Interstitial brachytherapy for malignant brain tumors: preliminary results

The authors report their experience with interstitial brachytherapy in 46 patients with malignant brain tumors. Twenty-three patients received implants after external radiation for newly diagnosed malignant astrocytoma, as part of a randomized study (Group I). Eighteen patients received implants for recurrent malignant astrocytoma (Group II) and 3 for recurrent solitary cerebral metastasis from adenocarcinoma of the lung (Group III). Two additional patients received implants as part of their initial therapy for a radiation-induced malignant astrocytoma and a malignant fibrous histiocytoma. In all patients high-activity iodine-125 sources were implanted temporarily by a stereotactic technique. To date 50 patients have been entered in the randomized study with a maximum follow-up of 31 months. The small numbers and short follow-up preclude any conclusions regarding the efficacy of brachytherapy used as part of initial therapy. The median survival to date in the 23 patients in this group who received implants is 60 weeks. The median survival to date for the 18 patients who received implants for recurrent malignant astrocytoma is 44 weeks postimplant. Two of the three patients who received implants for recurrent solitary metastasis are alive at 41 and 49 weeks postimplant; a third died at 39 weeks postimplant. Significant complications attributable to interstitial brachytherapy have been observed in 10 of 46 patients (21.7%). A second operation for clinical and radiological deterioration was performed in 12 patients (26.1%) 8 to 105 weeks after brachytherapy. The authors conclude that interstitial brachytherapy is beneficial for selected patients with recurrent malignant astrocytoma and solitary recurrent metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical resection and permanent brachytherapy for recurrent atypical and malignant meningioma

OBJECTIVE: Recurrent atypical and malignant meningiomas are difficult to treat successfully. Chemotherapy to date has been unsuccessful, and radiosurgery is limited to smaller tumors. Reoperation alone provides limited tumor control and limited prolonged survival. The addition of brachytherapy at the time of operation is an option. Here, we report the results of our series of patients with recurrent malignant meningioma treated with resection and brachytherapy with permanent low-dose (125)I. METHODS: The charts of patients in our database with recurrent atypical and malignant meningiomas treated by surgical resection and permanent (125)I brachytherapy at the University of California, San Francisco, between 1988 and 2002 were selected for this study. Calculations of disease-free survival and overall survival curves were made by the Kaplan-Meier actuarial method. Univariate analysis between Kaplan-Meier curves was based on the log-rank statistic, with a significance level set at a value of P 相似文献   

Recurrent malignant gliomas: survival following interstitial brachytherapy with high-activity iodine-125 sources

The authors report survival data for the first 41 patients treated for recurrent malignant gliomas with interstitial brachytherapy at the University of California, San Francisco (1980-1984). Iodine-125 (125I) sources were temporarily implanted using stereotaxic techniques. The median survival period for 18 patients with recurrent glioblastomas was 52 weeks after brachytherapy; two patients are alive more than 5 years after brachytherapy. The median survival period for 23 patients with recurrent anaplastic astrocytomas is 153 weeks after brachytherapy, with 10 patients alive more than 3 years and four patients alive more than 4 years after brachytherapy. Both groups did significantly better (p less than 0.01) than groups of patients with the same diagnoses and similar general characteristics who were treated at recurrence with chemotherapy alone. Because of deterioration of their clinical condition and evidence of recurrence from computerized tomographic scans, 17 (41%) of 41 patients required reoperation 20 to 72 weeks after brachytherapy. Despite the invariable presence of apparently viable tumor cells mixed with necrotic tissue in the resected specimen, nine patients have survived more than 2 years after reoperation and two of the nine are still alive 4 years after reoperation. The authors conclude that brachytherapy with temporarily implanted 125I sources for well-circumscribed, hemispheric, recurrent malignant gliomas is effective and offers a chance for long-term survival even though focal radiation necrosis can seriously degrade the quality of survival in a minority of patients.     

