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

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

Single brain metastases: surgery plus radiation or radiation alone.

We reviewed the records of patients treated for single brain metastases from non-small-cell lung cancer for 1978 through 1982. Forty-three patients received surgical treatment, including 37 who had surgery plus postoperative whole-brain radiation therapy and 6 patients who had surgery after failing to respond to radiation therapy. The surgically treated patients were matched with 43 patients treated with radiation therapy alone. The combined therapy group had significantly longer survivals than those treated with radiation therapy alone (19 months versus 9 months). The rates of local recurrence and neurologically related deaths were significantly higher in the radiation therapy-alone group. Patients treated with combined therapy survived longer, and the increased survival was due to lower recurrence of brain metastases after surgery and fewer neurologically related deaths.

Intraventricular therapy of cryptococcal meningitis via a subcutaneous reservoir.

Intraventricular administration of amphotericin B for meningitis due to Cryptococcus neoformans is usually reserved for selected, seriously ill patients with recurrent disease. Between September 1973 and November 1983, 10 of 23 patients treated for cryptococcal meningitis at Memorial Sloan-Kettering Cancer Center received intraventricular amphotericin B through subcutaneous reservoirs, in addition to systemic therapy. The value of intraventricular amphotericin B was assessed in the 13 patients treated for first episodes of meningitis with systemic amphotericin B and flucytosine. Death during therapy occurred in one of six patients with intraventricular and systemic therapy compared with six of seven patients with systemic therapy alone (p = 0.025). The cerebrospinal fluid was sterilized in six of six patients given systemic and intraventricular therapy compared with three of seven given systemic therapy alone (p = 0.049), and the cerebrospinal fluid cryptococcal antigen titer declined in six of six patients given systemic and intraventricular therapy compared with two of seven given systemic therapy alone (p = 0.016). In the 10 patients who received intraventricular therapy, there were no complications related to reservoir insertion; however, complications related to reservoir use requiring replacement or revision occurred in two patients, and bacterial infection occurred in one but was treated successfully without removal of the reservoir. Although these data are retrospective, they suggest that early therapy with intraventricular amphotericin B in combination with systemic therapy may be beneficial and relatively safe in patients with cryptococcal meningitis and a poor prognosis.

Patterns of failure following treatment for glioblastoma multiforme and anaplastic astrocytoma.

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

Resection of brain metastases from non-small-cell lung carcinoma. Results of therapy. Memorial Sloan-Kettering Cancer Center Thoracic Surgical Staff.

The treatment of patients with a solitary brain metastasis has been evolving, with most centers recommending resection in patients with good performance status. To evaluate the results of resection of brain metastases from non-small-cell lung cancer, we reviewed our 16-year experience with 185 consecutive patients undergoing resection of brain metastases from 1974 to 1989, inclusive. There were 89 men and 96 women; ages ranged from 34 to 75 years (median 54). Sixty-five (35%) had synchronous and 120 (65%) metachronous brain metastases. Discounting the brain metastasis, 68 patients (37%) had stage I, 13 (7%) stage II, 62 (33%) stage IIIA, 30 (16%) stage IIIB, and 12 (6%) stage IV carcinoma. There was no significant difference in age, locoregional stage (TN), or histologic features in patients with synchronous versus metachronous lesions. The overall survival rates (n = 185) were as follows: 1 year, 55%; 2 years, 27%; 3 years, 18%; 5 years, 13%; and 10 years, 7% (median 14 months). There was no significant difference in survival between patients with synchronous and metachronous lesions. To evaluate the impact of locoregional stage and treatment of the primary site, we analyzed only those patients with synchronous brain metastases. Multivariate analysis demonstrated that locoregional stage had no significant effect on survival (p = 0.97), but complete resection of the primary disease significantly prolonged survival (p = 0.002). Therefore complete resection, and not stage, of the locoregional primary lesion is the primary determinant of survival in patients undergoing resection of brain metastases from non-small-cell lung cancer.

Modified open thoracic rhizotomy for treatment of intractable chest wall pain of malignant etiology.

We describe the surgical technique of modified open thoracic rhizotomy for treatment of intractable chest wall pain of malignant etiology. In a series of 14 patients, 9 (64%) had an excellent result, 4 (29%) had a good result, and 1 (7%) had a poor result. Successful palliation was made possible by identification with computed tomographic scan or magnetic resonance imaging of the nerve roots involved. Pain control lasted in most patients until death (median, 22 weeks; range, 6 to 45 weeks). The extrathecal procedure described has certain advantages over intradural transection of nerve roots. Indications for performing this procedure are discussed along with other therapeutic options.

