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Postoperative Management in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Widjaja E, Connolly DJA, Gatscher S, McMullen J, Griffiths PD. Spurious leptomeningeal enhancement on immediate post-operative MRI for paediatric brain tumours. Pediatr Radiol 2005; 35:334-8. [PMID: 15756544 DOI: 10.1007/s00247-004-1318-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2004] [Revised: 08/02/2004] [Accepted: 08/04/2004] [Indexed: 11/26/2022]
Abstract
Immediate post-operative MRI has been recommended as an accurate and robust method to assess residual brain tumour. Early enhancement at the resection margin and in the dura is well recognized, but we describe two cases of enhancement in the basal cisterns on immediate post-operative MRI that resolved on follow-up. The underlying cause of the enhancement remains to be elucidated, but it should be recognized that leptomeningeal enhancement may occur after surgery and that this does not necessarily imply tumour spread.
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Affiliation(s)
- Elysa Widjaja
- Department of Radiology, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
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Warmuth-Metz M. Postoperative imaging after brain tumor resection. ACTA NEUROCHIRURGICA. SUPPLEMENT 2004; 88:13-20. [PMID: 14531556 DOI: 10.1007/978-3-7091-6090-9_4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Prognosis after surgery for a brain tumor is not only influenced by its histology but also by the completeness of resection. The exact identification of a possible residual tumor is crucial also for follow-up and the purpose of evaluation of response to treatment. A review of the current and past literature addressing the individual value, the technique, and the pitfalls of postoperative imaging with Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) for the definition of a postoperative residue after the resection of brain tumors is given. The different problems and possibilities are illustrated by imaging examples.
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Affiliation(s)
- M Warmuth-Metz
- Department of Neuroradiology, University of Würzburg, Würzburg, Germany.
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Neuwelt EA. Mechanisms of Disease: The Blood-Brain Barrier. Neurosurgery 2004; 54:131-40; discussion 141-2. [PMID: 14683550 DOI: 10.1227/01.neu.0000097715.11966.8e] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2003] [Accepted: 09/03/2003] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The blood-brain barrier (BBB) is often perceived as a passive membrane. However, evidence has demonstrated that the BBB plays an active role in normal homeostasis and in certain disease processes. METHODS Approximately 300 peer-reviewed publications that discussed normal or abnormal BBB function were reviewed. RESULTS The role of the BBB and how it contributes to disorders of the central nervous system vary, depending on the specific disease process. CONCLUSION In health and disease and extending to old age, endothelial cells, neurons, and glia constitute a neurovascular unit that regulates the BBB. Advances toward penetrating the BBB must account for both normal and abnormal functions of the neurovascular unit.
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Affiliation(s)
- Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, Portland, Oregon 97201, USA.
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Ekinci G, Akpinar IN, Baltacioğlu F, Erzen C, Kiliç T, Elmaci I, Pamir N. Early-postoperative magnetic resonance imaging in glial tumors: prediction of tumor regrowth and recurrence. Eur J Radiol 2003; 45:99-107. [PMID: 12536087 DOI: 10.1016/s0720-048x(02)00027-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study investigated the value of early-postoperative magnetic resonance (EPMR) imaging in the detection of residual glial tumor and investigated the role of EPMR for the prediction of tumor regrowth and recurrence. METHODS AND MATERIALS We retrospectively analyzed pre- and post-operative magnetic resonance imaging results from 50 adult patients who underwent surgical treatment for supratentorial glial tumor. There were glioblastoma multiforme in 25 patients, astrocytoma (grades II and III) in 11 patients, oligodendroglioma (grades II and III) in 9 patients, and oligoastrocytoma (grades II and III) in 5 patients. EPMR imaging was performed within 24 h after surgery. EPMR findings were compared with the neurosurgeon's intraoperative estimation of gross tumor removal. Patterns of contrast enhancement at the resection site, in residual and developing tumor tissue and blood at the resection site were evaluated on EPMR and in follow-up studies. 'Residual tumor' was defined as contrast enhancing mass at the operative site on EPMR. 'Regrowth' was defined as contrast enhancing mass detected on follow-up in the same location as the primary tumor. 'Recurrence' was defined as appearance of a mass lesion in the brain parenchyma distant from the resection bed during follow-up. RESULTS Nineteen patients showed no evidence of residual tumor, regrowth, or recurrence on EPMR or any of the later follow-up radiological examinations. EPMR identified 20 cases of residual tumor. Follow-up showed tumor regrowth in 10 patients, and tumor recurrence in 1 case. EPMR showed contrast enhancement of the resection bed in 45 of the 50 patients. Four of the 20 residual tumors showed a thick linear enhancement pattern, and the other 16 cases exhibited thick linear-nodular enhancement. No thin linear enhancement was observed in the residual tumor group. Nine of the 10-regrowth tumors showed a thick linear-nodular enhancement pattern, and one exhibited thin linear enhancement in EPMR. For predicting regrowth tumor EPMR sensitivity was 91%, specificity was 100%, positive predictive value 1; negative predictive value was 0.9375. CONCLUSION EPMR, depending on the surgical site enhancement pattern, is a valuable means of demonstrating residual tumors, and can be used to predict possible regrowth after surgery.
