Double-Blind Phase III Randomized Trial of the Antiprogestin Agent Mifepristone in the Treatment of Unresectable Meningioma: SWOG S9005

PURPOSE

Progesterone receptors are expressed in approximately 70% of meningiomas. Mifepristone is an oral antiprogestational agent reported to have modest activity in a phase II study. This multicenter, prospective, randomized, placebo-controlled phase III trial conducted by SWOG was planned to define the role of mifepristone in the treatment of unresectable meningioma.

PATIENTS AND METHODS

Eligible patients were randomly assigned to receive either mifepristone or placebo for 2 years unless disease progressed. Patients who were stable or responding to protocol therapy after 2 years had the option to continue with the same blinded therapy. Serial follow-up allowed assessment of efficacy and toxicity. Time to treatment failure and overall survival were ascertained for all randomly assigned patients. On progression, patients receiving placebo could cross over and receive active drug.

RESULTS

Among 164 eligible patients, 80 were randomly assigned to mifepristone and 84 to placebo. Twenty-four patients (30%) were able to complete 2 years of mifepristone without disease progression, adverse effects, or other reasons for discontinuation. Twenty-eight patients (33%) in the placebo arm completed the 2-year study. There was no statistical difference between the arms in terms of failure-free or overall survival.

CONCLUSION

Long-term administration of mifepristone was well tolerated but had no impact on patients with unresectable meningioma.

Comparison of clinical and neuropathologic diagnoses of Alzheimer's disease in 3 epidemiologic samples

BACKGROUND

Studies of dementia in populations avoid many of the selection biases in clinical samples but require special evaluation and diagnostic methods to obtain high participation rates. To address this issue, we developed a unique in-home dementia assessment. We assessed validity of these assessments using neuropathologic confirmation of the clinical diagnosis in 3 epidemiologic samples.

METHODS

Subjects were 175 participants in 3 ongoing studies of dementia. Two were population based and identified dementia by cognitive screening. The third study sought volunteers via advertisements. Dementia evaluations were then conducted at the participants' residences by specially trained nurses and psychometricians. Evaluation results were interpreted, and preliminary diagnoses were assigned by a geropsychiatrist or neurologist and a psychologist. Final diagnoses were assigned by a consensus panel of neurologists, geropsychiatrists, and psychologists. We compared the clinical diagnoses with the gold-standard neuropathologic diagnoses for those participants who subsequently underwent autopsy.

RESULTS

Among the demented, the sensitivity of a clinical diagnosis of probable or possible Alzheimer's disease (AD) was 93% across the 3 studies. The rate of overall diagnostic agreement was 81%. Measures of agreement did not differ meaningfully across varying levels of dementia severity.

CONCLUSIONS

Rates of neuropathologic confirmation for clinical AD diagnoses in these studies were similar to those reported from clinic-based samples. These results support the validity of clinical diagnoses of AD from a structured in-home assessment of community dwelling and institutionalized individuals using relatively economical methods of dementia screening and assessment.

A phase II study of cisplatin preceded by a 12-h continuous infusion of concurrent hydroxyurea and cytosine arabinoside (Ara-C) for adult patients with malignant gliomas (Southwest Oncology Group S9149)

Inhibition of DNA excision repair can modulate resistance to cisplatin. Cytosine arabinoside (Ara-C) and hydroxyurea (HU), in combination, inhibit the excision-repair system and removal of platinum-DNA adducts. Marked cytotoxic synergy had been demonstrated in vitro at clinically achievable levels. The three-drug regimen was found to be feasible in clinical pilot studies. A Phase II study in patients with relapsed or progressive anaplastic astrocytoma (AA) or glioblastoma multiforme (GBM) was performed in the Southwest Oncology Group. The primary end point was 6 month survival, historically about 42%. A loading dose of HU 1,260 mg/m2 IV over 1 h was followed by Ara-C 1,200 mg/m2 plus HU 5,040 mg/m2 IV over 12 h, followed by cisplatin 100 mg/m2 IV over 1 h. A total of 76 patients were registered. The GBM stratum registered 56 patients in a two-stage accrual. Among 51 eligible GBM patients, the 6-month survival probability was 41% (95% CI 28-55%), and median overall survival was 5 months (95% CI 4-6 months). The 6-month progression-free survival probability was 25% (95% CI 14-37%), and median progression-free survival was 2 months (95% CI 2-4 months). One patient achieved a partial response (2%, 95% CI 0-10%), 13 patients had stable disease (25%, 95% CI 14-39%). Twenty-two patients progressed, and 14 were not assessable for response. The AA stratum was closed early after 20 patients due to slow accrual. Among 19 eligible patients, the 6-month survival probability was 58% (95% CI 36-80%), and median overall survival was 7 months (95% CI 7-14 months). The 6-month progression-free survival probability was 26% (95% CI 6-46%), and median progression-free survival was 3 months (95% CI 2-5 months). No responses were seen. Six patients (32%) had stable disease (95% CI 13-57%), 11 progressed, and 2 were not assessable for response. Of the 70 patients evaluable for toxicity, two died of infection. Twenty-three patients (33%) experienced Grade 4 toxicities, primarily hematological. Cisplatin combined with HU and Ara-C did not improve the 6 month survival rate in patients with relapsed or progressive AA or GBM. Significantly more hematological toxicity was seen than expected from cisplatin alone. Although benefit might be possible in a more platinum-sensitive tumor type, further clinical trials with this regimen for patients with glioblastoma multiforme or anaplastic astrocytoma are not justified.

Subependymomas: An analysis of Clinical and Imaging Features

OBJECTIVE:

Subependymomas are slow-growing, benign tumors usually found incidentally in the fourth ventricle at autopsy. They are typically associated with the ventricular system and become apparent clinically only when symptoms of hydrocephalus or mass effect develop. We review clinical, histological, and contemporary radiographic presentations of 16 subependymomas, including 2 intraparenchymal tumors.