Brachytherapy in the treatment of recurrent solitary brain metastases

Conventional therapy for solitary brain metastases includes radiotherapy and surgical resection in selected cases. Often, however, the metastasis recurs and limits the quality of life and survival of the patient. Once the metastasis recurs, therapeutic options are limited. Brachytherapy delivers a high total dose of radiation to a localized area, allowing reirradiation at the time of recurrence. Three patients with recurrent brain metastases treated with iridium-192 implants are presented; two of these patients had breast carcinoma and one had malignant melanoma. The implants allowed long term survival in the two patients with recurrent metastatic breast carcinoma. Unfortunately, the patient with melanoma did not respond to the brachytherapy and died within 7 months of implantation. The approaches to treatment to metastatic brain tumors and the rationale for using brachytherapy are discussed.     

Treatment of recurrent brain stem gliomas and other central nervous system tumors with 5-fluorouracil, CCNU, hydroxyurea, and 6-mercaptopurine

Twenty-one patients with recurrent malignant central nervous system gliomas were treated with a combination of 5-fluorouracil, CCNU, hydroxyurea, and 6-mercaptopurine. Thirteen patients had brain stem gliomas, 3 patients had spinal cord gliomas, 3 patients had thalamic gliomas, and 2 patients had cerebellar astrocytomas. All patients had received radiation therapy, and 4 brain stem patients had also been treated with chemotherapy. Sixteen patients (76%) responded to treatment with either stabilization of disease or improvement. Nine of the 13 patients with brain stem gliomas (71%) had response or stabilization of disease. The median time to tumor progression (TTP) for the brain stem patients who responded or had stabilization of disease was 25 weeks. The median survival from recurrence for the brain stem glioma patients was 27 weeks. Patients with cerebellar, thalamic, and spinal cord tumors did very well, with an 87% response or stabilization of disease and a median TTP of 122 weeks.     

Treatment of recurrent gliomas with 1,3-bis(2-chloroethyl)-1-nitrosourea and alpha-difluoromethylornithine

Thirty-eight patients with primary recurrent anaplastic gliomas and glioblastomas, were treated with 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and the polyamine inhibitor alpha-difluoromethylornithine (DFMO). There were 5 brain stem, 1 cerebellar, and 32 supratentorial glioma tumors. All had been treated with surgery (except in the case of 4 brain stem tumors for which biopsies were not obtained) and radiotherapy. Eight patients had received prior chemotherapy. Of the 21 patients with evaluable supratentorial anaplastic gliomas, 2 (9.5%) had a partial response and 10 (47.6%) had stable disease. The median time to tumor progression for the anaplastic gliomas has not been attained yet. However, median survival for these 12 patients was 119 weeks measured from the initiation of chemotherapy. Median survival for the entire anaplastic glioma group of 21 was 56 weeks. Minimal activity was seen against glioblastoma multiforme. The median time to tumor progression was 8 weeks with median survival of 21 weeks. Of the 5 patients with brain stem tumors, 3 are alive with stable disease at 77, 93, and 220 weeks. The combination was well tolerated with dose-limiting toxicity being myelosuppression and hearing loss. Further trials are warranted to compare the combination of BCNU and DFMO against BCNU alone in a prospective randomized trial.     

Interstitial irradiation and hyperthermia for the treatment of recurrent malignant brain tumors

Between June 1987 and June 1989, 29 recurrent malignant gliomas or recurrent solitary brain metastases in 28 patients were treated in a Phase I study of interstitial irradiation and hyperthermia. Patient age ranged from 18 to 65 years, and the Karnofsky Performance Status scores ranged from 40 to 90%. There were 13 glioblastomas, 10 anaplastic astrocytomas, 3 melanomas, and 3 adenocarcinomas. Catheters were implanted stereotactically after computed tomography-based preplanning. Hyperthermia was administered before and after brachytherapy, using one to six 2450- or 915-MHz helical coil microwave antennas and one to three multisensor fiberoptic thermometry probes. The goal was to heat as much of the tumor as possible to 42.5 degrees C for 30 minutes. Within 30 minutes after the first hyperthermia treatment, implant catheters were afterloaded with high-activity iodine-125 seeds delivering tumor doses of 32.6 to 61.0 Gy. Most patients had no sensation of heating. Complications included seizures in 5 patients, reversible neurological changes in 9 patients, a scalp burn in 1, and infections in 3. Of 28 evaluable 2-month follow-up scans, 11 showed definite improvement in the radiological appearance of the tumor, 4 were slightly improved, 7 were stable, and 6 showed tumor progression. Ten patients underwent reoperation for persistent tumor and/or necrosis. Eleven of 28 patients are alive 40 to 97 weeks after treatment. Thirteen patients died of a brain tumor, 2 died of extracranial melanoma metastases, 1 died of new brain melanoma metastases, and 1 died of a pulmonary embolus. The median survival was 55 weeks overall. Median survival has not yet been reached for the anaplastic astrocytoma subgroup. We conclude that interstitial brain hyperthermia using helical coil microwave antennas is technically feasible. The level of toxicity is acceptable, and the computed tomographic response rate is encouraging.     

