Early Magnesium Treatment After Aneurysmal Subarachnoid Hemorrhage: Individual Patient Data Meta-Analysis

BACKGROUND AND PURPOSE

Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Trials of magnesium treatment starting <4 days after symptom onset found no effect on poor outcome or DCI in SAH. Earlier installment of treatment might be more effective, but individual trials had not enough power for such a subanalysis. We performed an individual patient data meta-analysis to study whether magnesium is effective when given within different time frames within 24 hours after the SAH.

METHODS

Patients were divided into categories according to the delay between symptom onset and start of the study medication: <6, 6 to 12, 12 to 24, and >24 hours. We calculated adjusted risk ratios with corresponding 95% confidence intervals for magnesium versus placebo treatment for poor outcome and DCI.

RESULTS

We included 5 trials totaling 1981 patients; 83 patients started treatment<6 hours. For poor outcome, the adjusted risk ratios of magnesium treatment for start <6 hours were 1.44 (95% confidence interval, 0.83-2.51); for 6 to 12 hours 1.03 (0.65-1.63), for 12 to 24 hours 0.84 (0.65-1.09), and for >24 hours 1.06 (0.87-1.31), and for DCI, <6 hours 1.76 (0.68-4.58), for 6 to 12 hours 2.09 (0.99-4.39), for 12 to 24 hours 0.80 (0.56-1.16), and for >24 hours 1.08 (0.88-1.32).

CONCLUSIONS

This meta-analysis suggests no beneficial effect of magnesium treatment on poor outcome or DCI when started early after SAH onset. Although the number of patients was small and a beneficial effect cannot be definitively excluded, we found no justification for a new trial with early magnesium treatment after SAH.

Late neurocognitive sequelae in patients with WHO grade I meningioma

BACKGROUND

Information on neurocognitive outcome following treatment of benign meningiomas is virtually lacking. This is remarkable considering that survival in these patients is the most favourable of all intracranial tumours. The aim of the present study was therefore to document the extent and nature of neurocognitive deficits in patients with World Health Organization (WHO) grade I meningioma after treatment.

METHODS

89 patients with WHO grade I meningioma who underwent surgery with or without adjuvant radiotherapy were individually matched to 89 healthy controls for age, sex and educational level. Neurocognitive functioning of patients was assessed at least 1 year following treatment and compared with that of healthy controls using the Student's t test. Additionally, associations between tumour characteristics (size, lateralisation and localisation), treatment characteristics (radiotherapy) and epilepsy burden (based on seizure frequency and antiepileptic drug use) and neurocognitive functioning were investigated.

RESULTS

Compared with healthy controls, patients with meningioma showed significant impairments in executive functioning (p<0.001), verbal memory (p<0.001), information processing capacity (p = 0.001), psychomotor speed (p = 0.001) and working memory (p = 0.006). Patients with skull base meningiomas performed significantly lower on three out of six neurocognitive domains compared with convexity meningiomas. Left-sided as opposed to right-sided meningiomas were related to verbal memory deficits. A higher epilepsy burden was significantly associated with lower executive functioning which primarily could be attributed to antiepileptic drug use. No significant associations were established between neurocognitive status and radiotherapy or tumour volume.

CONCLUSIONS

Meningioma patients are characterised by long term deficits in neurocognitive functioning that can partly be attributed to the use of antiepileptic drugs and tumour location but not to the use of radiotherapy.

The effects of irradiation on cell migration from glioblastoma multiforme biopsy spheroids

BACKGROUND

Glioblastoma multiforme (GBM) is a primary brain tumour with a very poor prognosis despite aggressive multi-modality treatment. This pre-clinical experimental study focuses on the effect of irradiation on three-dimensional glioma biopsy spheroids in vitro using an outgrowth assay to evaluate cell survival and migrational capacity of the glioma cells.

MATERIALS AND METHODS

Tumour tissue of 16 patients with high-grade glioma and two GBM cell lines were used for spheroid preparation. Outgrowth and cell density were the parameters chosen to evaluate cell cytotoxicity and migrational capacity after irradiation (20 Gy and 4 x 5 Gy).