METHODS:

We retrospectively evaluated eight patients with pathologically proven subependymomas. Initial magnetic resonance imaging and magnetic resonance spectroscopy were reviewed when available. Imaging was also available on eight outside subependymoma cases reviewed by our radiology department.

RESULTS:

Twelve of these subependymomas were intraventricular, one was in the posterior fossa, two were intraparenchymal, and one was an intramedullary spinal cord tumor. These lesions were hypo- to hyperintense on T1- and T2-weighted magnetic resonance imaging, with minimal to moderate enhancement. Initial complaints included headache, seizures, tingling sensations, and weakness. Among our eight patients who underwent gross total resection with no adjuvant therapy, no recurrences have been noted on follow-up magnetic resonance imaging.

CONCLUSION:

Subependymomas are rare, representing only 0.51% of all central nervous system tumors operated on during an 8-year period at the University of Utah. Clinical symptoms were associated with tumor location: intracranial masses caused headaches, seizures, and neurological complaints, and spinal cord locations resulted in neurological deficit. The authors review the clinical presentation, management, and contemporary radiographic appearance of this rare tumor.

Juvenile pilocytic astrocytoma of the brainstem in children

OBJECT

In reports involving the operative treatment of brainstem tumors, multiple histological types are often grouped together. To determine prognosis after resection, histology-specific data may be helpful.

METHODS

Twenty-eight patients with juvenile pilocytic astrocytoma (JPA) of the brainstem (six in the midbrain, four in the pons, and 18 in the medulla) were identified from the medical records. Initial treatment was resection in 25 and biopsy sampling in three. Postoperative imaging revealed gross-total resection (GTR) or resection with linear enhancement (RLE) in 12 of 25 patients and solid residual tumor in the other 13. In 10 of the 13 patients harboring solid residual tumor, observation was undertaken; the residual lesion disappeared in one, was stable in four, and progressed in five. Of the 12 patients with complete excision or RLE only, seven underwent no further treatment, with tumor progression occurring in one. All patients were alive at last follow-up examination (range 0.3-20.4 years, mean 6 years). New neurological deficits commonly appeared immediately after resection but often resolved. In six of the 28 patients, the new postoperative deficit was still present at last follow-up visit. The 5- and 10-year progression-free survival was 74 and 62%, respectively, after GTR or RLE and 19 and 19%, respectively, when solid residual tumor was present.

CONCLUSIONS

Long-term survival after resection of JPAs of the brainstem has been observed and appears to be related to the extent of initial excision.

Population-based study of medical comorbidity in early dementia and "cognitive impairment, no dementia (CIND)": association with functional and cognitive impairment: The Cache County Study

OBJECTIVE

Authors investigated medical comorbidity in persons with dementia and "Cognitive Impairment, No Dementia" (CIND).

METHODS

The Cache County Study is an ongoing population-based study of the epidemiology of dementia, the risk factors for conversion from CIND to dementia, and the progression of dementia. As part of the study's first incidence wave, persons with dementia (N=149), CIND (N=225), or without cognitive impairment (N=321) were identified and studied. Participants received comprehensive clinical evaluations and were rated on the General Medical Health Rating (GMHR), a global measure of seriousness of medical comorbidity. Participants and informants also completed the Mini-Mental State Exam and provided self-report information about comorbid medical conditions and functioning in activities of daily living.

RESULTS

There were few differences in number or type of comorbid medical conditions between persons with CIND and dementia, but persons with dementia were prescribed more medications. Stroke was more common in dementia participants, but other illnesses common in old age were not significantly different across cognitive groups. Medical comorbidity was more serious in both dementia and CIND, such that both groups were less likely to have "little to no" comorbidity. Seriousness of medical comorbidity was significantly associated with worse day-to-day functioning and cognition.

CONCLUSIONS

Persons with CIND and dementia have more serious medical comorbidity than comparable persons without cognitive impairment. This comorbidity may play a role in the progression of CIND and dementia. Future studies should investigate the role of medical comorbidity and its treatment on dementia onset or progression, as well as the mechanisms mediating its neuropathologic effects.

Intraventricular tanycytic ependymoma: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Tanycytic ependymomas are a rare ependymoma subtype showing a marked predilection for the spine, with only a few reports of supratentorial tumors. We present a case of a tanycytic ependymoma arising from the lateral and third ventricle.

CLINICAL PRESENTATION

The patient was a 55-year-old woman who complained of intermittent, progressively worsening dysequilibrium for several months. The neurologic exam in the neurosurgery clinic was without deficit.

INTERVENTION

MRI of the brain revealed a 3-cm, minimally enhancing lesion centered in the superior aspect of the third ventricle. The tumor involved the left wall of the third ventricle, the septum pellucidum, and the anterior horn of the left lateral ventricle. Surgery was recommended for diagnosis and to prevent obstructive hydrocephalus. A gross total resection was achievedvia a transcallosal approach. Postoperatively, the patient remained neurologically intact.

CONCLUSION

The long-term prognosis for tanycytic ependymomas is the same or slightly better than for other ependymoma subtypes. The current treatment plan includes gross total resection followed by radiologic surveillance. Repeat resection or radiation treatment will be recommended in the event of recurrence.

The role of methionine in ethylmalonic encephalopathy with petechiae

BACKGROUND

Among patients with ethylmalonic aciduria, a subgroup with encephalopathy, petechial skin lesions, and often death in infancy is distinct from those with short-chain acyl-coenzyme A dehydrogenase deficiency or multiple acyl-coenzyme A dehydrogenase deficiency. The nature of the molecular defect in this subgroup is unknown, and the source of the ethylmalonic acid has been unclear.

OBJECTIVE

To determine whether the administration of candidate amino acids increased the excretion of ethylmalonic acid.

DESIGN

Examination of patterns of organic acids excreted in the urine before and following loading doses of isoleucine and methionine.

SETTING

General clinical research center.