Selection bias, survival, and brachytherapy for glioma.

Interstitial irradiation is a promising treatment for malignant glioma. Longer than expected survival periods following treatment of recurrent tumor have led to the use of brachytherapy as an adjuvant treatment. The impact of patient selection on survival data was studied among candidates for this therapy. Consecutive, conventionally treated adults with newly diagnosed supratentorial tumors were identified retrospectively at a center where experience with glioma is population-based. Based on imaging and performance status, two surgeons and a radiation oncologist designated each patient as either eligible or ineligible for adjuvant brachytherapy. The survival and prognostic factors in the eligible and ineligible groups were analyzed. Overall, the patients eligible for brachytherapy (32% of the series) lived significantly longer than the ineligible patients (16.57 vs. 9.30 months), were younger, and had larger resections and better function. For glioblastoma, 40% of patients were eligible, and lived much longer than those who were ineligible (13.90 vs. 5.80 months). It is concluded that better outcome following adjuvant brachytherapy for glioma is at least in part the result of patient selection. Randomized trials of comparably selected patients will be necessary to demonstrate conclusively that longer survival is also a result of treatment.     

High dose rate brachytherapy for early stage oral tongue cancer

BACKGROUND: High dose rate (HDR) interstitial brachytherapy of the oral tongue is a new treatment modality. Our study evaluates the outcomes of patients with early stage oral tongue cancer as treated by HDR interstitial implant. METHODS: We reviewed the records of 19 patients who were seen between 1994 and 2000 with carcinoma of the oral tongue and whose primary tumors were treated solely with interstitial implant using HDR remote afterloading technique. Ten patients had T1 N0 disease, and the remaining 9 had T2 N0 disease. Elective neck treatment was withheld for 12 patients. The remaining seven patients had ipsilateral elective neck dissection. The male-female ratio was 1:0.9, and the median age was 60 years (range, 32-81 years). The median follow-up time was 43 months (range, 6-78 months). The afterloading catheters were positioned by the submandibular approach with the assistance of a template set. Fifteen patients had single planar implants, and the remaining four had double planar implants. The median number of catheters inserted was 5 (range, 4-9). The median dose given was 55 Gy in 10 fractions over 6 days. The minimal interfraction interval was 7 hours for the first 7 patients and was extended to 8 hours for the other 12. Mandibular shields were inserted before treatment. RESULTS: The mucositis lasted for 6 to 20 weeks (median, 9 weeks). One patient had local failure, and the 4-year local failure-free survival rate was 94.7%. Three of the 12 patients without elective neck treatment had ipsilateral regional failure develop. They were salvaged by neck node dissection and regionally remained in control. One patient with multiple nodal metastases and extracapsular spread had biopsy-proven liver metastases and died 6 months after implant. One of the seven patients who were treated with elective neck dissection had multiple nodal metastases and extracapsular spread. She was treated with postoperative radiotherapy to the neck. She died 30 months after implant with evidence of regional and distant failure. One patient treated with double planar implant had grade II necrosis of the soft tissue and bone develop. The necrosis resolved with conservative treatment. Another four patients had small area of soft tissue deficit of the tongue attributed to aggressive debulking or biopsy before brachytherapy. CONCLUSIONS: Our experience in treating early stage tongue cancer with HDR remote afterloading technique is encouraging, because it gives a local control rate of 94.7% at 4 years with acceptable morbidity. Further studies are eagerly awaited to delineate the optimum schedule for this new treatment modality.     

