In vivo and in vitro studies on multidirectional mechanism of anti-allergic activity of budesonide

Most studies on the effects of glucocorticosteroid therapy in rhinitis relate to their inhibitory effect on activation and the number of inflowing cells that are involved in the development and maintenance of inflammation. It is also very important to determine the range of effect of budesonide on residing cells (epithelial cells). The purpose of this study was to evaluate the effect of local budesonide therapy on the cytological image of the nasal mucosa, with attention paid to columnar cells in patients with rhinitis. The in vivo results obtained were analyzed in correlation with changes in normal CHO-K1 cells exposed to budesonide at concentrations falling within the pharmacological dose range. Fifty patients diagnosed with rhinitis with suspected allergic background without nasal polyps were included in clinical trials. The control group were 10 healthy people without clinical signs of rhinitis. Only in patients with homogeneous cytological picture, exfoliative cytology was performed before treatment and after 4 weeks of therapy with budesonide used in aerosol form. Papanicolaou and Pappenheim - stained smears were evaluated qualitatively and quantitatively for changes in nasal mucosal cells. The nasal mucosal image of the patients before treatment clearly indicated the pathological state confirmed by the presence of numerous neutrophils, eosinophils, abundant bacterial flora and goblet or epithelial cells prevalence. In contrast, in smears of patients post-treatment budesonide observed a clear improvement in their nasal mucosa by reducing inflammation. There was a significant increase in the number of columnar cells and the appearance of very numerous epithelial cells with increased cytoplasmic vacuolization and visible leucophagocytosis. In vitro studies were performed on normal CHO-K1 cells that were treated with budesonide at concentrations of 0.5 μM - 45 μM. After 48 hours of incubation with the test agent, the samples were prepared for optical microscopy using the H&E method and transmission electron microscopy. Comparison of cells exposed to budesonide with control cells (without addition of test agent) revealed vacuolization changes with autophagy. Apoptotic changes have also been demonstrated, which occured to a lesser extent than vacuolization. The changes observed after budesonide treatment in the cytological picture of patients with allergic rhinitis indicate the therapeutic effect of this drug. On the other hand, the changes observed in the cytoplasm of epithelial cells, such as autophagy (clearly promoted in CHO-K1 cells) and leucophagocytosis, may indicate an additional mechanism of action for budesonide.

Cement salvage of instrumentation-associated vertebral fractures

BACKGROUND AND PURPOSE

Spinal instrumentation plays a key role in the treatment of spinal instability in patients with metastatic tumors. Poor bone quality, radiation, and diffuse osseous tumor involvement present significant challenges to spinal stabilization with instrumentation and occasionally result in postinstrumentation compression fractures. Vertebral cement augmentation has been effective in the treatment of painful tumor-related compression fractures. Our objective was to describe cement augmentation options in the treatment of vertebral compression fractures associated with spinal instrumentation in patients with metastatic tumors.

MATERIALS AND METHODS

Patients who underwent percutaneous vertebral cement augmentation in the treatment of instrumentation-associated vertebral compression fractures between 2005 and 2011 were included in the analysis. Only fractures that occurred within the construct or at an adjacent level were included. The change in Visual Analog Scale and need for further surgery were analyzed.

RESULTS

Eleven patients met the inclusion criteria, with 8 tumors located in the thoracic spine and 3 tumors in the lumbar spine. The median time between instrumented surgery and vertebral augmentation was 5 months (1-48 months) and the median follow-up after cement augmentation was 24 months (4-59 months). A total of 22 vertebrae that were either within or immediately adjacent to the surgical instrumentation underwent vertebral augmentation. All patients reported a decrease in their pain scores (mean decrease: 6 Visual Analog Scale points; P < .003). One patient required reoperation after cement augmentation. None of the patients experienced vertebral cement augmentation-related complications.

CONCLUSIONS

Vertebral cement augmentation represents a safe and effective treatment option in patients with recurrent or progressive back pain and instrumentation-associated vertebral compression fractures.

An integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions

OBJECTIVE

To evaluate an integrated battery of preoperative functional magnetic resonance imaging (fMRI) tasks developed to identify cortical areas associated with tactile, motor, language, and visual functions.

METHODS

Sensitivity of each task was determined by the probability that a targeted region was activated for both healthy volunteers (n = 63) and surgical patients with lesions in these critical areas (n = 125). Accuracy of each task was determined by the correspondence between the fMRI maps and intraoperative electrophysiological measurements, including somatosensory evoked potentials (n = 16), direct cortical stimulation (n = 9), and language mapping (n = 5), and by preoperative Wada tests (n = 13) and visual field examinations (n = 6).

RESULTS

For healthy volunteers, the overall sensitivity was 100% for identification of the central sulcus, visual cortex, and putative Wernicke's area, and 93% for the putative Broca's area (dominant hemisphere). For patients with tumors affecting these regions of interest, task sensitivity was 97% for identification of the central sulcus, 100% for the visual cortex, 91% for the putative Wernicke's area, and 77% for the putative Broca's area. These sensitivities were enhanced by the use of multiple tasks to target related functions. Concordance of the fMRI maps and intraoperative electrophysiological measurements was observed whenever both techniques yielded maps and Wada and visual field examinations were consistent with fMRI results.

