Tumor Treating Fields (TTFields) for Newly Diagnosed Glioblastoma in the Real World: A Systematic Review and Survival Meta-Analysis

PURPOSE/OBJECTIVE(S)

Tumor Treating Fields (TTFields) are electric fields that exert forces on cancer cells, disrupting processes critical for cancer cell viability and tumor progression. TTFields therapy is FDA-approved for patients with newly diagnosed glioblastoma (GBM) on the basis of the randomized controlled EF-14 study (NCT00916409). Subsequent approvals and increased worldwide adoption of TTFields has led to the question of whether or not a consistent survival benefit has been observed in the real-world setting, and whether device usage has played a role.

MATERIALS/METHODS

PubMed, Embase, and the Cochrane Library were searched using pre-defined terms, to identify clinical studies (including comparative and single-cohort studies) evaluating overall survival (OS) in adult patients with GBM treated with TTFields therapy added to radiochemotherapy. The Cochran Q test was used to assess inter-study heterogeneity, and results were quantified using the Higgins I2 statistic. Data were pooled, and a survival curve created using a distribution-free random-effects method.

RESULTS

Records identified from the literature search were screened and distilled using pre-specified methods, down to 8 studies evaluating the clinical efficacy of TTFields therapy in newly diagnosed GBM (spanning diverse geographic regions). Six studies (reporting on a total of 1378 patients) compared the addition of TTFields therapy to standard of care (SOC) vs SOC alone, and were included in a pooled analysis for OS. Meta-analysis of data from the 6 studies indicated a significant OS benefit for patients receiving TTFields therapy vs those who did not (hazard ratio [HR]: 0.62; 95% CI, 0.52-0.73; P < 0.001). Sensitivity analysis confirmed the pooled effect was robust and not dependent on any individual study. Of the 6 included in the analysis, 5 were post-approval for which the pooled median OS was 22.2 months (95% CI, 17.3-42.6) vs 17.3 months (95% CI, 13.6-22.0) for the TTFields/SOC group and the SOC group, respectively. Rates of gross total resection were numerically higher in the real-world setting, irrespective of TTFields use. Among studies reporting data on TTFields device usage, an average device usage rate of 75% or higher was found to consistently correlate with prolonged OS when compared to an average usage rate < 75% (pooled HR: 0.63; 95% CI, 0.48-0.83; P = 0.001).

CONCLUSION

Meta-analysis of comparative studies suggests a significant OS benefit when TTFields therapy is added to standard radiochemotherapy for patients with newly diagnosed GBM, and that a ≥ 75% usage rate may translate to clinical benefit in the real-world setting.

Heavy metals in plants in constructed and natural wetlands: concentration, accumulation and seasonality

The accumulation of heavy metals in plants is a function of uptake capacity and intracellular binding sites. The concentrations of heavy metals in plants growing in constructed wetlands vary considerably between species and systems but in general, the concentrations are within the range commonly found in natural stands. The highest concentrations are mostly found in roots, followed by rhizomes, leaves and stems. Unfortunately, concentration values are commonly used to evaluate the 'accumulation' of heavy metals, but this approach is not correct. In order to evaluate heavy metal accumulation, the biomass of particular plant parts must be taken into consideration. In addition, there are two other factors, which need to be taken into consideration when accumulation is evaluated, namely seasonality and distribution within the plant shoot. It has been found that the seasonal distribution of heavy metals in the biomass varies between heavy metals and mostly does not follow the pattern known for nutrients. In addition, the concentration and accumulation of heavy metals vary considerably within the shoot and this fact should be taken into consideration when analyses are carried out.

Are there differences between macrocyclic gadolinium contrast agents for brain tumor imaging? Results of a multicenter intraindividual crossover comparison of gadobutrol with gadoteridol (the TRUTH study)

BACKGROUND AND PURPOSE

Gadobutrol (Gadavist) and gadoteridol (ProHance) have similar macrocyclic molecular structures, but gadobutrol is formulated at a 2-fold higher (1 mol/L versus 0.5 mol/L) concentration. We sought to determine whether this difference impacts morphologic contrast-enhanced MR imaging.

MATERIALS AND METHODS

Two hundred twenty-nine adult patients with suspected or known brain tumors underwent two 1.5T MR imaging examinations with gadoteridol or gadobutrol administered in randomized order at a dose of 0.1 mmol/kg of body weight. Imaging sequences and T1 postinjection timing were identical for both examinations. Three blinded readers evaluated images qualitatively and quantitatively for lesion detection and for accuracy in characterization of histologically confirmed brain tumors. Data were analyzed by using the Wilcoxon signed rank test, the McNemar test, and a mixed model.

RESULTS

Two hundred nine patients successfully completed both examinations. No reader noted a significant qualitative or quantitative difference in lesion enhancement, extent, delineation, or internal morphology (P values = .69-1.00). One hundred thirty-nine patients had at least 1 histologically confirmed brain lesion. Two readers found no difference in the detection of patients with lesions (133/139 versus 135/139, P = .317; 137/139 versus 136/139, P = .564), while 1 reader found minimal differences in favor of gadoteridol (136/139 versus 132/139, P = .046). Similar findings were noted for the number of lesions detected and characterization of tumors (malignant/benign). Three-reader agreement for characterization was similar for gadobutrol (66.4% [κ = 0.43]) versus gadoteridol (70.3% [κ = 0.45]). There were no significant differences in the incidence of adverse events (P = .199).

