Pneumocystis pneumonia in brain tumor patients: risk factors and clinical features

Perception of pneumocystis jirovecii pneumonia (PJP) prophylaxis in glioma patients receiving concurrent temozolomide and radiation- a patient and physician survey

PURPOSE

Pneumocystis jirovecii pneumonia (PJP) prophylaxis is required by provincial and national drug monographs during glioma treatment using temozolomide (TMZ) concurrently with radiation (TMZ-RT). However, real-world data suggest the potential benefits of PJP prophylaxis may not outweigh its potential harms in this population.

METHODS

We conducted a single-center patient survey and a national physician survey to explore the role of PJP prophylaxis amongst glioma patients undergoing TMZ-RT.

RESULTS

23% (31/133) of physicians and 60% (44/73) of patients completed a survey. The median patient age was 42 (range 20-77); 85% (34/40) had completed adjuvant TMZ. Although only 2.4% (1/41) of patients received PJP prophylaxis, only one person (without PJP prophylaxis) was hospitalized for pneumonia. When presented with hypothetical PJP risks, 13.2% (5/38) of patients were concerned about PJP infection, while 26% (10/38) were concerned about potential side effects from prophylactic antibiotics. Most physicians (77%, 17/22) perceived the evidence for PJP prophylaxis as weak; 58% (11/19) did not routinely prescribe prophylaxis, and 73% (16/22) felt that PJP prophylaxis should be limited to patients with additional risk factors. Over 95% of physicians estimated that the incidence of PJP was < 1% in their last 5 years of practice regardless of PJP prophylaxis. For 73% (16/22) of physicians, to prescribe PJP prophylaxis, the risk of PJP infection needed to be 3-8%.

CONCLUSION

The current recommendation to routinely prescribe PJP prophylaxis in patients receiving TMZ-RT in the absence of other risk factors warrants reconsideration.

Medical and Neurological Management of Brain Tumor Complications

PURPOSE OF REVIEW

The diagnosis of brain tumors often leads to complications that are either related to the tumor itself or the tumor-directed and supportive therapies, increasing the burden on the patients' quality of life and even survival. This article reviews the medical and neurological conditions that commonly complicate the disease course of brain tumors patients.

RECENT FINDINGS

Various mechanisms have been newly identified to be involved in the pathophysiology of seizures and brain edema and can help advance the treatment of such complications. There have also been new developments in the management of thromboembolic disease and cognitive impairment. Medical and neurological complications are being identified more often in brain tumor patients with the improved survival provided by therapeutic advances. Early and proper identification and management of such complications are crucial for a better survival and quality of life.

Pneumocystis jirovecii Pneumonia in Neurologic Disorders: Is Prophylaxis Necessary?

BACKGROUND

The incidence of Pneumocystis jirovecii pneumonia (PJP) in patients with underlying neurologic conditions is not well established, and the necessity of PJP prophylaxis for immunocompromised patients with neurologic disorders is uncertain.

METHODS

Single-center retrospective analysis of non-HIV PJP patients at a tertiary referral center from 2007 to 2016 to determine the incidence of PJP in patients with primary neurologic disorders.

RESULTS

The study included 142 patients with PJP without HIV. Twenty patients had primary neurologic diagnoses, and 122 had non-neurologic conditions. Associated neurologic diagnoses included brain malignancies (N = 14), myasthenia gravis (MG) (N = 2), myopathy (N = 2), neuromyelitis optica (NMO) (N = 1), and CNS vasculitis (N = 1). Estimated incidences of PJP were 0.7% for patients with NMO and 0.3% for patients with MG for the 10-year study period, whereas 4.6% of patients with NMO and 3.8% of patients with MG were placed on PJP prophylaxis. A survey of 24 neurologists who prescribe immunotherapy or chemotherapy confirmed an infrequent occurrence of PJP in their practice. Malignancy or parenchymal organ failure was present in 90% of neurologic patients with PJP, and coexisting infections occurred in 45%.

CONCLUSIONS

The overall incidence of PJP in patients with non-neoplastic neurologic disorders is exceedingly low, raising doubt about the value of routine PJP prophylaxis in neurologic patients outside neuro-oncology. PJP infection occurs frequently in patients with malignancy or parenchymal organ failure, indicating that overall health status may serve as a predisposing factor for PJP.

