The Morbidity and Mortality of Brain Tumors: A Perspective on Recent Advances in Therapy

Ocular Motor Cranial Nerve Palsies and Increased Risk of Primary Malignant Brain Tumors: South Korean National Health Insurance Data

The aim of this study was to investigate the association between ocular motor cranial nerve palsies (OMCNP) and the occurrence of primary malignant brain tumors in a Korean population, using the national sample cohort database from Korea National Health Insurance Service (KNHIS). KNHIS data between 2010 and 2017 were analyzed. Our sample encompassed 118,686 participants, including 19,781 from a recently diagnosed OMCNP cohort and 98,905 from a matched control cohort through a 1:5 propensity score matching based on age and gender. To counteract the issue of reverse causation, we integrated a one-year time lag in our sensitivity analysis. Study participants were followed up until 31 December 2019. Cox proportional hazard regression analysis was used to compute the adjusted hazard ratio (HR) for primary malignant brain tumors according to the OMCNP diagnosis. Additionally, we performed a subgroup analysis to discern effects of various factors on the association between OMCNP and primary malignant brain tumors. HR for primary malignant brain tumors was 3.272 (95% confidence interval [CI]: 2.294 to 4.665) in the OMCNP cohort compared to the control cohort in a fully adjusted model for age, sex, socio-economic status, smoking, drinking, regular physical exercise, hypertension, diabetes, dyslipidemia, obesity, chronic kidney disease, and human immunodeficiency virus infection. Further subgroup analysis revealed that the risk of primary malignant brain tumors was significantly increased in women with OMCNP compared to men with OMCNP (HR: 5.118 in women vs. 2.441 in men, p = 0.0440), and in those aged <65 years than in those aged ≥65 years (HR: 6.951 in age < 65 years vs. 1.899 in age ≥ 65 years, p = 0.0006). Our population-based cohort study demonstrated a significantly increased risk of subsequent primary malignant brain tumors in patients with OMCNP. Particularly, OMCNP-afflicted women aged below 65 manifested a heightened probability of developing primary malignant brain tumors compared to those devoid of OMCNP.

Biopsy versus resection in the management of malignant gliomas: a systematic review and meta-analysis

Object

The aim of this study was to answer the question whether quality of life and progression-free and overall survival are increased in adults with supratentorial malignant glioma who are treated with cytoreductive resection as compared with those who only undergo biopsy.

Methods

A literature search of the electronic databases MEDLINE, EMBASE, and CENTRAL was performed to identify relevant studies published before May 2008. Hand-searching of reference lists of the identified studies and relevant review articles was also performed. A study was considered eligible, regardless of study design (prospective or retrospective), if: 1) quality of life and/or progression-free and/or overall survival was compared among adult patients undergoing biopsy or resection, and 2) patient age and Karnofsky Performance Scale scores were not significantly different among the 2 groups compared.

Results

One randomized controlled trial and 4 retrospective studies (involving a total of 1111 patients) were found eligible for this systematic review. A meta-analysis of the eligible studies demonstrated a significant increase in overall survival in the patients treated with resection instead of biopsy (hazard ratio 0.61, 95% CI 0.52–0.71, p < 0.0001, fixed-effect model). Although statistical pooling was not feasible, the available data suggest that quality of life was increased in patients treated with resection rather than biopsy, while there did not seem to be any significant difference in progression-free survival between the 2 groups.

Conclusions

Based on the best available evidence, it appears that cytoreductive resection in adults with supratentorial malignant glioma is associated with improved overall survival as compared with biopsy. However, well-designed prospective studies are needed for more solid conclusions to be drawn.

