Experience of Low Dose Perampanel to Add-on in Glioma Patients with Levetiracetam-uncontrollable Epilepsy

After introduction of levetiracetam (LEV), treatment of seizures in patients with malignant brain tumors has prominently improved. On the other hand, we still experience some cases with LEV-uncontrollable epilepsy. Perampanel (PER) is a noncompetitive α-amino-3-hydroxy-5-methyl-4-isoaxazolepropionate acid receptor antagonist that has recently been approved for treating focal epilepsy as a secondary drug of choice. Available literature reporting PER medication in patients with gliomas is still sparse. Here, we report our initial experience with glioma patients and report efficacy of adding low dose 2–4 mg PER to LEV in patients whose seizure were uncontrollable with LEV monotherapy. Clinical outcome data of 18 consecutive patients were reviewed. This included nine males and nine females aged 24–76 years (median, 48.5 years), treated for glioma between June 2009 to December 2018. We added PER to patients with LEV-uncontrollable epilepsy. Adverse effects, irritability occurred in two patients, but continuous administration was possible in all cases. Though epileptic seizures occurred in four cases receiving 2 mg PER, 17 cases achieved seizure freedom by dose increments; final dose, 2–4 mg PER added to LEV 500–3000 mg. Our study revealed anti-epileptic efficacy of low dose PER 2–4 mg as first add-on therapy to LEV in glioma patients who have failed or intolerable to LEV monotherapy. Low dose PER added on to LEV may have favorable efficacy with tolerable adverse effects in glioma patients with LEV-uncontrollable epilepsy.

Sturge-Weber syndrome with intracerebral hemorrhage: a case report

Introduction

Sturge–Weber syndrome (SWS) is a rare congenital disease that affects the brain, skin, and eyes, and is a sporadically occurring neurocutaneous syndrome that affects intracerebral veins, which is associated with venous thrombosis. However, intracranial hemorrhage in patients with SWS is rare. We herein report a rare case of SWS with intracerebral hemorrhage derived from sinus thrombosis.

Case description

A 62-year-old man suddenly fell into a coma and was admitted to our hospital. His neurological status was assessed as GCS 6 (E1V1M4) with right-sided hemiparesis. At birth, he had a right-sided facial port-wine stain typical of SWS that involved the ophthalmic division of the trigeminal nerve. Laboratory findings showed that he was dehydrated, and his serum D-dimer concentration was increased. Computed tomography revealed left thalamic hemorrhage with acute hydrocephalus and cortical calcification in the right occipital lobe. Magnetic resonance imaging displayed a vascular malformation of the right cerebral hemisphere consistent with SWS. Magnetic resonance venography showed steno-occlusion of the superior sagittal sinus, straight sinus, and left internal cerebral vein (ICV). Emergency ventricular drainage was performed. Seven days after surgery, his consciousness improved to GCS 14 (E4V4M6). Rehydration therapy was performed to prevent sinus thrombosis.

Discussion and Evaluation

His postoperative course was uneventful. Sudden congestion of the left ICV may have caused left thalamic hemorrhage.

Conclusions

SWS with major sinus occlusion needs to be diagnosed with utmost caution in order to allow for preoperative neurological and radiological assessments.

Intraparenchymal ultrasound application and improved distribution of infusate with convection-enhanced delivery in rodent and nonhuman primate brain

OBJECT

Convection-enhanced delivery (CED) is an effective drug delivery method that delivers high concentrations of drugs directly into the targeted lesion beyond the blood-brain barrier. However, the drug distribution attained using CED has not satisfactorily covered the entire targeted lesion in tumors such as glioma. Recently, the efficacy of ultrasound assistance was reported for various drug delivery applications. The authors developed a new ultrasound-facilitated drug delivery (UFD) system that enables the application of ultrasound at the infusion site. The purpose of this study was to demonstrate the efficacy of the UFD system and to examine effective ultrasound profiles.

