Procarbazine, lomustine and vincristine toxicity in low-grade gliomas

Background

Procarbazine, lomustine, and vincristine (pcv) significantly improve survival outcomes in lgg (low-grade gliomas). Administration of pcv to lgg patients increased tremendously over the past years as it went from 2 patients per year between 2005 and 2012 to 23 patients in 2015 only in our centre. However, serious hematological and non-hematological adverse events may occur. The purpose of this study was to evaluate the toxicity of pcv and its clinical relevance in our practice.

Methods

We retrospectively reviewed the charts of 57 patients with lgg who received pcv at the Centre hospitalier de l'Université de Montréal between 1 January 2005 and 27 July 2016.

Results

Procarbazine, lomustine, and vincristine were associated with severe hematological toxicity as clinically significant grade 3 anemia, neutropenia, and thrombocytopenia occurred in 7%, 10%, and 28% of patients, respectively. Other frequent adverse events such as the increase of liver enzymes, cutaneous rash, neurotoxicity, and vomiting occurred in 65%, 26%, 60%, and 40% of patients, respectively. Patients with prophylactic trimethoprim/sulfamethoxazole had more grade 3 hematological toxicity with pcv, especially anemia (p = 0.040) and thrombocytopenia (p = 0.003) but we found no increase in pcv toxicity in patients on concurrent anticonvulsants. Patients with grade 3 neutropenia had a significantly lower survival (median survival 44.0 months vs. 114.0 months, p = 0.001). Patients who were given pcv at diagnosis had more grade 3 anemia than those who received it at subsequent lines of treatment (p = 0.042).

Conclusion

Procarbazine, lomustine, and vincristine increase survival in lgg but were also associated with major hematologic, hepatic, neurologic, and cutaneous toxicity. Anti-Pneumocystis jiroveci pneumonia (pjp) prophylaxis, but not anticonvulsants, enhances hematologic toxicity.

Aneurysm rupture after endovascular flow diversion: the possible role of persistent flows through the transition zone associated with device deformation

Haemorrhagic complications can occur following aneurysm treatment with flow diverters (FD), but the underlying mechanism remains unknown. We describe a case where deformation of the device may have contributed to the complication. A patient with a giant, previously unruptured cavernous aneurysm that extended intracranially to cause oedema of the internal capsule was treated with flow diversion. Treatment was followed by multiple episodes of peri-aneurysmal haemorrhages within eight days. A deformation of the device which occurred where it curved to cross the aneurysm neck created residual flows which, in the presence of a stent stenosis immediately beyond the neck, may have contributed to the observed ruptures. Following multiple haemorrhages the patient subsequently died. Autopsy demonstrated early red thrombus partially bridging the struts of the flow diverter, and intra-aneurysmal thrombus of various ages. Microscopic pathology showed an aneurysm wall consisting of collagen infiltrated with neutrophils, but the wall was absent near the cerebral peduncle, adjacent to the brain haemorrhage. Radiographs of the extracted specimen confirmed deformation of the FD construct, located at the transition zone of the stent, leading to increased pore size and porosity. The site of the deformation correlated with the angiographic presence of a continued blood inflow jet into the aneurysm. Stent deformation at the transition zone may promote persistent blood entry into the aneurysm, and in turn potentially contribute to haemorrhagic complications.

Thrombosis heralding aneurysmal rupture: an exploration of potential mechanisms in a novel giant swine aneurysm model

BACKGROUND AND PURPOSE

The relationship between aneurysm dimensions, flow, thrombosis, and rupture remains poorly understood. We attempted to clarify this relationship by exploring various swine aneurysm models.

MATERIALS AND METHODS

Bilateral carotid aneurysms were constructed according to 3 protocols in 24 animals: small aneurysms with wide necks (group 1; n = 6 animals); small aneurysms with small necks (group 2; n = 4 animals), and giant aneurysms with large necks (group 3; n = 14 animals). Group 3 included 3 subgroups, related to testing the model in various experimental conditions: The neck was clipped in 3 animals; venous pouches lacked an endothelial lining in 4 animals; and 7 were control animals. Animals were followed until rupture, or for 1-4 weeks. Angiography was performed postoperatively and before euthanasia. We studied lesion pathology, paying attention to thrombosis, recanalization, wall composition, and perianeurysmal hemorrhage.

