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Haim O, Agur A, Efrat OT, Valdes P, Ram Z, Grossman R. The clinical significance of radiological changes associated with gliadel implantation in patients with recurrent high grade glioma. Sci Rep 2023; 13:11. [PMID: 36593342 PMCID: PMC9807577 DOI: 10.1038/s41598-022-27128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023] Open
Abstract
Gliadel occasionally induces edema following its implantation. We aimed to correlate such post-surgical radiological changes to its efficacy and subsequent survival. Fifty-six patients with recurrent high grade glioma were treated between 2005 and 2016 with Gliadel implantation. Volumetric measurements of MRI features, including FLAIR abnormalities, tumor bulk (volume of gadolinium enhancement on T1) and resection cavity volumes over time were conducted. To assess dynamics over time, linear regression trendlines for each of these were calculated and examined to correlate with survival. Median follow-up after resection was 21.5 months. Median survival post-Gliadel implantation and overall survival since diagnosis were 12 months and 22 months, respectively. A subgroup of patients (n = 6) with a transient increase in FLAIR changes volume over time survived significantly longer post-Gliadel compared to those who did not demonstrate such change (36 vs 12 months, p = .03). Positive trends, representing overall growth in volume over time, of tumor bulk and resection cavity predicted survival in multivariate analyses (hazard ratios 7.9 and 84, p = .003 and .002, respectively). Increase in tumor bulk and resection cavity over time were associated with decreased survival, while transient FLAIR increase was a favorable prognostic factor. This may represent a transient inflammatory process in the tumor, possibly stemming from a presumed immune-mediated anti-tumor response.
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Affiliation(s)
- Oz Haim
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Ariel Agur
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Or-Tal Efrat
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Pablo Valdes
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Zvi Ram
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Rachel Grossman
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
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Fujii Y, Ogiwara T, Kato H, Hanaoka Y, Hardian RF, Goto T, Hongo K, Horiuchi T. Cerebral Edema Due to Chemotherapeutic Wafer Implantation for Malignant Glioma: Registry Study of Correlation with Perioperative Epileptic Seizures. Neurol Med Chir (Tokyo) 2022; 62:328-335. [PMID: 35613880 PMCID: PMC9357456 DOI: 10.2176/jns-nmc.2021-0398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Factors predicting adverse events following implantation with wafers containing 1,3-bis (2-chloroethyl) -1-nitrosourea (carmustine, BCNU), which is used in local chemotherapy for malignant gliomas (MGs), are unknown. The association between cerebral edema (CE), which often occurs after implantation, and perioperative seizures, which are often observed in MG cases, is under debate. This study investigated risk factors for CE associated with BCNU wafer implantation and their relationship with perioperative seizures. A total of 31 surgical cases involving 28 adult patients who underwent BCNU wafer implantation for MGs were investigated and classified into those with and without postoperative transient CE. We assessed the correlations between CE caused by BCNU implantation and various factors, including postoperative epileptic seizures. World Health Organization (WHO) grade III MGs significantly affected postoperative CE (p = 0.003) and the occurrence of seizures (p = 0.0004). Factors predictive of postoperative seizures were WHO grade III MGs (p = 0.0026), increased postoperative CE (p = 0.0272), and history of preoperative seizures (p = 0.0316). Postoperative CE, WHO grade III MGs, and a history of preoperative seizures might predict the postoperative occurrence of seizures, necessitating stringent management of seizures and CE in the affected patients.