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Affiliation(s)
- Gazanfer Ekinci
- Marmara University Medical Faculty, Department of Radiology, Istanbul, Turkey
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Bergman R, Jones J, Lanz O, Inzana K, Shell L, Moon M, Wright RE. Post-operative computed tomography in two dogs with cerebral meningioma. Vet Radiol Ultrasound 2000; 41:425-32. [PMID: 11052366 DOI: 10.1111/j.1740-8261.2000.tb01866.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Post-operative computed tomography (CT) has been described as a technique for diagnosing incomplete resection or recurrence of cerebral neoplasms in humans. The characteristics of immediate postoperative CT images in dogs with intracranial pathology are unknown. This report describes findings from preoperative, immediate post-operative, and 4 week to 9 month follow-up CT examinations in two dogs with histologically-confirmed cerebral meningiomas. In images of one dog after surgery there was mild contrast enhancement of the tissue surrounding the surgical site. This enhancement had resolved in later images and was probably the result of surgically induced trauma. In post operative images of the other dog there was significant hyperattenuation of the tissues around the surgical site. In post contrast images there was increased enhancement that was evident in later images. These findings, although not supported by necropsy, probably indicate incomplete excision of the tumor.
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Affiliation(s)
- R Bergman
- Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA 24061-0442, USA
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Derlon JM. The in vivo metabolic investigation of brain gliomas with positron emission tomography. Adv Tech Stand Neurosurg 1999; 24:41-76. [PMID: 10050211 DOI: 10.1007/978-3-7091-6504-1_2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- J M Derlon
- Service de Neurochirurgie, CHU, Caen, France
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8
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Spetzger U, Thron A, Gilsbach JM. Immediate postoperative CT contrast enhancement following surgery of cerebral tumoral lesions. J Comput Assist Tomogr 1998; 22:120-5. [PMID: 9448774 DOI: 10.1097/00004728-199801000-00022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Our goal was to evaluate the immediate postoperative contrast enhancement behavior of cerebral lesions and to gain further information about contrast enhancement in patients under general anesthesia. METHOD In the early postoperative period, CT scans with the without contrast medium were performed in 46 patients. The time interval between surgery and postoperative CT imaging ranged from 1 to 7.5 h (mean 4 h). Nineteen patients were under general anesthesia during CT investigation. RESULTS In the early postoperative period, contrast medium leakage into the tumor resection cavity was noted In 14 patients (30%). Another phenomenon that was observed was the appearance of a strong demarcation and distinct contrast of gray against white matter in 24 patients (52%). This characteristic, global contrast enhancement of the cerebral cortex, occurred in 17 of 19 patients (89%) investigated under general anesthesia. CONCLUSION In immediate postoperative CT scans, contrast medium leakage due to extravasation of contrast medium into the tumor resection cavity can be detected early. Moreover, a global contrast enhancement of the cerebral cortex can be detected as a frequent pattern in patients investigated under general anesthesia.
