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Hashemi-Sadraei N, Peereboom DM. Chemotherapy in newly diagnosed primary central nervous system lymphoma. Ther Adv Med Oncol 2010; 2:273-92. [PMID: 21789140 PMCID: PMC3126018 DOI: 10.1177/1758834010365330] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) accounts for only 3% of brain tumors. It can involve the brain parenchyma, leptomeninges, eyes and the spinal cord. Unlike systemic lymphoma, durable remissions remain uncommon. Although phase III trials in this rare disease are difficult to perform, many phase II trials have attempted to define standards of care. Treatment modalities for patients with newly diagnosed PCNSL include radiation and/or chemotherapy. While the role of radiation therapy for initial management of PCNSL is controversial, clinical trials will attempt to improve the therapeutic index of this modality. Routes of chemotherapy administration include intravenous, intraocular, intraventricular or intra-arterial. Multiple trials have outlined different methotrexate-based chemotherapy regimens and have used local techniques to improve drug delivery. A major challenge in the management of patients with PCNSL remains the delivery of aggressive treatment with preservation of neurocognitive function. Because PCNSL is rare, it is important to perform multicenter clinical trials and to incorporate detailed measurements of long-term toxicities. In this review we focus on different chemotherapeutic approaches for immunocompetent patients with newly diagnosed PCNSL and discuss the role of local drug delivery in addition to systemic therapy. We also address the neurocognitive toxicity of treatment.
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Angelov L, Doolittle ND, Kraemer DF, Siegal T, Barnett GH, Peereboom DM, Stevens G, McGregor J, Jahnke K, Lacy CA, Hedrick NA, Shalom E, Ference S, Bell S, Sorenson L, Tyson RM, Haluska M, Neuwelt EA. Blood-brain barrier disruption and intra-arterial methotrexate-based therapy for newly diagnosed primary CNS lymphoma: a multi-institutional experience. J Clin Oncol 2009; 27:3503-9. [PMID: 19451444 DOI: 10.1200/jco.2008.19.3789] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Primary CNS lymphoma (PCNSL) is confined to the CNS and/or the eyes at presentation and is usually initially treated with intravenous methotrexate-based chemotherapy and whole-brain radiotherapy (WBRT). However, the intact blood-brain barrier (BBB) can limit diffusion of methotrexate into brain and tumor. With BBB disruption (BBBD), enhanced drug delivery to the tumor can be achieved. PATIENTS AND METHODS This report summarizes the multi-institutional experience of 149 newly diagnosed (with no prior WBRT) patients with PCNSL treated with osmotic BBBD and intra-arterial (IA) methotrexate at four institutions from 1982 to 2005. In this series, 47.6% of patients were age > or = 60 years, and 42.3% had Karnofsky performance score (KPS) less than 70 at diagnosis. Results The overall response rate was 81.9% (57.8% complete; 24.2% partial). Median overall survival (OS) was 3.1 years (25% estimated survival at 8.5 years). Median progression-free survival (PFS) was 1.8 years, with 5-year PFS of 31% and 7-year PFS of 25%. In low-risk patients (age < 60 years and KPS > or = 70), median OS was approximately 14 years, with a plateau after approximately 8 years. Procedures were generally well tolerated; focal seizures (9.2%) were the most frequent side effect and lacked long-term sequelae. CONCLUSION This large series of patients treated over a 23-year period demonstrates that BBBD/IA methotrexate-based chemotherapy results in successful and durable tumor control and outcomes that are comparable or superior to other PCNSL treatment regimens.