PATIENT

An infant with ethylmalonic aciduria, global developmental delay, acrocyanosis, and intermittent showers of petechiae.

MAIN OUTCOME MEASURE

Excretion of ethylmalonic acid in the urine.

RESULTS

Loading with methionine increased the excretion of ethylmalonic acid, whereas loading with isoleucine did not. Restriction of the dietary intake of methionine decreased ethylmalonic acid excretion.

CONCLUSION

In ethylmalonic acid encephalopathy with petechiae, methionine is a precursor of ethylmalonic acid.

Sciatic nerve sarcoidosis: utility of magnetic resonance peripheral nerve imaging and treatment with radiation therapy

✓ Sarcoidosis may involve both the central and peripheral nervous system, although peripheral nerve manifestations are usually seen late in the disease. In this report, the authors describe a case of sarcoidosis in a 22-year-old woman who presented with a foot drop. Although results of conventional lumbar magnetic resonance (MR) imaging were normal, MR peripheral nerve imaging of the thigh showed a mass in the sciatic nerve indicating tumor. An intraoperative biopsy sample revealed noncaseating granulomas consistent with sarcoid. The patient was treated with steroid drugs to control the manifestations of her disease but exhibited early signs of femoral bone necrosis, which required discontinuation of the steroids. She was then treated with local radiation therapy. At her 2-year follow-up visit the patient demonstrated relief of her symptoms and improvement on MR peripheral nerve imaging. This case demonstrates that sarcoidosis may present with peripheral nerve manifestations. The appearance of a diffusely swollen nerve on MR imaging should prompt clinicians to include sarcoidosis in the differential diagnosis and plan surgery accordingly. Patients who are not responsive to or who are unable to tolerate medical therapy may be treated with radiation therapy.

Oligodendroglioma and juvenile pilocytic astrocytoma presenting as synchronous primary brain tumors

✓ Multiple metastatic brain tumors and multifocal primary brain tumors of a single histological type are well described in the literature. The concurrent presence of multiple primary brain tumors with different histological characteristics, however, is very rare. The authors describe the first known case in which an oligodendroglioma and a juvenile pilocytic astrocytoma (JPA) presented as synchronous primary brain tumors in the same patient.

This 43-year-old man presented with a 2-month history of progressive headaches, nausea, and vomiting. Magnetic resonance imaging demonstrated an enhancing heterogeneous right medial cerebellar lesion and a larger calcified, nonenhancing, heterogeneous right frontal lesion with surrounding edema and a mass effect. The results of a metastatic workup were unremarkable.

The patient underwent an initial right frontotemporal craniotomy and a subsequent suboccipital craniectomy 2 years later for resection of the posterior fossa lesion. Histological examination revealed the frontal and cerebellar lesions to be an oligodendroglioma and JPA, respectively. A molecular analysis detected a deletion of chromosome 1p36 in the oligodendroglioma, but not in the JPA. After the initial operation, the patient received follow-up care for his oligodendroglioma, but eventually required temozolomide for tumor progression. His condition remains stable both neurologically and according to imaging studies.

The authors describe the first known case in which a low-grade oligodendroglioma and a JPA presented as synchronous primary brain tumors. They review the literature on multiple primary brain tumors with different histological characteristics and discuss potential mechanisms for the development of these lesions.

Anaplastic oligodendrogliomas: prognostic factors for tumor recurrence and survival

OBJECTIVES

Anaplastic oligodendrogliomas (AO) are uncommon primary brain tumors whose natural history, prognosis, and optimal management are not yet fully understood. However, they are associated with a better prognosis and response to multimodality therapy based on specific molecular changes. In this multicenter retrospective study, we analyzed the clinical characteristics of patients with AO to identify prognostic factors that influence time to progression (TTP) and survival.

METHODS

A retrospective search of the brain tumor databases of three institutions (the University of Texas M. D. Anderson Cancer Center, the University of California at San Francisco, and the University of Utah) for patients between 1977 and 1995 with histologically confirmed AO identified a cohort of 106 patients that was further analyzed in this study. Initial treatment included surgery alone (n = 12) or surgery followed by one of the following: radiotherapy (RT) alone (n = 49), chemotherapy alone (n = 4), chemotherapy followed by RT (n = 10), RT followed by chemotherapy (n = 20), and others (n = 11).

RESULTS

The median age at diagnosis was 43 years, and the median Karnofsky performance score (KPS) was 90. The overall median survival was 7.3 years, and the 5-year survival rate was 62%. Univariate analysis of several clinical variables showed that only age (p < 0.0001) and KPS (p = 0.04) correlated significantly with survival. Fifty patients had disease progression after initial therapy. The median TTP was 48 months. Age at diagnosis was the only variable that correlated significantly with TTP.

CONCLUSIONS

A trend towards longer survival with a greater extent of resection was evident. The relative efficacy of various treatment modalities could not be definitively determined because of the heterogeneity of the therapies used. Overall, patients with AO have a better prognosis after therapy compared with those who have other malignant gliomas.

Spontaneous hemorrhage associated with a pilomyxoid astrocytoma. Case report

Pilomyxoid astrocytomas have been identified as a more aggressive variant of pilocytic astrocytomas that occur in infants and in young children. These tumors are characterized by a perivascular arrangement of pilocytic cells that has a monomorphous architecture with uniform, elongated bipolar cells loosely ranged within a prominent myxoid background. The authors present the case of a 24-year-old man with a pilomyxoid astrocytoma of the temporal lobe, who presented with a hemorrhage. The patient underwent gross-total tumor resection, and no evidence of residual or recurrent tumor was found on magnetic resonance images at the 6-month follow-up examination. The occurrence of a pilomyxoid astrocytoma in an adult suggests that this tumor is not limited to children. The tumor described in this report is unique because of its presentation with a hemorrhage, which has not been previously described in cases of pilomyxoid astrocytomas and is rarely found in those of pilocytic astrocytomas. Although this tumor predominantly exhibited the pattern of a pilomyxoid astrocytoma, there was a small focus of pilocytic astrocytoma, indicating that there is a spectrum of histological components found in these tumors and that certain elements may be associated with a more aggressive phenotype. In this paper the authors review the literature on pilomyxoid astrocytomas and discuss the unique aspects of this particular tumor presentation.

