Cognitive functions in primary central nervous system lymphoma: literature review and assessment guidelines.

BACKGROUND: Treatment-related neurotoxicity has been recognized as a significant problem in patients with primary central nervous system lymphoma (PCNSL) as effective treatment has increased survival rates. There is, however, a paucity of research on cognitive functions in this population. DESIGN: In a review of the literature, a total of 17 articles that described cognitive outcome in adult PCNSL patients were identified. RESULTS: The studies that assessed cognitive functions after whole-brain radiotherapy combined with chemotherapy reported cognitive impairment in most patients. Patients treated with chemotherapy alone had either stable or improved cognitive performance in most studies. Methodological problems, however, limited the ability to ascertain the specific contribution of disease and various treatment interventions to cognitive outcome. On the basis of the literature review, a battery of cognitive and quality-of-life (QoL) measures to be used in prospective clinical trials was proposed. The battery is composed of five standardized neuropsychological tests, covering four domains sensitive to disease and treatment effects (attention, executive functions, memory, psychomotor speed), and QoL questionnaires, and meets criteria for use in collaborative trials. CONCLUSION: The incorporation of formal and systematic cognitive evaluations in PCNSL studies will improve our understanding of treatment-related neurotoxicity in this population.     

Seizure remission and antiepileptic drug discontinuation in children with tuberous sclerosis complex

BACKGROUND: Epilepsy is a common neurologic complication of tuberous sclerosis complex (TSC) and it is often refractory to treatment. Therefore, treating physicians are often reluctant to discontinue antiepileptic drugs (AEDs) in individuals with TSC who have attained seizure remission. To our knowledge, seizure remission and AED discontinuation in children with TSC has not been studied. OBJECTIVE: To characterize seizure remission and AED discontinuation in children with TSC. METHODS: Retrospective medical record and neuroimaging analysis of 15 children with TSC and epilepsy who had seizure remission, with a subsequent trial of discontinuation of AED treatment. RESULTS: The seizure remission rate for the group of patients with TSC and epilepsy was 14.2%. From the group of 15 patients who had a remission, the absolute relapse rate was 26.7% after a mean follow-up of 5 years 7 months. Patients with sustained remission were more likely to have normal intelligence and only a few cortical or subcortical lesions on neuroimaging. CONCLUSIONS: The proportion of children with TSC and epilepsy who achieve seizure remission is small. Nevertheless, some do attain seizure remission, and AEDs may be successfully discontinued. Mild cerebral involvement is a general clinical marker for seizure remission. The relapse rate in those who have undergone a trial of discontinuation of AED therapy is comparable with the rate in the general pediatric population with epilepsy.     

Respiratory failure and intraoperative oxygenation following oesophagectomy

Respiratory complications are a major cause of morbidity andmortality following oesophagectomy.¹ We hypothesized that patientswho develop postoperative respiratory failure would have anunstable intraoperative course. Two stage oesophagectomy requiresa period of one lung ventilation (OLV) and one measure of intraoperativeinstability is desaturation during OLV. We therefore studiedthe relationship between Sa_O2 during OLV and postoperative course.Previous work has focused on preoperative factors associatedwith postoperative complications.² There is little informationon intraoperative factors that may influence outcome. We performed a retrospective analysis of all elective oesophagectomiesperformed between January 1998 and August 1999. Seventy-sevenpatients had a 2-stage sub-total oesophagectomy requiring OLV.Oxygen saturation recorded on the anaesthetic chart during OLVwas plotted on a fixed linear scale of 0–100% againsttime for each patient. The area above the curve was calculated,as a measure of intraoperative oxygenation during OLV. Thiswas standardized by dividing the area by the OLV duration, thusobtaining the Area Per Unit Time (APUT). The postoperative courseof each patient was recorded including outcome, total durationof ITU stay and the worst Pa_O2/F_O2 ratioattained. ARDS was defined using the American-European ConsensusConference on ARDS criteria. Twenty-one patients had a prolongedITU stay (>48 h) and all had a persistent Pa_O2/F_O2<27. Thirteen patients (17% of the total) fulfilled the ConsensusConference criteria for ARDS and seven of these died in hospital. Total OLV time was not significantly different between the groupsbut patients who developed ARDS had significantly greater intraoperativehypoxaemia as measured by the APUT (Table 17). We conclude thatintraoperative hypoxaemia is associated with respiratory failurefollowing oesophagectomy.     

Neoadjuvant temozolomide followed by complete resection of a 1p- and 19q-deleted anaplastic oligoastrocytoma: case study

A 38-year-old woman presented with an infiltrative tumor of the right frontal lobe and genu of the corpus callosum that was deemed only partially resectable. A stereotactic biopsy was performed, which revealed a right frontal oligoastrocytoma that had some anaplastic features as well as allelic loss of chromosome arms 1p and 19q. The patient was treated with temozolomide for 24 months. The partial response of the tumor to chemotherapy rendered the lesion amenable to gross total resection, which was performed subsequently. The patient remains alive and well without evidence of recurrence 7 months after resection and 48 months after initial diagnosis. Thus, preoperative chemotherapy decreased tumor mass to a degree that subsequently enabled a gross total resection. This treatment strategy, although common in the treatment of other solid tumors, is rarely utilized in adult neuro-oncology and raises another potential role for chromosome testing in oligodendroglial tumor management.     

The effect of natural antibody in guinea-pig serum on mouse lymphoma cells in vitro and in vivo

Normal guinea-pig serum was found to have a cytotoxic effect in vitro upon several newly induced mouse lymphoblastic leukaemias and on normal mouse thymocytes. This reaction was complement dependent, and cross-absorption experiments showed that the reactivity could be abolished by absorption with any susceptible cell type. It was concluded that normal guinea-pig serum contained a natural antibody which reacted in common with normal mouse thymocytes and certain lymphomas. The growth of lymphomas which had proved highly sensitive to guinea-pig serum in vitro was inhibited by guinea-pig serum in vivo. In contrast, lymphomas showing insensitivity to guinea-pig serum in vitro were also insensitive to it in vivo. It is suggested that the inhibition of lymphoma growth in vivo was due to the natural cytotoxic antibody present in guinea-pig serum.