Optimal Management of Corticosteroids in Patients with Intracranial Malignancies

OPINION STATEMENT

Corticosteroids have been essential in the management of brain tumor patients for decades, primarily for the treatment of peritumoral cerebral edema and its associated neurologic deficits. Dexamethasone is the drug of choice with standard practice being administration up to four times per day, however, because of its long biologic half-life and high potency, once or twice a day dosing is likely adequate in patients without elevated intracranial pressure. The length of corticosteroid treatment should be limited to the shortest period of time to minimize the risk of potential toxicities that can significantly affect quality of life, as well as to avoid a possible detrimental impact on survival in high-grade glioma patients and abrogation of the effect of immunotherapy. Agents such as bevacizumab should be considered in patients who are unable to wean completely off of steroids as well as those who have symptomatic edema and are on immunotherapy. Several other agents have been studied without much success. An increased understanding of the complex pathophysiology of peritumoral vasogenic edema is critically needed to discover new agents that are safer and more effective.

Neurological and Medical Complications in Brain Tumor Patients

PURPOSE OF REVIEW

Patients with brain tumors are susceptible to multiple complications that can affect their survival or quality of life. The scope of these complications is widening due to prolonged overall survival and improved therapies. In this review, we discuss the most common complications in this patient population focusing on the recent literature. We specifically concentrated on tumor-related epilepsy, vasogenic edema, infectious, vascular, chemotherapeutic, radiation, endocrine, and cognitive complications.

RECENT FINDINGS

Molecular biomarkers play a role in epileptogenicity in brain tumor patients, and anti-epileptic drugs may cause neuro-cognitive side effects independent of other factors. The pathophysiology of vasogenic edema remains complex and poorly understood. Limited data suggest that newer oral anticoagulants appear to be safe and effective in venous and arterial thromboembolic complications. Brain tumor patients are prone to a wide variety of complications, including some related to new therapies. Optimal management of these complications improves quality of life, and in some cases overall survival.

Etiology and prognosis of acute respiratory failure in patients with primary malignant brain tumors admitted to the intensive care unit

PURPOSE

Acute respiratory failure (ARF) is common and potentially fatal in patients with primary malignant brain tumors (PMBT). However, few data are available regarding its precipitating factors and prognosis. We sought to: (1) compare the causes of ARF and the outcome between patients with PMBT and patients with other peripheral solid tumors (PST), (2) identify the factors influencing ICU survival in PMBT patients.

METHODS

Two-center retrospective case-control study from March 1996 to May 2014. Primary central nervous system lymphomas were also included.

RESULTS

Eighty-four patients with PMBT and 133 patients with PST were included. Acute infectious pneumonia was more frequent in PMBT than PST patients (77 vs. 36%, p < 0.001). Pulmonary embolism was also more frequent in PMBT patients (13% vs. 5%, p = 0.042), while cardiogenic pulmonary edema and acute-on-chronic respiratory failure were more frequent in PST patients (37 vs. 10%, p < 0.001). Among acute infectious pneumonia, Pneumocystis pneumonia and aspiration pneumonia were more frequent in PMBT patients (19 vs. 2%, p < 0.001 and 19 vs. 8%, p < 0.001, respectively). ICU mortality was similar between PMBT and PST patients (24% vs. 24%, p = 0.966). In multivariate analysis, cancer progression (OR 7.25 95% CI 1.13-46.45, p = 0.034), need for intubation (OR 7.01 95% CI 1.29-38.54, p = 0.022), were independently associated with ICU mortality in PMBT patients.

CONCLUSIONS

The cause of ARF in patients with PMBT differs significantly than those with PST and up to 50% may have been prevented. Mortality did not differ between the two groups. These results suggest that PMBT alone is not a relevant criterion for ICU recusal.

Medical Complications of Brain Tumors

PURPOSE OF REVIEW

This article discusses common and emergent medical complications encountered in patients with primary brain tumors.

RECENT FINDINGS

Clinical studies and systematic reviews published in recent years have improved knowledge regarding the incidence of neurologic and medical complications occurring in patients with primary brain tumors. Studies in tumor-related epilepsy and venous thromboembolism provide data for the clinician to make evidence-based decisions about perioperative management, prophylaxis, and therapy. Patients with brain tumors experience unique toxicities related to novel drugs and chemotherapeutics that result in hematologic, infectious, and endocrine disorders. Recent work that has focused on quality of life in patients with brain tumors highlights the importance of good supportive care and optimal medical management of neurobehavioral symptoms and late complications of treatment.