A novel central nervous system-enriched spinocerebellar ataxia type 7 gene product

CONTEXT

Polyglutamine-mediated neurodegeneration in spinocerebellar ataxia type 7 (SCA7) involves specific central nervous system structures despite widespread expression of the mutant ataxin-7 protein.

OBJECTIVE

To determine whether expression of multiple gene products could contribute to selective neurodegeneration in SCA7.

RESULTS

We identified a novel SCA7 transcript and protein, both of which are enriched within the central nervous system. An isoform-specific antibody revealed that the novel ataxin-7 variant, in contrast with the previously described protein, localizes to neuronal cytoplasm and not to inclusion bodies present within the tissues of patients with SCA7.

CONCLUSIONS

In addition to expanding our understanding of SCA7 gene expression, identification of a novel ataxin-7 protein enriched in the central nervous system suggests that expression of multiple polyglutamine-containing proteins may play a role in generating the neurodegenerative patterns characteristic of SCA7 and other polyglutamine expansion diseases.

Autopsy-proven, sporadic pick disease with onset at age 25 years

CONTEXT

Pick disease is uncommon and accounts for less than 2% of adult-onset dementias. Reports of Pick disease in young adults have apparently increased in the last decade.

OBJECTIVE

To document the presentation and course of a patient with tau-positive Pick disease presenting at an extremely young age.

SETTING

A university hospital.

PATIENT

A white woman with cognitive impairment that began at age 25 years. She experienced progressive dementia over an 8-year period with radiographic evidence of severe cerebral atrophy of the frontotemporal lobes. Autopsy findings confirmed the diagnosis of Pick disease characterized by tau-positive Pick bodies in the neurons of the fascia dentata.

CONCLUSION

Pick disease should be considered in the differential diagnosis of young adults presenting with behavioral symptoms, especially those of frontal impairment.

Phase II trial of amonafide in central nervous system tumors: a Southwest Oncology Group study

Amonafide 300 mg/M2 was administered intravenously on a daily x 5 schedule to 27 eligible patients with recurrent or progressive central nervous system tumors. There were no objective responses. The most common toxicities were gastrointestinal, hematologic and neurologic. Further study of amonafide in patients with central nervous system malignancies is not indicated.

Intraneural perineurioma of the common peroneal nerve. Case report and review of the literature

Intraneural perineurioma, or localized hypertrophic mononeuropathy (LHM), is a focal lesion that produces a slowly progressive mononeuropathy in a peripheral nerve. The authors describe the clinical presentation, magnetic resonance (MR) neurography characteristics, and pathological characteristics of a perineurioma involving the peroneal nerve. Although there has been much debate surrounding the cause of this lesion, a literature review supports the argument that this is a neoplastic lesion, best referred to as intraneural perineurioma. Surgical management includes excision to prevent progression of palsy and placement of a nerve graft if clinically indicated. A 28-year-old woman presented with a 2-year history of progressive painless right peroneal nerve palsy. Magnetic resonance neurography revealed a right common peroneal nerve mass. At surgery, the mass was easily excised, leaving significant nerve fascicles intact. Intraoperative biopsy was not performed nor was a nerve graft placed. Pathological investigation demonstrated onion bulb-shaped whorls consistent with the appearance of intraneural perineurioma; immunochemical analysis confirmed the diagnosis. A review of the literature supports the argument that perineurioma, or LHM, is a neoplastic process, making "intraneural perineurioma" the most appropriate name. The authors also demonstrate the utility of MR neurography in the identification isolated nerve tumors and review the surgical management of this lesion.

Ataxin-7 expression analysis in controls and spinocerebellar ataxia type 7 patients

Expansion of polymorphic CAG repeats encoding polyglutamine cause at least eight inherited neurodegenerative diseases, including Huntington disease and the spinocerebellar ataxias. However, the pathways by which proteins containing expanded polyglutamine tracts cause disease remain unclear. To gain insight into the function of the SCA7 gene product, ataxin-7, as well as its contribution to cell death in spinocerebellar ataxia type 7 (SCA7), polyclonal antibodies were generated and ataxin-7 expression was examined within neuronal tissues from controls and three SCA7 patients. Immunoblotting demonstrates that ataxin-7 is widely expressed but that expression levels vary between tissues. Immunohistochemical analyses indicate that ataxin-7 is expressed within neurons both affected and unaffected in SCA7 pathology and that subcellular localization varies depending upon the neuronal subtype. Additionally, ataxin-7 staining was detected throughout control retina, including intense staining within the cell bodies and photosensitive outer segments of cone photoreceptors. Anti-ataxin-7 antibodies revealed intranuclear inclusions within surviving inferior olivary and cortical pyramidal neurons, as well as within surviving photoreceptor and ganglion cells of SCA7 patients harboring either 42 or 66 CAG repeats at the SCA7 locus. In contrast, inclusion formation was not detected within neurons of a patient with 41 repeats. This study broadens the current understanding of ataxin-7 localization and incorporates for the first time analysis of late-onset SCA7 patients where polyglutamine tract lengths are relatively shorter and disease course less severe than in previously described infantile-onset cases.

Intravascular lymphomatosis: contribution of cerebral MRI findings to diagnosis

Intravascular lymphomatosis (IL) is a rare variant of non-Hodgkin's lymphoma with an unusual predilection for the central nervous system (CNS). Most cases are not diagnosed until postmortem because of variable clinical presentation and nonspecific laboratory findings. Neuroimaging findings vary widely and range from diffuse involvement of the deep white matter to infarct-like lesions. Cerebral magnetic resonance imaging (MRI) may show parenchymal and meningeal gadolinium enhancement. The authors describe brain MRI findings of linear, punctate, and patchy enhancement suggestive of CNS IL in two patients confirmed by brain biopsy/histologic studies. High index of clinical suspicion and careful interpretation of MRI (including gadolinium contrast studies) may contribute to premortem diagnosis and early intervention of this often-missed disease.