CONCLUSIONS

Gadoteridol and gadobutrol at 0.1 mmol/kg of body weight provide similar information for visualization and diagnosis of brain lesions. The 2-fold higher gadolinium concentration of gadobutrol provides no benefit for routine morphologic imaging.

Does higher gadolinium concentration play a role in the morphologic assessment of brain tumors? Results of a multicenter intraindividual crossover comparison of gadobutrol versus gadobenate dimeglumine (the MERIT Study)

BACKGROUND AND PURPOSE

Gadobenate dimeglumine has proved advantageous compared with other gadolinium-based contrast agents for contrast-enhanced brain MR imaging. Gadobutrol is a more highly concentrated agent (1.0 mol/L). This study intraindividually compared 0.1-mmol/kg doses of these agents for qualitative and quantitative evaluation of brain tumors.

MATERIALS AND METHODS

Adult patients with suspected or known brain tumors underwent 2 identical MR imaging examinations at 1.5T, 1 with gadobenate dimeglumine and the other with gadobutrol, both at a dose of 0.1-mmol/kg body weight. The agents were injected in randomized order separated by 3-14 days. Imaging sequences and acquisition timing were identical for the 2 examinations. Three blinded readers evaluated images qualitatively for diagnostic information (lesion extent, delineation, morphology, enhancement, global preference) and quantitatively for CNR and LBR.

RESULTS

One hundred fourteen of 123 enrolled patients successfully underwent both examinations. Final diagnoses were intra-axial tumors, metastases, extra-axial tumors, "other" tumors, and "nontumor" (49, 46, 8, 7, and 4 subjects, respectively). Readers 1, 2, and 3 demonstrated preference for gadobenate dimeglumine in 46 (40.7%), 54 (47.4%), and 49 (43.0%) patients, respectively, compared with 6, 7, and 7 patients for gadobutrol (P < .0001, all readers). Highly significant (P < .0001, all readers) preference for gadobenate dimeglumine was demonstrated for all other qualitative end points. Inter-reader agreement was good for all evaluations (κ = 0.414-0.629). Significantly superior CNR and LBR were determined for gadobenate dimeglumine (P < .019, all readers).

CONCLUSIONS

Significantly greater morphologic information and lesion enhancement are achieved on brain MR imaging with 0.1-mmol/kg gadobenate dimeglumine compared with gadobutrol at an equivalent dose.

Gamma knife radiosurgery for endocrine-inactive pituitary adenomas

BACKGROUND

The goal of nonsecreting pituitary adenoma radiosurgery is to halt tumour growth and to maintain normal performance of the hypophysis and the functionally important structures around the sella. The effectiveness of gamma knife radiosurgery was evaluated.

METHOD

Over a period of 10 years (1993-2003), 140 patients with nonsecreting pituitary adenoma were treated by Leksell gamma knife at our Centre. Seventy-nine of them were followed up for longer than 3 years. Their age range was 24-73 years, with a median of 54 years. Eighty-five percent of them had previous open surgery. Fifteen patients had adenoma contact with the optic tract. Fourteen patients had a normally functioning hypophysis, 48 patients had complete panhypopituitarism, while the rest retained partial functions of the normal hypophysis. Adenoma volumes ranged between 0.1 and 31.3, the median being 3.45 ccm. The marginal dose ranged between 12 and -35 Gy, with a median of 20 Gy.

FINDINGS

The follow-up ranged from 36 to 122 months, with a median of 60 months. No adenoma growth was detected; 89% of treated adenomas decreased in size, with a median volume reduction of 61%. There was no perimeter vision impairment after radiosurgery, while 4 out of 52 patients with abnormal perimeter vision reported improvement. There was no impairment of oculomotor nerve function. Impairment of hypophysis function was observed in 2 patients.

CONCLUSIONS

Radiosurgery has a reliable antiproliferative effect on nonsecreting pituitary adenomas. It is a safe treatment with a low risk of morbidity. Short contact between a nonsecreting pituitary adenoma and the optic pathway is not an absolute contraindication for Gamma knife radiosurgery.

Lesion evolution after gamma knife irradiation observed by magnetic resonance imaging

PURPOSE

Our study is focused on the magnetic resonance imaging (MRI) observation of lesion development and hippocampus related functional impairments in rats after irradiation with a Leksell Gamma knife (LGK).

MATERIALS AND METHODS

We exposed 32 three-month-old Long-Evans rats to various radiation doses (25 Gy, 50 Gy or 75 Gy). The rats were scanned by a 4.7 T magnetic resonance (MR) spectrometer at several timepoints (1 - 18 months) after irradiation. The lesion size was evaluated by manual segmentation; the animals were behaviorally tested in a Morris water maze and examined histologically.

RESULTS

We found that a dose of 25 Gy induced no edema, necrosis or behavioral change. The response of the rats to higher doses was not uniform; the first occurrence of lesions in the rat brains irradiated with 50 and 75 Gy was detected six months post-irradiation. Functional impairment correlated well with the lesion size and histology.

CONCLUSIONS

Rat brains showed the development of expanding delayed lesions after 50 or 75 Gy doses from the LGK during the first year after irradiation.