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Affiliation(s)
- Lilyana Angelov
- 3181 SW Sam Jackson Park Rd, Mailcode L603, Portland, OR 97239, USA
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Correa DD, Maron L, Harder H, Klein M, Armstrong CL, Calabrese P, Bromberg JEC, Abrey LE, Batchelor TT, Schiff D. Cognitive functions in primary central nervous system lymphoma: literature review and assessment guidelines. Ann Oncol 2007; 18:1145-51. [PMID: 17284616 DOI: 10.1093/annonc/mdl464] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment-related neurotoxicity has been recognized as a significant problem in patients with primary central nervous system lymphoma (PCNSL) as effective treatment has increased survival rates. There is, however, a paucity of research on cognitive functions in this population. DESIGN In a review of the literature, a total of 17 articles that described cognitive outcome in adult PCNSL patients were identified. RESULTS The studies that assessed cognitive functions after whole-brain radiotherapy combined with chemotherapy reported cognitive impairment in most patients. Patients treated with chemotherapy alone had either stable or improved cognitive performance in most studies. Methodological problems, however, limited the ability to ascertain the specific contribution of disease and various treatment interventions to cognitive outcome. On the basis of the literature review, a battery of cognitive and quality-of-life (QoL) measures to be used in prospective clinical trials was proposed. The battery is composed of five standardized neuropsychological tests, covering four domains sensitive to disease and treatment effects (attention, executive functions, memory, psychomotor speed), and QoL questionnaires, and meets criteria for use in collaborative trials. CONCLUSION The incorporation of formal and systematic cognitive evaluations in PCNSL studies will improve our understanding of treatment-related neurotoxicity in this population.
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Affiliation(s)
- D D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Abstract
As effective treatment interventions have increased survival rates, there has been greater awareness that many brain tumor patients experience cognitive dysfunction despite adequate disease control. Cognitive difficulties often have an impact on quality of life and interfere with the patient's ability to function at premorbid levels; however, the incidence of cognitive dysfunction in brain tumor patients is unknown, because it has not been investigated systematically. Future prospective clinical trials in neuro-oncology should include cognitive outcome measures to increase understanding of the contribution of the tumor and the delayed effects of treatment to cognitive dysfunction.
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Affiliation(s)
- Denise D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Jahnke K, Doolittle ND, Muldoon LL, Neuwelt EA. Implications of the blood–brain barrier in primary central nervous system lymphoma. Neurosurg Focus 2006; 21:E11. [PMID: 17134113 DOI: 10.3171/foc.2006.21.5.12] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ The optimal treatment of primary central nervous system lymphoma (PCNSL), a rare form of extranodal non-Hodgkin lymphoma, has yet to be defined. Whole-brain radiation therapy (WBRT) has limited efficacy as a single therapeutic modality and is associated with a high risk of delayed neurotoxicity. Methotrexate-based chemotherapy regimens yield poor drug penetration across the blood–brain barrier (BBB), thus necessitating administration of high doses with the concomitant risk of increased systemic and neurological toxicity. Combined-modality therapy (WBRT plus chemotherapy) can improve response and survival rates, yet it is associated with a high risk of neurotoxicity. The aim of chemotherapy in conjunction with BBB disruption is to maximize drug delivery to the brain and improve the agent's efficacy, while preserving neurocognitive function and minimizing systemic toxicity. Methotrexate-based chemotherapy regimens administered in conjunction with BBB disruption have shown promising results in PCNSL. Animal models of central nervous system lymphoma and drug neurotoxicity offer new possibilities to study the effects of various treatments on PCNSL and normal brain and can also help understand biological and pathophysiological aspects of this disease. Because the intact BBB is even less permeable to antibodies than it is to drugs, preclinical and clinical studies of monoclonal antibody delivery (for example, rituximab and 90Y ibritumomab tiuxetan) to the brain in conjunction with BBB disruption offer a new possibility to make these novel treatments more efficient against PCNSL. Regarding the evaluation of more sensitive and specific diagnostic imaging tools, iron oxide–based contrast agents for magnetic resonance imaging have shown promise for better differentiation of PCNSL from other white matter diseases.
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Affiliation(s)
- Kristoph Jahnke
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
Two challenges need to be addressed to improve the outcome of patients with primary central nervous system lymphoma. The first challenge is to develop therapies that result in less toxicity and improved long-term outcome. The second challenge is to develop interventions to help those patients who develop treatment-related neurotoxicity; ongoing collaborative efforts are required to improve communication and understanding of this complication. Long-term follow up of prospective therapeutic studies should report on both disease control and the development of neurotoxicity. New protocols should include prospective longitudinal measures of neurocognitive function.