Surgical resection of brain metastases from renal cell carcinoma in 50 patients.

OBJECTIVES: Metastases are frequently diagnosed among patients with renal cell carcinoma (RCC). Of 709 patients with brain metastases (BMET) who were operated on at our institution between 1974 and 1993, 50 (7%) were of renal origin. METHODS: Medical records were reviewed retrospectively. Survival time was calculated by the Kaplan-Meier method and Cox proportional hazards model. RESULTS: There were 38 men and 12 women. The median age was 60 years. The primary RCC was resected in 47 patients. Forty patients had a metachronous diagnosis of RCC and BMET. Median interval between the diagnosis of RCC and BMET was 17 months. In all 50 patients overall median survival (MS) from diagnosis of primary RCC was 31.4 months and from craniotomy was 12.6 months. Postoperative mortality was 10% (5 patients). In patients with primary RCC in the left kidney (n=25) versus right kidney (n=25) median survival from craniotomy was longer; 21.3 versus 7.4 months (P<0.014). Twenty-three patients (46%) had intratumoral hemorrhage. Eight patients had cerebellar metastasis (MS, 3.0 months) and 9 had multiple metastases resected (MS, 7.6 months). Thirty-eight patients had both brain and pulmonary metastases, and 16 of them had pulmonary resection (MS, 18.6 versus 8.0 months; P<0.03). Twenty-two patients received whole-brain radiation therapy (WBRT) after craniotomy and 18 did not receive WBRT (MS, 13.3 versus 14.5 months; P<0.62). The 1-year, 2-year, 3-year, and 5-year survival was 51%, 24%, 22%, and 8.5% respectively. CONCLUSIONS: Only the resection of lung metastasis, supratentorial location of BMET, left-sided localization of primary RCC, and lack of neurologic deficit before craniotomy were statistically significant prognostic factors in Cox regression analysis. In the absence of effective systemic treatment, we suggest that patients with BMET from RCC be considered for operative resection for treatment and palliation.

Surgical treatment of brain metastases from renal cell carcinoma.

Between January 1976 and December 1986, 22 patients with renal cell carcinoma underwent surgical resection of brain metastases at Memorial Sloan-Kettering Cancer Center. Ten of the patients had metastases limited to the brain and 12 also had extracranial metastases. Twenty patients received external radiotherapy. Five had craniotomy after failing radiation therapy and 15 had adjuvant radiotherapy. Two patients died within thirty days following craniotomy; the median survival of the remaining 20 patients was 20.9 +/- 6.8 months calculated according to a Weibull survival model. Variables examined in relation to survival included absence or presence of extracranial metastases at time of craniotomy, time interval between nephrectomy and diagnosis of cerebral metastases, neurologic status prior to craniotomy, location of the brain tumor, and patient age. None of the variables was significant at the 10 percent level by the Weibull analysis. However, three favorable prognostic factors, namely metachronous brain metastasis more than one year after nephrectomy, minimal or no neurologic deficit at time of craniotomy, and infratentorial lesions show a trend toward improved survival with p less than 0.20. The data suggest that surgical resection of a single and occasionally multiple brain metastases is warranted in selected patients with renal cell carcinoma.

An animal model of epidural compression of the spinal cord.

A new model of subacute compression of the spinal cord is described. Using an expanding epidural mass, a gradual, progressive, and highly reproducible neurological deficit was induced in rats over a 7-day period, resulting in paraplegia. Studies of spinal cord edema, disruption of the blood-spinal cord barrier, and somatosensory evoked responses, as well as histopathological and microangiographical studies, revealed a marked similarity to changes produced in other spinal compression models and in humans. The model may serve to answer some fundamental questions regarding the pathophysiology and efficacy of various treatment modalities of spinal cord compression.

Reoperation in the treatment of recurrent intracranial malignant gliomas.