[Time perception in functional brain imaging]

BACKGROUND

Knowledge of physiological mechanisms underlying time perception is still rather limited. The aim of our study was to search for a 'time accumulator', i.e. the part of the brain where information on the duration of time is stored.

METHODS AND RESULTS

Nine healthy volunteers were given a time reproduction task during event-related fMRI. Subjects were instructed to retain the duration of the stimulus presented (presentation phase) and then to reproduce it by pressing a button (reproduction phase). Two different analyses were made: event-related (P < 0.05, FWR corrected) and parametric (BOLD signal increase/decrease during the presentation/reproduction phases correlated with the time intervals; P < 0.01, FDR corrected). When the event-related approach was employed, activation was noted bilaterally in the inferior prefrontal cortex (IPFC), supplementary motor area (SMA), precuneus and secondary visual cortex. On the right, there was activation in the dorsolateral prefrontal cortex (DLPFC), gyrus cinguli and inferior parietal lobule. On the left, the primary sensory-motor cortex was activated. While during the presentation phase the left DLPFC activity inversely correlated with the presented duration, a nearly identical area showed positive correlation in the reproduction phase.

CONCLUSIONS

The event-related analysis did not allow distinguishing the process of time perception from many cognitive processes running simultaneously. In turn, the parametric analysis was based on visualizing regions, in which the signal correlated with the varying duration of the time interval provided the level of attention, decision-making and the processes of behavioral response planning and execution were constant. Moreover, the right and left DLPFC seem to play different roles in time perception. While the left one is functioning as a "time accumulator", the right one is rather involved in the recognition of previously perceived intervals.

Horizontal sub-surface flow constructed wetland with pulsing water level

A constructed wetland with horizontal sub-surface flow at Dolni Mesto (Czech Republic) was put into operation in 1999 and treats municipal wastewater from 522 PE. The total area of vegetated beds of 2,646 m2 is divided into two parallel sections of equal size, each with two beds in series. Between two periods of water discharge there is no outflow from the bed. During the period of September 1999-September 2000 one bed was operated with a pulsing water level while the other one was not pulsing, i.e., was operated as regular sub-surface flow in order to evaluate the effect of pulsing on treatment efficiency, especially on removal of NH4-N. Between September 1999 and February 2000 the pulse was 8 cm, for the rest of the experimental period the pulse was 15 cm. The results indicate a positive effect of pulsing on removal of BOD5 (annual average of 53%), COD (30%) and NH4-N (27%) as compared to non-pulsing beds. For SS, a decrease in removal effect by 30% was observed. This is probably due to the higher outflow velocity of discharged water from pulsing beds which can flush out settled particles. The results also indicate that a pulsing level of 15 cm was more efficient than 8 cm.

[Initial experience with magnetic resonance cholangiopancreatography]

BACKGROUND

Magnetic resonance cholangiopancreaticography (MRCP) is based on heavily weighted T2 sequences (ETSE--echo-train spin echo) with suppression of fat, giving visualisation of slowly flowing or stagnating fluid. MRCP are short sequences in coronary plane with thickness of 8 cm or 4 mm. Retrospective analysis of all MRCP examinations performed during last 12 months is presented.

METHODS AND RESULTS

Eighty-eight examinations were done, of which 67 ones with both adequate technical quality and clinical indication were included into the study (20 males aged 25-83 years, 47 women aged 19-82 years). Patients were divided into 4 groups regarding to the indications (group I.--temporary cholestasis, normal abdominal ultrasound, II.--definite cholestasis, III.--pathologic findings on pancreas, IV.--other). Vast majority of patients were included into group I (35 subjects). In 7 (20%) of them choledocholithiasis and/or stenoses (including multiple stenoses in primary sclerotizing cholangoitis) were found. MRCP brought diagnostic information in subjects with cholestasis (group II.) and answered questions given by clinicians. However, in 1 of 4 subjects with primary sclerotizing cholangoitis, MRCP did not reveal intra-hepatic stenoses, which were later visualised by classical ERCP. Only the extrahepatic stenoses were diagnosed by MRCP in the latter subject.

CONCLUSIONS

MRCP should become a standard examination in the diagnostic algorithm in patients with cholangiopathies. MRCP has its value not only in subjects with unsuccessful or contraindicated ERCP, but also in subjects with temporary cholestasis with negative ultrasound finding.

Distribution of Mn, Al, Cu and Zn in a constructed wetland receiving municipal sewage

A constructed wetland at Nucice near Prague, Czech Republic, has been in operation since 1996 and the system is designed to treat sewage from 650 PE together with stormwater. The total area of the beds planted with Phalaris arundinacea and Phragmites australia is 3,224 m2 (two beds 62 x 26 m each). Pea gravel (8/16 mm) is used as a filtration material. During the period 1998-1999, removal of Mn, Al, Cu and Zn from wastewater and distribution of the metals in sediments and plants were studied. Metals were measured in three vertical profiles of the filtration bed (0-15, 15-30 and 30-60 cm) and at four locations along the longitudinal profile of the bed (5, 16, 32, 48 m from the inlet). Metal concentrations in plant tissues (roots, stems, leaves) of Phalaris arundinacea were measured along the longitudinal profile of the bed at the same locations as for sediments. The results showed that the retention of metals is high (up to 98%) with the major decrease in metal concentrations within the first 5 metres of the bed. The major decrease in metal concentration in the filtration material was observed in the inlet zone between 5 and 16 metres. In Phalaris tissue, metal concentrations decreased in the order roots > stems > leaves but statistically significant differences varied among the studied metals.