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Affiliation(s)
- Yu Fujii
- Department of Neurosurgery, School of Medicine, Shinshu University
| | | | - Hiroto Kato
- Department of Neurosurgery, School of Medicine, Shinshu University
| | - Yoshiki Hanaoka
- Department of Neurosurgery, School of Medicine, Shinshu University
| | | | - Tetsuya Goto
- Department of Neurosurgery, School of Medicine, Shinshu University.,Department of Neurosurgery, School of Medicine, St. Marianna University
| | - Kazuhiro Hongo
- Department of Neurosurgery, School of Medicine, Shinshu University.,Department of Neurosurgery, Ina Central Hospital
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Masuda Y, Akutsu H, Ishikawa E, Matsuda M, Masumoto T, Hiyama T, Yamamoto T, Kohzuki H, Takano S, Matsumura A. Evaluation of the extent of resection and detection of ischemic lesions with intraoperative MRI in glioma surgery: is intraoperative MRI superior to early postoperative MRI? J Neurosurg 2019; 131:209-216. [PMID: 30095340 DOI: 10.3171/2018.3.jns172516] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/06/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE MRI scans obtained within 48-72 hours (early postoperative MRI [epMRI]), prior to any postoperative reactive changes, are recommended for the accurate assessment of the extent of resection (EOR) after glioma surgery. Diffusion-weighted imaging (DWI) enables ischemic lesions to be detected and distinguished from the residual tumor. Prior studies, however, revealed that postoperative reactive changes were often present, even in epMRI. Although intraoperative MRI (iMRI) is widely used to maximize safe resection during glioma surgery, it is unclear whether iMRI is superior to epMRI when evaluating the EOR, because it theoretically shows fewer postoperative reactive changes. In addition, the ability to detect ischemic lesions using iMRI has not been investigated. METHODS The authors retrospectively analyzed prospectively collected data in 30 patients with glioma (22 and 8 patients with enhancing and nonenhancing lesions, respectively) who underwent tumor resection. These patients had received preoperative MRI within 24 hours prior to surgery, postresection radiological evaluation with iMRI during surgery, and epMRI within 24 hours after surgery, with all neuroimaging performed using identical 1.5T MRI scanners. The authors compared iMRI or epMRI with preoperative MRI, and defined a postoperative reactive change as a new postoperative enhancement or T2 high-intensity area (HIA), if this lesion was outside of the preoperative original tumor location. In addition, postoperative ischemia was evaluated on DWI. The iMRI and epMRI findings were compared in terms of 1) postoperative reactive changes, 2) evaluation of the EOR, and 3) presence of ischemic lesion on DWI. RESULTS In patients with enhancing lesions, a new enhancement was seen in 8 of 22 patients (36.4%) on iMRI and in 12 of 22 patients (54.5%) on epMRI. In patients with nonenhancing lesions, a new T2 HIA was seen in 4 of 8 patients (50.0%) on iMRI and in 7 of 8 patients (87.5%) on epMRI. A discrepancy between the EOR measured on iMRI and epMRI was noted in 5 of the 22 patients (22.7%) with enhancing lesions, and in 3 of the 8 patients (37.5%) with nonenhancing lesions. The occurrence of ischemic lesions on DWI was found in 5 of 30 patients (16.7%) on iMRI, whereas it was found in 16 of 30 patients (53.3%) on epMRI (p = 0.003); ischemic lesions were underestimated on iMRI in 11 patients. CONCLUSIONS Overall, given the lower incidence of postoperative reactive changes on iMRI, it was superior to epMRI in evaluating the EOR in patients with glioma, both with enhancing and nonenhancing lesions. However, because ischemic lesions can be overlooked on iMRI, the authors recommend only the additional DWI scan during the early postoperative period. Clinicians need to be mindful about not overestimating the presence of residual tumor on epMRI due to the high incidence of postoperative reactive changes.
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Affiliation(s)
| | | | | | | | - Tomohiko Masumoto
- 2Radiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki; and
| | - Takashi Hiyama
- 2Radiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki; and
| | - Tetsuya Yamamoto
- Departments of1Neurosurgery and
- 3Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
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Matsumura H, Ishikawa E, Matsuda M, Sakamoto N, Akutsu H, Takano S, Matsumura A. Symptomatic Remote Cyst after BCNU Wafer Implantation for Malignant Glioma. Neurol Med Chir (Tokyo) 2018; 58:270-276. [PMID: 29780071 PMCID: PMC6002679 DOI: 10.2176/nmc.cr.2017-0218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 43-year-old man was operated on for right frontal oligoastrocytoma. 14 years after the surgery, magnetic resonance imaging and positron emission tomography revealed a new lesion near the surgical cavity. He underwent gross total resection of the lesion and implantation of bis-chloroethylnitrosourea (BCNU) wafers after intraoperative pathological diagnosis of recurrent high-grade glioma. A few days after the operation, the level of consciousness gradually worsened and left hemiparesis developed. A computed tomography scan revealed a cyst remote to the surgical cavity which did not exist 3 days prior. We performed anterior cyst wall fenestration and removed all wafers. The characteristic pathological finding at the wafer implantation site was severe inflammation within and around small vessels. This inflammatory reaction was not seen on the surface of the brain parenchyma. After surgery and rehabilitation, the patient’s Karnofsky Performance Status stabilized to a pre-incident score of 90 and he returned to work. The exact pathophysiological mechanism of the cyst was not clear, but check-valve and/or osmotic gradient mechanisms related to BCNU wafer implantation could have contributed to this phenomenon. As remote cyst development happened a week after surgery, surgeons should be aware of such a rare condition when implanting wafers as consciousness impairment and hemiparesis may occur. Close radiological follow-up is therefore necessary.