DNA topoisomerase II-alpha as a proliferation marker in astrocytic neoplasms of the central nervous system: correlation with MIB1 expression and patient survival

DNA topoisomerase II-alpha (topo II-alpha) is the target of a variety of clinically used anticancer drugs such as etoposide, teniposide, and doxorubicin. The enzyme has also been used as a cell proliferation marker. Because proliferation measurements in central nervous system (CNS) astrocytic neoplasms have been shown to have prognostic importance and because drugs targeting topo II-alpha may be useful in treating these tumors, we determined topo II-alpha expression in 26 patients with CNS astrocytomas. In these tumors, topo II-alpha expression correlated well with the known proliferation marker, MIB1 (correlation coefficient = 0.94). Topo II-alpha expression also correlated with the histologic classification of the tumor. Grade 1 lesions had an average topo II-alpha index of 2.1 (range, 0 to 3.4); grade 2 lesions, 4.0 (range, 0 to 11.4); grade 3 lesions, 17.3 (range, 3.8 to 69.8); and grade 4 lesions (glioblastoma multiforme), 39.5 (range, 14.8 to 84.0). The average topo II-alpha and MIB1 index of patients alive two years after diagnosis was 8.8 (range, 0 to 45.6) and 11.8 (range, 0.2 to 44.0), respectively. In contrast, the average topo II-alpha and MIB1 index of 30.5 (range, 2.8 to 69.8) and 33.8 (range, 2.2 to 84.6), respectively, was observed in tumors from patients who were dead from disease by two years. The topo II-alpha index between patients alive and dead at two years was statistically different at the 95% confidence level. The MIB1 differences between these two groups of patients was not found to be statistically different.

Evidence for preganglionic pupillary involvement in superficial siderosis

A 36-year-old man presented with spinal myoclonus, ataxia, hearing loss, and unilateral pupillary dilation. MRI demonstrated hemosiderin deposition along the superficial surfaces of the brain, brainstem, cerebellum, and spine. The pupillary changes were localized to the preganglionic oculomotor nerve. In contrast to vasculopathic oculomotor nerve palsies, superficial siderosis may cause selective involvement of the superficially located pupillary fibers.

Contrasting effects of anti-adhesion molecule therapy in experimental allergic encephalomyelitis and Theiler's murine encephalomyelitis

An augmentation of experimental allergic encephalomyelitis (EAE) was observed when monoclonal antibody (mAb) to intercellular adhesion molecule 1 (ICAM-1) was administered after adoptive transfer. Clinical disease was more severe in the ICAM-1 specific mAb-treated EAE mice and included prominent ataxia compared to the PBS-treated controls or Theiler's murine encephalomyelitis virus (TMEV) infected mice treated with ICAM-1 specific mAb. Neuropathologic evaluation demonstrated a distinctly different distribution of lesions in the anti-ICAM-1-treated EAE mice which featured prominent demyelination and inflammation in the cerebellum, brainstem and cerebrum. These structures were minimally involved in the control mice and mAb treatment did not alter the neuropathology in TMEV-infected mice. These results indicate that anti-ICAM-1 can alter trafficking of lymphocytes and mononuclear cells in EAE but not TMEV-induced demyelinating disease.

Calciphylaxis mimicking dermatomyositis: ischemic myopathy complicating renal failure

BACKGROUND

Among the complications of chronic renal failure is a syndrome of medial calcification of small- to medium-sized arteries associated with ischemic necrosis of the skin and other organ systems, leading to gangrene and a poor prognosis. The syndrome has been reviewed in the renal, dermatologic, and surgical literature under the term calciphylaxis, which describes a postulated pathogenetic mechanism whereby sensitization to an endogenous or exogenous substance (such as parathyroid hormone) predisposes to calcium deposition after exposure to a challenging agent. Myopathy has rarely been reported as the presenting feature, and the syndrome has not been discussed in the neurologic literature.

METHODS

We report two patients with renal failure and systemic calciphylaxis who presented to our hospital with myopathic complaints and signs suggesting dermatomyositis. We also discuss possible disease mechanisms and treatment.

CONCLUSIONS

Because early treatment (including aggressively lowering the calcium and phosphate levels and parathyroidectomy) may improve the outcome, early recognition of the syndrome of calciphylaxis is essential.

Correlation of tumor O6 methylguanine-DNA methyltransferase levels with survival of malignant astrocytoma patients treated with bis-chloroethylnitrosourea: a Southwest Oncology Group study

PURPOSE

Prior studies show that increased levels of the DNA repair protein O6 methylguanine-DNA methyltransferase (MGMT), also referred to as O6-alkylguanine-DNA alkyltransferase (AGT) correlate with the resistance of glioma cell lines to nitrosoureas. The observed nitrosourea sensitivity of MGMT-deficient lines (methyl excision repair negative [MER-]) and those repair-proficient lines pretreated with MGMT-specific inhibitors (eg, O6 benzylguanine) has raised the possibility that tumor MGMT levels may be an important predictor of survival in patients with gliomas.

PATIENTS AND METHODS

We correlated the MGMT level in malignant astrocytoma tissues, obtained from patients treated with radiotherapy and bis-chloroethylnitrosourea (BCNU) on a prior prospective trial (Southwest Oncology Group [SWOG] 8737), with overall and failure-free survival.