Preliminary results of interstitial 192Ir brachytherapy for malignant gliomas.

Twenty-six patients with recurrent or unremovable malignant gliomas were treated by interstitial brachytherapy with iridium-192 seeds. Stereotactic implantation of the afterloading catheters using the Brown-Roberts-Wells computed tomography (CT)-guided stereotactic system was performed in 24 patients and surgical implantation in two patients with pontine glioma. The response to therapy was measured by serial CT, magnetic resonance imaging, and clinical examination. Tumor regression was seen in 17 patients 1-3 months after implantation. Tumor progression was seen in only three patients. After interstitial brachytherapy, the most commonly observed CT finding was central low density. Median survival time was 18 months after implantation. Autopsies in five patients revealed the delayed effects of radiation injury such as typical vascular changes, microcalcification, and coagulative necrosis in the implant area and tumor recurrence at the periphery. The results suggest that brachytherapy is not curative but prolonged the median survival time by 6 months.     

Long-Term Follow-Up of Brachytherapy in Untreated Malignant Glioma

Objective: Long-term follow-up of patients with malignant glioma randomized to treatment with and without brachytherapy. Methods: Twenty-six patients were randomized to brachytherapy and external radiation, and 23 to external radiation alone. There were 19 and 17 glioblastomas, and 3 and 8 anaplastic astrocytomas, in the nonimplant and implant groups, respectively, and 1 malignant oligodendroglioma in each group. For brachytherapy, iodine- 125 seeds were implanted to deliver a homogeneous dose of 40 cGy/hr for a maximum of 6000 cGy to the enhancing tumor margin. All patients received external radiation for a total of 6020 cGy delivered to the tumor plus 3 cm margin over 7 weeks, followed by BCNU chemotherapy. Conclusions: The median survival was 78 and 66 weeks in the implant and nonimplant groups respectively, and their survival curves were not different (log rank, p=0.394). A significant multivariate relationship did exist between survival and age (p=0.0092), tumor grade (p=0.0001), and Karnofsky (p=0.021). Treatment with brachytherapy is subject to selection bias, which does exclude a large proportion of patients.     

Temozolomide in the treatment of recurrent malignant glioma

Temozolomide (TMZ) has demonstrated activity and acceptable toxicity for the treatment of recurrent malignant gliomas in carious prospective phase II studies. No information is, however, available on TMZ treatment for recurrent malignant glioma in Japanese patients. We report Hokkaido University Hospital experience on 35 adult patients with a recurrent malignant glioma, including 13 glioblastomas, 9 anaplastic astrocytomas, and 13 anaplastic oligondendroglial tumors. The median age was 52 years. The starting dose of TMZ was 150 mg/m2/day for 5 days. When no remarkable toxicity was observed, the dose was increased to 200 mg/m2 for subsequent cycles, every 4 week. In the 35 patients, the overall objective response rate (partial response) was 12% and 74% of the patients achieved disease stabilization. The median progression-free survival was 28 weeks and the median overall survival was 43 weeks. Although hematological toxicity was the most frequent adverse event (CTC grade 3 or 4 in 6 patients), overall toxicity was generally mild. Four patients required hospitalization due to the toxicity, but 28 patients had been treated with TMZ at our outpatient clinic. These results suggested that the reported efficacy and toxicity profile of TMZ for the treatment of Japanese patients with recurrent malignant glioma is reproducible from the setting of clinical trials in the western countries.     

An inflatable balloon catheter and liquid 125I radiation source (GliaSite Radiation Therapy System) for treatment of recurrent malignant glioma: multicenter safety and feasibility trial