Fifty-five consecutive patients with recurrent intracranial malignant gliomas were reoperated at Memorial Sloan-Kettering Cancer Center from 1972 to 1983. The patients were 10 to 70 years old (median, 48 years). Thirty-five patients (64%) had glioblastoma multiforme, and 20 (36%) had anaplastic astrocytoma. The median interval between the first operation and reoperation was 43 weeks. The Karnofsky rating before reoperation ranged from 40 to 90 (median, 70). Eleven patients (20%) had more than one reoperation. The mortality rate was 1.4% per procedure, and the morbidity rate was 16% per procedure. After reoperation, 41 patients (75%) had chemotherapy and/or radiation therapy. The median survival for all patients was 92 weeks. The median survival after reoperation was 36 weeks. Patients with Karnofsky ratings of greater than or equal to 70, with anaplastic astrocytomas, or in whom gross total removal of the tumor was undertaken lived longer than their respective counterparts (P less than 0.05). Prereoperation Karnofsky rating and extent of surgical resection were the most important independent factors related to survival after reoperation according to multivariate analysis (P less than 0.01 and P less than 0.05, respectively). Twenty-five patients (45%) had improved Karnofsky ratings after reoperation, and the 32 patients (58%) who were independent after reoperation were able to stay so for more than 6 months of their survival time (median value). Reoperation is feasible and can be accomplished with acceptable mortality and morbidity. When intracranial malignant gliomas recur, the combined use of reoperation and adjuvant therapy prolongs good quality life.(ABSTRACT TRUNCATED AT 250 WORDS)

Endodermal sinus tumor of the pineal region: case report.

A 13-year-old boy presented with symptoms and signs of a posterior 3rd ventricle tumor associated with raised levels of serum and cerebrospinal alpha-fetoprotein. The patient underwent subtotal resection of the tumor followed by craniospinal radiation. Histopathological examination revealed a pure endodermal sinus tumor. Endodermal sinus tumors represent a rare type of germ cell tumor, only 13 intracranial cases having been reported in the literature.

Radiation necrosis after treatment of solitary intracranial metastases.

During the period from July 1977 to June 1980, 75 patients underwent the surgical excision of solitary brain metastases, and 61 of these patients received whole brain radiation. Three patients developed chronic radiation necrosis. In the 3 patients with necrosis, computed tomography suggested recurrent tumor; the histological diagnosis of necrosis only was obtained at operation in 2 of these patients and by autopsy in the third. Radiation damage resulted in the death of 1 patient, a chronic vegetative state in another, and severe neurological deficit in the third. An additional 4 patients had neurological complications probably related to radiation therapy. As the survival of such patients is prolonged by aggressive treatment, the incidence of radiation-induced complications is likely to increase. The optimal dose of radiation necessary to destroy microscopic foci of tumor after the surgical resection of a single brain metastasis is unknown. Because of the significant incidence of damage after radiation as currently delivered, studies using graded, lower doses are indicated.

The significance of morphologically viable glioma cells found at the time of operation after interstitial brachytherapy.

The significance of finding morphologically intact viable glioma cells in tumors treated with high-dose irradiation delivered by interstitial brachytherapy was examined. Freshly resected tissue was taken from 12 patients after (n = 8) or both before and after (n = 4) interstitial brachytherapy. All posttreatment tissue was taken from regions within a radius of 2.0 to 4.0 cm of the radioactive source. From each sample, monolayer cell culture was established. All untreated samples from primary tumors grew well and became established as cell lines within 1 to 3 weeks. In contrast, cells from treated tumors only formed small colonies of 50 to 100 cells each. These cells grew slowly and, within 14 to 21 days, degenerated. Neither the use of conditioned medium or cell extract from established glioma cell lines nor the application of growth factors (platelet-derived growth factor and/or epidermal growth factor) stimulated growth or lengthened survival. The only exception was tumor resected from approximately 4 cm from the nearest radioactive source and from which a viable cell line could be established (IRR). Cytogenetic analysis of tissue from one sample (IR) before source implantation and from another (IRR) after source implantation, both from the same patient, showed that cells IR and IRR were derived from the same stem cell. To establish the reason why cell IRR remained clonogenic despite high-dose irradiation, IRR cells were irradiated with gamma irradiation with a dose rate of approximately 1 Gy/min for 24 hours. This colony-forming assay showed that IRR cells were radiosensitive.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative measurement of cerebral and tumor blood flow with laser-Doppler flowmetry.

A new technique, laser-Doppler flowmetry, has been used intraoperatively to measure blood flow responses in normal brain tissue and brain tumor to blood pressure and arterial blood gas alterations. We have observed that blood flow is reduced in most cerebral tumors, and that most tumors retain the normal response to changes in arterial blood gas; however, these responses are varied. One group of tumors in our study demonstrated an autoregulatory capacity; a second behaved passively--that is, blood flow changes followed blood pressure--while a third showed no response.

Cerebrospinal fluid markers in central nervous system metastases from testicular carcinoma.