RESULTS

Of 64 assessable patients with malignant astrocytoma (63% glioblastoma, 37% anaplastic astrocytoma), 64% had high (> 60,000 molecules/nucleus) MGMT levels. The overall median survival for patients with high versus low MGMT levels was 8 and 29 months, respectively (P=.0002), and median failure-free survival 3 and 6 months, respectively (P=.008). Subset analysis by histology (high v low MGMT levels) for anaplastic astrocytoma was 14 versus 62 months (n=24) and for glioblastoma was 7 versus 12 months (n=40). The overall hazards ratio (risk for death) for high versus low MGMT levels was 3.41; in young patients, the hazards ratio was higher (age 18 to 40 years, 4.19; age 41 to 60 years, 3.08) but became equal by MGMT level at age older than 60 years (1.11). Multivariate analysis showed that MGMT was independent of other known prognostic factors (age, performance status, histology).

CONCLUSION

The MGMT level in tumor tissue specimens may be a predictive marker of survival in patients with malignant astrocytoma that is independent of other previously described prognostic variables.

Tissue and cell-type specific expression of the tuberous sclerosis gene, TSC2, in human tissues

TSC2 is a gene on chromosome 16p13.3 associated with the autosomal dominant neurocutaneous disorder, tuberous sclerosis complex (TSC). By using a partial nucleotide sequence from the cloned TSC2 and polymerase chain reaction methodology, we constructed a digoxigenin-labeled complementary DNA probe to examine TSC2 gene expression in autopsy- or biopsy-derived human tissues by in situ hybridization. TSC2 messenger RNA was widely expressed in various cell types throughout the body, including epithelia, lymphocytes, and cells with endocrine functions, e.g., adrenal cortex and anterior pituitary. It was prominently and selectively (within the central nervous system) expressed in pyramidal cells of the cerebral cortex and other motor neurons, e.g., in spinal cord and brainstem nuclei. Visceral TSC2 expression was comparable in autopsy tissues from patients with and without TSC; TSC2 messenger RNA expression was most prominent in cells with a rapid mitotic rate and turnover, e.g., epithelia and lymphocytes, with central nervous system pyramidal cells and other neurons being an obvious exception, and/or in cells with important secretory/transport functions. This widespread expression of the TSC2 gene supports the view that it encodes a protein vital to cell growth and metabolism or one that functions as a tumor/growth suppressor.

Aprosencephaly and cerebellar dysgenesis in sibs

Aprosencephaly is a rare, lethal malformation sequence of the central nervous system that has been attributed to a postneuralation encephaloclastic process. We describe autopsy findings consistent with aprosencephaly in 2 fetuses conceived from a consanguineous mating (first cousins). Both showed anencephalic manifestations; however, the crania were intact, with fused sutures. The neuropathologic findings were essentially identical. Each fetus had complete absence of the telecephalon and pyramidal tracts, rudimentary diencephalic and mesencephalic structures, primitive cerebellar hemispheres, posterolateral clusters of primitive neural cells in the medullas suggesting an abnormality of neural migration, a normally-formed spinal cord, and retinal dysplasia within normally-formed globes. In addition, both fetuses manifested a peculiar perivascular mesenchymal proliferation seen only within the central nervous system. The similarity of these cases, coupled with parental consanguinity, suggests a primary malformation in brain development due to the homozygous representation of a mutant allele. We hypothesize that these patients may represent a defect in a gene important in brain development, the nature of which has yet to be elucidated.

Cerebellopontine angle glioneuronal hamartoma

Roughly 90% of cerebellopontine angle tumors are acoustic neuromas. Other prevalent lesions include meningiomas and epidermoid tumors; additional lesions are rare. We describe a patient with a neuroglial hamartomatous mass of the internal auditory canal who was thought to have a schwannoma preoperatively. In this case, the hamartomatous tissue containing neuroectodermal elements may have become separated from the developing neuraxis during neural migration. Hamartomas should be considered when masses are discovered originating from eighth nerve branches other than the superior vestibular nerve and when magnetic resonance signal characteristics vary from the T1 enhancement typically seen with schwannomas and meningiomas.

Accessory brains (extracerebral heterotopias): unusual prenatal intracranial mass lesions

Prenatal ultrasonographic evidence of intracranial mass lesions generally results in a diagnosis of primary glial or primitive neuroectodermal neoplasm. We describe two infants, one who was stillborn at 25 weeks' estimated gestational age and one term infant who was born live and died shortly after birth with large intracranial space-occupying lesions that exerted significant mass effect. At autopsy, large soft-tissue spheres of partially organized brain tissue containing neurons, astrocytes, oligodendroglia, ependyma, and choroid plexus were found adjacent to intact, fully formed cerebral hemispheres with normal brain stems and cerebelli within the cranial cavity. We have termed these extracerebral heterotopias "accessory brains." The telencephalic vesicles arise as lateral outpouchings at the rostral end of the developing embryo during the 5th week of embryogenesis. These accessory brains may arise embryologically from an accessory third evagination inferior to the telencephalic vesicles.

Atelencephalic aprosencephaly

Absence of the telencephalon and diencephalon characterizes the syndrome of aprosencephaly, while in atelencephaly, only the telencephalon is absent. Atelencephalic aprosencephaly is characterized by the presence of at least a rudimentary diencephalon. Embryologically, aprosencephaly is thought to occur after the optic vesicles form but before the cerebral vesicles appear. The syndrome is quite rare, with only 10 cases previously reported. We describe two fetuses with atelencephalic aprosencephaly. A 25-week estimated gestational age fetus was born to first-cousin parents and had a prenatal ultrasonographic diagnosis of anencephaly. The second, a 19-week estimated gestational age fetus, was thought to have semilobar holoprosencephaly by prenatal ultrasound. At autopsy, neuropathologic examination in both cases showed virtual absence of the cerebral hemispheres with an incomplete diencephalon. Microscopic examination in one case revealed disorganized neuropil with a proliferative vasculopathy. The optic globes were completely formed and attached to hypoplastic optic nerves, but retinal dysplasia was apparent histologically in both cases, and bilateral colobomata were present in one case. The findings in these cases demonstrate a spectrum of congenital variations that lie between the syndromes of atelencephaly and aprosencephaly, underscoring the complexity of the congenital anomalies.

