Surface antigenic characteristics of human glial brain tumor cells.

The surface antigenic characteristics of human glial brain tumor (HGBT) cells were studied by complement-dependent cytotoxic antibody assays and indirect membrane immunofluorescence. Eight permanent, well-characterized cell lines derived from human gliomas were used for analysis with antisera raised by hyperimmunization of nonhuman primates (Macaca fascicularis) with glioblastoma multiforme tissue or established HGBT cells lines. Exhaustive absorption of these antisera to remove predominantly antispecies activity rendered HLA nonreactive "preabsorbed" antisera, which reacted with a large panel of gliomatous and nongliomatous human tumor cells; 1 carcinoma, 2 sarcomas, 2 melanomas, 1 neuroblastoma, and 8 HGBT cell lines. Four lymphoblastoid lines and 2 carcinomas were unreactive. After further absorption with a human osteogenic sarcoma cell line, the antisera demonstrated significant levels of reactivity for 8 tested HGBT cell lines and no longer reacted with the nongliomatous cultured tumor cells lines. Therefore, extensive absorption of nonhuman primate anti-human glioma sera removed all activity for the nongliomatous cell lines tested, but it left significant reactivity against a glial tumor cell line-associated antigen(s) present on all 8 human glioma cell lines tested.

Specific chromosomal abnormalities in malignant human gliomas.

Karyotypic analysis of 54 malignant human gliomas (5 anaplastic astrocytomas, 43 glioblastoma multiformes, 3 gliosarcomas, 2 giant cell glioblastomas, 1 anaplastic mixed glioma) has demonstrated that 12 tumors contained normal stemlines or only lacked one sex chromosome. The 42 tumors with abnormal karyotypes included 38 tumors which could be completely analyzed. Six of these 38 cases had near-triploid or near-tetraploid stemlines and 32 had near-diploid stemlines. Statistically significant numerical deviations in the near-diploid group were gains of chromosome 7 (26 of 32; P less than 0.001), and losses of chromosome 10 (19 of 32; P less than 0.001). Double minutes occurred in 18 of 32 near diploid tumors. The distribution of structural abnormalities was analyzed statistically by comparing the incidence of breakpoint in each chromosomal arm to the expected value based on chromosomal arm length. This analysis demonstrated that structural abnormalities of 9p and 19q were significant statistically (P less than 0.005 and P = 0.02, respectively). Although chromosome 1, 6p, the centromeric region of chromosome 11, 13q, and 15q were also frequently involved in structural abnormalities, the incidence of these breaks did not reach statistical significance. This demonstration of specific chromosomal abnormalities in near-diploid gliomas provides the basis for the investigation of genes which may be quantitatively or qualitatively altered in these neoplasms.

Preradiation intracarotid cisplatin treatment of newly diagnosed anaplastic gliomas. The CNS Cancer Consortium.

PURPOSE: This phase II study was performed to assess the response of patients with newly diagnosed, untreated malignant gliomas (anaplastic astrocytoma [AA] and glioblastoma multiforme [GBM]) to intracarotid (IC) cisplatin. PATIENTS AND METHODS: Eligibility criteria included surgical intervention limited to biopsy only, measurable contrast-enhancing tumor, and unilateral tumor location within the vascular territory of one internal carotid artery. Patients were scheduled to receive four infusions of IC cisplatin (75 mg/m2 every 4 weeks) before beginning standard radiotherapy. Twenty-six patients were treated, and 22 were assessable for response. RESULTS: Ten patients (45%) showed a greater than 25% decrease in the enhancing tumor area before radiotherapy with stabilization or improvement of neurologic deficits, and three patients (14%) had a greater than 70% decrease in tumor area. The likelihood of response to IC cisplatin was not clearly linked to patient age, tumor histology, or pretreatment tumor size. Myelosuppression, nephrotoxicity, and ototoxicity were mild. Optic neuropathy occurred in one patient, seizures in two, and fatal postinfusion cerebral edema in one. CONCLUSION: This study design, which permits assessment of the drug sensitivity of the untreated glioma, has shown definite antitumor activity of IC cisplatin in newly diagnosed malignant glioma patients.

Intravenous recombinant interferon beta in patients with recurrent malignant gliomas: a phase I/II study.