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Affiliation(s)
- U Spetzger
- Department of Neurosurgery, University of Technology, Aachen, Germany
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Herman M, Pozzi-Mucelli RS, Skrap M. CT and MRI findings after stereotactic resection of brain lesions. Eur J Radiol 1996; 23:228-34. [PMID: 9003930 DOI: 10.1016/s0720-048x(96)00774-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe postoperative CT and MRI findings and their time course in uncomplicated cases after stereotactic volumetric resections of brain lesions. MATERIALS AND METHODS One-hundred twenty-eight imaging studies (CT, 86; MRI, 42), performed 6 h to 2 years after 52 stereotactic operations, were retrospectively reviewed and analyzed in relation to time of surgery in cases without complications. RESULTS The extent of resection bed did not change during the first week after operation; reduction of size then began and continued up to 3-6 months. Mass effect and edema showed no changed during the first 4 days, then later regressed gradually. Pneumocephalus was found in 58% of cases in the first 3 weeks, but never later. Benign, surgically-induced enhancement appeared at the margins of encephalotomy and retractor at the end of the first postoperative week, became more prominent during the following weeks, and lasted up to 3-5 months. In the majority of cases enhancement prevented recognition of the residual tumor. Dural enhancement was observed at the craniotomy site very early after the operation and persisted up to 1 year. Meningeal enhancement over convexities was found in 44% of MRI studies. CONCLUSION Extent of the resection bed, mass effect, edema, and pneumocephalus show, in uncomplicated cases, a regular regression during the postoperative period. The time course of enhancement is complex and can be a source of diagnostic misinterpretation.
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Affiliation(s)
- M Herman
- Department of Radiology, University Hospital of Cattinara, Trieste, Italy.
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Deshmukh A, Scott JA, Palmer EL, Hochberg FH, Gruber M, Fischman AJ. Impact of fluorodeoxyglucose positron emission tomography on the clinical management of patients with glioma. Clin Nucl Med 1996; 21:720-5. [PMID: 8879874 DOI: 10.1097/00003072-199609000-00010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The past decade has seen the identification of many clinical settings in the treatment of primary brain tumors in which information from fluorodeoxyglucose positron emission tomography (FDG-PET) might be useful, if not essential, to therapeutic formulation. FDG-PET is currently used at referral centers in the management of primary brain tumors. The clinical pattern of FDG-PET use was assessed and its value compared to other information sources in clinical decision making. The clinical records of 75 glioma patients who were evaluated by FDG-PET were reviewed. The range of circumstances in which FDG-PET was employed included: pretherapeutic baseline studies for monitoring the effect of a therapy (1% of all cases), mapping of hypermetabolic regions before surgery or biopsy (2%), mapping of hypermetabolic regions before radiotherapy (2%), postsurgical evaluation for residual tumor (2%), assessment of the malignancy of a mass as a substitute for biopsy (11%), and distinguishing between radiation necrosis and recurrent tumor (87%). Other sources of information that contributed to the therapeutic management of patients included: gadolinium-enhanced MRI, contrast-CT, and clinical findings.
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Affiliation(s)
- A Deshmukh
- Department of Radiology, Massachusetts General Hospital, Boston 02114, USA
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Steinbok P. Early postoperative neuroimaging. J Neurosurg 1996; 85:523-4. [PMID: 8751645 DOI: 10.3171/jns.1996.85.3.0523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Barker FG, Prados MD, Chang SM, Gutin PH, Lamborn KR, Larson DA, Malec MK, McDermott MW, Sneed PK, Wara WM, Wilson CB. Radiation response and survival time in patients with glioblastoma multiforme. J Neurosurg 1996; 84:442-8. [PMID: 8609556 DOI: 10.3171/jns.1996.84.3.0442] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The determine the value of radiographically assessed response to radiation therapy as a predictor of survival in patients with glioblastoma multiforme (GBM), the authors studied a cohort of 301 patients who were initially treated according to uniform clinical protocols. All patients had newly diagnosed supratentorial GBM and underwent the maximum safe resection followed by external- beam radiation treatment (60 Gy in standard daily fractions or 70.4 Gy in twice-daily fractions of 160 cGy). The radiation response and survival rates were assessable in 222 patients. The extent of resection and the immediate response to radiation therapy were highly correlated with survival, both in a univariate analysis and after correction for age and Karnofsky performance scale (KPS) score in a multivariate Cox model (p< 0.001 for radiation response and p=0.04 for extent of resection). A subgroup analysis suggested that neuroimaging obtained within 3 days after surgery served as a better baseline for assessment of radiation response than images obtained later. Imaging obtained within 3 days after completion of a course of radiation therapy also provided valid radiation response scores. The impact of the radiographically assessed radiation response on survival time was comparable to that of age or KPS score. This information is easily obtained early in the course of the disease, may be of value for individual patients, and may also have implications for the design and analysis of trials of adjuvant therapy for GBM, including volume-dependent therapies such as radiosurgery or brachytherapy.