SUMMARY

A thorough understanding of the variety of medical and neurologic complications in patients with primary brain tumors improves the clinician's ability to quickly recognize and manage common and urgent conditions.

Neurologic and Medical Management of Brain Tumors

Patients with brain tumor encounter a wide spectrum of tumor and treatment-related complications during their disease course. Tumors may serve as seizure substrates, are associated with a hypercoagulable state that results in thromboembolic complications, and may influence mood and cognition. Antitumor and supportive therapies may also have deleterious effects. Herein, we discuss major aspects of supportive care for patients with brain tumors, with attention to benefit and complications derived from the management of seizures, brain edema, venous thromboembolism, fatigue, mood alterations, and cognitive dysfunction.

The Effect of Ophthalmic Artery Chemosurgery on Immune Function in Retinoblastoma Patients: A Single Institution Retrospective Analysis

BACKGROUND

Ophthalmic artery chemosurgery (OAC) is associated with grade 3 and 4 neutropenia, however the effect on T-cell number and function is unknown. The purpose of this retrospective review was to confirm that patients treated with OAC do not develop immunosuppression warranting Pneumocystis pneumonia prophylaxis.

PROCEDURE

IRB approval was obtained for a single center retrospective review of immune function tests in retinoblastoma patients who received OAC.

RESULTS

Twenty-three patients received ≥3 cycles of OAC and had immune function testing (absolute CD4 count) performed at a median of 34 days postcompletion of therapy (range, 15 to 63 d). Only 1 patient had a low absolute CD4 count of 189 cells/μL (normal, 359 to 1570 cells/μL) 2 and a half months after IV carboplatin and 28 days after their third dose of OAC. This patient was found to have coexisting hypogammaglobulinemia. Repeat immune function testing normalized through continued OAC treatment.

CONCLUSIONS

Clinically significant immune suppression appears rare following OAC alone, but patients previously treated with IV chemotherapy may be immunosuppressed and may benefit from pneumocystis pneumonia prophylaxis until the CD4 count recovers.

Acute hemolysis in a patient with a newly diagnosed glioblastoma

We describe a 62-year-old of Egyptian origin who presented with sudden, severe and symptomatic anemia requiring hospitalization shortly after beginning concurrent radiation and temozolomide for his newly diagnosed glioblastoma. He had also recently been started on steroids, anticonvulsants and Pneumocystis jirovecii prophylaxis. He was ultimately diagnosed with G6PD deficiency with an acute hemolytic anemia precipitated by dapsone. Screening for G6PD deficiency should be considered in high-risk patient populations where P. jirovecii prophylaxis is planned.

Medical management of brain tumors and the sequelae of treatment

Patients with malignant brain tumors are prone to complications that negatively impact their quality of life and sometimes their overall survival as well. Tumors may directly provoke seizures, hypercoagulable states with resultant venous thromboembolism, and mood and cognitive disorders. Antitumor treatments and supportive therapies also produce side effects. In this review, we discuss major aspects of supportive care for patients with malignant brain tumors, with particular attention to management of seizures, venous thromboembolism, corticosteroids and their complications, chemotherapy including bevacizumab, and fatigue, mood, and cognitive dysfunction.

Severity, etiology and possible consequences of treatment-related lymphopenia in patients with newly diagnosed high-grade gliomas

Lymphopenia is a common consequence of therapy for malignant glioma. Current standard therapy includes corticosteroids, temozolomide and radiation therapy, all of which are toxic to lymphocytes. The resulting immunosuppression has serious clinical consequences. Decreased lymphocyte counts can result in opportunistic infections, decreased efficacy of immunotherapy and reduced overall survival. The exact mechanisms underlying the association between decreased survival and lymphopenia in malignant glioma patients are unclear. However, as lymphocytes are key effector cells in the immune response to cancer, it is likely that depleting their numbers renders the immune system less effective at eliminating malignant cells. Currently, no strategies exist for the prevention or reversal of treatment-related immunosuppression in malignant glioma patients, although there are several promising theoretical approaches. This article reviews the current state of knowledge regarding the severity, etiology and possible consequences of treatment-related lymphopenia in patients with malignant glioma.