RESULTS

Groups differed significantly in aneurysm dimensions and aspect ratio (P = .002). Ruptures occurred more frequently in animals with untreated giant aneurysms (7/7) than in animals with small wide-neck (0/6) or small-neck (2/4) aneurysms (P = .002). Ruptures occurred only in animals with thrombosed aneurysms. Lesions lacking an endothelial lining and 5 of 6 clipped venous pouches thrombosed but did not rupture. One giant lesion ruptured despite complete clipping. The wall was deficient in α-actin and was infiltrated with inflammatory cells and erythrocytes in all thrombosed cases, ruptured or not. Ruptures were associated with recanalizing channels in 9 of 10 cases.

CONCLUSIONS

Thrombosis, inflammation, and recanalization may precipitate aneurysmal ruptures in a swine model.

Multidrug resistance in brain tumors: roles of the blood-brain barrier

Malignant brain tumors and brain metastases present a formidable clinical challenge against which no significant advances have been made over the last decade. Multidrug resistance (MDR) is one of the main factors in the failure of chemotherapy against central nervous system tumors. The MDR1 gene encoding P-glycoprotein (P-gp), a drug efflux pump which plays a significant role in modulating MDR in a wide variety of human cancers, is highly expressed in the blood-brain barrier (BBB). The BBB controls central nervous system exposure to many endogenous and exogenous substances. The exact molecular mechanisms by which the BBB is involved in the resistance of brain tumors to chemotherapy remain to be identified. The purpose of this review is to summarize reports demonstrating that P-gp, one of the most phenotypically important markers of the BBB, is present in primary brain tumors and thus plays a crucial role in their clinical resistance to chemotherapy.

Expression of multidrug-resistance P-glycoprotein (MDR1) in human brain tumors

Multidrug resistance (MDR) is associated with the expression of P-glycoprotein (P-gp), an ATP-dependent transporter which expels anti-cancer drugs from cells. In the present study, MDR1 P-gp was immunodetected by Western blot analysis in 60 human brain tumors, including meningiomas, schwannomas, low-grade gliomas (astrocytomas, pilocytic astrocytomas) and high-grade gliomas (anaplastic astrocytomas, glioblastomas and anaplastic oligodendrogliomas). Most samples from primary tumors expressed P-gp at the same levels as normal brain tissue except for schwannomas, in which levels were reduced by 65%, and meningiomas, in which levels were more than 10-fold higher in 7 of 10 samples. P-gp levels were 70% and 95% lower in brain metastases from melanomas and lung adenocarcinomas, respectively, than in normal brain tissue. These results indicate that the majority of primary brain tumors express MDR1 P-gp and that its high expression levels in meningiomas may be a marker for this type of brain tumor.

Isolation of endothelial cells from brain, lung, and kidney: expression of the multidrug resistance P-glycoprotein isoforms

Endothelial cells (EC) were isolated from brain, lung, and renal cortex using magnetic microbeads cross-linked to an antibody directed against the platelet-endothelial cell adhesion molecule-1 (PECAM-1). Levels of endothelial nitric oxide synthase (eNOS) and PECAM-1 were measured by Western blots and both were enriched in the positively selected EC fractions. The multidrug resistance P-glycoprotein (P-gp) was strongly enriched (59-fold) in the EC fraction from brain and was absent in the negative fraction, in which the glial fibrillary acidic protein (GFAP), an astrocyte marker, was present. Lower P-gp levels were detected in EC from renal cortex and lung. Reverse transcription-polymerase chain reaction analysis showed that the mdr1a gene was preferentially expressed in EC fraction from the brain. The mdr1b gene was found in EC from renal cortex whereas both mdr1 genes were detected in EC from lung. Our results indicate that EC can be isolated using microbeads and that the isoform of P-gp found in brain is mostly mdr1a, associated with EC.