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Affiliation(s)
- F G Barker
- Neuro-Oncology Service of the Brain Tumor Research Center, Department of Neurological Surgery, School of Medicine, University of California, San Francisco, USA
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Henegar MM, Moran CJ, Silbergeld DL. Early postoperative magnetic resonance imaging following nonneoplastic cortical resection. J Neurosurg 1996; 84:174-9. [PMID: 8592218 DOI: 10.3171/jns.1996.84.2.0174] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Postcraniotomy residual tumor is often determined by magnetic resonance (MR) imaging. Magnetic resonance changes that occur in the postoperative setting must be defined to ensure both the optimum timing of postoperative image acquisition and the accurate assessment of images for residual tumor. Postoperative changes in nontumor parenchyma have previously been described for computerized tomography but not for MR imaging. In the present study, 11 patients without intracranial neoplastic disease (six females and five males with a median age of 36 years) submitted to MR imaging 17 to 28 hours after undergoing temporal lobectomies for epilepsy. Four of the operations were performed with the patients under general anesthesia and seven under local anesthesia. Postoperative MR images (T1-weighted, T1-weighted gadolinium enhanced, and T2-weighted) were reviewed. Extraaxial fluid, air, or blood was present in all cases. Enhancement of the resection bed parenchyma occurred in seven (64%) of 11 patients. In three of the remaining four patients, assessment of parenchymal enhancement was obscured by extraaxial fluid collections. Dural enhancement occurred adjacent to the resection site in all of the cases and remotely in 73%. Eight (73%) of 11 patients displayed enhancement of the pia-arachnoid of the ipsilateral cerebral convexity, two (18%) of the contralateral convexity, and four (36%) of the pia-arachnoid overlying the cerebellum. Contrary to previous reports, contrast enhancement of nonneoplastic human brain parenchyma can occur postoperatively within 17 hours. Benign parenchymal contrast enhancement is usually linear in appearance; nonneoplastic dural and leptomeningeal enhancement can occur both adjacent to and distant from the surgical site. Extraaxial fluid collections can hinder MR evaluation of the resection bed.
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Affiliation(s)
- M M Henegar
- Department of Neurological Surgery and Radiology (Neuroradiology), Washington University School of Medicine, St. Louis, Missouri, USA
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Boudraa AE, Champier J, Cinotti L, Bordet JC, Lavenne F, Mallet JJ. Delineation and quantitation of brain lesions by fuzzy clustering in positron emission tomography. Comput Med Imaging Graph 1996; 20:31-41. [PMID: 8891420 DOI: 10.1016/0895-6111(96)00025-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this study, we investigate the application of the fuzzy clustering to the anatomical localization and quantitation of brain lesions in Positron Emission Tomography (PET) images. The method is based on the Fuzzy C-Means (FCM) algorithm. The algorithm segments the PET image data points into a given number of clusters. Each cluster is an homogeneous region of the brain (e.g. tumor). A feature vector is assigned to a cluster which has the highest membership degree. Having the label affected by the FCM algorithm to a cluster, one may easily compute the corresponding spatial localization, area and perimeter. Studies concerning the evolution of a tumor after different treatments in two patients are presented.
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Affiliation(s)
- A E Boudraa
- Laboratoire de Biophysique, Faculté de Médecine Alexis Carrel, Lyon, France.