OBJECT: In this study the authors evaluated the safety and performance of the GliaSite Radiation Therapy System (RTS) in patients with recurrent malignant brain tumors who were undergoing tumor resection. METHODS: The GliaSite is an inflatable balloon catheter that is placed in the resection cavity at the time of tumor debulking. Low-dose-rate radiation is delivered with an aqueous solution of organically bound iodine-125 (lotrex [sodium 3-(125I)-iodo-4-hydroxybenzenesulfonate]), which are temporarily introduced into the balloon portion of the device via a subcutaneous port. Adults with recurrent malignant glioma underwent resection and GliaSite implantation. One to 2 weeks later, the device was filled with Iotrex for 3 to 6 days, following which the device was explanted. Twenty-one patients with recurrent high-grade astrocytomas were enrolled in the study and received radiation therapy. There were two end points: 1) successful implantation and delivery of brachytherapy; and 2) safety of the device. Implantation of the device, delivery of radiation, and the explantation procedure were well tolerated. At least 40 to 60 Gy was delivered to all tissues within the target volume. There were no serious adverse device-related events during brachytherapy. One patient had a pseudomeningocele, one patient had a wound infection, and three patients had meningitis (one bacterial, one chemical, and one aseptic). No symptomatic radiation necrosis was identified during 21.8 patient-years of follow up. The median survival of previously treated patients was 12.7 months (95% confidence interval 6.9-15.3 months). CONCLUSIONS: The GliaSite RTS performs safely and efficiently. It delivers a readily quantifiable dose of radiation to tissue at the highest risk for tumor recurrence.     

Recurrent Malignant Gliomas Treated with Radiosurgery

The inability to control malignant glioma results in a high incidence of local failure and poor survival. Focal therapy such as radiosurgery permits delivery of a high dose of radiation with moderate toxicity. This report summarizes the outcome of patients with recurrent malignant glioma treated with radiosurgery at University of Wisconsin Hospital, between January 1989 and December 1997, when 30 patients were treated radiosurgically. All patients had undergone and failed external beam radiotherapy (median dose of 59.4 Gy) prior to radiosurgery. All recurrences were detected by clinical deterioration and confirmed by radiographic progression. No patient was treated for radiographic progression only in the context of a screening protocol. Eight out of 30 patients underwent subtotal resection prior to radiosurgery and 3 received chemotherapy along with radiosurgery. Radiosurgery was delivered in a single fraction using a modified linear accelerator. The median tumor volume was 7.2 cm³ (range 0.42–35.1 cm³) and the median minimal tumor dose was 12 Gy at the 50–80% isodose line. Median follow-up is 70 months. The median overall survival is 8 months; the 1- and 2-year survival rates are 20% and 9%, respectively. For patients with an initial diagnosis of non-glioblastoma, the median survival is 11 months and for those with glioblastoma the median survival is 7 months. The median progression-free survival is 4 months for the entire cohort, 5 months for nonglioblastoma, and 3 months for glioblastoma. The 1-year actuarial reoperation rate after radio-surgery is 7.6%. Radiosurgery for recurrent malignant glioma may improve short-term survival for selected patients with a lower reoperation rate than brachytherapy.     

Stereotactic radiosurgery in the treatment of metastatic disease to the brain

OBJECTIVE: In recent years, stereotactic radiosurgery has been growing in popularity as a treatment modality for metastatic disease to the brain. The technique has advantages of reduced cost and low morbidity compared with open surgical treatment. Furthermore, it avoids the potential cognitive side effects of fractionated whole-brain radiotherapy. We undertook this study to determine the usefulness of adjuvant radiation therapy and to determine prognostic factors in patients treated with stereotactic radiosurgery. METHODS: We reviewed our series of patients with metastatic tumors treated using gamma knife stereotactic radiosurgery from August 1994 to February 1999. Nonparametric methods were used to compare treatment subgroups by demographic features including age, Karnofsky Performance Scale score, diagnosis, and systemic disease status. Univariate and multivariate analyses of survival and freedom from progression were performed using Kaplan-Meier and Cox proportional hazards regression techniques. RESULTS: This study included 190 patients harboring 431 lesions who were treated in 263 treatment sessions. The median follow-up after radiosurgery was 36 weeks for all patients. The median actuarial survival from the time of radiosurgery in all patients was 34 weeks. When patients were stratified according to tumor histology, those without melanoma had a median survival of 39 weeks, and those with melanoma had a median survival of 28 weeks. The cause of death could be determined in 122 (92%) of the patients known to have died during the data capture period. For patients harboring melanoma, death was attributable to systemic disease in 31 (47%), to central nervous system-related processes in 29 (44%), and to unknown causes in 6 (9%). For non-melanoma patients, death was attributable to systemic disease in 45 (68%), to central nervous system-related processes in 17 (26%), and to unknown causes in 4 (6%). Significantly improved survival (P = 0.002) was observed in patients with controlled systemic disease. No significant difference in survival could be ascertained for patients presenting with up to four lesions, although patients with a total tumor volume greater than 9 cc had shortened survival. No survival benefit could be demonstrated for whole-brain radiotherapy administered either concomitantly or after radiosurgery. CONCLUSION: Factors correlated with significantly improved survival included controlled systemic disease and non-melanoma histology. We found no significant survival benefit that could be discerned from adjuvant whole-brain radiotherapy in this patient group.     