Immunotoxin pharmacokinetics: a comparison of the anti-glioblastoma bi-specific fusion protein (DTAT13) to DTAT and DTIL13

DTAT13, a novel recombinant bispecific immunotoxin (IT) consisting of truncated diphtheria toxin, an amino-terminal (AT) fragment of the urokinase-type plasminogen activator (uPa), and a fragment of human IL-13 was assembled in order to target receptors on glioblastoma multiforme (GBM) and its associated neovasculature. Previous in vitro studies confirmed the efficacy of DTAT13 against various GBM cell lines expressing both IL-13 receptor or uPA receptor, and previous in vivo testing demonstrated the efficacy of DTAT13 in significantly inhibiting a range of xenograft tumors and showed that DTAT13 was 160- and 8-fold less toxic to the parental fusion IT, DTAT and DTIL13, respectively. To further understand the properties of DTAT13, pharmacokinetic/biodistribution experiments were performed. Binding analysis revealed that the IL-13 domain functioned independently of the uPA domain and that the K (d) for each binding domain was essentially the same as that of DTIL13 and DTAT. Flow cytometry studies indicated that DTAT13 bound better than DTAT or DTIL13. Analysis of the rate of protein synthesis inhibition in U87 MG cells by DTAT13 compared to DTAT revealed a faster rate of inhibition with DTAT13 compared to DTAT. The rate of protein synthesis inhibition of DTAT13 was identical to that of DTIL13 in U373 MG cells. Intracranial biodistribution studies revealed that DTAT13 was able to cross to the contralateral hemisphere unlike DTIL13 but similar to DTAT. These studies show that DTAT13 has properties encompassing those of both DTIL13 and DTAT and warrants further consideration for clinical development.

Immunotoxin therapy for CNS tumor

Surgery, chemotherapy, and radiation therapy have become standard of practice in treating malignant brain tumors. Unfortunately, the prognosis of these malignant tumors still remains poor. Immunotoxins are a relatively new adjuvant treatment for brain tumors. Within the last few years an increased amount of clinically-oriented research involving immunotoxins has been published. This has led to numerous clinical trials which although encouraging have not yet born out the "magic bullet" concept envisioned for immunotoxins. In this review article the history, design, toxicity, and pharmokinetics of immunotoxins will be discussed in detail.

A cost-minimising analysis of standard radiotherapy and two experimental therapies in glioblastoma

BACKGROUND AND PURPOSE

Accelerated radiotherapy (ART) and intracavity brachytherapy (ICBT) have been introduced in the primary treatment of glioblastoma. Our objective was to determine total treatment costs, hospitalisation time, and treatment outcome in these two experimental therapies compared to standard treatment.

MATERIALS AND METHODS

In the time period 1985 to 1st May 1999, a total of 174 patients with histologically confirmed glioblastoma multiforme were given postoperative radiotherapy according to three different treatment schedules at three different time intervals. A conventional regime of external radiotherapy (54Gy/30 fractions) was given to 58 patients (group I), 75 patients were treated with ART (48Gy/twice daily 30 fractions) (group II), and 41 patients were given ICBT (60Gy/ten fractions) (group III). Treatment costs including surgery, hospital stay, hospital hotel stay, and radiotherapy were calculated.

RESULTS

The total mean costs employing the three treatment alternatives were calculated to $25,618 (group I), $23,442 (group II), and $14,534 (group III). Total mean stay in hospital for the whole primary treatment was 48.8, 41.6, and 19 days for groups I, II, and III respectively. Median survival figures were 16, 14, and 13 months for groups I, II, and III, respectively.

CONCLUSIONS

The total cost of postoperative radiotherapy in glioblastoma is comparable to other health care services. ART did not improve the total treatment cost or influence the need for hospitalisation compared to standard treatment. ICBT seemed to have economic benefits with less need for hospitalisation.

Pediatric brain tumors

Pediatric brain tumors differ from adult brain tumors in several major ways. First, the types of tumors encountered in children are uncommon in adults, and vice versa. Second, tumors of the posterior fossa comprise a far greater percentage of tumors in children as compared to adults. Third, the value of extensive tumor resection, which is controversial for malignant brain tumors in adults, has been confirmed for a variety of childhood brain tumors. Fourth, chemotherapy has been shown to be effective in improving overall outcome in several childhood brain tumors, but has yet to be demonstrated to have a major benefit for adult tumors. In addition, to avoid the morbidity of irradiation on the developing nervous system, chemotherapy is increasingly used to delay or avoid using radiotherapy in children younger than 3 years of age with high-grade and incompletely resected low-grade tumors. Fifth, the prognosis for histologically similar tumors is often more favorable in children than adults. A review of general principles in the clinical presentation, diagnostic evaluation, and treatment of childhood brain tumors is followed by discussion of surgical management, adjuvant therapy, and outcome of the more common types of tumors.