CONCLUSION

This integrated fMRI task battery offers standardized and noninvasive preoperative maps of multiple critical functions to facilitate assessment of surgical risk, planning of surgical routes, and direction of conventional, intraoperative electrophysiological procedures. Thus, a greater range of structural and functional relationships is brought to bear in the service of optimal outcomes for neurosurgery.

Brain mapping in sedated infants and young children with passive-functional magnetic resonance imaging

Functional magnetic resonance imaging (fMRI) in pediatric patients presents a unique set of problems due to the need for patient compliance, the frequent need for sedation and an early developmental status. A new method for using fMRI in sedated infants and young children is presented using passive stimuli focused on visual, sensorimotor and language functions. All of these stimuli are presented such that no patient interaction is required. Eight sedated children undergoing diagnostic MRI scans of the brain participated in these passive fMRI procedures. Cortical regions were identified using standard techniques applied to the blood-oxygen-level-dependent signal which is the basis for fMRI. The results support the feasibility of brain mapping in sedated children with passive fMRI techniques.

Management of tumors of the thoracolumbar spine

Current improvements in radiologic imaging and surgical instrumentation have greatly expanded the role of surgery in management of tumors of the thoracolumbar junction. For primary malignant tumors, the aim of surgery should be curative, with eradiction of all gross disease. For metastatic tumors, indications for surgery include cancer therapy, stabilization, neurologic palliation, tissue diagnosis, and pain relief. Because the thoracolumbar region is a transitional zone, surgical stabilization may require anterior-posterior approaches and instrumentation.

High-dose edatrexate with oral leucovorin rescue: a phase I and clinical pharmacological study in adults with advanced cancer

Our objective was to determine the maximum tolerated dose and toxicity of i.v. edatrexate with p.o. leucovorin. Thirty-one adults with advanced solid tumors received edatrexate as a 2-h infusion, once a week for 3 weeks, recycled every 28 days. p.o. leucovorin (10 mg/m2, every 6 h for 10 doses) began 24 h later. All had urinary alkalinization and p.o. hydration. Nine dosage levels ranging from 120 to 3750 mg/m2 were explored. Fatigue, epistaxis, nausea/emesis, mucositis, rash, myalgias, leukopenia, thrombocytopenia, and transient elevations of serum aspartate transferase were observed. Leukoencephalopathy with clinical manifestations occurred in two patients (one had prior cranial irradiation). Pharmacokinetic studies carried out at the 120- and 1080-mg/m2 dose levels revealed no significant difference in the elimination half-life at the two dose levels studied and no significant intrapatient variability between day 1 and day 8 edatrexate administration. Serum edatrexate levels measured using a dihydrofolate reductase inhibition assay correlated with those by high-performance liquid chromatography. Three major and two minor antitumor responses occurred. The maximum tolerated dose was 3750 mg/m2, with grade 3 or 4 leukopenia (one patient), stomatitis (one patient), and leukoencephalopathy (one patient). Because of the occurrence of leukoencephalopathy, further study of high-dose edatrexate with leucovorin rescue is not recommended.

Indications and results of combined anterior-posterior approaches for spine tumor surgery

Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5-year period (1989-1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty-eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty-three patients (48%) underwent combined anterior-posterior resection and instrumentation. 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.

Balancing service and education: improving internal medicine residencies in the managed care era

BACKGROUND

Internal medicine training programs must adapt to health care systems faced with balancing the competitive priorities of patient-care responsibilities and educational needs.

OBJECTIVE

To evaluated the effects of a major organizational change on the inpatient service of an internal medicine residency program in a vertically integrated health system.

METHODS

We changed the structure of our program from a system in which the hospitalized patients' primary physicians were responsible for daily inpatient management, while teaching was assigned to a defined teaching rounder, to a method in which the rounding attending was responsible for both teaching and patient care. Measurements before and after the change in the rounding system included: the McGill University clinical tutor evaluations, time-motion observations of house staff, patient satisfaction surveys, average length of stay data, and physician focus groups to assess physician satisfaction.

RESULTS

The rounding attendings consistently received excellent to superior ratings by the house staff both before and after the implemented change. Compared to time-motion observations performed before the change, observations recorded after the change suggested that a greater percent of house staff time was spent on educational activities. The responses of patient satisfaction surveys indicated that the perception of quality of care remained high after the system change. Lastly, the average length of stay for patients on the general internal medicine and subspecialty services was reduced from 7.6 days before the change to 6.6 days after the change, a difference of 0.92 day (95% confidence interval 1.3 to 0.6, P < 0.001).

CONCLUSIONS

Through organizational restructuring, it is possible to improve the quality of patient care and improving the efficiency of patient-care management.