RESULTS

Radiation inhibited outgrowth of cell line spheroids, but not of the biopsy spheroids. All biopsy and cell line spheroids showed a significantly lower cell number (95 vs. 24 cells/0.25 mm2) in the outgrowth area after irradiation.

CONCLUSION

Irradiation has a cytotoxic effect in GBM biopsy spheroids but it hardly affects cell migration. No correlation was found between patient survival and cell migration nor with cytotoxicity.

Combined targeting of adenoviruses to integrins and epidermal growth factor receptors increases gene transfer into primary glioma cells and spheroids

Adenoviral-mediated gene transfer is suboptimal in human glioma and limits in vivo gene therapy approaches. There is a need for targeted vectors able to enhance gene transfer into the tumor as well as to lower the viral load in the surrounding normal tissues. We evaluated primary human tumor samples by immunohistochemistry and fluorescence-activated cell sorter for expression of the Coxsackie-adenovirus receptor and other antigens with potential utility to redirect adenoviruses (Ads) to gliomas. In the majority of the samples, Coxsackie-adenovirus receptor expression was low. This correlated with inefficient gene transfer in vitro. Epidermal growth factor receptor (EGFR) and alpha(v)beta5 integrins were often highly, but heterogeneously, expressed. We hypothesized that these receptors, overexpressed in tumor but not in normal brain, could serve as independent binding sites for alternative pathways of infection with targeted Ads. We examined this, using Ads that expressed the luciferase reporter gene under the cytomegalovirus promoter. Targeting to the EGFR was performed with a single-chain bispecific antibody directed against the human EGFR and against the fiber knob of the Ad. Targeting to the alpha(v) integrins was performed by insertion of an integrin-binding sequence, RGD-4C, in the HI-loop of the Ad. Increased luciferase gene transfer in primary glioma cells was observed in 8 of 13 samples with EGFR-targeting (2-11 times enhancement; median, 6) and in all of the samples with RGD-targeting (2-42 times enhancement; median, 12). Combining the two targeting motifs further enhanced the gene transfer in primary glioma cells in an additive manner (3-56 times; median, 20). The double-targeted Ads also strongly augmented gene transfer into organotypic glioma spheroids. Conversely, gene transfer into normal brain explants was reduced dramatically using Ads targeted to the tumor. Our findings demonstrate the feasibility and benefit of binding multiple ligands to the adenoviral fiber knob. These vectors have a great potential for clinical use in the context of tumors that are usually heterogeneous for target antigen expression at the single-cell level.

AgNOR staining may reflect the growth potential of pilocytic astrocytomas

The value of AgNOR staining as a tumor biological marker was tested in 26 children with pilocytic astrocytomas (20) and fibrillary astrocytomas (6). All patients were surgically treated and then followed up by periodic MRI or CT scans. Follow-up ranged from 8 to 84 months, with a mean of 44 months. AgNOR expression was determined by using semi-automated computer-assisted surface area measurements. AgNOR values ranged from 1.4 to 81.4 microm(2) per cell, with a mean of 26.6 and a median of 15.2. The median value was taken as a "cut-off" score separating two groups of patients with low and high AgNOR scores. Of the 13 patients in the low scoring group, 8 had total resections without recurrence, 3 had stable residual tumors, 1 had regressing residual tumor after irradiation and 1 had a recurrence 5 years after neuroradiologically complete resection of a fibrillary astrocytoma. In the group with high AgNOR scores only 2 patients had total resections without recurrence; 5 had stable residual tumors and 6 had residual tumors that showed progression, all within 1 year after surgery. Among the patients with classic juvenile pilocytic astrocytomas of the cerebellum 7 had residual tumor, which progressed in 2 patients, both of whom had high AgNOR scores. Among 7 patients with optic/hypothalamic tumors the 3 with rapidly progressing tumors all had very high AgNOR scores. The determination of AgNOR expression might be helpful in selection of patients with residual tumor after surgery, who may benefit from additional chemotherapy or (stereotactic) radiation therapy.