Depression followed by dementia and disordered movement. Clinicopathologic correlation

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Acalvaria: a unique congenital anomaly

Acalvaria is a rare malformation usually regarded as a postneurulation defect. It consists of absence of the calvarial bones, dura mater and associated muscles in the presence of a normal skull base and normal facial bones. The condition is frequently confused by prenatal ultrasonography with anencephaly or an encephalocele. Whereas the cerebral hemispheres are absent in anencephaly, the cranial contents in acalvaria are generally complete, though some neuropathological abnormality is often present. The presumed pathogenesis of acalvaria is faulty migration of the membranous neurocranium with normal placement of the embryonic ectoderm, resulting in absence of the calvaria but an intact layer of skin over the brain parenchyma. We describe 2 cases of acalvaria, one misdiagnosed ultrasonographically as an occipital encephalocele prenatally. The brain in one fetus demonstrated semilobar holoprosencephaly and micropolygyria, but in the other, was structurally and histologically normal with the exception of hydrocephalus.

A randomized trial of radiotherapy versus radiotherapy plus CCNU for incompletely resected low-grade gliomas: a Southwest Oncology Group study

Sixty adult patients with incompletely excised low-grade gliomas were randomly assigned to receive radiotherapy (55 Gy over a total of 6 1/2 to 7 weeks) either alone or with 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU; 100 mg/sq m every 6 weeks). Pathological review showed that six patients were ineligible for the study. Evaluation of patient age, extent of surgery, tumor grade, and performance status showed no significant differences between the treatment arms. The response rate, as judged by the disappearance or reduction in size of the tumor on computerized tomography scans, was 79% for radiation therapy alone versus 54% for irradiation plus CCNU. The median survival time was 4.45 years for all patients, with no significant difference between treatment arms (p = 0.7). For the group as a whole, patient age and performance status were the most important prognostic parameters. The majority of patients receiving chemotherapy experienced moderate hematological toxicity. This study demonstrates that CCNU chemotherapy does not improve the results of radiation therapy in the treatment of incompletely excised low-grade gliomas.

Symptomatic hyponatraemia: can myelinolysis be prevented by treatment?

The treatment of hyponatraemia is controversial because of the risk of causing central or extrapontine myelinolysis (EPM). Rapid correction with hypertonic saline to a low normal sodium level has its proponents; others feel that slow correction to below normal sodium values is preventative. Most investigators feel that overcorrection should be avoided. It is not known whether the magnitude of serum sodium change is more important than the actual rate of correction. We present three patients with hyponatraemia ranging from 103 to 105 mmol/l who were corrected slowly with normal saline, corrected quickly with hypertonic saline, or rapidly overcorrected with hypertonic saline. All became comatose and died; all had EPM with or without central pontine myelinolysis (CPM). The rate of correction, the solution used, or the magnitude of correction did not seem to protect against demyelination. In a review of 67 reported CPM cases since 1983, no patients documented as having CPM or EPM by radiological studies or necropsy were treated with water restriction only. A group of 27 hyponatraemic patients treated only with water restriction and 35 with diuretic cessation alone did not develop CPM or EPM. This may be a reasonable approach to patients with symptomatic hyponatraemia and normal renal function.

Augmentation of adoptively transferred experimental allergic encephalomyelitis by administration of a monoclonal antibody specific for LFA-1 alpha

We investigated the effect of an anti-leukocyte function antigen 1 (LFA-1 alpha) monoclonal antibody, M17/4.2, on murine relapsing experimental allergic encephalomyelitis (EAE). In vitro investigations demonstrated that M17/4.2 inhibited proliferation with concanavalin A or myelin basic protein. Control mice treated with phosphate buffered saline (PBS) developed a mild to moderate disease at 7-10 days followed by a long-term relapsing clinical course. With administration of M17/4.2, the time of disease onset was unchanged; however, the severity of the disease was greatly augmented, resulting in early mortality. The pathology correlated well with the clinical course. M17/4.2 mice showed more inflammation and demyelination than PBS or anti-CD4 treated mice. Therefore, this anti-LFA-1 specific monoclonal antibody augmented EAE.

Pre- and postsynaptic neurotoxic effects of dopamine demonstrated by intrastriatal injection

Considerable evidence indicates that dopamine (DA) may play a neurotoxic role in brain in certain pathologic circumstances. To investigate this issue, dopamine (1000 nmol/1 microliter) was directly injected into the striatum of anesthetized Sprague-Dawley rats. Control animals received equal-volume injections of gamma-aminobutyric acid (GABA) or NaCl at identical concentrations (diluted in distilled H2O, pH 7.0-7.7). Brains were removed 7 to 9 days later and frozen or fixed and sectioned for histologic and autoradiographic analysis. Dopamine injection resulted in a small-volume (3.3-mm3) lesion in comparison to control GABA and NaCl injections which produced only a needle track < 0.6 mm3 in volume (P < 0.01). Dose dependency of DA toxicity was demonstrated, with substantial parenchymal damage requiring an injection of 500 nmol/1 microliter. Within the lesion, marked neuronal loss, macrophage invasion, and capillary and glial proliferation were present. Acetylcholinesterase staining and D1 receptor binding were markedly reduced as well. [3H]RO5-4864 binding to peripheral benzodiazepine receptors (on astrocytes) was increased in the periphery of the lesion. The binding of 1-[3H]benzo[b]cyclohexylthiophenylpiperidine to dopamine uptake sites was also reduced, but over a wider striatal area in comparison to local parenchymal damage. Prior interruption of the dopaminergic nigrostriatal pathway (by injection of 6-hydroxydopamine) appeared to potentiate the toxicity of intrastriatal dopamine injection. The findings indicate that local injection of dopamine produces both post- and presynaptic damage to nigrostriatal structures, and support the contention that dopamine may act as a low-potency neurotoxin.