Neuroimaging and cerebrospinal fluid cytology in the diagnosis of leptomeningeal metastasis

The diagnosis of leptomeningeal metastasis is often difficult and usually requires the demonstration of malignant cells in the cerebrospinal fluid. Neuroimaging, however, may establish or support the diagnosis in some patients. Radiographic abnormalities consistent with or suggestive of leptomeningeal metastasis include leptomeningeal, subependymal, dural, or cranial nerve enhancement; superficial cerebral lesions; and communicating hydrocephalus. We evaluated 137 cancer patients with clinical symptoms suspicious for leptomeningeal metastasis with neuroimaging or cerebrospinal fluid cytology or both. Neuroimaging findings were abnormal in 70 of 128 tested patients; cytology was performed in 58 of these 70 and the results were positive in 37. Conversely, cytological findings were positive in 53 of 115 tested patients; neuroimaging was performed in 49 of these 53 and the findings were abnormal in 37 (26/29 solid tumors and 11/20 hematological tumors). Of the total series of 137 patients, leptomeningeal metastasis was diagnosed in 77; in 24 (31%) the diagnosis was made on the basis of clinical picture and abnormal neuroimaging alone. Neuroimaging is a valuable tool in the investigation of leptomeningeal metastasis in the cancer population, and the presence of typical clinical features together with appropriate neuroimaging abnormalities is adequate to make the diagnosis of leptomeningeal metastasis even if cerebrospinal fluid cytological results are negative.

Primary amyloidoma of the brain: CT and MR presentation

We present CT and MR imaging studies of a histologically proved case of a primary intraaxial amyloidoma of the brain. Noncontrast CT and T1-weighted MR images revealed increased density and hyperintensity respectively of amyloid tissue. There was mixed intensity on proton-density and T2-weighted sequences, and marked contrast enhancement was demonstrated on both modalities.

Rebound caloric nystagmus

Rebound caloric nystagmus (RCN), a distinctly different phenomenon from secondary phase nystagmus (SPN), was serendipitously discovered during the course of routine neurotological evaluations. RCN occurred when the horizontal semicircular canal was brought into a truly horizontal plane after the primary phase nystagmus (PPN) had ended. The maximum slow-phase velocities (SPVMax) of both PPN and RCN were almost identical. The pathological lesion was an Arnold-Chiari malformation (ACM). Two other patients with posterior fossa lesions also showed RCN. To determine if RCN is an unrecognized normal phenomenon, 11 healthy subjects were tested. The average SPV of RCN in normals was 0.7 degrees per second. Such a small value of RCN is probably of no significance. It therefore appears that RCN is a sign of posterior fossa neuroaxial lesions.

Percutaneous lateral cervical cordotomy: target localization with water-soluble contrast medium

Water-soluble intrathecal contrast material was used for radiographic identification of the cord target in 13 patients undergoing percutaneous lateral cervical cordotomy. Adequate visualization of the dentate ligament, considered essential for successful placement of the electrode, was achieved in seven cases. In the remaining six patients, four with suboptimal definition and two with nonvisualization of the ligament, an additional injection of contrast medium using a modified coaxial needle system outlined the entire thickness of the cervical cord. This technique improved needle-tip positioning in relation to the cord and resulted in successful surgery in all six patients.

MRI changes in intracranial hypotension

We report seven patients with the syndrome of intracranial hypotension who were referred to Memorial Sloan-Kettering, primarily because of suspicion of meningeal tumor or infection raised by the finding of meningeal enhancement on MRI. In three patients, symptoms occurred after lumbar puncture; in four, there was no clear precipitating event. Lumbar puncture after MRI in six patients revealed low CSF pressure (six patients) and pleocytosis or high protein, or both (four patients). Three patients had subdural effusions. Six patients had measurable descent of the brain on midsagittal images. Postural headache resolved in all seven patients, six of whom had follow-up MRIs. Meningeal enhancement resolved or diminished in all six. Subdural effusions resolved spontaneously in two and were evacuated (but were not under pressure) in one. Downward brain displacement improved or resolved in all patients. The clinical syndrome and MRI abnormalities generally resolve on their own. An extensive workup is not helpful and may be misleading. Patients should be treated symptomatically.

Evaluation of Neoplastic Involvement of Brachial and Lumbosacral PlexusImaging Aspects

Traditionally, the regions of brachial and lumbosacral plexi have been difficult to evaluate, both by physical examination and conventional radiography. Presenting symptoms of plexus involvement may include pain, paresthesia, focal weakness, sensory deficits, and muscle atrophy. The symptomatology as well as electrodiagnostic studies are nonspecific and many conditions, such as mechanical compromise of the pathway by a benign process, inflammation, and infiltration by a neoplasm originating or metastatic to the region of plexi share similar features and cannot be differentiated. A general term "brachial or lumbosacral plexopathy" is universally used, to describe a variety of clinical syndromes, including tumor infiltration, neuritis, postsurgical, and postradiation changes as well as idiopathic conditions. Significant progress in detection and assessment of the extent of plexus disease has been made after introduction of computed tomography (CT). Further anatomical detail and tissue characteristics have been provided by magnetic resonance imaging (MRI). However, in spite of valuable contribution from both imaging methods, the plexi frequently present a challenging problem for a clinician as well as for a radiologist.

