrocytomas and oligodendrogliomas arise in the cerebral hemispheres. Poorly differentiated, malignant glial tumours include anaplastic astrocytomas and glioblastoma multiforme; these tumours are most common in older adults with a peak annual incidence of 7.3/100,000 in the sixth decade. The major complication of brain tumours is due to their mass effect from tumour growth and from peritumoral oedema. Surgical excision of gliomas is difficult and usually incomplete due to the infiltrative nature of the tumour. As yet these tumours respond poorly to irradiation and chemotherapy.

Advances in rational combination chemotherapy

Due to the high frequency of micro- or macrometastatic disease at the time of diagnosis of cancer, and to the increasing prevalence of cancer in this country, the use of chemotherapy to evoke cure or prolongation of survival has become critically important. In addition, the growth kinetics of large tumor burdens and the high probability of drug-resistant cells in a tumor mass at the time of diagnosis necessitate combinations of chemotherapeutic agents rather than single agents as the most effective mode of treatment. Since there are 40 to 50 active anticancer drugs now utilized, and since synergy between drug combinations is often dose and/or schedule dependent, the number of possible drug combinations and permutations is vast. Thus, screening for effective drug combinations requires a rational approach which will allow for accurate predictions of synergy. Most advances in this scientific approach have utilized biochemical modulation in conjunction with in vitro cytotoxicity assays, in particular, clonogenic assays. Such an approach has generated a number of drug combinations, such as sequential MTX-5FU, with widely applicable clinical efficacy. The continued use of biochemical modulation should rapidly generate new effective drug combinations which will, hopefully, allow us to cure even those cancers presently considered incurable.

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.

In vitro killing of human glioblastoma by interleukin-2-activated autologous lymphocytes

Culture of peripheral blood lymphocytes (PBL) from brain-tumor patients with recombinant interleukin-2 (IL-2) results in the activation of lymphokine-activated killer cells (LAK) with the capacity to lyse autologous and allogeneic glioblastoma. In this study, PBL obtained from brain-tumor patients were cultured with or without IL-2 for 3 to 7 days and then tested for their ability to lyse target cells in a 4-hour chromium release cytotoxicity assay. The PBL were drawn 1 to 2 weeks following operative tumor debulking. Cells used as targets included fresh brain-tumor cells obtained at the time of craniotomy, fresh brain-tumor cells grown from 1 to 3 weeks in tissue culture, fresh autologous PBL, and allogeneic glioblastoma cells grown in tissue culture. Peripheral blood lymphocytes from brain-tumor patients that were cultured without IL-2 did not significantly lyse autologous or allogeneic glioblastoma. However, when these PBL were cultured with IL-2, LAK were generated which produced marked lysis of autologous as well as allogeneic tissue-culture glioblastoma in all of eight cases. Significant lysis of autologous fresh tumor by patient LAK was observed in four of five experiments. By contrast, patient LAK did not kill autologous normal PBL. The ability to generate LAK was not influenced by the patient's age, previous therapy, or the administration of steroids.

Anguidine potentiates cis-platinum in human brain tumor cells

Anguidine pretreatment was previously shown to potentiate cis-platinum in Chinese hamster ovary cells by 100-fold, probably by enhancing cellular cis-platinum uptake. Since both cis-platinum and anguidine have been reported to have clinical efficacy in human brain tumors, the present study was initiated to investigate whether anguidine's potentiation of cis-platinum was applicable to human brain tumor cells in culture. Using the colony formation assay, it was found that anguidine enhanced cis-platinum's cytotoxicity by ten-fold, producing a dose modification factor of 1.74. Alkaline elution analysis of cis-platinum-induced DNA cross-links found that anguidine enhanced cross-linking by a factor of 1.55, 1.76, 1.63, and 1.48 at 0, 6, 24, and 48 hr, respectively, after cis-platinum treatment. This enhancement of cross-linking is evidence for anguidine increasing cis-platinum uptake. Thus, anguidine enhances cis-platinum-induced DNA cross-linking and subsequent cytotoxicity in human brain tumor cells, and may be clinically useful in combination with cis-platinum in those tumors.