A multicenter phase I/II trial of a human recombinant interferon beta (Betaseron; Triton Biosciences, Alameda, CA) was conducted in patients with recurrent glioblastoma and anaplastic astrocytoma in six centers between 1986 and 1988. Betaseron was given intravenously three times per week, starting at 90 x 10(6) IU per dose and escalating by 90 x 10(6) IU every 2 weeks up to a maximum dose of 540 x 10(6) per treatment. All patients had failed prior radiotherapy, and most had failed one or more courses of chemotherapy. Of the 72 patients entered into the protocol, 65 were considered assessable. Of 65 patients, 41 had glioblastoma, and 24 had anaplastic astrocytoma. Of the 65 assessable patients, 15 (23%) had an objective response (R), and 18 (28%) had stable disease (S), with a combined R and S rate of 51%. The Kaplan-Meier median time to progression was 24 weeks for the responders, 10 weeks for the nonresponders, and 23 weeks for the whole group. These results suggest that Betaseron has definite activity in recurrent gliomas, with an R + S rate of 51%. The maximum-tolerated dose (MTD) is between 180 and 360 x 10(6) IU, with neurotoxicity being the most troublesome toxicity at higher doses. Two patients died of treatment-related complication. Since most responders showed responses at the 180 x 10(6 IU dose range, further studies using a lower dose of Betaseron aimed at decreasing toxicity and allowing chronic maintenance therapy are merited.

Phase II diaziquone-based chemotherapy trials in patients with anaplastic supratentorial astrocytic neoplasms.

We treated 103 patients with histologically confirmed anaplastic supratentorial astrocytic neoplasms with either diaziquone (AZQ) and carmustine (BCNU) or AZQ and procarbazine. There were 74 patients with glioblastoma multiforme (GBM) and 29 patients with anaplastic astrocytoma (AA). AZQ plus BCNU produced partial (PR) or unequivocal responses in seven of 32 (21.9%) patients with GBMs and three of ten (30%) patients with AAs. Two patients with GBMs (6.3%) and five patients with AAs (50%) showed stable disease (SD). AZQ plus procarbazine produced PRs or unequivocal responses in five of 42 (11.9%) patients with GBMs and nine of 19 (47.4%) patients with AAs. Eight patients with GBMs (19%) and one patient with an AA (5.2%) showed SD. In addition to histologic diagnosis, only the Karnofsky performance-status (KPS) rating independently influenced response and survival. Differences in response rates between the two regimens were not significant, although estimated median survival after adjusting for performance status was slightly better with AZQ plus BCNU than with AZQ plus procarbazine (P = .031). Neither age nor prior chemotherapy were significant independent risk factors. Toxicity was mild and primarily hematologic. We conclude that these AZQ-based regimens have activity in patients with recurrent anaplastic gliomas, but that they are not clearly superior to other agents in current use. The histologic diagnosis of GBM is associated with a significantly worse prognosis than AA, and we believe that this important distinction must be recognized in phase II as well as phase III trials.

Phase II treatment of medulloblastoma and pineoblastoma with melphalan: clinical therapy based on experimental models of human medulloblastoma.

We conducted a phase II study of intravenous (IV) melphalan in the treatment of children with recurrent medulloblastoma and in the initial treatment of children with poor-prognosis medulloblastoma and pineoblastoma. There was one complete response (CR) and two partial responses (PRs) among the 12 children with recurrent medulloblastoma. There were three PRs in the four patients initially treated with melphalan for poor-prognosis medulloblastoma or pineoblastoma. Toxicity was limited to severe myelosuppression with marked neutropenia and thrombocytopenia. These results support our laboratory studies demonstrating melphalan activity in human medulloblastoma, suggest that similar activity may be demonstrated against pineoblastoma, and support further trials with this agent (administered prior to radiotherapy) in the treatment of patients with newly diagnosed poor-prognosis medulloblastoma.

Chiasmal syndrome due to intrasellar abscess.

A 43-year-old woman had diabetes insipidus and amenorrhea. There was panhypopituitarism on endocrine testing and visual field examination showed inexorably progressive loss to bitemporal hemianopsia. All radiographic findings were normal, but craniotomy disclosed the cause of this chiasmal syndrome to be an intrasellar abscess which, on culture, grew a Gram-positive anaerobe, Peptococcus. Intrasellar or pituitary abscess is rare, but it must always be considered in the differential diagnosis of the chiasmal syndrome, since loss of pituitary and visual function may occur much more rapidly than with the tumors most often responsible for this syndrome and since surgical cure is possible.

Heterogeneity of Genotypic and phenotypic characteristics of fifteen permanent cell lines derived from human gliomas.