Adjuvant brachytherapy for treatment of chest wall sarcomas

Thirty patients treated with surgical resection and brachytherapy for chest wall sarcoma at Memorial Sloan-Kettering Cancer Center from 1980 through 1987 were reviewed. Patients selected to receive adjuvant irradiation were those for whom there was doubt as to the completeness of surgical resection. Overall 5-year survival and locoregional control after brachytherapy were 65% and 54%, respectively. Locoregional control was similar for tumors treated at initial diagnosis (12 patients), at the time of recurrence (13 patients), or for tumors that were metastatic to the chest wall (five patients). Six patients with tumors larger than 10 cm in maximum dimension had a locoregional recurrence rate of 69% versus a recurrence rate of 39% for 18 patients with smaller tumors (p = 0.27). Fifty-four percent of high-grade tumors recurred locoregionally versus 28% of low-grade tumors (p = 0.37). Bone invasion or the presence of positive resection margins was not clearly associated with a higher locoregional failure rate. Only one patient (1/28; 7%) was known to have had recurrence within the irradiated area. Eight patients (8/28; 37%) had recurrence adjacent to the implanted area, and the precise failure site could not be determined for the remaining two patients. Because of the relatively high risk of regional versus in-field recurrence, patients with chest wall sarcoma who receive adjuvant treatment should be treated primarily with external-beam irradiation to allow more generous coverage of the tumor bed. Brachytherapy could be used as a tumor bed "boost" treatment. In patients undergoing resection of recurrent tumor in a previously irradiated site, adjuvant brachytherapy, without external-beam irradiation, should be considered to reduce the risk of extensive soft tissue necrosis.     

Results of a phase II trial of the GliaSite radiation therapy system for the treatment of newly diagnosed, resected single brain metastases

OBJECT: The aim of this study was to evaluate the effectiveness of brachytherapy using the GliaSite Radiation Therapy System in patients with a newly diagnosed resected single brain metastasis. The primary end point of the study was local tumor control. The secondary end points included patient survival, distant brain recurrence, quality of life, and treatment toxicity. METHODS: The authors conducted a prospective multiinstitutional phase II study of GliaSite brachytherapy prescribed at a 60-Gy dose administered to a 1-cm depth after resection of a single brain metastasis. No whole-brain radiation therapy was given. Patients were assessed at 1 and 3 months after brachytherapy and every 3 months thereafter for up to 2 years. Seventy-one patients were enrolled at 13 centers. A GliaSite balloon catheter was implanted in 62 patients. Fifty-four patients received brachytherapy. The median patient age was 60 years. The most common tumor (54%) was non-small cell lung cancer. Fifty-seven percent of patients had brain metastasis only, whereas 43% had extracranial metastasis. The median final administered dose was 60 Gy. The magnetic resonance imaging--determined local control rate, based on several different methods, was 82 to 87%. Both the median patient survival time and the median duration of functional independence were 40 weeks. Among the 35 patients who died, the cause of death was neurological in 11%. Thirteen patients underwent reoperation for suspected tumor recurrence or radiation necrosis, and histological diagnoses included radiation necrosis without tumor (nine patients), radiation necrosis mixed with tumor (two patients), and tumor only (two patients). Extracranial metastasis, tumor size, and radiation necrosis were significant factors affecting patient survival. CONCLUSIONS: In patients with a resected single brain metastasis, GliaSite brachytherapy leads to a local control rate, median patient survival time, and duration of functional independence similar to those achieved with resection plus whole-brain radiation therapy.     