Spinal epidural tumor in patients with prostate cancer. Clinical and radiographic predictors of response to radiation therapy

The authors retrospectively reviewed 50 episodes of spinal epidural tumor that occurred in 42 patients with metastatic prostate cancer and were treated with external-beam radiation. Treatment response was evaluated in terms of symptoms, neurologic status, and, in most cases, reduction of tumor on repeat myelography. At the completion of therapy, 92% of treated patients experienced pain relief and 67% had significant to complete improvement on neurologic examination. Thirty days after treatment, repeat myelography was performed in 40 of the 50 cases; compared with the initial findings immediately preceding radiation therapy (RT), the results of 58% of these studies had normalized completely, results were improved in 25%, and the results had not changed in 18%. The presence of a high-grade compression fracture of the vertebral body was an indicator of poor prognosis for tumor response on repeat myelography. The ability of a patient to walk before treatment and tumor response on repeat myelography were associated significantly with improved outcome of RT and with survival. The authors conclude that RT can effectively palliate epidural lesions from metastatic prostate cancer. The prognosis for the long-term response to therapy may be indicated by pretreatment ambulatory status and posttreatment imaging of the epidural space.

Binocular infrared oculography

A new system of infrared oculography has been developed which provides binocular recordings and allows simultaneous measurement of horizontal and vertical eye movements. The sensitivity of the system is 1 minute of arc, and it has a horizontal range of +/- 30 degrees and a vertical range of +/- 20 degrees. Using this system for routine clinical evaluations, it was possible to record divergent spontaneous nystagmus and divergent thermally induced nystagmus. Rotatory nystagmus can also be recorded. The binocular infrared oculographic system (BIRO) satisfies nearly all the requirements of an ideal recording system.

Occult epidural chloroma complicated by acute paraplegia following lumbar puncture

Acute paraplegia complicating lumbar puncture in a leukemic patient with an unsuspected epidural chloroma is described, including the postmortem findings. Lumbar puncture can precipitate irreversible injury to the spinal cord in the patient with an occult lesion causing subarachnoid block. This account, in addition to documenting this phenomenon, suggests a potential advantage to magnetic resonance imaging over myelography.

Percutaneous Radiofrequency Neurolysis Guided by Computed Tomography for the Treatment of Glossopharyngeal Neuralgia

The technique of radiofrequency neurolysis guided by computed tomography for the treatment of glossopharyngeal neuralgia is described. This technique has the advantage of being performed in a neutral head position, affording excellent visualization of the jugular foramen, and also of simulating radiographically the precise trajectory of the electrode. This procedure is of particular value in treating patients with neoplastic disease and those in whom the outlines of the jugular foramen are poorly visualized on fluoroscopy or plain radiography.

Percutaneous radiofrequency neurolysis guided by computed tomography for the treatment of glossopharyngeal neuralgia

The technique of radiofrequency neurolysis guided by computed tomography for the treatment of glossopharyngeal neuralgia is described. This technique has the advantage of being performed in a neutral head position, affording excellent visualization of the jugular foramen, and also of simulating radiographically the precise trajectory of the electrode. This procedure is of particular value in treating patients with neoplastic disease and those in whom the outlines of the jugular foramen are poorly visualized on fluoroscopy or plain radiography.

Decompression of epidural metastases from germ cell tumors with chemotherapy

Epidural cord compression from germ cell tumor metastases is not common. Treatment usually requires high dose corticosteroids with radiation therapy and/or surgical decompression. Three patients with epidural germ cell tumor metastases were treated with cisplatin-based chemotherapy and all three had complete neurologic recovery. Systemic chemotherapy should be considered as initial therapy with corticosteroids for epidural cord compression from metastatic germ cell tumor.

Primary CNS lymphoma: combined treatment with chemotherapy and radiotherapy

Primary central nervous system lymphoma (PCNSL), an uncommon tumor, is occurring with increasing frequency. Conventional therapy with corticosteroids and cranial radiotherapy (RT) usually gives a dramatic initial response, but median survival is only 10 to 18 months. Chemotherapy is more successful in comparable systemic lymphoma and has been employed for PCNSL at relapse, causing remission but not cure. Between June 1985 and June 1988, we prospectively staged 32 patients with PCNSL at Memorial Sloan-Kettering Cancer Center and treated 28 on a new protocol that combined chemotherapy and radiotherapy at diagnosis. None had occult systemic lymphoma, but 19% had ocular and 69% had definite or probable leptomeningeal lymphoma. There were no complications in 19 stereotactic biopsies, but 4/10 patients who had a complete resection suffered a severe postoperative deficit. Four patients received RT alone, and 28 received chemotherapy and cranial RT, 17 of whom (group A) received a combination regimen using pre-RT systemic (1 g/m2) and intra-Ommaya methotrexate (MTX), 4,000 cGy whole-brain RT with a 1,440 cGy boost, and 2 courses of post-RT high-dose cytosine arabinoside; 5 other patients received an identical regimen but with a decreased dose of MTX (200 mg/m2). Sixty-three percent of assessable patients had a response to MTX independent of corticosteroid and prior to RT. Eighteen of 26 (69%) assessable patients who received combined therapy are alive with a median follow-up of 25.4 months. Twelve of 16 (75%) assessable group A patients are alive in the same period. Chemotherapy-related toxicity was minimal, and no late toxicities have occurred to date.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of aluminum and magnesium antacids and ranitidine on the absorption of ciprofloxacin