Six new permanent cell lines were established from human gliomas and compared to nine other cell lines from human gliomas. All fifteen lines had individually distinct HLA phenotypes and all but two, which were from a black patient, had type B glucose-6-phosphate-de;hydrogenase isoenzymes. Morphologically, the lines could be classified into four patterns descriptively designated as fibroblastic, fascicular, epithelial, or glial. Four of the lines grew progressively and could be serially transplanted when injected into athymic mice; two others grew initially and then regressed. From none to 100% of cells developed elongated tapering processes and showed reduction in nuclear-cytoplasmic ratio in the presence of 1 mM cyclic AMP and theophylline. Levels of 2'-3' cyclic nucleotide 3'-phosphohydrolase activity ranged from nondetectable to 12.78 +/- 1.49 micromoles 2' AMP formed per hr mgm total protein. None of the lines had detectable S-100 protein, but two had readily demonstrable glial fibrillary acidic protein in indirect immunofluorescence. Fibronectin levels in spent culture supernatants ranged from undetectable levels to 21.4 micrograms/ml/10(5) cells. All but one line shared surface antigens with normal human adult or fetal brain, as detected in absorption analyses with nonhuman primate antiserum raised against glioblastoma multiforme tissue or cell line U-251 MG. Although there were many common properties of the lines, each line had a unique profile of the parameters evaluated. This heterogeneity most likely reflects the individuality of the tumors of origin and individual genotypes and capacity for a range of phenotypic expression of cells.

Immunotherapy of brain tumors.

The fight against neoplasia still represents a formidable challenge. At the present time the mechanism of cell-mediated immunity seems to offer the most promise. At the same time, one is cautioned by the implication that minimal cell-mediated responses threaten acceleration of tumor growth. Therefore, one is impressed with the need for investigation of these approaches in a model system prior to their application to humans. The data currently available suggest that when active tumor growth is present within the host, a state of immune deficiency exists: cell-mediated immune responses may be quantitatively deficient or this response may be negated by the presence of blocking factor in the serum. Efficient and effective immune responses imply adequate cell-mediated immunity and the absence of blocking factor activity within the serum.

Tumoricidal activity of an acute promyelocytic leukemia cell line (HL-60) is augmented by human interferon alpha.

Normal human peripheral blood polymorphonuclear leukocytes (PMNs) and cells from a human acute promyelocytic leukemia line (HL-60) were tested for cytotoxic potential against two human glioma and one normal fibroblast line. Both the PMNs and HL-60 exhibited significant cytotoxicity against the tumor targets while sparing the normal fibroblasts. However, the two glioma cell lines were not equally susceptible to the effector cells. Addition of low levels of purified human lymphoblastoid interferon alpha (IFN) during the assay period significantly enhanced the tumoricidal effect against one of the glioma targets. HL-60 cells, partially differentiated to myelocytes and metamyelocytes by incubation with dimethylsulfoxide (DMSO), expressed reduced levels of cytotoxicity; IFN added during the assay was able to restore the cytotoxic activity against both glioma cell lines. Undifferentiated HL-60 cells were also able to lyse K562 targets in a six hour 51Cr release assay; this activity was also significantly enhanced by IFN. Separate incubation of both effectors and targets proved that the enhancement of cytotoxic activity demonstrated was due to an effect on the HL-60 effector cells. In contrast, the lysis of HSB-2, another NK sensitive target cell, was not enhanced by the addition of IFN to a mixture of HSB-2 and HL-60 cells. Pretreatment of effector and target cells separately with IFN demonstrated a dual effect: IFN both protected HSB-2 targets from lysis by the HL-60 effectors and induced significantly greater cytotoxicity by HL-60 cells.

Chromosomal evolution in malignant human gliomas starts with specific and usually numerical deviations.

Our previous karyotypic studies of malignant human gliomas have demonstrated that their most consistent early or primary gross changes include gains of #7, losses of #10, #22, and the gonosomes, and the presence of double minutes. Karyotypes of 15 additional malignant human gliomas reported here have confirmed these observations and, by enlarging our series, we can now show that in addition to double minutes, certain other gross structural abnormalities also are clearly associated with the early evolution of this type of tumor. The most prevalent deviations are deletions and translocations involving 9p. Other chromosomes commonly involved in rearrangements are #1, #6, and #13, and less frequently #7, #11, and #16.

Metastatic renal cell carcinoma mimicking a meningioma.