Hematoma in a low-grade medullary astrocytoma: report of an unusual case and literature review

We describe the case - to our knowledge unique - of an 8-year-old boy who presented with acute onset of lower cranial nerve palsy and tetraparesis caused by a hematoma in a dorsal exophytic pilocytic astrocytoma of the medulla oblongata. The boy showed near-complete recovery after neurosurgical management in two stages: first, emergency evacuation of the hematoma with tumor biopsy, and second, complete tumor removal 5 months after the initial event. Intraoperative electrophysiological monitoring techniques for the lower cranial nerves are of value in preserving their functional integrity. Ultrasonography is helpful in assessing the extent of tumor removal. Although the pathological diagnosis of a pilocytic astrocytoma would not justify radiotherapy, local field radiotherapy was added mainly because of the unexpectedly rapid tumor progression during the interval between the two surgical procedures. The literature on brainstem and tumor hematoma in children is reviewed.

The proliferative potential of the pilocytic astrocytoma: the relation between MIB-1 labeling and clinical and neuro-radiological follow-up

The proliferative potential of 39 pilocytic and 5 low grade astrocytomas was studied in relation to the Ki-67 activity as measured by the MIB-1 Labelings Index. The results were correlated to the biological behaviour of the tumor as measured by clinical and neuro-radiological (CT- or MRI-scans) follow-up of the patient. This study was undertaken to answer the question whether MIB-1 expression reflects differences in biological behaviour of these tumors, such as rapid progression of residual tumor or stable remaining tumor. MIB-1 LI values ranged from 0 to 19% in the group of pilocytic astrocytomas (mean 4.2%) and from 0 to 15% in the 5 low grade astrocytomas (mean 4,2%). All patients were operated and 23 of them had incomplete tumor resection as proven on postoperative neuro-imaging studies. Those 23 patients could be subdivided into two groups; one without progression of residual tumor during follow-up (n=12) and the other with tumor progression (n=11). mean MIB-1 LI in the group with 'quiescent' tumor tended to be lower than in the group with progressive tumor: 3,3% vs. 6,6%. Residual tumors which were negative for MIB-1 staining showed fewer progressions of residual tumor compared to those being positive for MIB-1 staining, however this difference was not significant (p=0, 15, Fisher exact test). Tumor samples of a second operation of the same patient had lower MIB-1 LI values than those of the samples taken at first operation. The proliferating potential seemed to be decreased after part of the tumor was resected. Pilocytic astrocytomas with a negative MIB-1 LI are unlikely to show progression of residual tumor after partial resection. MIB-1 staining might be an additional tool in determining the frequency and duration of follow-up and in making decisions regarding further treatment of a patient operated for a pilocytic astrocytoma with residual tumor.

Cerebellar pilocytic astrocytoma: a treatment protocol based upon analysis of 73 cases and a review of the literature

In a retrospective study of 73 patients operated on for cerebellar pilocytic astrocytomas, results of treatment, outcome and biological behaviour of residual tumour were analysed. Complete tumour resection proven by CT or MRI scans within 1 year after surgery was achieved only in 69% of cases. In 31% of cases the surgeon's opinion on the extent of surgical resection was not borne out by the result of postoperative neuroimaging. Progression of residual tumour or tumour recurrence appeared in 19% of patients. 1 patient showed metastatic spread along the craniospinal axis, and in 1 patient malignant degeneration appeared during follow-up. Stable residual tumour or regression of residual tumour was seen in 14% of patients. Outcome after surgical treatment, which was combined with irradiation in 10 patients (14%), was favourable in 80% and unfavourable in 20% of patients. This outcome of treatment was not influenced by a second operation for progression of residual tumour or recurrent tumour. Characteristics of patients with tumour progression after the first operation did not differ from those of the whole group. There were 17 reoperations for residual or recurrent tumour, 10 of which took place within 4 years after the initial surgical treatment. Surgery-related morbidity was 15% and mortality 4%. Irradiation to residual tumour in 8 patients was followed by complete regression in 1 patient, progression in 4 patients and no changes in 1 patient. For the remaining 2 patients the effect of irradiation on the residual tumour is unknown. Factors that determine the prognosis are discussed on the basis of this retrospective analysis and the data from the literature. It is concluded that optimal treatment for a cerebellar pilocytic astrocytoma does not consist solely in surgery with the aim of total tumour removal and careful tumour handling in order to avoid spread of tumour cells and subsequent metastases and additional radiation therapy is strictly selected cases, but also in posttreatment follow-up based on direct postoperative neuroimaging, preferably by MRI. An algorithm for postoperative follow-up management is presented.