METHODS

The authors fabricated a steel bar-based device that generates ultrasound and enables infusion of the aqueous drug from one end of the bar. The volume of distribution (Vd) after infusion of 10 ml of 2% Evans blue dye (EBD) into rodent brain was tested with different frequencies and applied voltages: 252 kHz/30 V; 252 kHz/60 V; 524 kHz/13 V; 524 kHz/30 V; and 524 kHz/60 V. In addition, infusion of 5 mM gadopentetate dimeglumine (Gd-DTPA) was tested with 260 kHz/60 V, the distribution of which was evaluated using a 7-T MRI unit. In a nonhuman primate (Macaca fascicularis) study, 300 μl of 1 mM Gd-DTPA/EBD was infused. The final distribution was evaluated using MRI. Two-sample comparisons were made by Student t-test, and 1-way ANOVA was used for multiple comparisons. Significance was set at p < 0.05.

RESULTS

After infusion of 10 μl of EBD into the rat brain using the UFD system, the Vds of EBD in the UFD groups were significantly larger than those of the control group. When a frequency of 252 kHz was applied, the Vd of the group in which 60 V was applied was significantly larger than that of the group in which 30 V was used. When a frequency of 524 kHz was applied, the Vd tended to increase with application of a higher voltage; however, the differences were not significant (1-way ANOVA). The Vd of Gd-DTPA was also significantly larger in the UFD group than in the control group (p < 0.05, Student t-test). The volume of Gd-DTPA in the nonhuman primate used in this study was 1209.8 ± 193.6 mm3. This volume was much larger than that achieved by conventional CED (568.6 ± 141.0 mm3).

CONCLUSIONS

The UFD system facilitated the distribution of EBD and Gd-DTPA more effectively than conventional CED. Lower frequency and higher applied voltage using resonance frequencies might be more effective to enlarge the Vd. The UFD system may provide a new treatment approach for CNS disorders.

Local convection-enhanced delivery of an anti-CD40 agonistic monoclonal antibody induces antitumor effects in mouse glioma models

BACKGROUND

Glioblastoma is one of the most malignant brain tumors in adults and has a dismal prognosis. In a previous report, we reported that CD40, a TNF-R-related cell surface receptor, and its ligand CD40L were associated with glioma outcomes. Here we attempted to activate CD40 signaling in the tumor and determine if it exerted therapeutic efficacy.

METHODS

CD40 expression was examined in 3 mouse glioma cell lines (GL261, NSCL61, and bRiTs-G3) and 5 human glioma cell lines (U87, U251, U373, T98, and A172). NSCL61 and bRiTs-G3, as glioma stem cells, also expressed the glioma stem cell markers MELK and CD44. In vitro, we demonstrated direct antitumor effects of an anti-CD40 agonistic monoclonal antibody (FGK45) against the cell lines. The efficacy of FGK45 was examined by local convection-enhanced delivery of the monoclonal antibody against each glioma model.

RESULTS

CD40 was expressed in all mouse and human cell lines tested and was found at the cell membrane of each of the 3 mouse cell lines. FGK45 administration induced significant, direct antitumor effects in vitro. The local delivery of FGK45 significantly prolonged survival compared with controls in the NSCL61 and bRiTs-G3 models, but the effect was not significant in the GL261 model. Increases in apoptosis and CD4(+) and CD8(+) T cell infiltration were observed in the bRiTs-G3 model after FGK45 treatment.

CONCLUSIONS

Local delivery of FGK45 significantly prolonged survival in glioma stem cell models. Thus, local delivery of this monoclonal antibody is promising for immunotherapy against gliomas.

Total regression of brain metastases in non-small cell lung cancer patients harboring EGFR mutations treated with gefitinib without radiotherapy: two case reports

Background

Gefitinib is an epidermal growth factor receptor tyrosine kinase inhibitor. Clinical trials have reported its effectiveness in the treatment of brain metastases from non-small cell lung cancer by overcoming the blood–brain barrier. Gefitinib is generally regarded as a relatively safe agent, and several reports have described its efficacy in patients with epidermal growth factor receptor mutation-positive non-small cell lung cancer and a poor performance status.