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Albert FK, Forsting M, Sartor K, Adams HP, Kunze S. Early Postoperative Magnetic Resonance Imaging after Resection of Malignant Glioma. Neurosurgery 1994. [DOI: 10.1227/00006123-199401000-00008] [Citation(s) in RCA: 226] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Albert FK, Forsting M, Sartor K, Adams HP, Kunze S. Early postoperative magnetic resonance imaging after resection of malignant glioma: objective evaluation of residual tumor and its influence on regrowth and prognosis. Neurosurgery 1994; 34:45-60; discussion 60-1. [PMID: 8121569 DOI: 10.1097/00006123-199401000-00008] [Citation(s) in RCA: 165] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
In the vast majority of studies that address the role of surgery in the management of high-grade gliomas, the degree of tumor removal accomplished is solely based on the intraoperative perception of the neurosurgeon. Despite its fundamental importance for a comparison of different treatment modalities, little systematic effort has been made to evaluate the residual gross tumor by neuroimaging methods immediately after surgery. We report the results of a prospective study using contrast-enhanced computed tomography and magnetic resonance imaging (MRI) to monitor 60 patients after the resection of a high-grade glioma. In each case, the first scans were obtained between Days 1 and 5 after surgery, followed by serial imaging every 2 to 3 months, usually until the condition of the patient deteriorated severely or the patient died. Gadolinium-enhanced MRI proved to be extremely valuable for assessing gross residual tumor when performed during Days 1 to 3 after the resection of a preoperatively enhancing high-grade glioma. This timing avoided surgically induced contrast enhancement and minimized interpretative difficulties. In delineating residual tumor, MRI was vastly superior to computed tomography. About 80% of tumor "recurrences" emerged from definitely enhancing remnants, as revealed by early postoperative MRI. The neurosurgeon's estimation of gross tumor burden reduction could be shown to be much less accurate (by a factor of 3) than the postoperative assessment by modern neuroimaging. In our series, residual tumor enhancement was the most predictive prognostic factor of survival in patients with glioblastoma, followed by radiotherapy. Patients with a residual tumor postoperatively had a 6.595-times higher risk of death in comparison to patients without a residual tumor. Patients undergoing radiotherapy had a 0.258-times lower risk of death in comparison to patients who were not treated with radiation. Concerning survival, the prognostic significance of both variables surpassed age and performance.
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Affiliation(s)
- F K Albert
- Department of Neurosurgery, University of Heidelberg, Germany
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Finlay JL, Geyer JR, Turski PA, Yates AJ, Boyett JM, Allen JC, Packer RJ. Pre-irradiation chemotherapy in children with high-grade astrocytoma: tumor response to two cycles of the '8-drugs-in-1-day' regimen. A Childrens Cancer Group study, CCG-945. J Neurooncol 1994; 21:255-65. [PMID: 7699420 DOI: 10.1007/bf01063775] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE This study was undertaken to evaluate the radiographic response to two cycles of chemotherapy prior to irradiation in newly diagnosed children with high-grade astrocytomas. PATIENTS AND METHODS One hundred and thirty children less than 21 years of age with newly-diagnosed high-grade astrocytoma were treated with the 'eight-drugs-in-one-day' chemotherapy regimen as part of a phase III multi-institutional Childrens Cancer Group (CCG) trial. Computerized Tomographic (CT) or Magnetic Resonance Image (MRI) scans, obtained after two cycles of chemotherapy had been administered, were compared with post-operative scans to determine treatment response. Scans were evaluated by institutional radiologists, and were reviewed centrally by a single neuroradiologist. RESULTS Of 79 patients with evaluable post-operative residual tumor on CT or MRI scans, 26 (33%) were determined on institutional evaluation to have had an objective response. However, central review of scans documented responses on only 14/79 (18%). A significantly higher response rate on central review was observed for those children 36 months of age or less at study entry than for older children (33% v 11%; p < 0.001). However, a higher disease progression rate was also observed for those children 36 months of age or less than for older children (21% v 2.6%; p < 0.001). CONCLUSION In this study, the largest yet reported in newly-diagnosed children with high-grade astrocytomas, the chemotherapy regimen has activity in younger children. The differences in response rates reported by institutional and central review highlight the difficulties inherent in assessing response to brain tumor therapy. However, the study does demonstrate the consistent ability of radiologists to identify disease progression within the institutional and central reviews.
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Affiliation(s)
- J L Finlay
- Memorial Sloan-Kettering Cancer Center, New York, NY
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