Phase I clinical trial of intracarotid bis-chloroethylnitrosourea (BCNU) and 2' dioxy-5-fluorouridine (FUDR) in malignant astrocytomas

Systemic chemotherapy has been of limited benefit in the treatment of intracranial neoplasms, due, in part, to the inability to deliver effective drug doses to the neoplasm without systemic toxicity. We have completed a clinical trial of intracarotid BCNU and FUDR using an implantable pump in patients with unilateral malignant astrocytomas (Grade III and IV) in the hope of obtaining better tumor control with less systemic toxicity. Six patients had in-dwelling catheters placed in the internal carotid artery attached to a percutaneous refillable pump (Infusaid 400). The treatment program consisted of bolus BCNU 400 mg every 6 weeks and FUDR by continuous infusion at dosages ranging from 0.5 mg/24 h to 2.5 mg/24 h. The maximum tolerable dose of FUDR was 1 mg/24 h with ipsilateral mucositis and conjunctivitis being dose limiting factors. Flow studies demonstrated significant perfusion of the ipsilateral eye and surrounding face secondary to ophthalmic artery collaterals. No patient had systemic toxicity and the lowest WBC encountered was 2 400 with normal differential and platelets.

Effects of ACNU and radiotherapy on malignant glioma

A randomized clinical study of irradiation and irradiation combined with ACNU in the treatment of malignant gliomas was performed in order to determine if there was an enhancing therapeutic effect of ACNU given in addition to radiotherapy. An effect was defined as a reduction in tumor size, changes in neurological signs and performance status within 1 month after the completion of radiotherapy, or statistically improved survival times. Seventy-seven patients from 14 neurosurgical clinics were included in this validated study group. Radiotherapy with a total dose of 5000 to 6000 rads, given in 25 to 30 subdoses, was applied to the whole brain and to a generous field surrounding the tumor. Patients who were assigned to receive chemotherapy were given ACNU intravenously once or twice during radiotherapy at a dose of 100 mg/sq m of body surface area. The response rate (more than 50% reduction of the tumor size) was 13.5% in the group treated by radiotherapy alone and 47.5% in the group with radiotherapy and ACNU. The hematological toxicity was more severe in the group treated with radiotherapy and ACNU. Other toxicity was mild and acceptable. The survival rates of patients with astrocytoma grade III and glioblastoma multiforme at 36 months after the surgery were 48.9% and 0% for radiotherapy alone and 59.0% and 16.3% for radiotherapy plus ACNU, respectively. The differences between the survival curves were not significant at the p = 0.05 level. This study has demonstrated that, although the use of ACNU during radiotherapy suppressed malignant gliomas more than radiotherapy alone, the survival time was not extended significantly. It is necessary to continue to search for an effective chemotherapeutic regimen to prolong survival of patients with malignant gliomas.

Intraarterial cis-platinum chemotherapy for patients with primary and metastatic brain tumors

A total of 49 patients were treated using intraarterial cis-platinum infusions at a dose of 100 mg/m2. The patients were separated into three groups. There were 13 patients with metastatic tumors, 10 with recurrent malignant gliomas, and 22 patients with high-grade gliomas who received intraarterial cis-platinum as part of an adjuvant program. In addition, four nongliomatous primary brain tumors were treated in this fashion. Cis-platinum was filtered immediately prior to intraarterial infusion using a 0.22-micron filter. Response to treatment was evaluated by follow-up CAT scans and neurologic examinations. There were three complete and eight partial responses in metastatic tumors, and eight partial responses in recurrent gliomas. The median survival was 19 weeks for patients with metastatic disease, and 16 weeks for patients with recurrent gliomas. Those high-grade glioma patients who received intraarterial cis-platinum as adjuvant chemotherapy along with CCNU and radiation therapy had a projected median survival of 91+ weeks. Toxicity from intraarterial cis-platinum following drug filtration was markedly reduced when compared with previous reports. Only five patients experiencing visual or central nervous system toxicity utilizing filtered cis-platinum and no radiographic or histopathologic evidence of central nervous system toxicity was observed. Bilateral deafness was observed following vertebral artery infusion in both patients treated in this manner and thus vertebral artery infusions should be avoided. Systemic toxicity was mild. Intracarotid infusion is a safe, well-tolerated delivery system for filtered cis-platinum with a high response rate for patients with both metastatic and primary malignant brain tumors.