We report a patient with renal cell carcinoma metastatic to the left trigone, which mimicked an intraventricular meningioma. The metastasis was recognized 1.3 years after removal of the primary tumor, a longer disease-free interval than any previously reported cases with brain metastases of renal cell carcinoma. The patient is now free of disease of years after resection and 17 years after the discovery of the primary tumor. Metastatic disease should be considered in all patients with prior resection of renal cell carcinoma who experience the onset of neurological disease, even after a prolonged disease-free interval. Long term survival is observed after the resection of solitary metastases, particularly if these appear after a prolonged disease-free interval.

Efficacy of vincristine and cyclophosphamide in the therapy of recurrent medulloblastoma.

We conducted a Phase II study of combination therapy with vincristine and cyclophosphamide in the treatment of patients with recurrent or metastatic medulloblastoma. Fourteen patients were treated with vincristine 2 mg/m2 (2.0-mg maximal dose) by intravenous bolus on Day 1 and cyclophosphamide 1 g/m2 by intravenous infusion on Days 1 and 2, with cycles repeated every 4 weeks. All 4 patients with extraneural disease (biopsy-proven bony metastases) responded (duration of responses 2+, 6+, 8, and 16+ months) and 4 of 8 evaluable patients with neuraxis disease responded (duration of response 2, 2+, 2+, and 21+ months). Toxicity was limited to neutropenia without any episodes of infection. These therapeutic results compare favorably with other reports of therapy for recurrent medulloblastoma and support the inclusion of vincristine and cyclophosphamide in randomized adjuvant therapy trials of patients with medulloblastoma.

Recognition of special qualifications in neurological surgery.

In recent years, one-half of the 23 recognized specialty boards in medicine have begun formally to recognize subspecialization with some type of certification process. One such board, the American Board of Internal Medicine, examines and certifies in 11 subspecialty areas while the American Board of Pathology does so in nine, the American Board of Pediatrics in eight, the American Board of Obstetrics and Gynecology in four, and the American Board of General Surgery in three. Arguments for and against similar recognition of subspecialization within neurosurgery are reviewed. The present position of other specialties and their boards regarding this sensitive issue is summarized, as well as their certification structure. The various pathways available to certifying boards for recognition of subspecialization are also presented. The American Board of Neurological Surgery (ABNS) has approved a subspecialty certificate called a "certificate of Special Qualification in Critical Care Medicine." This is a subspecialty that is longitudinally oriented, touching on a number of other specialties in addition to neurosurgery, and thus differs from a vertical subspecialty such as Pediatric Neurosurgery or Cerebrovascular Neurosurgery. The background for development of such a certificate and the current requirements for obtaining it are reviewed. At the present time, the ABNS opposes the possible fragmentation of neurosurgery by offering certification in multiple subspecialty areas. Nonetheless, the current trend in medicine as a whole is in the direction of such subspecialization and its formal recognition. Increasing numbers of neurosurgeons tend to concentrate all or a good deal of their professional efforts in a specific area. Thus, organized neurosurgery must continue to consider methods for subspecialty recognition.

Computerized tomography brain scan tumor volume determinations. Sensitivity as an objective criterion of response to therapy.

In an effort to define more precisely and objectively computerized tomography (CT) brain scan evidence of glioma patient response to treatment, planimetric measurements of serial CT images of enhancing tumor areas were made using a digitizing tablet interfaced to a microcomputer for computing three-dimensional tumor volumes. The ability of a single investigator to measure a "significant change" in tumor volume was determined from that investigator's coefficient of variation (COV) for triplicate volume measurements (a total of 1701) on 155 scans of 27 patients with malignant gliomas. Planimetric volume data were compared with geometric computation of volumes based upon the product of the maximum diameter of enhancing tumor and the perpendicular diameter for each image made simultaneously with each planimetric measurement. The planimetric method COV was less than that for geometric computation, and the former method was employed for analysis of response to therapy in these same patients. Overall, for a tumor volume change to be significant (COV plus 2 standard errors of the means), the percentage change was determined to be 20%. However, the smaller the tumor volume being measured, the greater was the percentage change required in order to be significant. Thus, minimal measurable changes (%) were separately defined for large (greater than 14 cc), medium (8 to 14 cc), and small (less than 8 cc) tumor volumes. Tumor volumes computed from baseline (prior to investigational therapy) and from subsequent serial CT scans were compared, with response defined as a significant change. Responses to therapy based on significant volume changes were compared in each instance to the conventional visual viewbox comparison ("Gestalt") of serial scans. In 28% of scan comparisons, planimetric technique sensitivity permitted determination of significant enlargement or reduction in tumor size, while Gestalt comparison suggested no change. The use of quantitative tumor volume analysis of planimetric determinations of changes in tumor size during investigational therapy appears to permit recognition of either progression or regression of tumor size earlier than by Gestalt comparison in one-fourth of instances.