A proposed preoperative grading scheme to assess risk for surgical resection of primary and secondary intraaxial supratentorial brain tumors

Although surgical resection of brain tumors has been performed for over a century, complications still occur with distressing frequency.

The authors propose a simple preoperative grading scheme to assess surgical risk for resection of primary and secondary intraaxial supratentorial brain tumors.

The authors retrospectively reviewed the clinical records, neuroimaging studies, and outcomes of 224 surgeries performed in 207 patients from January 1993 to December 1995 at the Cleveland Clinic Foundation Brain Tumor Center. Subsequently, they considered and statistically analyzed multiple variables related to the patients and their lesions. Surgical risk was defined as any complication occurring within 30 days postoperatively, and was divided into transient operative complications, transient medical complications, and new sustained neurological deficits. Length of stay was also recorded. The overall incidence of complications was 10.6% and the mortality rate was 2.7%, with a median hospital stay of 3 days. Patient age greater than 60 years (p < 0.001), preoperative Karnofsky Performance Scale scores of 50 or less (p < 0.03), previous irradiation (p < 0.001), tumor location in eloquent regions (p < 0.03), and depth of tumor invasion (p < 0.001) independently predicted complicated outcome or increased length of stay. Finally, the authors derived a simple five-tier grading scheme in which these patient risk factors are added together to obtain a grade of I to V that corresponds to outcome and length of hospital stay.

This grading scheme may be used to identify patients at higher risk and facilitate comparison of results between institutions and individual surgeons.

High-grade astrocytomas: resource use, clinical outcomes, and cost of care

OBJECTIVE

To describe the clinical course, survival, resource use, and direct medical costs of care for patients with high-grade astrocytomas.

MATERIAL AND METHODS

All patients with grade 3 or 4 astrocytoma who resided in Olmsted County, Minnesota, or one of the six adjacent counties and had a tissue diagnosis first made between 1987 and 1992 were studied. Clinical characteristics, initial management, use of resources, clinical course, survival, and medical charges were analyzed.

RESULTS

Sixty-four patients, with a mean age of 62 years, were identified; 81% had glioblastoma multiforme. Approximately 60% underwent surgical resection, 80% had radiotherapy, and 50% had chemotherapy for initial management. After initial treatment (median duration, 116 days), approximately 75% of patients had a course with stable disease (median duration, 198 days). The overall median duration of survival was 323 days; lower grade and younger age were significantly associated with longer median survival-for example, 1,493 days for patients younger than 65 years with grade 3 astrocytomas and 205 days for patients 65 years old or older with grade 4 astrocytomas. The mean total direct medical charges were $67,887.

CONCLUSION

In most patients with high-grade astrocytomas, a substantial period elapsed before disease progressed. Although the overall median duration of survival was less than 1 year, younger patients, especially those with grade 3 astrocytomas, had a longer survival. The management of patients with high-grade astrocytomas uses substantial health-care resources.

Long term results of stereotactic brachytherapy used in the initial treatment of patients with glioblastomas

BACKGROUND

Despite optimal therapy with surgery and radiotherapy, the prognosis of patients with glioblastomas remains poor. Stereotactic brachytherapy involves the accurate placement of radioactive isotopes within brain tumors, significantly increasing the dose of radiation that can be delivered to the tumor bed without substantial risk to surrounding normal tissue, potentially improving local tumor control and patient survival.

METHODS

Between February 1987 and July 1993, the authors treated 56 patients with glioblastomas with stereotactic brachytherapy as part of their initial therapy. Patients underwent surgery, limited field external beam radiotherapy, and brachytherapy with temporary high-activity iodine 125 sources, giving an additional 50 Gy to the tumor bed.