The rationale and methodology for intra-arterial chemotherapy with BCNU as treatment for glioblastoma

The rationale for, methodology of, and experience with intra-arterial BCNU infusion therapy of malignant glioma are described. This approach achieves tumor levels of drug four times greater than equal doses infused intravenously, and has been used to treat 79 patients over the course of 4 years. The drug was given in 192 infraophthalmic and 66 supraophthalmic carotid artery infusions. Patients who were treated via infraophthalmic carotid artery infusion following tumor recurrence (after both operation and irradiation) survived 54 additional weeks (92 weeks after initial diagnosis). Patients who were treated with BCNU immediately after initial irradiation therapy survived 64 weeks (infraophthalmic carotid artery infusion) and 49.5 weeks (supraophthalmic carotid artery infusion). The major ocular complications (pain and diminished visual acuity) associated with infraophthalmic carotid artery infusion are avoided by selective balloon-guided supraophthalmic carotid artery administration. However, both approaches were associated with white-matter changes, seen as diminished absorption on computerized tomography scans, in 20% of patients treated following irradiation therapy. This toxicity appears to preclude intra-arterial BCNU treatment in the immediate postirradiation period. Better results are being achieved with our current therapy, which involves four infusions of BCNU (400 mg every 4 weeks) into the infraophthalmic or supraophthalmic carotid artery in advance of irradiation. Cisplatin infusions (60 to 90 mg/sq m every 5 weeks) are offered for recurrent glioblastoma.

Intraarterial 1,3-bis(2-chloroethyl)-1-nitrosourea chemotherapy for the treatment of malignant gliomas of the brain: a preliminary report

In a clinical trial, 10 patients with malignant gliomas underwent partial resection of their tumors and were treated by intraarterial 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) chemotherapy. The drug was given at least 1 month after the completion of postoperative radiotherapy in total doses of 270-280 mg/m2 in two sessions separated by a 48-hour interval (the two sessions with interval were equal to one course). This therapy was repeated every 8-10 weeks. Four patients had three courses and the other six patients had two courses of chemotherapy. This therapy was the only antitumor chemotherapy for this group of patients. Our preliminary results demonstrate the safety of this new procedure and suggest that intraarterial BCNU chemotherapy may be more effective, and has a better tolerance and less toxicity, than intravenous BCNU chemotherapy. Furthermore, it was demonstrated that, in the case of one patient, higher antitumor activity resulted from intraarterial BCNU chemotherapy as compared to intravenous BCNU therapy.

Reduced systemic drug exposure by combining intra-arterial chemotherapy with hemoperfusion of regional venous drainage

Four patients with malignant cerebral gliomas received 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) into the internal carotid artery (ICA) while the ipsilateral jugular drainage was pumped extracorporeally through a hemoperfusion cartridge containing a nonionic adsorbant resin. Each patient received 220 mg/sq m BCNU, infused over 45 minutes through a toposcopic catheter positioned with the tip in the ICA beyond the origin of the ophthalmic artery. Jugular blood was pumped extracorporeally at 300 ml/min through a large-bore catheter in the jugular bulb. Plasma samples were obtained for BCNU measurement at frequent intervals from the right atrium. During a separate treatment, 6 weeks before or after the hemoperfusion treatment, the same dose of BCNU was infused into the ICA and atrial samples were obtained on a similar schedule. Hemoperfusion of the jugular blood during intracarotid infusion reduced the systemic exposure by 56% to 87% and increased total body clearance of BCNU by two- to eightfold. The calculated pharmacokinetic advantage (brain:body exposure ratio) was between 21 and 55:1 when the combined treatment was used.