Serum values of alpha-fetoprotein (AFP) and human chorionic gonadotrophin (HCG) have been used to monitor disseminated testicular carcinoma. Serial measurements of these markers have been used to monitor the response to therapy, to follow the progress of disease, and to detect subclinical recurrences. With increasingly effective chemotherapy for systemic disease, central nervous system (CNS) metastases in testicular carcinoma are becoming increasingly important as a cause of treatment failure. Cerebrospinal fluid (CSF) values of AFP and HCG seem to be important ancillary acids in the neurosurgical management of CNS metastases from testicular cancer. Our preliminary experience with three cases suggests that these CSF markers (plus computerized tomograhic scanning) should be evaluated in patients with this disease.

High dose versus low dose dexamethasone in experimental epidural spinal cord compression.

A compound of methylcellulose-silicone expanding progressively over a 1-week period by moisture absorption was implanted in the midthoracic epidural space of 17 Sprague Dawley adult rats. When the animals became paraplegic 6.3 +/- 1.6 days later, they were randomized into three groups: untreated control (n = 5), high dose dexamethasone (HD, 1.25 mg/kg intramuscularly, twice daily, n = 5), and low dose dexamethasone (LD, 0.125 mg/kg intramuscularly, twice daily, n = 7). Motor strength was evaluated daily by an observer unaware of the treatment given to the rats. Animals treated with dexamethasone (HD or LD) improved faster than untreated control animals. No significant difference in the rate of recovery or degree of motor improvement was noted between the HD and LD groups. Mortality was higher in the HD group because of infections and gastrointestinal perforation/bleeding.

The role of postoperative radiotherapy after resection of single brain metastases.

To assess the value of whole brain radiotherapy (WBRT) after complete resection of a single brain metastasis we reviewed the records of 98 patients who had elective craniotomy between 1978 and 1985. Seventy-nine patients received postoperative WBRT (Group A) and 19 patients no radiotherapy (RT) (Group B). Neurological relapse was designated as local (i.e., at the site of the original metastasis) or distant (i.e., elsewhere in the brain). Postoperative WBRT significantly prolonged the time to any neurological relapse (P = 0.034) with a 1-year recurrence rate of 22% in Group A and 46% in Group B patients; however, it did not specifically control either local or distant cerebral recurrence. Recurrence of metastatic brain disease was not affected by location of the original lesion; however, meningeal relapse occurred in 38% of cerebellar lesions, but only in 4.7% of supratentorial metastases (P = 0.003). The total radiation dose or fractionation scheme of RT did not affect survival nor time to neurological relapse. The median survival was 20.6 and 14.4 months for Groups A and B, respectively (not statistically different). Forty-eight percent of Group A and 47% of Group B patients survived for 1 year or longer; however, 11% of patients who had received RT and survived 1 year developed severe radiation-induced dementia. All patients with radiation-related cerebral damage received hypo-fractionated RT with high daily fractions as commonly designed for rapid palliation of macroscopic brain metastases.(ABSTRACT TRUNCATED AT 250 WORDS)

A spring-coil tipped cannula for anchoring cystic lesions during stereotactic aspiration. Technical note.

A device to facilitate the stereotactic aspiration of cystic lesions is described. The device anchors the cyst wall, allows penetration of the lesion without displacement, and assures proper positioning of the tip of the aspiration needle within the cyst so that the contents may be evacuated without spillage.

Vertebral body reconstruction with a modified Harrington rod distraction system for stabilization of the spine affected with metastatic disease.

Anterior spinal decompression has become widely used for neoplasia arising from the vertebral bodies. Replacement for the resected vertebral body must achieve spinal stability, restitution of lost height, correction of kyphotic deformities, and allow for early ambulation. A spinal fixator based on the Harrington ratchet locking system was found to fulfill this requirement. The fixator, its technique of implementation, and surgical results in 10 patients are described.

The effect of passive hyperventilation on intraventricular pressure in the dog.

The effectiveness of passive hyperventilation in reducing intracranial pressure was studied in mongrel dogs by varying the levels of end-tidal pCO2 and airway pressure, and comparing the positive-negative and positive-atmospheric pressure. It has been shown that there is a point beyond which reduction of pCO2 does not affect cerebral blood flow. The present study demonstrates that another limiting factor is the degree of positive or negative airway pressure. Positive airway pressure impedes venous drainage, thereby increasing intracranial pressure. This increase could only partly be offset by applying negative expiratory airway pressure, since it was found that excessive negative airway pressure (greater than static recoil pressure of the lung) may trap air in alveoli. An optimal range of positive and negative airway pressures is defined.