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Affiliation(s)
- Lauren E Abrey
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Marchi N, Cavaglia M, Fazio V, Bhudia S, Hallene K, Janigro D. Peripheral markers of blood-brain barrier damage. Clin Chim Acta 2005; 342:1-12. [PMID: 15026262 DOI: 10.1016/j.cccn.2003.12.008] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2003] [Revised: 12/03/2003] [Accepted: 12/04/2003] [Indexed: 12/13/2022]
Abstract
Neurological diseases are often associated with cerebrovascular dysfunction and changes in blood-brain barrier (BBB) function. This is important for two seemingly conflicting reasons. On the one hand, a leaky BBB may lead to brain disease by allowing extravasation of cells and molecules normally segregated in the periphery, while on the other hand an intact BBB may hamper drug delivery to the ailing brain. Under both circumstances, it would be desirable to follow closely over time BBB "tightness". Several lines of evidence have suggested that the astrocytic protein S100beta is a potentially useful peripheral marker of BBB permeability. Other markers of brain-to-blood barriers have been recently discovered by a proteomic approach. These proteins are virtually absent in normal blood, appear in serum from patients with cerebral lesions, and can be easily detected. We will present clinical and laboratory evidence supporting the use of these markers as modern neurodiagnostic tools.
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Affiliation(s)
- Nicola Marchi
- Department of Neurological Surgery, Cerebrovascular Research Center, NB20, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Kanner AA, Marchi N, Fazio V, Mayberg MR, Koltz MT, Siomin V, Stevens GHJ, Masaryk T, Ayumar B, Vogelbaum MA, Barnett GH, Janigro D. Serum S100beta: a noninvasive marker of blood-brain barrier function and brain lesions. Cancer 2003; 97:2806-13. [PMID: 12767094 PMCID: PMC4135471 DOI: 10.1002/cncr.11409] [Citation(s) in RCA: 213] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND S100beta protein is expressed constitutively by brain astrocytes. Elevated S100beta levels in cerebrospinal fluid and serum reported after head trauma, subarachnoid hemorrhage, and stroke were correlated with the extent of brain damage. Because elevated serum S100beta also was shown to indicate blood-brain barrier (BBB) dysfunction in the absence of apparent brain injury, it remains unclear whether elevation of serum levels of S100beta reflect BBB dysfunction, parenchymal damage, or both. METHODS The authors conducted a prospective study of serum S100beta levels in six patients who underwent hyperosmotic BBB disruption (BBBD) with intraarterial chemotherapy for primary central nervous system lymphoma. In addition, 53 serum S100beta samples were measured in 51 patients who had a variety of primary or metastatic brain lesions at the time of neuroimaging. RESULTS S100beta was correlated directly with the degree of clinical and radiologic signs of BBBD in patients who were enrolled in the hyperosmotic study. In patients with neoplastic brain lesions, gadolinium enhancement on a magnetic resonance image was correlated with elevated S100beta levels (n = 45 patients; 0.16 +/- 0.1 microg/L; mean +/- standard error of the mean) versus nonenhancing scans (n = 8 patients; 0.069 +/- 0.04 microg/L). Primary brain tumors (n = 8 patients; 0.12 +/- 0.08) or central nervous system metastases also presented with elevated serum S100beta levels (n = 27 patients; 0.14 +/- 0.34). Tumor volume was correlated with serum S100beta levels only in patients with vestibular schwannoma (n = 6 patients; 0.13 +/- 0.10 microg/L) but not in patients with other brain lesions. CONCLUSIONS S100beta was correlated directly with the extent and temporal sequence of hyperosmotic BBBD, further suggesting that S100beta is a marker of BBB function. Elevated S100beta levels may indicate the presence of radiologically detectable BBB leakage. Larger prospective studies may better determine the true specificity of S100beta as a marker for BBB function and as an early detection or follow-up marker of brain tumors.