The effect of an antacid (Maalox) and ranitidine administration on the absorption of ciprofloxacin was evaluated in healthy male volunteers who were enrolled in three separate studies. Each study was designed at a three- or four-period crossover and included the administration of 750 mg ciprofloxacin alone as a control treatment. Treatments that were evaluated included the administration of ciprofloxacin 5 to 10 minutes, 2 hours, 4 hours, and 6 hours after a single 30 ml dose of antacid; the administration of antacid 2 hours after ciprofloxacin was given; and the administration of ciprofloxacin 2 hours after a 200 mg ranitidine tablet. Administration of antacid within 4 hours before ciprofloxacin dose resulted in a significant decrease in ciprofloxacin absorption (p less than 0.05). Percentages of relative bioavailability compared with control values were 15.1%, 23.2%, and 70% for the 5 to 10 minute, 2 hour, and 4 hour antacid pretreatments, respectively. Administration of antacid 6 hours before or 2 hours after the ciprofloxacin dose did not affect absorption. Ranitidine did not alter ciprofloxacin absorption. Antacids that contain magnesium and aluminum salts may reduce the absorption of ciprofloxacin. The extent of this interaction appears to increase as the time between administration of the two drugs decreases. Ranitidine is suggested as an alternative to antacids for patients receiving treatment with ciprofloxacin.

MR imaging of the cranial meninges with emphasis on contrast enhancement and meningeal carcinomatosis

MR imaging was used to investigate normal and abnormal meningeal enhancement, with an emphasis on meningeal carcinomatosis. Three groups of patients were studied on a 1.5-T system. In group 1, the normal meninges were examined in 20 patients and were found to show fine linear enhancement in short segments, especially in a parasagittal distribution. In group 2, all gadolinium-enhanced head scans were reviewed retrospectively. Abnormal meningeal enhancement was detected in 52 patients. In some of these, the enhancement was associated with pathologic conditions of the meninges, including leptomeningeal tumor and meningeal infections and other inflammatory conditions; in others the enhancement was adjacent to subdural hematomas, subacute infarcts, and skull lesions, such as metastases or postoperative defects. In group 3, 30 cases of meningeal carcinomatosis were studied prospectively. Enhancement was seen in approximately two-thirds of cases and usually was quite diffuse and applied to the inner table of the skull. Frank nodules were seen less often. Contrast-enhanced CT was equal to MR in the detection of nodules but was nearly always unable to show diffuse meningeal enhancement against the inner table of the skull. Contrast-enhanced MR was more sensitive than contrast-enhanced CT in the examination of normal and abnormal meninges. Abnormal findings, such as meningeal carcinomatosis, were demonstrated more often by MR than by CT.

Spondylectomy for malignant tumors of the spine

Spondylectomy is the complete surgical removal of all parts of one or more vertebrae above the sacrum. We report our initial experience with spondylectomy in eight patients with malignant tumors of the spine operated on over a 7-year period (1980 to 1986). Four patients had primary neoplasms of the spine, and four others had solitary metastases to the vertebrae. Following surgery, five patients underwent radiation therapy (RT) and chemotherapy depending on histology of the tumor. Radiographic confirmation of tumor resection was obtained on all patients. Pain relief was noted in all patients, and six patients with preoperative neurological deficits improved. There was no surgical mortality, and one patient developed wound dehiscence following surgery. Six of the eight patients are alive with a median follow-up of 36 months, and local control was achieved in six of the eight patients. These preliminary data suggest that malignant tumors of the spine can be completely resected using a staged approach. In potentially responsive tumors, systemic chemotherapy is recommended between the two operations to reduce the risk of systemic dissemination.

Inability of computed tomography appearance of recurrent malignant astrocytoma to predict survival following reoperation

Computed tomographic (CT) scans of 39 patients who underwent reoperation for recurrent malignant astrocytoma at Memorial Sloan-Kettering Cancer Center from 1980 through 1987 were reviewed and correlated with the patients' clinical course. Histologic diagnosis (anaplastic astrocytoma v glioblastoma multiforme) had a statistically significant impact on survival following reoperation (P = .038). Patients with high preoperative performance status (P = .29), total resection by postoperative CT scan (P = .15), and frontal lobe tumors (P = .17) tended to survive longer following reoperation. The size of the tumor at the time of recurrence did not correlate with survival following reoperation. Patients with a small amount of peritumoral edema at the time of recurrence tended to survive longer, but the effect was small (P = .16). Prognosis following reoperation cannot be accurately predicted on the basis of tumor appearance on CT scan.