Temperature dependence of polymer-gel dosimeter nuclear magnetic resonance response

The purpose of this study was to find a physical-mathematical description capable to correct a polymer-gel dosimeter relaxation rate R2-dose response for different temperatures. Four different modifications of polymer-gel dosimeters were used in this study. Samples with polymer-gel dosimeter in glass test vessels were homogeneously irradiated by 60Co gamma photons. A multi-echo sequence with 16 equidistant echoes was used for evaluation of irradiated polymer-gel dosimeters. The sequence parameters were as follows: TR 2000 ms, TE 22.5-360.0 ms, slice thickness 5 mm, FOV 255 mm, one acquisition. The proposed description recommends to subtract R2 response of the nonirradiated dosimeter from the total R2-dose response. The relaxation rate for the irradiated dosimeter can be expressed as a function of temperature and dose. The temperature dependence has an exponential behavior in the measured range. The proposed description allows to correct the measured NMR R2-dose responses for different temperatures.

Chronic liver disease: relaxometry in the brain after liver transplantation

Relaxometry revealed changes in the basal ganglia in T(1) and T(2) relaxation times due to liver disease. Manganese is probably responsible for T(1) and T(2) shortening (as the concentration is known to be higher in both the liver and blood due to hepatic cirrhosis). The aim of this study was to follow possible recovery after liver transplantation by MR relaxometry. Together with a group of 20 healthy volunteers we scanned 53 patients before and after liver transplantation (some of them repeatedly). Both T(1) and T(2) values were evaluated in the basal ganglia, thalamus, and frontal white matter. T(1) relaxation time was shortened by approx. 20-25% compared to the control group, probably the result of manganese deposition in the brain caused by hepatic cirrhosis. After liver transplantation the relaxation time recovered gradually with almost normal values reached approx. 2 years after surgery. T(1) recovery was observed in all evaluated structures. Similar results were observed with T(2) relaxation in the basal ganglia and thalamus. In the white matter T(2) remained low even 2 years after surgery.

Biota participating in wastewater treatment in a horizontal flow constructed wetland

During the period 1996-1997, three constructed wetlands with sub-surface horizontal flow were investigated. All systems are designed to treat municipal sewage from small villages (150, 200 and 300 PE). The survey included microscopical identification of organisms in both wastewater and filtration substrate. The organisms were used as an indication of oxygen conditions (aerobic, anoxic and anaerobic) in the particular microenvironment. Saprobiological terms characterizing different levels of saprobity were employed to characterize inflowing wastewater, filtration bed and outflowing water. The occurrence of organisms was correlated with BOD5 values in particular profiles. It has been found that the biocenosis in the inflowing wastewater differs from those found in the filtration bed and water outflowing from the vegetated beds. The organisms were grouped into those living under anaerobic and anoxic conditions and those living under aerobic conditions. More than 70 species of bacteria, amoebae, ciliates, rotifers, colorless flagellates, cyanobacteria and algae were found and the most important 45 species were figured in a plate together with saprobiological information for each species. Biota of the inflowing water is usually restricted to bacteria, ciliata and colorless flagellata while the organisms found in outflowing water as well as in periphyton growing on outflow structures indicate 2-3 levels better quality.

Bacterial dynamics in the sub-surface constructed wetland

Constructed wetlands have been shown to be capable of removing a wide variety of contaminants, including bacterial pollution. However, only limited information exists on the distribution of bacteria on roots of macrophytes growing in constructed wetlands. Constructed wetland with sub-surface horizontal flow at Nucice near Prague, Czech Republic, was put in operation in 1996. The system treats municipal sewage from 650 PE and the total area of the beds, planted with Phalaris arundinacea and Phragmites australis in alternate stripes perpendicular to the flow direction, is 3,224 m2 (2 beds 62 x 26 m each). Pea gravel (8/16 mm) was used as a filtration material. During the period 1998-1999, distribution of total aerobic and anaerobic bacteria, coliform bacteria and fecal streptococci was monitored in wastewater as well as on roots of both macrophyte species. Counts of bacteria on root surface in the system at Nucice indicate that there is a steep decrease in bacterial numbers within the first few metres of the bed and that there is significantly more bacteria on roots of Phragmites as compared to Phalaris. There was no statistically significant influence of the season on the bacterial counts on roots of macrophytes.

Constructed wetlands for wastewater treatment in the Czech Republic

The first constructed wetland (CW) for wastewater treatment was built in the Czech Republic in 1989. This recent survey shows that at the end of 1999 101 systems are in operation and several more are under construction. 95 CWs are designed with sub-surface horizontal flow, 6 systems are hybrid with a combination of vertical and horizontal flow beds. Most systems (56) were designed for the treatment of municipal and domestic sewage while 38 CWs were designed for the treatment of wastewater from combined sewer systems. The most commonly used size of vegetated beds is 1,001-2,500 m2 (31 systems) followed by the area between 51-250 m2 (19%). The area of vegetated bed of the largest system is 4,493 m2. Size distribution is quite evenly spread from very small systems (PE = 3 or 4) up to 1,000 PE. However, most systems (44) were sized to treat wastewater from sources between 101 and 500 PE. The most commonly used macrophyte is Common reed (Phragmites australis) which is used in 34 systems as a monotypic stand and in 44 systems in combination with other macrophytes, most frequently with Reed canarygrass (Phalaris arundinacea) (31 systems) and cattails (Typha spp.) (8 systems).