Case presentation

We herein described two patients with brain metastasis from non-small cell lung cancer who achieved the total regression of metastasis with the administration of gefitinib. A 70-year-old Japanese woman was referred to our hospital with a severe cough. Brain magnetic resonance imaging revealed a metastatic lesion in the left temporal lobe. The tumor was positive for an epidermal growth factor receptor L858R mutation in exon 21 using the peptide nucleic acid-locked nucleic acid polymerase chain reaction clamp method. She was treated with 250 mg gefitinib per day, and, 1 month later, the primary lesion and brain metastasis had totally resolved. A 58-year-old Japanese woman was referred to our hospital with nausea and headache. Brain magnetic resonance imaging revealed a metastatic lesion in the left cerebellar hemisphere and meningeal dissemination. The tumor was positive for the epidermal growth factor receptor L858R mutation in exon 21. She was treated with 250 mg gefitinib per day, and, 3 weeks later, the primary lesion, brain metastasis, and meningeal dissemination had completely resolved.

Conclusion

We successfully treated two lung cancer patients with brain metastasis using gefitinib. Gefitinib therapy may be a suitable treatment for brain metastasis in lung cancer with an epidermal growth factor receptor mutation, particularly in elderly patients with a poor performance status.

CD40/CD40L expression correlates with the survival of patients with glioblastomas and an augmentation in CD40 signaling enhances the efficacy of vaccinations against glioma models

BACKGROUND

The prognosis of glioblastoma (GBM) remains poor; therefore, effective therapeutic strategies need to be developed. CD40 is a costimulatory molecule whose agonistic antibody has been shown to activate antitumor effects. Recently, CD40 has been extensively targeted for immunotherapeutic purposes.

METHODS

Expressions of CD40/CD40L mRNAs were examined in 86 cases of World Health Organization grade IV GBM and 36 cases of grade III gliomas and correlated with outcomes. CD40 signaling was employed to augment the efficacy of immunotherapy against gliomas. The efficacy of FGK45, an agonistic antibody for CD40, was examined by adding it to a tumor lysate-based subcutaneous vaccination against a GL261 glioma model and an NSCL61 glioma-initiating cell-like cell tumor model.

RESULTS

We demonstrated for the first time using quantitative PCR that grade III gliomas express higher levels of CD40/CD40L than does grade IV GBM. The higher expression of CD40/CD40L was associated with good prognoses in patients with GBM. Addition of FGK45 to the subcutaneous tumor cell lysate-based vaccination significantly prolonged survival in both tumor models. However, the efficacy was modest in NSCL61-model mice. Therefore, we established combination immunotherapeutic strategies using FGK45 and OX86, an agonistic antibody for OX40. Combination immunotherapy significantly prolonged survival with synergistic effects. Apoptosis increased and proliferation decreased in tumors treated with combination immunotherapy.

CONCLUSIONS

The high expression of CD40/CD40L can be used as a biomarker for better prognoses in patients with gliomas. Immunotherapy using FGK45 significantly prolonged survival and represents a potential therapeutic strategy for gliomas including glioma-initiating cells.

OX40 ligand expressed in glioblastoma modulates adaptive immunity depending on the microenvironment: a clue for successful immunotherapy

Background

Glioblastoma is the most malignant human brain tumor and has a dismal prognosis; however, some patients show long-term survival. The interaction between the costimulatory molecule OX40 and its ligand OX40L generates key signals for T-cell activation. The augmentation of this interaction enhances antitumor immunity. In this present study, we explored whether OX40 signaling is responsible for antitumor adaptive immunity against glioblastoma and also established therapeutic antiglioma vaccination therapy.

Methods

Tumor specimens were obtained from patients with primary glioblastoma (n = 110) and grade III glioma (n = 34). Quantitative polymerase chain reaction (PCR), flow cytometry, and immunohistochemistry were used to analyze OX40L expression in human glioblastoma specimens. Functional consequences of OX40 signaling were studied using glioblastoma cell lines, mouse models of glioma, and T cells isolated from human subjects and mice. Cytokine production assay with mouse regulatory T cells was conducted under hypoxic conditions (1.5% O₂).