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Doishita S, Shimono T, Yoneda T, Yamada E, Tsukamoto T, Takemori D, Kimura D, Tatekawa H, Sakamoto S, Miki Y. In vitro Study of Serial Changes to Carmustine Wafers (Gliadel) with MR Imaging and Computed Tomography. Magn Reson Med Sci 2017; 17:58-66. [PMID: 28867760 PMCID: PMC5760234 DOI: 10.2463/mrms.mp.2017-0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Implantation of carmustine wafers (Gliadel) in vivo is accompanied by characteristic serial changes on MRI and CT, such as transient hyperintensity of the wafers on T1-weighted images (T1WIs) and considerable gas accumulation in surgical resection cavities. The purpose of this study was to evaluate intrinsic imaging changes to carmustine wafers in vitro. METHODS Three phantoms simulating a surgical resection cavity were constructed. Each contained either a carmustine wafer fixed with oxidized regenerated cellulose and fibrin sealant, an unfixed carmustine wafer, or a fixed polyethylene control disk, immersed in phosphate-buffered saline. Image acquisition of the phantoms was performed on MRI and CT until 182 days after construction. The radiological appearances of the object in each phantom were assessed by visual evaluation and quantification of the region of interest. The volume of gas around the objects at 24 h after constructing the phantoms was also measured. RESULTS The carmustine wafers showed low signal intensities on T1WIs and T2-weighted images (T2WIs), and high densities on CT images at 24 h. The signal intensities and CT densities gradually approximated those of saline over a period of months. However, the carmustine wafers never showed hyperintensity on T1WIs in vitro. The fixed carmustine wafer showed slower radiological changes, as compared to the unfixed wafer. The gas volume around the fixed carmustine wafer was greater than that around the fixed control disk. CONCLUSION Changes to the carmustine wafers probably reflected penetration of fluid inside and degradation of the hydrophobic matrix. Reported transient hyperintensity of wafers on T1WIs in vivo is regarded as the result of biological reactions, whereas the initial production of gas is considered as an intrinsic characteristic of wafers.
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Affiliation(s)
- Satoshi Doishita
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Taro Shimono
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Tetsuya Yoneda
- Department of Medical Physics in Advanced Biomedical Sciences, Faculty of Life Sciences, Kumamoto University
| | - Eiji Yamada
- Department of Radiological Technology, Osaka City University Hospital
| | - Taro Tsukamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Daichi Takemori
- Department of Radiological Technology, Osaka City University Hospital
| | - Daisuke Kimura
- Department of Radiological Technology, Osaka City University Hospital
| | - Hiroyuki Tatekawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Shinichi Sakamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
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Kleinberg L. Polifeprosan 20, 3.85% carmustine slow release wafer in malignant glioma: patient selection and perspectives on a low-burden therapy. Patient Prefer Adherence 2016; 10:2397-2406. [PMID: 27920506 PMCID: PMC5125766 DOI: 10.2147/ppa.s93020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Polifeprosan 20 with carmustine (GLIADEL®) polymer implant wafer is a biodegradable compound containing 3.85% carmustine (BCNU, bischloroethylnitrosourea) implanted in the brain at the time of planned tumor surgery, which then slowly degrades to release the BCNU chemotherapy directly into the brain thereby bypassing the blood-brain barrier. Carmustine implant wafers were demonstrated to improve survival in randomized placebo-controlled trials in patients undergoing a near total resection of newly diagnosed or recurrent malignant glioma. Based on these trials and other supporting data, carmustine wafer therapy was approved for use for newly diagnosed and recurrent malignant glioma in the United States and the European Union. Adverse events are uncommon, and as this therapy is placed at the time of surgery, it does not add to patient treatment burden. Nevertheless, this therapy appears to be underutilized. This article reviews the evidence for a favorable therapeutic ratio for the patient and the potential barriers. Consideration of these issues is important for optimal use of this therapeutic approach and may be important as this technology and other local therapies are further developed in the future.
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Affiliation(s)
- Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, USA
- Correspondence: Lawrence Kleinberg, Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, 401 North Broadway, Suite 1440, Baltimore, MD 21231, USA, Email
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