RESULTS

Median survival for patients undergoing brachytherapy was 18 months compared with 11 months for a matched brachytherapy control group with similar clinical and radiologic features (P < 0.0007). Survival rates at 1, 2, and 3 years after diagnosis of 83%, 34%, and 27%, respectively, for patients receiving brachytherapy were significantly increased compared with survival rates of 40%, 12.5%, and 9%, respectively, for control subjects. Thirty-six patients (64%) underwent reoperation for symptomatic radiation necrosis from 3 to 42 months (median, 11 months) after brachytherapy. The median survival of patients undergoing reoperation was 22 months compared with 13 months for those who did not have further surgery (P < 0.02). Thirty-five percent of patients relapsed locally within the brachytherapy target volume, whereas 65% had marginal or distant relapses.

CONCLUSIONS

Brachytherapy may improve local tumor control and prolong survival when used in the initial treatment of selected patients with glioblastomas.

In vitro efficacy of transferrin-toxin conjugates against glioblastoma multiforme

The cytotoxic activity of immunotoxins constructed with human diferric transferrin (Tfn) as the carrier ligand and an abrin variant Pseudomonas exotoxin A (PE) and the diphtheria toxin mutant cross-reacting material (CRM) 107 as the toxin moieties were studied in vitro. Three malignant human cell lines, the glioblastomas multiforme SNB19 and SF295 and the LOX melanoma, and a nonhuman control murine melanoma cell line B16 were assessed. The presence of transferrin receptors on the cell lines was confirmed by direct 125I-Tfn binding assays. The 50% protein synthesis inhibitory concentration (IC50) values for all cell lines demonstrated that Tfn-abrin variant and Tfn-PE had comparable potency and were both more effective than Tfn-CRM 107. Monensin, a carboxylic ionophore, potentiated the effect of Tfn-abrin variant against glioma cells approximately 35-fold with IC50 values of 4.0 x 10(-13) M and 4.7 x 10(-12) M for SNB19 and SF295, respectively. Cytotoxic activity of Tfn-abrin variant (with or without monensin) and Tfn-PE was correlated with the degree of Tfn receptor expression measured on the cell lines. The exquisite in vitro cytotoxicity of Tfn-abrin variant and Tfn-PE immunotoxins against glioma and melanoma cells warrants further in vivo evaluation and future consideration of these agents for potential clinical application against glioblastoma multiforme and leptomeningeal neoplasia.

Immunotoxins and central nervous system neoplasia

The poor prognosis associated with central nervous system (CNS) malignancy has led investigators to seek new, innovative treatment modalities. Immunotoxins, carrier molecules linked to toxic agents, combine high specificity for tumor-associated antigens with extreme potency. The rationale for both the development of these compounds and for their application to CNS neoplasia is explained. This report discusses the design and construction of immunoconjugates, using toxins that differ in their mechanism of action bound to ligands directed against various antigens. A comparison is made between the in vitro efficacy of standard chemotherapy and immunotoxins in glioblastoma- and medulloblastoma-derived cell lines. A review is included of the results of experiments in animals with leptomeningeal neoplasia, where prolongation of survival following intrathecal administration of immunotoxins has been reported. The obstacles encountered in clinical trials with other types of cancer are addressed and approaches to optimize the use of these novel agents in the context of treating malignant disease of the CNS are suggested.

Longitudinal Gompertzian analysis of primary malignant brain tumor mortality in the U.S., 1962-1987: rising mortality in the elderly is the natural consequence of competitive deterministic dynamics

Age-adjusted mortality rates for primary malignant brain tumors (PMBT) in the United States from 1962 to 1987 were subjected to longitudinal Gompertzian analysis. Age-adjusted PMBT mortality rate distributions between age 25 and 65 years were determined by a variable environmental factor and a common intersect point. The environmental factor declined (improved) 1.58-fold for men and 2.34-fold for women in 1987 as compared to 1962. The age at the common intersect point was 68.4 years for men and 64.1 years for women. Between 1962 and 1987, non-age-standardized annual crude PMBT mortality rates increased 14.5% for men and 37.8% for women. However, PMBT mortality rates at age 77.5 years rose 259% for men and 409% for women between 1962 and 1987. Longitudinal Gompertzian analysis of PMBT mortality data suggests that rapidly rising PMBT mortality rates in the elderly are the natural consequence of competitive deterministic mortality dynamics and should not be attributed to environmental factors, past or present, that are directly contributing to PMBT mortality. Furthermore, longitudinal Gompertzian analysis demonstrates that PMBT mortality should not be studied in isolation, but rather should be examined in relation to other causes of death. When viewed from this perspective, the basis for the dramatic rise in PMBT mortality in the elderly becomes quite evident.