Results

OX40L mRNA was expressed in glioblastoma specimens and higher levels were associated with prolonged progression-free survival of patients with glioblastoma, who had undergone gross total resection. In this regard, OX40L protein was expressed in A172 human glioblastoma cells and its expression was induced under hypoxia, which mimics the microenvironment of glioblastoma. Notably, human CD4 T cells were activated when cocultured in anti-CD3-coated plates with A172 cells expressing OX40L, as judged by the increased production of interferon-γ. To confirm the survival advantage of OX40L expression, we then used mouse glioma models. Mice bearing glioma cells forced to express OX40L did not die during the observed period after intracranial transplantation, whereas all mice bearing glioma cells lacking OX40L died. Such a survival benefit of OX40L was not detected in nude mice with an impaired immune system. Moreover, compared with systemic intraperitoneal injection, the subcutaneous injection of the OX40 agonist antibody together with glioma cell lysates elicited stronger antitumor immunity and prolonged the survival of mice bearing glioma or glioma-initiating cell-like cells. Finally, OX40 triggering activated regulatory T cells cultured under hypoxia led to the induction of the immunosuppressive cytokine IL10.

Conclusion

Glioblastoma directs immunostimulation or immunosuppression through OX40 signaling, depending on its microenvironment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12943-015-0307-3) contains supplementary material, which is available to authorized users.

Treatment results of glioblastoma during the last 30 years in a single institute

Treatment results of glioblastoma (GB) during the last 30 years in Tohoku University were analyzed to identify any improvements in patient outcome in all 332 histologically proven cases of newly diagnosed GB treated consecutively in our department between 1982 and 2011. These 30 years was divided into 5 treatment eras, Group 1 (1982–1988, without preoperative evaluation by magnetic resonance [MR] imaging, n = 46), Group 2 (1989–1996, with preoperative MR imaging, n = 41), Group 3 (1997–1999, additionally underwent intraoperative functional brain mapping and neuronavigation system, n = 38), Group 4 (2000–August 2006, underwent 30 Gy of whole brain radiation followed by 30 Gy of extended local accelerated hyperfractionated radiation therapy, n = 96), and Group 5 (September 2006–2011, adjuvant usage of temozolomide [TMZ], n = 111). Overall survival (OS) was calculated from the date of surgery to the death from any cause. The median survival time/2-year OS/5-year OS of Groups 1 to 5 were 10.7 months/10.9%/0%, 17.3 months/26.2%/6.9%, 15.9 months/23.7%/5.3%, 20.1 months/34.8%/15.5%, and 20.9 months/45.5%/19.7%. The prognosis for patients with GB improved significantly after the introduction of MR imaging. Younger GB, defined as patients aged below 60 years, or total tumor resection with all ages in Group 5 had 5-year 0S of 31.0% and 30.1%, respectively. The prognosis of GB was improved significantly after the introduction of TMZ for elderly GB, recursive partitioning analysis class 5, or totally resected GB. Introduction of MR imaging and TMZ, and total resection of the tumor were important in the improvement of outcome for patients with GB.

Pilomyxoid astrocytoma of the cerebellum with Williams syndrome: a case report

CASE REPORT

A 3-year-old boy with Williams syndrome associated with supravalvular aortic stenosis was admitted to our hospital with disturbance of consciousness and a 2-month history of truncal ataxia. T1-weighted magnetic resonance imaging with contrast medium showed a heterogeneously enhanced tumor in the right cerebellum with severe hydrocephalus. The patient underwent tumor resection via suboccipital craniotomy. At the end of resection of the tumor, sudden cardiac arrest occurred after ST segment elevation. Despite immediate cardiopulmonary resuscitation, the patient died. Histological examination of the cerebellar tumor revealed that the tumor consisted of monomorphous bipolar spindle cells on a background of myxoid matrix, and angiocentric arrangement without Rosenthal fibers or eosinophilic granular body. The final diagnosis was pilomyxoid astrocytoma.

CONCLUSION

This case of Williams syndrome with cerebellar pilomyxoid astrocytoma suggests the importance of investigation of the development of brain tumors and occurrence of intraoperative cardiac arrest associated with Williams syndrome.