Sustained CD4+ T cell-driven lymphopenia without a compensatory IL-7/IL-15 response among high-grade glioma patients treated with radiation and temozolomide

Prolonged lymphopenia correlating with decreased survival commonly occurs among glioma patients undergoing radiation therapy (RT) and temozolomide (TMZ) treatment. To better understand the pathophysiology of this phenomenon, we prospectively monitored serum cytokine levels and lymphocyte subsets in 15 high-grade glioma patients undergoing combined radiation and TMZ (referred to as RT/TMZ) treatment. Sufficient data for analysis were acquired from 11 of the patients initially enrolled. Lymphocyte phenotyping data were obtained using cytofluorometric analysis and serum cytokine levels were measured using the a multiplex bead-based assays. Total lymphocyte counts (TLCs) were > 1000 cells per μL peripheral blood in 10/11 patients at baseline, but dropped significantly after treatment. Specifically, after RT/TMZ therapy, the TLCs were found to be < 500 cells/μL in 2/11 patients, 500-1000 cells/μL in 7/11 patients, and > 1000 cells/μL in the remaining 2 patients. Among residual mononuclear blood cells, we observed a proportional drop in B and CD4+ T cells but not in CD8+ T lymphocytes. Natural killer cells remained to near-to-baseline levels and there was a transient and slight (insignificant) increase in regulatory T cells (Tregs). The circulating levels of IL-7 and IL-15 remained low despite marked drops in both the total and CD4+ T lymphocyte counts. Thus, patients with malignant glioma undergoing RT/TMZ treatment exhibit a marked decline in TLCs, affecting both CD4+ T cells and B lymphocytes, in the absence of a compensatory increase in interleukin-7 levels. The failure to mount an appropriate homeostatic cytokine response may be responsible for the prolonged lymphopenia frequently observed in these patients.

Glucocorticosteroid in treatment of severe pneumonia

Airway diseases such as pneumonia constitute a major health burden on a global scale; untreated pneumonia may develop to severe pneumonia and consequently lead to to fatal episodes of mortality and morbidity. The balance between inflammatory mediators is key for the outcome of the pulmonary infection; elimination of invading pathogen was marked by the release of cytokines and other inflammatory mediators from alveolar macrophages and glucocorticoid steroids (GCs) acting on the inflammatory component. Treatments of severe pneumonia with GCs have been developing for years with inconclusive results. In many cases GCs have been administered empirically without clinical evidence. Recent studies assess beneficial impact on treatment of severe pneumonia by suggesting specific dosage, period of administration, and tapered dosage.

Corticosteroids in brain cancer patients: benefits and pitfalls

Glucocorticoids have been used for decades in the treatment of brain tumor patients and belong to the most powerful class of agents in reducing tumor-associated edema and minimizing side effects and the risk of encephalopathy in patients undergoing radiation therapy. Unfortunately, corticosteroids are associated with numerous and well-characterized adverse effects, constituting a major challenge in patients requiring long-term application of corticosteroids. Novel antiangiogenic agents, such as bevacizumab (Avastin®), which have been increasingly used in cancer patients, are associated with significant steroid-sparing effects, allowing neuro-oncologists to reduce the overall use of corticosteroids in patients with progressive malignant brain tumors. Recent experimental studies have revealed novel insights into the mechanisms and effects of corticosteroids in cancer patients, including modulation of tumor biology, angiogenesis and steroid-associated neurotoxicity. This article summarizes current concepts of using corticosteroids in brain cancer patients and highlights potential pitfalls in their effects on both tumor and neural progenitor cells.

Medical care of patients with brain tumors

PURPOSE OF REVIEW

Patients with brain tumors require close attention to medical issues resulting from their disease or its therapy. Effective medical management results in decreased morbidity and mortality and improved quality of life. The most frequent neurology-related issues that arise in these patients include seizures, peritumoral edema, venous thromboembolism, fatigue, and cognitive dysfunction. This article focuses on the most recent findings for the management of the most relevant medical complications among patients with brain tumors.

RECENT FINDINGS

Increasing evidence suggests that anticoagulation in patients with thromboembolic complications is safe even when they are receiving antiangiogenic therapy. There are also increasing data to support the use of newer, non-enzyme-inducing antiepileptic drugs, which have the advantage of lacking interactions with antineoplastic agents and are as effective as their older counterparts at preventing seizures. Relatively few studies have addressed the management of fatigue and depression, and definitive recommendations cannot be made.