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Affiliation(s)
- Andrew A. Kanner
- Brain Tumor Institute, The Cleveland Clinic, Cleveland, Ohio
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
| | - Nicola Marchi
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
| | - Vincent Fazio
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
| | - Marc R. Mayberg
- Brain Tumor Institute, The Cleveland Clinic, Cleveland, Ohio
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
| | - Michael T. Koltz
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
| | - Vitaly Siomin
- Brain Tumor Institute, The Cleveland Clinic, Cleveland, Ohio
| | | | - Thomas Masaryk
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
- Department of Neurological Surgery, The Cleveland Clinic, Cleveland, Ohio
| | - Barbara Ayumar
- Brain Tumor Institute, The Cleveland Clinic, Cleveland, Ohio
| | | | - Gene H. Barnett
- Brain Tumor Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Damir Janigro
- Brain Tumor Institute, The Cleveland Clinic, Cleveland, Ohio
- Cerebrovascular Research Center, The Cleveland Clinic, Cleveland, Ohio
- Department of Neurological Surgery, The Cleveland Clinic, Cleveland, Ohio
- Department of Cell Biology, The Cleveland Clinic, Cleveland, Ohio
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Abstract
The CNS is shielded from systemic influences by two separate barriers, the blood-brain barrier (BBB) and the blood-to-CSF barrier. Failure of either barrier bears profound significance in the etiology and diagnosis of several neurological diseases. Furthermore, selective opening of BBB tight junctions provides an opportunity for delivery of otherwise BBB impermeant drugs. Peripheral assessment of BBB opening can be achieved by detection in blood of brain-specific proteins that extravasate when these endothelial junctions are breached. We developed a proteomic approach to discover clusters of CNS-specific proteins with extravasation into serum that correlates with BBB openings. Protein profiles from blood samples obtained from patients undergoing iatrogenic BBB disruption (BBBD) with intra-arterial hyperosmotic mannitol were compared with pre-BBB opening serum. A low molecular weight protein (14 kDa) identified by mass spectroscopy as transthyretin (TTR) consistently correlated with BBBD. Protein gel electrophoresis and immunodetection confirmed that TTR was indeed extravasated in its monomeric form when CNS barriers were breached. The time course of TTR extravasation was compared with release from the brain of another BBB integrity marker, S-100beta (11 kDa). Kinetic analysis revealed that the appearance of S-100beta, presumably originating from perivascular astrocytic end feet, preceded extravasation of TTR by several minutes. Because TTR is localized primarily in choroid plexus and, as a soluble monomer, in CSF, we concluded that although S-100beta is a marker of BBB integrity, TTR instead may be a peripheral tracer of blood-to-cerebrospinal barrier.
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Affiliation(s)
- R Epelbaum
- Department of Oncology, Rambam Medical Center, Haifa, Israel
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Rapoport SI. Osmotic opening of the blood-brain barrier: principles, mechanism, and therapeutic applications. Cell Mol Neurobiol 2000; 20:217-30. [PMID: 10696511 DOI: 10.1023/a:1007049806660] [Citation(s) in RCA: 305] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
1. Osmotic opening of the blood-brain barrier by intracarotid infusion of a hypertonic arabinose or mannitol solution is mediated by vasodilatation and shrinkage of cerebrovascular endothelial cells, with widening of the interendothelial tight junctions to an estimated radius of 200 A. The effect may be facilitated by calcium-mediated contraction of the endothelial cytoskeleton. 2. The marked increase in apparent blood-brain barrier permeability to intravascular substances (10-fold for small molecules) following the osmotic procedure is due to both increased diffusion and bulk fluid flow across the tight junctions. The permeability effect is largely reversed within 10 min. 3. In experimental animals, the osmotic method has been used to grant wide access to the brain of water-soluble drugs, peptides, antibodies, boron compounds for neutron capture therapy, and viral vectors for gene therapy. The method also has been used together with anticancer drugs to treat patients with metastatic or primary brain tumors, with some success and minimal morbidity.