[Radiosurgical treatment of hypophyseal adenomas with the gamma knife: results in a group of 163 patients during a 5-year period]

BACKGROUND

Gamma knife radiosurgery of pituitary adenomas is considered to be very perspective. It can be a very useful complement of traditional microsurgery, pharmacotherapy or fractionated radiotherapy which are seldom a sufficient treatment on their own. The modern radiosurgery does not offer the experience representative enough in this indication. We can offer results of medium long follow-up for tumor growth and hormonal hypersecretion of pituitary adenomas in a relatively large series of patients.

METHODS AND RESULTS

We have analyzed a group of 163 patients with pituitary adenoma treated with gamma knife during 5 years and followed 12-60 months, median 24 months after irradiation. An antiproliferative effect has been achieved in 1-2 years using the minimal dose to the margin 16-35 Gy, median 20 Gy in all our patients who were controlled by MRI (n = 126 patients). One half of these adenomas evidently decreased their size. Our effective antiproliferative dose was safe for the surrounding structures. The hormonal normalization has been achieved at 50.4% from 133 hypersecreting adenomas (39/91 = 43% of acromegalics, 11/13 = 85% of patients with Cushing's disease, 2/9 = 22% of patients with Nelson's syndrome, 11/18 = 61% of prolactinomas). The median latency was 12 months. The minimal dose to the margin was 10-45 Gy, median 35 Gy. Rare side effects were provoked only by increasing the dose to influence the hypersecretion-the development of partial hypopituitarism in 3.1% of patients, the panhypopituitarism in 0.6% of patient and there was 1 hemianopic visual field defect (0.6%).

CONCLUSIONS

Radiosurgery by gamma knife has a similar value for pituitary adenomas as microsurgery has with different distribution of advantages and drawbacks. This makes it suitable for the combined treatment where pharmacotherapy has its place under special conditions. Fractionated radiotherapy has now a marginal importance.

Gamma knife radiosurgery of the brain stem cavernomas

Over 6 years (1992-1998) 26 patients with brain stem cavernomas were treated using the Leksell gamma knife in Prague. 25 patients had a follow up of 6-66, median 24 months. Annual risk of bleeding before radiosurgery was 4%. After gamma knife treatment sudden impairment of neurodeficit reported as rebleeding was observed in 4 patients at 6-51 months, median 16.5 months, after radiosurgery. This represented a 6.8% risk of rebleeding after radiosurgery, which is not significantly different from the risk before radiosurgery. MRI or CT was performed in 24 patients 6-48, median 24, months after radiosurgery. There were no signs of rebleeding in any of the patients, nor any increase of the cavernoma. A decrease of cavernoma size was observed in 8 (33%) of patients. Temporary collateral edema after radiosurgery was detected in 5 (21%) of patients 3-12, median 11, months after radiosurgery. Neurodeficit was observed in 21 of 26 patients before radiosurgery. Improvement of the neurodeficit was detected in 9 (43%) of them 6-36, median 8, months after radiosurgery. Temporary morbidity caused by collateral edema or rebleeding occurred in 7 patients (28%) and permanent morbidity remained in 2 patients (8%). 2 patients died because of rebleeding 6 and 51 months after radiosurgery and the third patient for unrelated reason. Radiosurgery of the brain stem cavernomas was indicated when there was bleeding in the history or progressive neurodeficit and microsurgery was considered too risky. Leksell gamma knife radiosurgery of cavernomas has proved its low morbidity and zero mortality. In case of an insufficient effect of radiosurgery, or if the protective effect from rebleeding comes too late, morbidity and mortality can correspond to the natural course of the disease, as it was left without any treatment.

Differentiation between hemosiderin- and ferritin-bound brain iron using nuclear magnetic resonance and magnetic resonance imaging

MRI is an optimal clinical (research) tool to provide information on brain morphology and pathology and to detect metal ions that possess intrinsic magnetic properties. Non-heme iron is abundantly present in the brain in three different forms: "low molecular weight" complexes, iron bound to "medium molecular weight complexes" metalloproteins such as transferrin, and "high molecular weight" complexes as ferritin and hemosiderin. The total amount and form of iron may differ in health and disease, and MRI can possibly quantify and monitor such changes. Ferritin-bound iron is the main storage form of iron and is present predominantly in the extrapyramidal nuclei where its amounts normally increase as a function of age. Ferritin is water soluble and shortens both, T1 and T2 relaxation, with as result a signal change on the MR images. Hemosiderin, a degradation product of ferritin, is water-insoluble with a stronger T2 shortening effect than ferritin. The larger cluster size of hemosiderin and its water-insolubility also explain a lack of significant T1-shortening effect on T1-weighted images. Using both in vitro specimens and intact brain tissue in vivo we demonstrate here that MRI may be able to distinguish between ferritin- and hemosiderin-bound iron.