The combined use of radiation therapy and lonidamine in the treatment of brain metastases

Lonidamine is an indazole carboxylic acid that has been shown to be synergistic with radiotherapy (RT) in tissue culture and animal models. Clinical experience has shown that lonidamine is well-tolerated, and appears to potentiate the activity of conventional chemotherapy in the treatment of brain metastases. A prospective randomized trial was undertaken to evaluate the use of lonidamine in combination with RT in the treatment of brain metastases. All patients received 3000 cGy of whole brain radiotherapy (WBRT). Fifty eight patients were enrolled; 31 received lonidamine plus WBRT and 27 received WBRT alone. There was no significant difference in response rate or survival between the treatment groups. Lonidamine blood levels were measured in 30 of the 31 patients who received the drug, and were therapeutic (greater than or equal to 15 micrograms/ml) in 50%. Survival and response rate were unaffected by the presence or absence of a therapeutic lonidamine level. The most common side-effects of lonidamine were myalgia, testicular pain, anorexia, and ototoxicity; however, only 2 patients had to discontinue the drug because of intolerable myalgias. No serious organ toxicity or myelosuppression was observed.

The effect of cirrhosis on the steady-state pharmacokinetics of oral ciprofloxacin

The pharmacokinetics of ciprofloxacin, a carboxyquinolone, was studied after oral administration of the drug to seven patients with biopsy-proved cirrhosis and to seven healthy volunteers. Serum concentrations of ciprofloxacin and its three metabolites--desethylene ciprofloxacin (M1), sulfociprofloxacin (M2), and oxociprofloxacin (M3)--were measured by an HPLC procedure. The pharmacokinetic parameters for ciprofloxacin were not significantly altered in cirrhotic patients. The elimination half-life (t 1/2) and the area under the serum concentration versus time curve (AUC) were, respectively, 3.71 hours and 16.18 microgram.ml-1.hr-1 in the normal subjects and 3.47 hours and 18.38 micrograms.ml-1.hr-1 in patients with cirrhosis. The formation of oxociprofloxacin was reduced by approximately one half in the cirrhotic subjects, as the Cmax was 0.29 micrograms/ml in normal subjects versus 0.14 micrograms/ml in cirrhotic patients and the mean AUC(0-t) was 1.54 micrograms.ml-1.hr-1 in normal subjects versus 0.70 micrograms.ml-1.hr-1 in cirrhotic patients. However, there appeared to be no significant difference between groups with respect to desethylene ciprofloxacin and sulfociprofloxacin. Therefore it appears from this study that no dosage adjustment is required in patients with hepatic cirrhosis.

Patterns of failure following treatment for glioblastoma multiforme and anaplastic astrocytoma

Recurrence patterns of glioblastoma multiforme (25) and anaplastic astrocytoma (9) were studied using CT scans of 34 patients who received all or a portion of their surgical treatment at Memorial Sloan-Kettering Cancer Center from January 1983 through February 1987. Thirty-two patients presented with unifocal tumors and two with multifocal tumors. All patients received radiation therapy following initial surgery. Eighteen patients who underwent re-operation following CT evidence of recurrence had histologic verification of recurrent tumor; sixteen patients had radiographic evidence of recurrence only. Seventy-eight percent (25/32) of unifocal tumors recurred within 2.0 cm of the pre-surgical, initial tumor margin, defined as the enhancing edge of the tumor on CT scan. Fifty-six percent (18/32) of tumors recurred within 1.0 cm of the initial tumor margin. Tumors for which a gross total resection was accomplished tended to recur closer to the initial tumor margin than did subtotally resected tumors (p greater than 0.1). Extensive pre-operative edema was associated with a decreased distance between initial and recurrent tumor margins. Large tumors were generally not more likely to recur further from the initial tumor margin than were smaller tumors. No unifocal tumor recurred as a multifocal tumor. Only one tumor (initially near the midline) recurred in the contralateral hemisphere. The findings support the use of partial brain irradiation for post-operative treatment of glioblastoma multiforme and anaplastic astrocytomas, and may help to determine the most appropriate treatment volume for interstitial irradiation.

Spinal lesions: quantitative and qualitative temporal evolution of gadopentetate dimeglumine enhancement in MR imaging

Seventy gadolinium-enhanced magnetic resonance imaging studies were reviewed, and 36 were selected for quantitative and qualitative analysis of the temporal evolution of contrast medium enhancement of spinal lesions. In the extradural space, lesions often showed mild increase of enhancement on delayed images, but enhancement was always visible on immediate postcontrast images. In the intradural extramedullary space, tumor nodules demonstrated most prominent enhancement on early images, although subtle, strandlike enhancement of the nerve roots showed some delayed uptake of contrast medium on later images. In the intramedullary space, enhancement often increased on delayed images, although this increase was usually mild. For clinical purposes, immediate postcontrast imaging should be sufficient to depict the majority of spinal lesions, regardless of location. However, selected cases, such as necrotic spinal cord tumors, will require delayed imaging.