SUMMARY

Corticosteroids to treat vasogenic edema should be used at the minimum amount required to control symptoms and should be tapered as quickly as possible. Anticonvulsants should be used only if patients have had seizures. Non-enzyme-inducing antiepileptic drugs are preferred to minimize interactions with concurrently administered chemotherapy. Thromboembolic complications are common and are preferably treated with low-molecular-weight heparins. Only patients with hemorrhagic complications require an inferior vena cava filter. Cognitive deficits are frequent in patients with brain tumors and include problems such as poor short-term memory, distractibility, personality change, emotional lability, loss of executive function, and decreased psychomotor speed. Stimulants can help to improve these symptoms.

Complications of brain tumors and their treatment

The diverse medical and neurologic complications of central nervous system (CNS) neoplasms or their treatment cause significant morbidity and mortality. Thus, their recognition and appropriate management by all members of the interdisciplinary team engaged in the care of patients with brain tumors is essential in optimizing quality of life and extending survival. Recognition of the acute, early delayed, and late complications of brain irradiation is essential to optimize management and mitigate their clinical impact.

Medical management of brain tumor patients

Brain tumors can present challenging medical problems. Seizures, peritumoral edema, venous thromboembolism, fatigue, and cognitive dysfunction can complicate the treatment of patients who have primary or metastatic brain tumors. Effective medical management results in decreased morbidity and mortality and improved quality of life for affected patients.

Supportive Care of Brain Tumor Patients

The supportive care of patients who have brain tumors consists mainly of the treatment of brain edema, seizures, venous thromboembolism, and cognitive dysfunction. Each of these complications may occur in patients who have primary or metastatic brain tumors. The development of any of these complications significantly increases the morbidity and mortality associated with brain tumors. Effective treatment is usually possible, however, and can result in an improved quality of life for these patients.

Medical management of patients with brain tumors

The most common medical problems in brain tumor patients include the management of seizures, peritumoral edema, medication side effects, venous thromboembolism (VTE), fatigue and cognitive dysfunction. Despite their importance, there are relatively few studies specifically addressing these issues. There is increasing evidence that brain tumor patients who have not had a seizure do not benefit from prophylactic antiepileptic medications. Patients on corticosteroids are at greater risk of Pneumocystis jerovecii pneumonia and may benefit from prophylactic therapy. There is also growing evidence suggesting that anticoagulation may be more effective than inferior vena cava IVC) filtration devices for treating VTE in brain tumor patients and the risk of hemorrhage with anticoagulation is relatively small. Low-molecular weight heparin may be more effective than coumadin. Medications such as modafinil and methylphenidate have assumed an increasing role in the treatment of fatigue, while donepezil and memantine may be helpful with memory loss.

Phase 2 trial of copper depletion and penicillamine as antiangiogenesis therapy of glioblastoma

Penicillamine is an oral agent used to treat intracerebral copper overload in Wilson's disease. Copper is a known regulator of angiogenesis; copper reduction inhibits experimental glioma growth and invasiveness. This study examined the feasibility, safety, and efficacy of creating a copper deficiency in human glioblastoma multiforme. Forty eligible patients with newly diagnosed glioblastoma multiforme began radiation therapy (6000 cGy in 30 fractions) in conjunction with a low-copper diet and escalating doses of penicillamine. Serum copper was measured at baseline and monthly. The primary end point of this study was overall survival compared to historical controls within the NABTT CNS Consortium database. The 25 males and 15 females who were enrolled had a median age of 54 years and a median Karnofsky performance status of 90. Surgical resection was performed in 83% of these patients. Normal serum copper levels at baseline (median, 130 microg/dl; range, 50-227 microg/dl) fell to the target range of <50 microg/dl (median, 42 microg/dl; range, 12-118 microg/dl) after two months. Penicillamine-induced hypocupremia was well tolerated for months. Drug-related myelosuppression, elevated liver function tests, and skin rash rapidly reversed with copper repletion. Median survival was 11.3 months, and progression-free survival was 7.1 months. Achievement of hypocupremia did not significantly increase survival. Although serum copper was effectively reduced by diet and penicillamine, this antiangiogenesis strategy did not improve survival in patients with glioblastoma multiforme.

Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients

Pneumocystis infection in humans was originally described in 1942. The organism was initially thought to be a protozoan, but more recent data suggest that it is more closely related to the fungi. Patients with cellular immune deficiencies are at risk for the development of symptomatic Pneumocystis infection. Populations at risk also include patients with hematologic and nonhematologic malignancies, hematopoietic stem cell transplant recipients, solid-organ recipients, and patients receiving immunosuppressive therapies for connective tissue disorders and vasculitides. Trimethoprim-sulfamethoxazole is the agent of choice for prophylaxis against Pneumocystis unless a clear contraindication is identified. Other options include pentamidine, dapsone, dapsone-pyrimethamine, and atovaquone. The risk for PCP varies based on individual immune defects, regional differences, and immunosuppressive regimens. Prophylactic strategies must be linked to an ongoing assessment of the patient's risk for disease.

Pneumocystis carinii pneumonia in HIV negative patients with primary brain tumors

BACKGROUND

Pneumnocystis carinii pneumonia (PCP) is an opportunistic infection with rather adverse outcomes. An unexpected increase in cases of PCP was noted in the brain tumor population at the Johns Hopkins Hospital (JHH) in 2000. This prompted the present review of the clinical features and risk factors for PCP in the human immunodeficiency virus (HIV) negative brain tumor population.

METHODS

The study was located at the JHH. A retrospective review of medical records was done to identify patients with discharge diagnosis of PCP from 1980 to 2001. Patients who were HIV positive were excluded. A detailed analysis was done of patients with brain tumors.

RESULTS

From 1980 to 2001, 468 cases of PCP were identified, diagnosed histologically or clinically, of which 110 were patients with an underlying malignancy. Of the 110 cases 15 were seen in the brain tumor population. Of these, 6 patients were seen in 2000 and one in early 2001. Three of these had primary central nervous system (CNS) lymphoma (PCNSL) on high dose methotrexate. Eight of the fifteen episodes (53.3%) were fatal despite institution of antibiotics and supportive therapy.

CONCLUSION

The incidence and mortality due to Pneumocystis carinii among the brain tumor population is increasing. While corticosteroids are known immunosupressants, prescribing patterns for these medications has not changed lately. However, high dose methotrexate is now being used in PCNSL and could be a complicating factor. Since effective prophylaxis exists, it should be considered in patients with brain tumors receiving high dose steroids, high dose methotrexate or with lymphopenia.

Brain metastases: treatment options to improve outcomes

In recent years, a broader base of treatment options has evolved to improve the outcome for patients with brain metastases. The selection of the most appropriate intervention for the individual patient is dependent on a careful evaluation of the extent of intracranial tumour, as well as an understanding of patient and tumour characteristics that are important determinants of prognosis. Recent analyses have confirmed good performance status, control of the primary tumour, absence of extracranial metastases and age less than 65 years to be predictors for longer survival. Medical therapy typically includes the use of corticosteroids, and some advances have been made in optimising the use of these agents. Prophylactic use of antiepileptic drugs in patients with brain metastases is generally discouraged. Chemotherapy was previously not considered to have a role in treating brain metastases, but has increasingly become an accepted treatment option. Recent clinical studies have evaluated the integration of chemotherapy with conventional treatments such as radiotherapy and the addition of biological response modifiers. In the past, radiotherapy has been the mainstay of treatment for brain metastases. A number of randomised controlled trials have explored external beam radiation therapy, radiation sensitisers, postoperative whole brain irradiation and prophylactic cranial irradiation. Significant improvements in survival have been demonstrated as a result of prophylactic cranial irradiation in patients with small-cell lung cancer, and improved local control of brain metastases has been achieved with postoperative whole brain irradiation. A number of studies have helped define a more efficient use of external beam irradiation. Radiosurgery in particular has been identified as an important advance in radiation treatment delivery and may provide an acceptable alternative to surgical resection in many patients. Conventional surgery has long had a role to play in establishing the diagnosis, guiding the choice of subsequent therapies and reversing life-threatening complications from brain metastases. The risks of surgery have been reduced with recent improvements in anaesthesia and intraoperative tumour localisation. Recent clinical studies have addressed the role of surgical resection in the management of patients with a single brain metastasis. Survival benefits have been demonstrated in patients undergoing surgical resection in addition to external beam radiation therapy. Despite the improvements achieved in the treatment of patients with brain metastases at first diagnosis, the question of retreatment may arise in due course. The therapeutic options available in this situation include re-operation, radiosurgery and brachytherapy.