The role of Gamma Knife radiosurgery in arteriovenous malformation with aneurysms

A review of 217 patients treated with Gamma knife radiosurgery (GKRS), at Hospital Na Homolce, Prague, between October 1992 and January 1998 for arteriovenous malformation (AVM) is presented. Forty-one patients (18.9%) with an AVM and associated aneurysm are the subjects of special interest for this study. The nidus volume in the presence of an aneurysm lying close to the nidus or within it was significantly larger than the nidus volume in cases where the AVMs had no associated aneurysm, suggesting that an increased flow in a larger AVM may be an important factor for aneurysm formation. The association of an arterial aneurysm with an AVM significantly increased the chance of hemorrhage when compared to the group with AVM and no aneurysm. Ten patients out of 14, who had an aneurysm close to or within the nidus, showed a complete obliteration of their AVM and aneurysm, although the latter was not always included within the irradiated volume. Thus, this study indicates that radiosurgery alone could be the method of choice for the treatment of a combination of AVM and aneurysm, if the aneurysm is close to or within the nidus.

Comparison of MR spectroscopy and MR imaging with contrast agent in children with cerebral astrocytomas

We studied 33 patients with astrocytomas of different grades (68 examinations) by magnetic resonance imaging (MRI) and proton MR spectroscopy ((1)H-MRS). We found that in 80% of the spectra, the presence of signals in the area of 0.8-1.5 ppm, assigned to lipids/lactate in (1)H-MR spectra, correlated with signal enhancement after Gd-DTPA administration. We suggest that visibility of lipid/lactate signals could be due to blood-brain barrier damage, which is characterized by contrast agent enhancement.

Gamma knife radiosurgery of meningiomas in the cavernous sinus region

For 6 years (1992-1998) we have treated 67 patients with cavernous sinus meningioma using the Leksell gamma knife in the Hospital Na Homolce, Prague. The age of the patients ranged between 19-82 years, median 57 years. Radiosurgery was the primary treatment in 64.2% of the patients, in the rest a microsurgical resection preceded. The volume of the tumour ranged from 0.9-31.4 cm3, median 7.8 cm3. The meningioma was distant from the optic tract in 58% of the cases, in 12% of the cases there was a contact with the tumour and the optic tract without its compression and in 30% of the cases there was a compression of the optic tract caused by the meningioma. The dose to the tumour margin ranged from 10-14 Gy, median 12 Gy. The follow up was available in 53 patients, in intervals of 2-60 months, median 19 months. There was no change in the tumour volume in 48% of the cases, in 52% of the cases a decrease of the tumour volume occurred. No increase of the tumour volume was observed. Clinical symptoms and signs improved in 35.8% of the patients, temporary morbidity was 3.8%. The mortality of the treatment was zero. Hitherto, the results of gamma knife radiosurgery of cavernous sinus meningioma have proved its safety and efficiency, although long term experience with a large group of patients is missing. Advances in neuroradiology and radiosurgical technique have allowed us to treat tumours with a closer contact to the optic tract and nerves compared with the past.

T1 and T2 in the brain of healthy subjects, patients with Parkinson disease, and patients with multiple system atrophy: relation to iron content

PURPOSE

To investigate the potential of magnetic resonance imaging for identification and quantification of brain iron in healthy subjects, patients with Parkinson disease, and patients with multiple system atrophy.

MATERIALS AND METHODS

Forty-nine subjects were studied at 1.5 T. Regional T1 and T2 values were compared among groups and also with histopathologic estimates of iron concentration.

RESULTS

In healthy subjects, interregional T1 and T2 differences in the cortex and basal ganglia showed a good correlation with reported values for iron concentration, and intraregional variations were generally consistent with reported variability of iron concentration. Patients with multiple system atrophy had T1 and T2 shortening in the globus pallidus consistent with reported increases in ferritin-bound iron and changes in the putamen consistent with accumulation of hemosiderin (posterior portion) and neuromelanin (remainder). Both groups of patients had changes in the cortex that are consistent with decreased ferritin concentration and T2 changes in white matter consistent with demyelination. Patients with Parkinson disease also had a (nonsignificant) T2 shortening in the substantia nigra that was suggestive of iron accumulation.

CONCLUSION

Most of the T1 and T2 findings appear to be related to changes in iron content and form and may possibly be used as indicators of such changes.

Dysprosium-DOTA-PAMAM dendrimers as macromolecular T2 contrast agents. Preparation and relaxometry

RATIONALE AND OBJECTIVES

The authors have investigated dysprosium [Dy]-DOTA-PAMAM, generation 5 (G = 5) dendrimers as a possible new class of macromolecular T2 contrast agents. The use of DOTA provides a metal complex with greater stability than can be achieved using DTPA as ligand, an important factor in the design of blood pool agents with long half-lives.

METHODS

Generation 5 ammonia-core PAMAM dendrimers were linked to the bifunctional ligand p-SCN-Bz-DOTA. After determination of the number of conjugated DOTA molecules by 1H nuclear magnetic resonance, Dy3+ was titrated at a 90% molar ratio. For comparison, single ionic chelates of Dy-DTPA and Dy-DOTA also were prepared. Using a variable field relaxometer, T1 and T2 relaxation times were measured at 13 different field strengths from 0.05 to 1.5 T and temperatures of 3, 10, 20 and 37 degrees C.