MR imaging of hemorrhagic intracranial neoplasms

Thirty patients with intracranial tumors containing hemorrhage of varying stages were examined with high-field-strength MR imaging and CT to determine what differences might exist between hemorrhagic tumor and pure hemorrhage. Pathology was obtained in the six patients with primary tumors and in 14 of the 24 patients with metastases. Similar to evolving intraparenchymal hematomas, hemorrhagic neoplasms undergo changes in their appearance that can be categorized into three distinct intensity patterns, or stages. Stage 1 is characterized as iso- or hypointensity on short TR sequences and as hypointensity on long TR sequences; stage 2 as developing hyperintensity on both short and long TR sequences, without evidence of a well-defined black rim; and stage 3 as a hyperintense lesion with a well-defined black rim on long TR sequences. An additional mixed-intensity pattern was identified, which contained areas corresponding to more than one stage. In all of the cases exhibiting this pattern, pathology confirmed that the appearance was due to recurrent bleeding. We found several characteristics on MR that, when present, suggest an underlying neoplasm. These include delay in evolution between stages, central or eccentric hyperintensity in stage 2, and a mixed-intensity pattern. In addition, the presence of a hemosiderin rim does not exclude an underlying neoplasm. We found that the MR patterns that characterize hemorrhagic intracranial neoplasms should help to determine the cause of the hemorrhage.

MR imaging of the cranial meninges with emphasis on contrast enhancement and meningeal carcinomatosis

MR imaging was used to investigate normal and abnormal meningeal enhancement, with an emphasis on meningeal carcinomatosis. Three groups of patients were studied on a 1.5-T system. In group 1, the normal meninges were examined in 20 patients and were found to show fine linear enhancement in short segments, especially in a parasagittal distribution. In group 2, all gadolinium-enhanced head scans were reviewed retrospectively. Abnormal meningeal enhancement was detected in 52 patients. In some of these, the enhancement was associated with pathologic conditions of the meninges, including leptomeningeal tumor and meningeal infections and other inflammatory conditions; in others the enhancement was adjacent to subdural hematomas, subacute infarcts, and skull lesions, such as metastases or postoperative defects. In group 3, 30 cases of meningeal carcinomatosis were studied prospectively. Enhancement was seen in approximately two-thirds of cases and usually was quite diffuse and applied to the inner table of the skull. Frank nodules were seen less often. Contrast-enhanced CT was equal to MR in the detection of nodules but was nearly always unable to show diffuse meningeal enhancement against the inner table of the skull. Contrast-enhanced MR was more sensitive than contrast-enhanced CT in the examination of normal and abnormal meninges. Abnormal findings, such as meningeal carcinomatosis, were demonstrated more often by MR than by CT.

Intramedullary disease of the spine: diagnosis using gadolinium-DTPA-enhanced MR imaging

Twenty-six patients with suspected lesions of the spinal cord were studied before and after administration of gadolinium-DTPA to assess whether contrast enhancement was useful in the MR evaluation of intramedullary disease. Nine patients had primary tumors, six had benign syringes, three had multiple sclerosis with cord involvement, three had thrombosed vascular malformations, three had probable intramedullary metastasis, and two were normal. Although all lesions were detected on noncontrast MR scans, gadolinium-DTPA was of great help in their delineation and characterization. Specifically, contrast material may be able (1) to localize tumor nidus and separate it from edema, in cases of hemangioblastomas and metastases; (2) to suggest regions of more active tumors, in cases of glioma, for surgical biopsy or removal; (3) to differentiate benign or reactive processes from neoplastic lesions, such as reactive cyst from tumor cyst or hematoma due to thrombosed malformation from tumor hemorrhage; and (4) possibly to differentiate active from inactive lesions, for example, in multiple sclerosis. Because of these advantages, gadolinium-DTPA probably will often be used routinely when intramedullary lesions are detected on noncontrast MR scans.

Combined treatment of osteosarcoma of the spine

We reviewed the clinical features and results of treatment in 24 patients with osteogenic sarcoma of the spine treated over a 35-year period. There were 14 male and 10 female patients 13 to 71 years old. The tumor arose de novo in 13 patients and was secondary to other conditions in 11. All patients presented with pain, and 16 (67%) had neurological deficits. Patients were divided into two treatment groups. Thirteen patients treated from 1949 to 1977 usually underwent limited tumor resection and external radiation therapy. The second group, 11 patients treated from 1978 to 1984, underwent more aggressive surgical resection and received combination chemotherapy as well as local radiation to the tumor bed. In the second group, there were 5 long term survivors, and only 1 patient developed metastatic disease while on therapy. Failure to obtain local control was the major cause of treatment failure. Complete surgical resection of the tumor by spondylectomy and combination chemotherapy offer the best prospect for cure of osteogenic sarcoma of the spine.