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Affiliation(s)
- S I Rapoport
- Section on Brain Physiology and Metabolism, National Institute on Aging, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Doolittle ND, Miner ME, Hall WA, Siegal T, Jerome E, Osztie E, McAllister LD, Bubalo JS, Kraemer DF, Fortin D, Nixon R, Muldoon LL, Neuwelt EA. Safety and efficacy of a multicenter study using intraarterial chemotherapy in conjunction with osmotic opening of the blood-brain barrier for the treatment of patients with malignant brain tumors. Cancer 2000; 88:637-47. [PMID: 10649259 DOI: 10.1002/(sici)1097-0142(20000201)88:3<637::aid-cncr22>3.0.co;2-y] [Citation(s) in RCA: 312] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to determine the safety and efficacy of intraarterial chemotherapy with osmotic opening of the blood-brain barrier (BBB) for the treatment of malignant brain tumors when administered across multiple centers. METHODS Patients with primary central nervous system lymphoma (PCNSL), primitive neuroectodermal tumor (PNET), germ cell tumor, cancer metastasis to the brain, or low or high grade glioma were eligible. Prior to entry, magnetic resonance imaging or computed tomography brain scan, medical history, neurologic status, and Karnofsky performance status were reviewed at the coordinating center. Standardized anesthesia and intraarterial catheterization guidelines were followed by a multidisciplinary team at each center. Between March 1994 and November 1997, 5 universities treated 221 adult patients with intraarterial chemotherapy with or without osmotic opening of the BBB (2464 procedures). RESULTS Of evaluable patients with PCNSL, 40 of 53 (75%) achieved complete response (CR). All evaluable patients with PNET (n = 17), metastatic disease (n = 12), or germ cell tumor (n = 4) achieved stable disease (SD) or better. Of 57 evaluable patients with glioblastoma multiforme, 45 (79%) achieved SD or better. Asymptomatic subintimal tear occurred in 11 of 221 patients (5%), pulmonary embolism in 6 of 221 (2.7%), and renal toxicity in 4 of 221 (1.8%). One patient with extensive glioma expired within 48 hours after treatment. CONCLUSIONS Using standard guidelines and protocols, intraarterial chemotherapy with or without osmotic opening of the BBB is feasible across multiple centers with a low incidence of catheter-related complications. In patients with chemotherapy-sensitive tumors, such as PCNSL, PNET, germ cell tumor, and cancer metastasis to the central nervous system, enhanced delivery results in a high degree of tumor response, with an efficacy profile that is reproducible across multiple centers.
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Affiliation(s)
- N D Doolittle
- Department of Neurology, Oregon Health Sciences University, Portland, OR 97201-3098, USA
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Doolittle ND, Miner ME, Hall WA, Siegal T, Hanson EJ, Osztie E, McAllister LD, Bubalo JS, Kraemer DF, Fortin D, Nixon R, Muldoon LL, Neuwelt EA. Safety and efficacy of a multicenter study using intraarterial chemotherapy in conjunction with osmotic opening of the blood-brain barrier for the treatment of patients with malignant brain tumors. Cancer 2000. [DOI: 10.1002/(sici)1097-0142(20000201)88:3%3c637::aid-cncr22%3e3.0.co;2-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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McAllister LD, Doolittle ND, Guastadisegni PE, Kraemer DF, Lacy CA, Crossen JR, Neuwelt EA. Cognitive Outcomes and Long-term Follow-up Results after Enhanced Chemotherapy Delivery for Primary Central Nervous System Lymphoma. Neurosurgery 2000. [DOI: 10.1093/neurosurgery/46.1.51] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Nancy D. Doolittle
- Department of NeurologyOregon Health Sciences University, Portland, Oregon
| | | | | | - Cynthia A. Lacy
- Sciences University, Portland, OregonOregon Health Sciences University, Portland, Oregon
- Department of NeurologyOregon Health Sciences University, Portland, Oregon
| | - John R. Crossen
- Department of Neurosurgery Oregon Health Sciences University, Portland, Oregon
| | - Edward A. Neuwelt
- Department of Division of Medical Informatics and Outcomes Research Oregon Health Sciences University, Portland, Oregon
- Department of NeurologyOregon Health Sciences University, Portland, Oregon