Expression of matrix metalloproteinases and their inhibitors in human brain tumors

Sixty human brain tumors, classified according to the New World Health Organization (WHO) classification including, grade I schwannomas, meningiomas and pilocytic astrocytomas, grade II astrocytomas, grade III anaplastic astrocytomas, grade IV glioblastomas, grade III anaplastic oligodendrogliomas and grade IV glioblastomas and lung and melanoma metastases were analyzed for the expression of three matrix metalloproteinases (MMPs), two tissue inhibitors of MMPs (TIMPs) and for MMP activity. Some correlation was found between MMP expression and the degree of malignancy. Western blotting analysis revealed a more uniform pattern of distribution of MMP-2 (gelatinase A) than of MMP-9 (gelatinase B) and MMP-12 (metalloelastase) among tumors. MMP-9 levels were found to be significantly higher in grade III anaplastic astrocytomas and anaplastic oligodendrogliomas than those in grade I schwannomas and meningiomas. Anaplastic astrocytomas and Grade IV glioblastomas expressed significantly higher levels MMP-12 than grade I meningiomas. All sixty tumors showed a similar pattern of activity in zymography, proMMP-9 being the major species detected. Interestingly, TIMP-1 and TIMP-2 expression levels were especially low in tumors of grade II and grade III but significantly higher in tumors of grade I, particularly in schwannomas. Taken together, these data suggest that: 1) a balance between MMPs and TIMPs has an important role to play in human brain tumors; 2) TIMP expression may be valuable markers for tumor malignancy.

Expression of matrix metalloproteinases and their inhibitors in human brain tumors

Sixty human brain tumors, classified according to the New World Health Organization (WHO) classification including, grade I schwannomas, meningiomas and pilocytic astrocytomas, grade II astrocytomas, grade III anaplastic astrocytomas, grade IV glioblastomas, grade III anaplastic oligodendrogliomas and grade IV glioblastomas and lung and melanoma metastases were analyzed for the expression of three matrix metalloproteinases (MMPs), two tissue inhibitors of MMPs (TIMPs) and for MMP activity. Some correlation was found between MMP expression and the degree of malignancy. Western blotting analysis revealed a more uniform pattern of distribution of MMP-2 (gelatinase A) than of MMP-9 (gelatinase B) and MMP-12 (metalloelastase) among tumors. MMP-9 levels were found to be significantly higher in grade III anaplastic astrocytomas and anaplastic oligodendrogliomas than those in grade I schwannomas and meningiomas. Anaplastic astrocytomas and Grade IV glioblastomas expressed significantly higher levels MMP-12 than grade I meningiomas. All sixty tumors showed a similar pattern of activity in zymography, proMMP-9 being the major species detected. Interestingly, TIMP-1 and TIMP-2 expression levels were especially low in tumors of grade II and grade III but significantly higher in tumors of grade I, particularly in schwannomas. Taken together, these data suggest that: 1) a balance between MMPs and TIMPs has an important role to play in human brain tumors; 2) TIMP expression may be valuable markers for tumor malignancy.

Expression of matrix metalloproteinases and their inhibitors in human brain tumors

Sixty human brain tumors, including grade I meningiomas, schwannomas, and pilocytic astrocytomas, grade II astrocytomas, grade III anaplastic astrocytomas and oligodendrogliomas, and grade IV glioblastomas and lung and melanoma metastases were analyzed for expression of four matrix metalloproteinases (MMPs), two tissue inhibitors of MMPs (TIMPs), and MMP activity. No marked correlation was found between MMP expression and the degree of malignancy. Western blotting analysis revealed a more uniform pattern of distribution of MMP-2 (gelatinase A) than of MMP-9 (gelatinase B) and MMP-12 (metalloelastase) among tumors. All 60 tumors showed a similar pattern of activity in zymography, MMP-2 being the major species detected. Interestingly, TIMP-1 and TIMP-2 expression levels were low in tumors of grade III but significantly higher in tumors of grade I, particularly schwannomas. Altogether, these data suggest that: (1) the balance between MMP-2 and TIMP-2 is important in human brain tumors; and (2) TIMP expression may be a valuable marker for tumor malignancy.