A phase II evaluation of tamoxifen in unresectable or refractory meningiomas: a Southwest Oncology Group study

Twenty-one patients with nonresectable refractory meningiomas were registered on a study giving tamoxifen 40 mg per M2 b.i.d. for four days, then 10 mg b.i.d. thereafter. Nineteen were eligible and evaluated for response. One patient (5%) achieved an MRI-documented partial response while two had a minor response measured on CT scan which was of short duration (4 and 20 months). Six patients (32%) remained stable for a median duration of 31 + months while ten (53%) demonstrated progression. Twenty-two percent (22%) reported subjective improvement though this did not correlate with objective improvement in all cases. At present, a definite recommendation for the use of tamoxifen in refractory meningiomas cannot be made. Further evaluation of hormonal therapy of meningiomas with a consensus for definition of endpoints for evaluation of response in view of the difficulty of evaluating radiologic findings with clinical outcome, is needed.

Intrapulmonary neuroglial heterotopia

Nonteratomatous intrapulmonary neuroglial heterotopia not associated with birth trauma or frank vascular embolization has been described rarely. This article briefly reviews the literature, and presents two additional cases of intrapulmonary neuroglial heterotopia. We found 14 cases in the literature. Twelve of these cases had central nervous system disruption, where neuroglial elements were in direct contact with amniotic fluid. Several hypotheses have been proposed, including fetal aspiration of detached neural fragments within amniotic fluid, neural crest migration defects, and vascular embolization with implantation. Of our two cases, one represents the first occurrence where central nervous system abnormalities were secondary to mechanical disruption, rather than to a primary neural tube defect. Our second case represents the youngest documented occurrence (17 weeks gestation) of intrapulmonary neuroglial heterotopia. Additionally, immunohistochemical studies were performed on these lesions, the results of which favor their neural origin. We present these findings and suggest they support the aspiration mechanism for neuroglial heterotopia in lung tissue.

Neurenteric cysts of the posterior fossa: recognition, management, and embryogenesis

Neurenteric cysts are endothelium-lined structures most commonly encountered in the lower cervical or upper thoracic spinal cord. The occurrence of neurenteric cysts within the cranial vault is unusual. We present three patients with neurenteric cysts located within the posterior fossa: one near the jugular foramen deforming the 4th ventricle, a second in the cerebellopontine angle, and a third in the prepontine cistern. Several different theories have been advanced to explain the embryogenesis of neurenteric cysts. We review these theories and conclude that cranial neurenteric cysts may arise from a disturbance of early gastrulation, shortly after the onset of primitive streak regression.

Neurenteric cysts of the posterior fossa: recognition, management, and embryogenesis

Neurenteric cysts are endothelium-lined structures most commonly encountered in the lower cervical or upper thoracic spinal cord. The occurrence of neurenteric cysts within the cranial vault is unusual. We present three patients with neurenteric cysts located within the posterior fossa: one near the jugular foramen deforming the 4th ventricle, a second in the cerebellopontine angle, and a third in the prepontine cistern. Several different theories have been advanced to explain the embryogenesis of neurenteric cysts. We review these theories and conclude that cranial neurenteric cysts may arise from a disturbance of early gastrulation, shortly after the onset of primitive streak regression.

Cerebral granular cell tumor occurring with glioblastoma multiforme: case report

A 65-year-old man presented with 4 weeks of partial right visual field loss. A left occipital granular cell tumor was diagnosed via open biopsy. No specific tumoricidal therapy was given, and the patient returned 2 weeks later with fluent dysphasia and mild right hemiparesis, and formed visual hallucinations. A large left parietotemporal mass, separate from the granular cell tumor, was diagnosed as a glioblastoma multiforme by stereotactic biopsy. The histogenesis of cerebral granular cell tumors is controversial; this case supports recent speculation of their possible glial origin.

Chimeric cytotoxin IL2-PE40 inhibits relapsing experimental allergic encephalomyelitis

IL2-PE40 is a chimeric protein composed of human interleukin-2 (IL2) genetically fused to a modified form of Pseudomonas exotoxin lacking the cell recognition domain. IL2-PE40 is cytotoxic for IL2 receptor-bearing lymphocytes in culture and can inhibit activation of T cells in vivo. IL2-PE40 can significantly diminish antigen-stimulated proliferation of lymphocytes sensitized to myelin basic protein. Intraperitoneal administration of IL2-PE40 not only markedly inhibits the clinical manifestations of adoptively transferred relapsing experimental allergic encephalomyelitis but also dramatically reduces both inflammation and demyelination characteristic of the disease.

Phase II evaluation of fludarabine phosphate in patients with central nervous system tumors. A Southwest Oncology Group trial

Twenty-three patients with malignant central nervous system tumors were treated with fludarabine phosphate (2-FAMP) on a 5 day bolus schedule. One brief partial response was observed in 20 malignant astrocytoma patients. 2FAMP as given in this protocol is inactive in previously treated patients with recurrent malignant astrocytomas.

Porphyrin-laser photodynamic induction of focal brain necrosis

A noninvasive photodynamic method has been developed to produce focal brain necrosis using porphyrin activated in vivo with laser light. After peripheral injection of the photosensitive porphyrin derivative, Photofrin I, mice were irradiated on the posterior lateral aspect of the head through the intact depilated scalp with 632 nm argon-dye laser light. Animals were studied at one, two and seven days after irradiation. Blood-brain barrier damage was detected by the intravenous injection of Evans blue, horseradish peroxidase and heterologous immunoglobulins. At one and two days after irradiation, the lesions were characterized by extravasation of immunoglobulin and Evans blue, and by edema, ischemia and infiltration by monocytes. On the seventh day after irradiation, the lesion was smaller than it had been two days after irradiation, and had reactive changes at its edges and coagulative necrosis at its center. Extravasation of Evans blue and immunoglobulin was markedly reduced by the seventh day after irradiation, but uptake of horseradish peroxidase by macrophages located at the periphery of the lesion was evident.

Dialysis disequilibrium syndrome

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