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Guha-Thakurta N, Damek D, Pollack C, Hochberg FH. Intravenous methotrexate as initial treatment for primary central nervous system lymphoma: response to therapy and quality of life of patients. J Neurooncol 1999; 43:259-68. [PMID: 10563432 DOI: 10.1023/a:1006210703827] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In anticipation of a consortium study of methotrexate (MTX) therapy provided to patients with primary central nervous system lymphoma (PCNSL) we have provided intravenous MTX without irradiation therapy to 31 nonimmunosuppressed individuals. Twenty (65%) achieved complete response and 11 (35%) partial response to therapy. For the 31 patients the median survival was 30.43 months with an actuarial median follow-up time of 30.69 months. The 2+ year survival was 63% for all patients and 90% for complete responders. Of 375 drug cycles, grade 3 leukopenia was identified in 3 cycles, mucositis in 6 cycles and delayed drug clearance in 47 cycles. Recurrences included brain (9/20) and/or spinal fluid (2/20). The median Karnofsky scale improved from 40 (10-80) prior to therapy to 90 after treatment. Eleven patients, in complete response for a median of 22+ months after diagnosis were evaluated using 4 instruments that assess Quality of Life Functional Assessment of Cancer Therapy - Brain (FACT-BR) modified, Symptom Questionnaire, Social Adjustment Scale-Self-Report and Problem Solving Inventory. Their psychosocial adjustment, well-being and stress coping abilities were comparable to the normative groups. Further there was no evidence of any MTX-induced, Magnetic Resonance Imaging (MRI)-detected encephalopathy in these individuals and there was preservation of clinical cognition and memory. We conclude that therapy with MTX, without radiation can be used in PCNSL patients without limitations of age or pretreatment Karnofsky scores. Further rates of response and median survival approach those of therapies using multiple drugs and radiation, but with a less likely risk of dementia.
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Affiliation(s)
- N Guha-Thakurta
- Neurology Service and the Brain Tumor Center of the Massachusetts General Hospital, USA
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Kim DG, Nam DH, Jung HW, Choi KS, Han DH. Primary central nervous system lymphoma: variety of clinical manifestations and survival. Acta Neurochir (Wien) 1996; 138:280-9. [PMID: 8861696 DOI: 10.1007/bf01411738] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A retrospective analysis of 23 non-immune compromised patients with primary central nervous system lymphoma (PCNSL) is reported. The patients consist of 14 males and 9 females and the median age is 50 years. Most patients presented with focal neurological deficits or symptoms of increased intracranial pressure (ICP) due to mass effects around the periventricular area. However, there were four cases of diffuse type, one case of intramedullary tumour, and four cases with rapid disease progression. All the patients underwent histological confirmation by craniotomy (16 cases) or stereotactic biopsy (7 cases). The radiation therapy started after histological diagnosis in all and 6 cases received additional chemotherapy. The median survival after diagnosis of overall patients was 23 months. Six patients are in disease free status at a mean of 35 months follow-up. The uni- and multi-variative risk analysis revealed five favourable factors on survival: (1) age less than 60 years (0.05 < p < 0.1); (2)pre-operative Karnofsky performance scale (KPS) > or = 70 (p < 0.05); (3) symptom duration over four weeks (p < 0.05); (4) radiation dosage > or = 5500 cGy (p < 0.05); (5)absence of malignant cells in cerebrospinal fluid (CSF) (p < 0.05). The most frequent site of recurrence was the local area as shown in seven cases out of 11 recurrent cases. But six patients had diffuse recurrence (4 cases), systemic recurrence (2 cases), and drop metastasis (1 case). Although the recurred PCNSL had rapid progression and a grave prognosis, aggressive treatment prolonged the postrecurrence survival time significantly. Our experience suggests that 1) there are various clinical and radiological presentations and progressions of the disease; 2) treatment method should be decided along with the clinical presentation, progression of disease, and prognostic factors; 3) early diagnosis and early detection of recurrence enable the start of definitive treatment when the medical condition is still satisfactory.