Systemic gamma-interferon therapy for recurrent gliomas.

Recombinant gamma-interferon (2 mg/sq m) was administered intravenously twice weekly in 8-week courses to 14 patients with recurrent gliomas. Computerized tomography (CT) evidence of response was seen in only one patient, and stabilization for 12 to 86 weeks was recorded in three. This was a disappointing result, particularly in a series of patients with relatively small initial tumor volumes (less than 50 cu mm on enhanced CT) and Karnofsky functional ratings of 70 or higher. In addition, several instances of toxicity potentially attributable to gamma-interferon were observed.

Immunobiology of primary intracranial tumors. Part 4: levamisole as an immune stimulant in patients and in the ASV glioma model.

Levamisole was evaluated as an immune stimulant in a randomized controlled study of patients with anaplastic gliomas, who had undergone surgical resection and who were also treated with radiotherapy and BCNU chemotherapy. Of 102 patients placed into the study, 85 were determined to comprise the adequately treated group (ATG): a full course of radiotherapy and two cycles of BCNU chemotherapy. Within the ATG, those patients who received levamisole did not demonstrate significantly different serial delayed hypersensitivity reactions, peripheral blood lymphocyte and T-cell counts, or serum IgM levels, compared to those patients not receiving levamisole. There was no significant difference in survival times of the two groups. Studies utilizing the avian sarcoma virus-induced glioma in rats also showed no improvement in survival with levamisole stimulation as the only immune agent, but the combination of active immunization and adjuvant stimulation with bacillus Calmette-Guerin plus levamisole was found to be therapeutically effective in this model and will be used in future pilot studies of active immunization in patients.

Immunobiology of primary intracranial tumors.

The avian sarcoma virus-induced glioma model in rats was used to study the effectiveness of immunotherapy, namely, Bacillus Calmette-Guérin (BCG) with or without sarcoma cells and/or chemotherapy with 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU), upon survival times. The most consistent prolongation of survival time was produced by triple therapy: BCG + intraperitoneally administered sarcoma cells + intravenously administered BCNU.

National survey of patterns of care for brain-tumor patients.

An excellent response by participating institutions was realized in this survey of patterns of care for patients with primary brain tumors. Since the histopathology of the tumor is such a strong predictor of outcome and influences care so greatly, most analyses were performed not only on the overall series of patients but also by World Health Organization histological classification. Several factors that influence outcome were identified: tumor type, patient age, patient Karnofsky rating, tumor location, and therapy. Very few cases were coded as regards the American Joint Committee on Cancer clinical stage, and few potentially eligible cases were placed in investigative protocols. It behooves those centers providing investigative protocol opportunities to develop liaisons with practicing physicians nearby as well as at some distance and to provide an organizational framework that will make participation in these protocols practical for a larger segment of our brain-tumor patient population. Between 1980 and 1985, the increased use of magnetic resonance imaging in neuroradiology is apparent as well as the increased use of stereotactic biopsy and interstitial radiotherapy. Complications of therapy seem acceptably low. Five-year survival for benign brain tumor is high, while that for the most common primary tumor, glioblastoma multiforme, is only 5.5%. Some of the findings in this survey confirm those from the literature while others, particularly the pattern of care, represent new data.

Value of sequential postoperative brain scans in patients with anaplastic gliomas.

The authors analyze the postoperative course of 30 patients with anaplastic supratentorial gliomas to evaluate the usefulness of sequential brain scanning as an adjunct to clinical neurological examinations in the early detection of tumor recurrence. The correlation between sequential scanning and clinical evaluation was excellent; no examples of divergent resu;ts were seen. With the exception of scans made very early in the postoperative period or when postoperative scalp flap infections were present, initial postoperative scans were easily interpreted in terms of both the superficial (postcraniotomy) and parenchymal changes. The specific type of postoperative therapy (radiation therapy, chemotherapy, or both) could not be correlated with whether scan or examination ultimately changed first. However, analysis of original tumor location revealed that while sequential postoperative scanning offered no advantage over repetitive neurological examinations in the detection of recurrent tumor in the neurologically dominant left hemisphere, scan changes preceded examination changes in eight of 17 cases involving tumors of the neurologically nondominant right hemisphere.