Medical management of patients with brain tumors

The most common medical problems in brain tumor patients involve the management of seizures, peritumoral edema, medication side effects, and venous thromboembolism. Despite the importance of these issues, there are very few studies specifically addressing them. Nonetheless, there has been some progress in recent years. There is increasing evidence that brain tumor patients who have not had a seizure do not benefit from prophylactic antiepileptic medications. Patients taking corticosteroids are at greater risk of Pneumocystis carinii pneumonia and may benefit from prophylactic therapy. There is also growing evidence suggesting that anticoagulation may be more effective than inferior vena cava filtration devices for treating venous thromboembolism in brain tumor patients and that the risk of hemorrhage with anticoagulation is relatively small.

Brain tumors

The total care of a patient with an incurable brain tumor is a complex task. It is best performed by a team of specialized care providers including neurologists, neuro-oncologists, neurosurgeons, radiation oncologists, nurses, neuropsychologists, social workers, and physical and occupational therapists. Hospice providers, and spiritual counselors provide particular skilled services and comfort to patients nearing the end of life. The role and prominence of each team member evolves during the course of the illness as the disease progresses and the symptoms and needs of the patient change. Family members often provide the bulk of the direct care, and themselves require support, education, and counseling. While we currently lack curative therapies for most patients with malignant brain tumors, careful attention to symptom diagnosis and management can greatly enhance the quality of life of a patient with a brain tumor throughout the course of the illness and at the end of life.

Pneumocystis carinii pneumonia during maintenance treatment of childhood acute lymphoblastic leukemia

BACKGROUND

Pneumocystis carinii pneumonia (PCP) is a wellknown risk among patients with deficient T-cell function such as children treated for acute lymphoblastic leukemia (ALL). The purpose of this study was to estimate the risk for PCP during maintenance treatment (MT) to identify patients at risk who could benefit from prophylaxis.

PROCEDURE

We registered all episodes of PCP during MT in 71 children diagnosed between January 1992 and June 1997 with non-B-cell ALL at The Copenhagen University Hospital. Sulphametoxazole and trimetroprim (SMX/TMP) prophylaxis against PCP was given during induction and consolidation therapy but stopped prior to MT with oral methotrexate/6-mercaptopurine. Patients with standard (SR), intermediate (IR), and high risk (HR) ALL started MT at 3, 8, and 15 months from diagnosis, respectively.

RESULTS

The HR group had a cumulated risk of 70% for developing PCP, whereas the risk for PCP in children with IR and the SR was 11 and 8%, respectively (P < 0.0001). All but one of these 13 cases of PCP occurred within 8 months after cessation of SMX-TMP prophylaxis.

CONCLUSIONS

The higher incidence of PCP among HR compared to non-HR patients following cessation of SMX/TMP prophylaxis probably reflects the significantly longer T-cell suppressive consolidation therapy in this group. The very low incidence of PCP during the later part of MT emphasizes that methotrexate/6-mercaptopurine MT have more impact on B-cell than on T-cell function. TMP/SMX prophylaxis should be recommended for all children treated for ALL.

Pneumocystis carinii pneumonia in patients without HIV infection

Pneumocystis carinii is an important, but sporadic, opportunistic pulmonary pathogen in immunosuppressed HIV seronegative persons. Historically, patients at highest risk for P. carinii pneumonia are included infants with severe malnutrition, children with primary immunodeficiencies, patients with hematological malignancies, and recipients of solid organ or bone marrow transplants. Recently, solid tumor patients, in particular those receiving high-dose corticosteroids for brain neoplasms, and patients with inflammatory or collagen-vascular disorders, especially patients with Wegener granulomatosis receiving immunosuppressive therapy, have been identified as subgroups at increased risk for P. carinii pneumonia. Other factors associated with P. carinii pneumonia include the intensity of the immunosuppressive regimen and tapering doses of corticosteroids. Because P. carinii pneumonia is associated with significant morbidity and mortality, it is important to identify high-risk patient populations to administer effective chemoprophylactic agents, such as trimethoprim-sulfamethoxazole.

Management of complications of glucocorticoid therapy

Corticosteroids are commonly employed in the treatment of a wide variety of pulmonary disorders, including asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, sarcoidosis, and pulmonary vasculitides; as well as in the lung transplant population. Frequently, steroid-induced complications contribute significantly to morbidity and diminished quality of life, often overshadowing the impact of the underlying lung disease. This article will discuss the more commonly encountered complications of corticosteroids in the context of the method of delivery, events occurring with chronic use, and events related to withdrawal.