The role of surgery in the management of supratentorial intermediate and high-grade astrocytomas in adults

In this analysis, the authors review studies over the last 50 years addressing the association between long-term survival and type of surgical management in adults with supratentorial intermediate or high-grade astrocytomas. Earlier reports are included because they are repeatedly referenced in current works and clearly are an important basis upon which present attitudes are predicated. Because recent work has definitively demonstrated the significance of prognostic variables on outcome, the handling of such factors in studies that investigated survival data according to degree of surgery is emphasized. Study design, experimental methods used, and methods of data analysis are also examined. This analysis shows that there is little justification for dogmatic statements concerning the relationship between increasing patient survival times and aggressive surgical management in adults with supratentorial intermediate or high-grade astrocytomas, if patients receive postoperative radiotherapy.

Long-term survival after malignant glioma. A clinical and histopathological study on the accuracy of the diagnosis in a population-based cancer register

The Stockholm Regional Cancer Register (SRCR) contains 1,002 patients with malignant glioma reported between 1958 and 1977. A total of 49 patients had a minimum survival time of 4 years and of these 48 were studied in search for histological characteristics that might explain the unexpectedly good prognosis. In only 8 of the 48 patients (17%) could the diagnosis of malignant glioma of high malignancy grade be verified at histopathological reexamination. All 8 were grade III tumors according to WHO and no primary glioblastomas were found. The explanation for the erroneous registration was either incorrect initial pathological diagnosis or incorrect registration. No common morphological features could be found among the correctly registered long-term survivors. Survival data on gliomas based on original histopathological diagnoses derived from information in population-based cancer registers should be cautiously interpreted. Reliable conclusions can only be drawn when such data are supplemented with clinical information and the histopathology is reviewed.

Hyperthermia for the treatment of brain tumors

Brain malignancy, either primary or metastatic, in general is associated with a very poor outcome in spite of the best therapy modern medicine has to offer. The multimodality approach appears to offer the best chance of achieving our goal of improved survival (quality and quantity) and ultimately cure. Hyperthermia, though its application to brain cancer remains experimental, has proven itself in its ability to improve cancer therapy results. There are many methods available to apply hyperthermia to the brain and its application, thus far, has been quite safe. Continued research in this exciting field is warranted.

Efficacy of intrathecal immunotoxin therapy in an animal model of leptomeningeal neoplasia

Immunotoxins comprise a new class of cell-type specific cytotoxic reagents which consist of a monoclonal antibody linked to a protein toxin. This report examines the efficacy of intrathecal immunotoxin therapy for the treatment of tumors of the cerebrospinal fluid compartment. A syngeneic animal model of leptomeningeal neoplasia was developed in which percutaneous inoculation of L2C tumor cells into the cisterna magna of Strain 2 guinea pigs produced disseminated leptomeningeal and intraventricular leukemia and death. Percutaneous intracisternal injection of 2 micrograms of an anti-idiotype monoclonal antibody (M6)-intact ricin immunotoxin 24 hours following intracisternal inoculation of 10(5) L2C cells (10,000 times the lethal dose) produced prolonged survival (p less than 0.005) of tumor-bearing animals. The immunotoxin therapy caused no detectable toxicity. Intracisternal injection of either M6 monoclonal antibody alone or a nonspecific control immunotoxin had no therapeutic effect. The observed extension of survival times in immunotoxin-treated animals corresponds to a median 2- to 3-log (99% to 99.9%) and, in some animals, possibly a 5-log (99.999%) or greater kill of tumor cells. These results support a possible role for immunotoxins in the clinical treatment of central nervous system neoplastic disease involving compartments (intrathecal, intraventricular, or cystic tumor).

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.