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Affiliation(s)
- D G Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Genetic and other defects leading to brain changes in Down syndrome, Alzheimer disease, amyotrophic lateral sclerosis, Huntington disease, Gaucher disease, hypertension and other disorders are rapidly being identified. If brain access were possible, new candidates for gene replacement therapy, antisense oligonucleotides, immune proteins or growth factors might be used for treating these disease (Lowenstein et al., 1994; Wielbo et al., 1995). Further, a number of drugs, peptides, antibodies and biological response modifiers have proven valuable in inhibiting malignant, infectious and other pathological processes in vitro, but are unlikely to be employed clinically because of their limited access to brain.
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Giovagnoli AR, Boiardi A. Cognitive impairment and quality of life in long-term survivors of malignant brain tumors. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1994; 15:481-8. [PMID: 7721551 DOI: 10.1007/bf02334609] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Thirtysix long-term survivors following the treatment of a malignant supratentorial brain tumor were examined for cognitive functions and global level of autonomy. Eighteen patients were symptom-free (SF) and 18 had clinical and neuroradiological recurrence (RE). The control group included 30 healthy subjects. All subjects underwent a neuropsychological battery for general and specific cognitive functions. The level of autonomy was assessed by means of the Karnofsky Performance Scale (KPS) for oncological patients. SF patients showed less impairment than RE patients both at the tests, as well as on the KPS. The cognitive deficits were subclinical in most SF patients, the tests for attention, memory and word fluency being the most sensitive in detecting subtle dysfunctions. The association between tumor location and specific cognitive deficits was inconstant in both patient groups. The results suggest that even subtle cognitive deficits can prevent SF long-term survivors from returning to premorbid autonomy and occupations, and that neuropsychological tests may be used as complementary routine indicators of their quality of life. Furthermore, our data show that, in selected patients, combined treatments and therapeutic insistence do not necessarily have the same deleterious effects.
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Sakamoto A, Ido T. Liposome targeting to rat brain: effect of osmotic opening of the blood-brain barrier. Brain Res 1993; 629:171-5. [PMID: 8287274 DOI: 10.1016/0006-8993(93)90499-d] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To determine whether sulfatide liposomes can cross the blood-brain barrier (BBB) with or without osmotic treatment by mannitol, we administered liposomes through the internal carotid artery in rats. Sulfatide liposomes could pass the BBB with osmotic treatment, but not without osmotic treatment. Therefore, we propose that the combination method of administration of the reticuloendothelial-system avoiding liposomes with osmotic treatment can be useful for treatment of various kinds of brain diseases.
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Affiliation(s)
- A Sakamoto
- Division of Radiopharmaceutical Chemistry, Tohoku University, Sendai, Japan
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Ainyette IG. Neuropsychological assessment outcomes of nonacquired immunodeficiency syndrome patients with primary central nervous system lymphoma before and after blood-brain barrier disruption chemotherapy. Neurosurgery 1993; 32:479-80. [PMID: 8318097 DOI: 10.1097/00006123-199303000-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Ainyette IG. Neuropsychological Assessment Outcomes of Nonacquired Immunodeficiency Syndrome Patients with Primary Central Nervous System Lymphoma before and after Blood-Brain Barrier Disruption Chemotherapy. Neurosurgery 1993. [DOI: 10.1227/00006123-199303000-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Affiliation(s)
- M K Gumerlock
- University of Oklahoma Health Sciences Center, Oklahoma City 73190
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