Resection of brain metastases previously treated with stereotactic radiosurgery

OBJECT: To date, no report has been published on outcomes of patients undergoing resection for brain metastases who were previously treated with stereotactic radiosurgery (SRS). Consequently, the authors reviewed their institutional experience with this clinical scenario to assess the efficacy of surgical intervention. METHODS: Sixty-one patients (each harboring three or fewer brain lesions), who were treated at a single institution between June 1993 and August 2002 were identified. Patient charts and their neuroimaging and pathological reports were retrospectively reviewed to determine overall survival rates, surgical complications, and recurrence rates. A univariate analysis revealed that patient preoperative recursive partitioning analysis (RPA) classification, primary disease status, preoperative Karnofsky Performance Scale score, type of focal treatment undergone for nonindex lesions, and major postoperative surgical complications were factors that significantly affected survival (p < or = 0.05). In contrast, only the RPA class and focal (conventional surgery or SRS) treatment of nonindex lesions significantly (or nearly significantly) affected survival in the multivariate analysis. Major neurological complications occurred in only 2% of patients. The median time to distant recurrence after resection was 8.4 months; that to local recurrence was not reached. The overall median survival time was 11.1 months, with 25% of patients surviving 2 or more years. Conventional surgery facilitated tapering of steroid administration. Conclusions. The complication, morbidity, survival, and recurrence rates are consistent with those seen after conventional surgery for recurrent brain metastases. Our results indicate that in selected patients with a favorable RPA class in whom nonindex lesions are treated with focal modalities, surgery can provide long-term control of SRS-treated lesions and positively affect overall survival.     

Safety and efficacy of permanent iodine-125 seed implants and carmustine wafers in patients with recurrent glioblastoma multiforme

OBJECT: Effective treatment options are limited for patients with recurrent glioblastoma multiforme (GBM), and survival is usually <1 year. Novel treatment approaches are needed. Localized adjunct treatment with carmustine (BCNU) wafers or permanent, low-activity 125I seed implants has been shown to be effective for GBM. This study assessed the efficacy and safety of these therapies in combination following tumor resection. METHODS: Thirty-four patients with recurrent GBM were treated with maximal tumor resection followed by implantation of BCNU wafers and permanent 125I seeds into the tumor cavity. Patients were followed up with clinical evaluations and magnetic resonance imaging studies once every 3 months. Survival and progression-free survival (PFS) were evaluated. RESULTS: During follow-up, local disease progression was observed in 27 patients, and 23 of them died. The median survival period was 69 weeks, and the median PFS was 47 weeks. The 12-month survival and PFS rates were 66 and 32%, respectively. Baseline factors associated with prolonged survival included Karnofsky Performance Scale score>or=70, 125I seed activity>or=0.8 mCi/cm3 of tumor cavity, and age<60 years. Brain necrosis developed in 8 patients (24%) and was successfully treated with surgery or hyperbaric oxygen therapy. CONCLUSIONS: The use of adjunct therapy combining BCNU wafers and permanent 125I seeds resulted in survival that compares favorably with data from similar studies performed in patients with recurrent GBM. The incidence of brain necrosis appeared to be higher than that expected with either treatment alone, although the necrosis was manageable and did not affect survival. This novel approach warrants further investigation in recurrent and newly diagnosed GBM.     

Brain metastasis in patients with esophageal carcinoma

BACKGROUND: Brain metastasis from esophageal carcinoma is rare, and its natural history is unclear. To determine predictors for their outcomes, we conducted a retrospective review of patients. METHODS: We treated 803 patients with metastatic brain tumors, and there were 17 patients with brain metastases from esophageal carcinoma. Their median age at the diagnosis was 57 years. RESULTS: In the 15 patients with the pretreatment KPS of 70 or higher, the median survival after the diagnosis of brain metastasis was 26.2 months. Seven patients showed the median survival of 17.7 months after resection alone. The median survival was 65.5 months in the 3 patients who were treated with resection plus radiation. CONCLUSIONS: Neurosurgical resection followed by WBRT seemed to be the indicated treatment in these patients.