Up-regulation of specific NF 1 gene transcripts in sporadic pilocytic astrocytomas

Pilocytic astrocytomas of the optic nerve (optic nerve gliomas) are closely associated with neurofibromatosis 1 (NF1), and allelic losses of the NF1 gene region on chromosome 17q occur in sporadic pilocytic astrocytomas. We therefore hypothesized that the NF1 gene acts as a tumor suppressor gene in pilocytic astrocytomas, and that NF1 gene expression would be reduced or absent in these tumors. To evaluate this possibility, we examined quantitative and qualitative aspects of NF1 gene expression in six sporadic pilocytic astrocytomas. Surprisingly, the NF1 gene was overexpressed up to fourfold in these tumors when compared with normal brain. This up-regulation was accompanied by immunohistochemical positivity using a carboxyl-terminal antibody and by the absence of mutations in one kilobase of the NF1 coding sequence, consistent with the expressed transcript and protein being full length and probably wild type. Pilocytic astrocytomas showed a marked predominance of transcripts containing exon 23a and lacking exon 9br, the same isoforms that are expressed by normal and reactive astrocytes and malignant astrocytomas. These data illustrate that pilocytic astrocytomas overexpress specific NF1 gene transcripts, perhaps as a regulatory response to growth stimuli. The role of the NF1 gene as a tumor suppressor in pilocytic astrocytomas, however, remains to be proven.

Glioblastoma multiforme in four siblings: a cytogenetic and molecular genetic study

The familial occurrence of gliomas, in the absence of well-defined neurological tumor syndromes such as the neurofibromatoses, is uncommon. We present a family of ten children in which the four eldest suffered from gliomas. Three of these siblings had histologically verified glioblastoma multiforme, and one patient also had an intestinal non-Hodgkin's lymphoma, but there were no stigmata or family history of a neurological tumor syndrome. Cytogenetic studies of the proband revealed a normal karyotype. Molecular genetic analysis of the proband's glioblastoma revealed two mutations in the p53 tumor suppressor gene, but these were not present in the germline DNA, mutations were not detected in the MTS1 gene in the tumors or in the germline DNA. These findings suggest that a genetic factor may be responsible for the clustering of glial tumors in this family, but it is unlikely that the genetic alteration is mutation of the p53 gene. The data are discussed in light of the literature on familial brain tumors.

[Surgical removal of the lip vermilion in the treatment of lip carcinoma; experience in 8 patients]

OBJECTIVE

To present the results of lipshave surgery in patients treated for squamous cell carcinoma of the lip, with actinic changes.

DESIGN

Descriptive.

SETTING

Medical Centre, Leeuwarden, the Netherlands.

METHOD

The histories were studied of 8 patients with carcinoma of the lip treated in 1988-1992 with lipshave surgery, if necessary in combination with a wedge excision. Postoperative results and lip function were observed; follow-up was from 9 to 53 months.

RESULTS

Two patients died prematurely from another cause than the lip cancer. In the other patients there were no signs of recurrence of the carcinoma. Although all patients had decreased lip sensibility, lip functions were fairly intact: 2 patients complained of drooling at times or rarely, 1 drooled often and 3 never. For 1 patient speaking had become a little more difficult, in the other 5 cases it had not changed. The drinking test was performed properly in all cases.

CONCLUSION

Lipshave surgery is a reliable treatment for lip carcinoma with actinic changes and also preserves the lip functions.