RESULTS

The synthesis resulted in a preparation with 76 DOTA and 68 Dy3+ ions per dendrimer molecule. The T1 relaxivity values for Dy-DTPA, Dy-DOTA, and the Dy-DOTA-based dendrimer all were independent of field strength, with values between 0.12 and 0.20 mM-1 sec-1. At lower fields (0.05-0.1 T), 1/T2 was identical to 1/T1. At higher fields, however, 1/T2 increased quadratically with field strength, with a strong dependence on temperature. The field-dependent component of 1/T2 was up to three times higher for the Dy-DOTA-based dendrimer compared with the single chelate molecules, with coefficients of 0.37 to 0.03 sec-1/Tesla2 for T = 3 to 37 degrees C.

CONCLUSIONS

The results are interpreted with the "inner sphere" theory of susceptibility effects (Curie spin relaxation). The large temperature dependence suggests that the dominant mechanism of relaxation is the contact interaction effect, with the proton residence time as the primary time constant. This largely unexplored relaxation mechanism has the potential to create a new class of T2-selective contrast agents.

Gamma knife treatment of trigeminal neuralgia: clinical and electrophysiological study

Between October 1995 and October 1996, we treated 49 patients suffering from trigeminal neuralgia with Gamma Knife radiosurgery. There were 23 males and 26 females. The mean age was 68 (range 38-94 years) The root of the trigeminal nerve close to brain stem was chosen as the target. The maximum dose was 70 Gy in 24 cases and 80 Gy in 25 cases. A single shot with the 4-mm collimator was used. 13 patients underwent Gamma Knife treatment of trigeminal nerve root without any previous surgical procedures. 31 patients suffered from an essential neuralgia (EN), while 7 had neuralgia related to multiple sclerosis (MS). Three had atypical neuralgia (AN) and 8 patients had postherpetic neuralgia (PN). Patients were divided into five groups according to pain reduction. The success rate of pain relief (excellent, very good and good responses) in these patients was: EN 77% of patients, MS 43%, AN 33% and PN 38% of patients. Pain relief occurred after latent intervals of between 1 day and 8 months (median 2 months and mean 2.8 months). Clinically detected complications after radiosurgery occurred only in the form of tactile hypesthesia in 6%. In a selected group of 18 patients, we observed slight electrophysiological changes in 2 patients (11%) after Gamma Knife treatment.

Leksell gamma knife radiosurgery of the tumor glomus jugulare and tympanicum

We have treated 14 patients with glomus tumor during the 4 years (of 1993 to 1997) using Leksell Gamma Knife radiosurgery. The male: female ratio was 1:3.7, and the mean age 48.6 years (range 22-75 years). The mean tumor volume was 5.5 cm3 (range 0.7-11.3 cm3). The mean maximum dose was 37.4 Gy (range 20-44 Gy). The mean margin dose was 19.4 Gy (range 10-25 Gy). In 3 patients, infrabasal spread of the tumor could not be delineated on peroperative stereotactic CT scans. As a result, this portion of the tumor was treated in 2 patients at a second stage using stereotactic MRI. Follow-up in 11 patients ranged from 6 to 42 months (mean 20.5 months). Hearing on the affected side was further impaired in 3 patients. Tinnitus, vertigo and ataxia improved in 3 patients, headache and nausea in 2 patients. Angiography after radiosurgery was performed in 3 patients. In one patient 12 months after the radiosurgery, pathological vascularisation had completely disappeared. In another patient pathological vascularisation was still present 22 months after the first stage, despite two-stage radiosurgery, although the tumor volume decreased 30%. In the last patient, vascularisation and tumor volume partially decreased 12 months after radiosurgery. The volume of the tumor decreased in 4 patients. No change in tumor volume has been observed in any of the other patients to date. Radiosurgery proves to be a safe treatment for glomus tumor with no acute morbidity. Because of its naturally slow growth rate, up to 10 years follow-up will probably be necessary to establish the therapeutic effectiveness of radiosurgery for glomus tumor.

Iron uptake by ferritin: NMR relaxometry studies at low iron loads

Twenty ferritin samples were prepared at pH 6.5 with average loadings of 0-89 Fe atoms per molecule. Nuclear magnetic relaxation times T1 and T2 were measured at 3 degrees C, 23 degrees C, and at 37 degrees C and at field strength from 0.025 to 1.5 T. The field dependence, temperature dependence, and approximate equality of T1 and T2 at low fields all suggest that nuclear magnetic relaxation in this range is caused primarily by solitary Fe3+ ions. The relaxivity (relaxation rate per mM ferritin) increases quickly with initial iron loading, reaches a peak at 13-14 Fe atoms per molecule, and then declines. This provides supportive evidence for the formation of antiferromagnetically-coupled clusters during early stages in iron loading; the failure to see a similar peak in an earlier study may be related to the nonphysiological pH that was used. Above 50 atoms per molecule, the relaxivity remains approximately constant, except that 1/T2 at high fields increases slightly, consistent with early core growth. The residual ionic relaxivity in this region is consistent with about three solitary Fe3+ ions remaining on the protein shell, indicating that spin cancellation is not complete. A similar value is obtained by extrapolating relaxation data at high loadings (up to 3000 Fe atoms per molecule), suggesting that these uncoupled spins persist on the protein shell even after an appreciable core has been built.