[An operated case of a meningioma causing acute subdural hematoma]

We report a rare case of a meningioma causing acute hematoma. A 67-year-old woman presented with sudden headache. No evidence of trauma was seen. CT demonstrated a subdural hematoma in the convexity of the fronto-temporal lobe. Magnetic resonance imaging showed marked signal heterogeneity in the convexity of the frontal lobe. One week later, the patient underwent hematoma evacuation and tumor resection including the attached dura mater. The histological diagnosis was meningothelial meningioma. The clot was connected directly to the tumor and the origin of the subdural hematoma was identified as the meningioma. Postoperative course was uneventful, and the headache improved. Meningiomas have a relatively benign course but rarely present with hemorrhage. Surgical exploration is the effective and recommended treatment.

Endovascular repair of ruptured aneurysm arising from fenestration of the horizontal segment of the anterior cerebral artery: case report

A 50-year-old man presented with an aneurysm arising from a fenestration of horizontal portion (A(1)) of the anterior cerebral artery manifesting as subarachnoid hemorrhage. Coil embolization was conducted and the aneurysm was occluded easily. Most reported cases of these types of aneurysms underwent direct surgery. Aneurysm arising from the A(1) fenestration is rare, but the present case shows that coil embolization can be an effective treatment modality. Three-dimensional rotational angiography and aneurysmography were helpful to characterize this complicated vascular structure.

[Childhood transverse sinus dural arteriovenous fistula treated with endovascular and direct surgery: a case report]

Infantile dural arteriovenous fistula is a rare cerebrovascular malformation carrying a poor prognosis with an anatomic cure of only 9%. Endovascular embolization is mainly selected to treat this entity, aiming to obtain normal development of the patients. We present a case of a 20-month-old girl with epilepsy. Digital subtraction angiography revealed a dural arteriovenous fistula involving the right transverse sinus. The arteriovenous fistula was fed by multiple dural branches from the middle meningeal, occipital, meningohypophyseal, and anteroinferior cerebellar arteries. The right transverse sinus was transvenously embolized with platinum coils. Although the shunt flow remained, the patient was liberated from epilepsy. Nine months later, the patient suffered from a recurrence of epilepsy. Digital subtraction angiography demonstrated some increase in shunt flow. Right middle meningeal, occipital, posterior deep temporal, and tentorial arteries were transarterially embolized using N-butyl cyanoacrylate, followed by complete surgical resection of the right transverse sinus. The shunt flow disappeared after surgery, and her epilepsy improved significantly. Our experience suggests that the combination of endovascular and surgical treatment is effective for recurrent infantile dural arteriovenous fistula.

[Brain metastasis from papillary thyroid carcinoma with acute intracerebral hemorrhage: a surgical case report]

We report a rare case of brain metastasis from papillary thyroid carcinoma with intracerebral hemorrhage. A 79-year-old woman presented with sudden headache and monoplegia of the right upper limb 10 years after diagnosis of thyroid papillary adenocarcinoma. Despite the known metastatic lesions in the cervical lymph nodes and lungs, she had been well for 10 years since thyroidectomy, focal irradiation and internal radiation of 131I. CT demonstrated intracerebral hemorrhage in the left temporal lobe. Magnetic resonance imaging showed marked signal heterogeneity. She underwent radical surgery on the day of the onset and the histological diagnosis was metastatic brain tumor of thyroid papillary carcinoma. Postoperative course was uneventful, and the monoplegia was improved. Papillary thyroid carcinoma has a relatively benign course, and surgical removal of the brain metastasis is able to contribute to longer survival times for patients.

[Ruptured aneurysm at the anterior wall of the internal carotid artery in a patient with systemic lupus erythematosus and secondary antiphospholipid syndrome]

A 60 year-old woman, who had a 45-year history of systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome, presented with subarachnoid hemorrhage due to a ruptured aneurysm at the anterior wall of the non-branching site of the right internal carotid artery. She underwent radical surgery on the day of onset. In light of the possibility of arterial dissection, we performed extracranial-intracranial bypass prior to careful exploration of the aneurysm. Based on the finding of saccular aneurysm, she ultimately underwent neck clipping of the aneurysm without complication. Postoperative course was uneventful, and she did not suffer from cerebral vasospasm. We recommend early surgical intervention in patients with aneurysmal SAH associated with SLE, while intrinsic pathologies of SLE such as fragile vascular structure and the risk for ischemic complication should be considered.