MR of cranial and spinal meningeal carcinomatosis: comparison with CT and myelography

Thirty-nine patients with histologically proved primary neoplasms, focal neurologic deficits, and positive CSF cytology were evaluated by enhanced cranial CT and MR, or complete myelography and MR of the spine. Intracranial abnormalities were noted on CT in 56% of cases and included abnormal enhancement of subarachnoid space and ventricular walls, ventricular dilatation, obliteration of cortical sulci, and enhancing nodules within the subarachnoid cisterns and lumen of the lateral ventricles. Although the degree of ventricular enlargement and intraventricular tumor deposits were equally well seen on CT and MR, involvement of ventricular walls, tentorium, subarachnoid cisterns, or subarachnoid space interpreted as abnormal enhancement on CT was not readily appreciated on routine T1- and T2-weighted spin-echo sequences. Forty-four percent of CT and 65% of MR studies were interpreted as normal. There was high correlation of myelographic findings with clinical diagnosis, and no false-negative myelograms. Nodular filling defects within the subarachnoid space, thickening and crowding of roots of the cauda equina, irregularity of individual roots, and scalloping of the subarachnoid membranes were demonstrated. MR was rather insensitive in detecting these changes, revealing a definite abnormality of the subarachnoid space in 27% of patients with positive myelograms. False-negative interpretation of MR of the spine was made in 44% of cases.

Cerebral necrosis following neutron radiation of an extracranial tumor

Radiation necrosis of the brain is a rare complication of irradiation for extracranial tumors. We present a patient who emphasizes the potential hazard of neutron therapy, the sensitivity of magnetic resonance imaging (MRI) which may detect white matter changes prior to the development of clinical symptoms, the potential diagnostic value of 18F-fluorodeoxyglucose/positron emission tomography, and the importance of a combined surgical and medical approach for proper treatment.

Intraparenchymal brain metastases: MR imaging versus contrast-enhanced CT

Prospective and retrospective studies of 75 patients were performed to assess the sensitivities of magnetic resonance (MR) imaging and computed tomography (CT) in the evaluation of suspected intraparenchymal brain metastases. The findings on MR images were equivalent to those on CT scans in 49 of the 75 patients; the remaining findings were discordant in 26 patients, and neither MR imaging nor CT was consistently superior. MR imaging demonstrated more metastases in nine of these 26 patients. However, contrast material-enhanced CT scans were superior in lesion depiction in eight of the 26 patients. Large enhanced lesions that were nearly isointense on MR images were seen well on CT scans. In several cases in which results were discordant, gadolinium-diethylenetriaminepentaacetic acid (DTPA)-enhanced MR images were obtained, and this agent behaved similarly to iodinated contrast agents. If indicated clinically, such as before surgery for a single metastasis, the authors perform both MR imaging and contrast-enhanced CT. Gd-DTPA-enhanced MR imaging may prove to be the method of choice for depiction of intraparenchymal metastases.

Distribution of brain metastases

The number and site of brain metastases were identified on the computed tomographic scans of 288 patients. There was one brain metastasis in 49%, two in 21%, three in 13%, four in 6%, and five or more in 11% of scans. In patients with one metastasis, the posterior fossa was involved in 50% of patients when the primary tumor was pelvic (prostate or uterus) or gastrointestinal, but it was involved in only 10% of patients with other primary tumors. Hemispheral metastases preferred the anatomic "watershed areas" (29% of the brain surface contained 37% of the metastases), indicating that tumoral microemboli tend to lodge in the capillaries of the distal parts of the superficial arteries. The charts of 134 patients with brain metastases from a primary tumor originating outside the lung revealed that the incidence of lung and spine metastases was the same, whether the primary tumor was pelvic or gastrointestinal or from another site. These data suggest that the high incidence of subtentorial lesions in patients with pelvic and gastrointestinal primary tumors cannot be explained by arterial embolization alone, and that this peculiar distribution is probably not explained by seeding of the brain through Batson's plexus.

Distribution of brain metastases

The number and site of brain metastases were identified on the computed tomographic scans of 288 patients. There was one brain metastasis in 49%, two in 21%, three in 13%, four in 6%, and five or more in 11% of scans. In patients with one metastasis, the posterior fossa was involved in 50% of patients when the primary tumor was pelvic (prostate or uterus) or gastrointestinal, but it was involved in only 10% of patients with other primary tumors. Hemispheral metastases preferred the anatomic "watershed areas" (29% of the brain surface contained 37% of the metastases), indicating that tumoral microemboli tend to lodge in the capillaries of the distal parts of the superficial arteries. The charts of 134 patients with brain metastases from a primary tumor originating outside the lung revealed that the incidence of lung and spine metastases was the same, whether the primary tumor was pelvic or gastrointestinal or from another site. These data suggest that the high incidence of subtentorial lesions in patients with pelvic and gastrointestinal primary tumors cannot be explained by arterial embolization alone, and that this peculiar distribution is probably not explained by seeding of the brain through Batson's plexus.