Relaxometry and magnetometry of ferritin

By combining nuclear magnetic relaxometry on 39 ferritin samples with different iron loading with magnetometry, results were obtained that suggest a new interpretation of the core structure and magnetic properties of ferritin. These studies provide evidence that, contrary to most earlier reports, the ferritin core is antiferromagnetic (AFM) even at body temperature and possesses a superparamagnetic (SPM) moment due to incomplete cancellation of antiparallel sublattices, as predicted by Néel's theory. This moment also provides a likely explanation for the anomalous T2 shortening in ferritin solution. However, the number of SPM moments derived from this model is less than the number of ferritin molecules determined chemically, and a similar discrepancy was found by retrospectively fitting previously published magnetometry data. In other words, only a fraction of the ferritin molecules seem to be SPM. The studies also provide evidence for paramagnetic (PM) Curie-Weiss iron ions at the core surface, where the local Néel temperature is lower; these ions are apparently responsible for the weaker T1 shortening. In fact, the conversion of uncompensated AFM lattice ions to PM ions could explain the small number of SPM particles. The apparent Curie Law behavior of ferritin thus appears to be a coincidental result of different temperature dependences of the PM and SPM components.

Hepatic hemosiderosis in non-human primates: quantification of liver iron using different field strengths

Using a non-human primate model of idiopathic hemochromatosis, hemosiderin-induced T2 shortening of the liver was assessed at nine different field strengths over a range of 0.05 to 1.5 Tesla. The 1/T2 values increased linearly with field strength, with all specimens having approximately the same zero-field intercept. The slope of the field increase, termed "field-dependent T2 proton relaxation enhancement (PRE)", appeared to be proportional to the chemically determined tissue iron content, viz. 10.8 s-1T-1(mg Fe/g wet tissue)-1. The correlation between iron content and field-dependent T2 PRE (r = 0.94) was better than the correlation between iron content and 1/T2 values obtained at single field strengths. For livers containing > or = 2 mg Fe/g wet weight, biexponential T2 relaxation behavior emerged at higher field strengths, with the short T2 component (intracellular water) exhibiting a linear dependence of 1/T2 on field, while T2 of the long component (extracellular/sinusoidal water) was nearly field-independent. After maceration of the specimens, all T2 relaxation curves became monoexponential, including those for high iron content at high field strengths. The present data suggest that the use of double-field MR imaging to assess the field-dependent T2 PRE has potential for specific quantification of (liver) tissue iron stores.

T1 and T2 of ferritin solutions: effect of loading factor

Proton magnetic relaxation times T1 and T2 were measured at field strengths from 0.05 T to 1.5 T in solutions of ferritin with loading factors from 90 to 3600 iron atoms per molecule. 1/T2 increased linearly with field strength, as previously observed, and the slope per unit iron was approximately the same in all samples. This latter finding indicates that the field dependence of T2 may be used as a measure of ferritin-bound iron, regardless of loading factor. A possible explanation is presented, based on the presumed antiferromagnetic structure of the ferritin core and the linear dependence of 1/T2 on core magnetization. A nonzero contribution to 1/T2 in the limit of low field and a contribution to 1/T1 were also found, both of which increase linearly with loading factor for constant protein concentration; these effects represent quantum mechanical dipole-dipole relaxation of water protons either by iron atoms on the surface of the core or by the iron core itself. Finally, the extrapolated intercept at LF = 0 for both 1/T1 and 1/T2 indicates a contribution from a small number of iron ions bound to the protein shell. These results may help in the use of MRI to measure brain iron and possibly even ferritin loading factor.

T1 and T2 alterations in the brains of patients with hepatic cirrhosis

PURPOSE

To determine whether previously reported T1-weighted MR hyperintensities in the brains of patients with hepatic cirrhosis are accompanied by changes in T2.

METHODS

We measured T1 and T2 in the brains of 10 patients with chronic liver disease and 7 age-matched healthy volunteers, using classic spin-echo sequences with multiple saturation recovery times and multiple echoes.

RESULTS

Both T1 and T2 were shortened in the basal ganglia, cortex, and white matter of the patients, with the greatest shortening in the globus pallidus, where 1/T1 was increased by 0.76 s-1 or 74% and 1/T2 by 1.45 s-1 or 11%.

CONCLUSIONS

The T1 changes were accompanied by T2 changes of greater magnitude that were not as visible because T2 is normally much shorter than T1, especially in the globus pallidus.

The relation between brain iron and NMR relaxation times: an in vitro study

T1 and T2 relaxation times and iron concentrations were measured in 24 specimens of gray matter from fresh human and monkey brains at magnetic fields from 0.05 to 1.5 Tesla. Three different effects were found that correlate with iron content: a T1-shortening that falls off somewhat at high fields, a T2-shortening that is field-independent and thus important at low fields, and a contribution to 1/T2 that increases linearly with field strength. This linear field dependence has been seen only in ferritin and other ferric oxyhydroxide particles. Our results are in agreement with in vivo MRI studies and are generally consistent with values for ferritin solution, except for differences such as clustering of ferritin in tissue. A cerebral cavernous hemangioma specimen showed similar T2-shortening, but with a 2.7 times larger magnitude, attributed to larger clusters of hemosiderin in macrophages. The dependence on interecho time 2 tau was measured in three brains; 1/T2 increased significantly for tau up to 32 ms, as expected from the size of the ferritin clusters. These findings support the theory that ferritin iron is the primary determinant of MRI contrast in normal gray matter.