Interrelationship between organelles in kidney cells of adult and developing rat

The morphologic interrelationships between mitochondria, the endoplasmic reticulum (ER) and other organelles were examined in rat kidney cells by stereomicroscopy of thick sections (0.3-1.0 micron) using either standard transmission (80-100 kV) or high voltage (1 mEV) electron microscopy. Mitochondria fit into three different categories: (1) elongated cylinders observed in S1 and S2 segments; (2) irregular lamina in the cortical ascending limb or plates in the distal straight and convoluted segments; (3) small spheres or short rods mostly in intercalated and principal cells of the collecting tubule. The chondrioma occupies a large volume in all cells except in the thin limb and in principal cells of the collecting tubule. This volume occupied by the chondrioma is likely to be related to metabolic functions, but its polymorphic configuration could also be explained by a passive adaptation of the mitochondria to the space left by the basilar membrane infoldings and the ER network, which was found to have an extensive three-dimensional organization which varies, as for the mitochondria, with the cell type. In fact, in the proximal nephron, mitochondria surrounded by the ER and the plasma membranes appear to form a functional unit. Organelle interrelationship is extensively modified during ontogeny or under hormonal influence. Disruption in organelle relationships or in their motility could probably have far reaching consequences which would be more deleterious than the pathological lesions observed at the level of a single organelle. The extent of the disassembly can be fully explored only with thick sections and stereomicroscopy.

Dopaminergic projection from nucleus raphe dorsalis to neostriatum in the rat

The existence of a dopamine (DA) projection from nucleus raphe dorsalis (RD) to neostriatum was demonstrated in the rat by combined tyrosine hydroxylase (TH) immunohistochemistry and radioautography after retrograde axonal transport of [3H]noradrenaline ([3H]NA). Intrastriatal injections of [3H]NA were carried out in normal rats or after ipsilateral destruction of the nigrostriatal DA system by injection of 6-hydroxydopamine (6-OHDA) into the substantia nigra. Some 1,000 TH-positive nerve cell bodies were counted within the confines of RD as defined by its content in serotonin (5-HT) neurons. These DA neurons occupied the upper third of the RD and they were part of its small cell population. In all cases, a small proportion of the TH-immunoreactive nerve cell bodies in RD were retrogradely radiolabeled. Radiolabeled but immunonegative cells were exceedingly rare. The double-labeled neurons were generally more numerous after elimination of the nigrostriatal DA innervation than in normal rats. They mostly lay within the ventral portion of the medial subdivision of RD and always predominated on the [3H]NA- injected side. Some were also present in nucleus linearis caudalis. It was concluded that [3H]NA had been taken up and retrogradely transported exclusively by catecholamine neurons; part of the DA cell group in RD projects to the neostriatum; and that most if not all non-5-HT neurons projecting from RD to neostriatum are likely to be dopaminergic.

[The dopaminergic innervation of neostriatum: a new possibility of radioautographic investigation (author's transl)]

Precise knowledge of the ultrastructural features and interneuronal relationships of dopaminergic (DA) axon terminals or varicosities in neostriatum is still lacking. This ignorance is due to current limitations of the methods applicable to their specific visualization at electron microscopic level. High resolution radioautography, in particular, has not yet permitted a clearcut identification of the DA nerve endings which take up and store exogenous catecholamines in vivo, due to an apparent mobilization of tracer during standard histological preparative procedures for light and electron microscopy (Fig. 1 A). In this context, histological processing of the central nervous system by vascular perfusion, tested in adult rats subjected to prolonged lateroventricular instillation of [3H]DA, led to the following results and conclusions: 1 Axonal varicosities having accumulated [3H]DA in vivo may be detected in great number in the ipsilateral paraventricular neostriatum (Figs. 1 B and 1 C). 2 The specificity of this radioautographic labelling is evidenced by: (a) its disappearance or persistance, depending on the addition of a high concentration of non-radioactive noradrenaline or serotonin to the [3H]DA solution (Fig. 1 C); (b) the absence of labelled axonal varicosities in the supraependymal region (Figs. 2 E and 2 F) and suprachiasmatic nucleus (Fig. 1 E to be compared with 1 F) after administration of [3H]DA alone; (c) the absence of any localized accumulation of [3H]DA in neostriatum following prior destruction of the nigro-striatal DA system by 6-hydroxydopamine (Fig. 1 D). 3 It seems that carrying out the double fixation with glutaraldehyde and osmium by vascular perfusion is the prerequisite for retaining in situ the [3H]DA accumulated in vivo by neostriatal nerve endings. 4 Preliminary ultrastructural examination shows that the DA axonal varicosities of paraventricular neostriatum are of small caliber (mean diameter: 0.5 micron) and mostly contain clear synaptic vesicles, occasionally associated with a few larger dense-core vesicles (figs. 2 A-D). Several of these nerve endings establish axo-dendritic synaptic junctions (Fig. 2 C) and a few, perhaps, axo-somatic contacts (Fig. 2 D).