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Abramson Cancer CenterNCI CANCERLIT® Search: Therapy of Brain Tumor - August 2002
National Cancer Institute®
Last Modified: August 1, 2002
- Gamma knife radiosurgery for neuroepithelial tumors: radiological and histological changes.
- [Prognosis of brain death in the surgical treatment of supratentorial glial tumors]
- Moving targets and ghosts of the past: outcome measurement in brain tumour therapy.
- Intracranial germ cell tumors: a retrospective study of 44 children.
- [Treatment of recidive malignant gliomas with temozolomide]
- [Chemotherapy of recurrent supratentorial malignant gliomas (phase II study)]
- Survival of patients with newly diagnosed glioblastoma multiforme treated with RSR13 and radiotherapy: results of a phase II new
- Stereotactic synchrotron microbeam radiotherapy.
- Primary brain lymphoma.
- A comparison of three anesthetic techniques in patients undergoing craniotomy for supratentorial intracranial surgery.
- Neurosurgical management of pineal tumours.
- [Application of neuroendoscopy in brain surgery]
- Surgical management of colloid cyst of the third ventricle--a study of 105 cases.
- Colloid cysts of the third ventricle: some comments.
- Optimizing brain tumor resection. Low-field interventional MR imaging.
- Optimizing brain tumor resection. Midfield interventional MR imaging.
- Optimizing brain tumor resection. High-field interventional MR imaging.
- Neuronavigation in interventional MR imaging. Frameless stereotaxy.
- Neuronavigation in interventional MR imaging. Prospective stereotaxy.
- Minimally invasive procedures. Interventional MR image-guided neurobiopsy.
- Minimally invasive procedures. Advances in image-guided delivery of drug and cell therapies into the central nervous system.
- Thermal therapies in interventional MR imaging. Laser.
- Jugular bulb oxygen saturation during propofol and isoflurane/nitrous oxide anesthesia in patients undergoing brain tumor surgery.
- [Proposing surgical management to a patient with low-grade glioma: controversies and ethical consequences]
- Intensity-modulated radiation therapy (IMRT) for meningioma.
- Acute effects of irradiation on cognition: changes in attention on a computerized continuous performance test during radiotherapy in
- Open low-field magnetic resonance imaging in radiation therapy treatment planning.
- Treatment planning and dosimetry for the Harvard-MIT Phase I clinical trial of cranial neutron capture therapy.
- Development of a novel indwelling balloon applicator for optimizing light delivery in photodynamic therapy.
- PTV margin determination in conformal SRT of intracranial lesions.
Table of Contents
1
UI - 11837537
AU - Uematsu Y; Fujita K; Tanaka Y; Shimizu M; Oobayashi S; Itakura T; Kubo K
TI -
Gamma knife radiosurgery for neuroepithelial tumors: radiological and
histological changes.
SO - Neuropathology 2001 Dec;21(4):298-306
AD - Department of Neurological Surgery, Wakayama Medical University,
Wakayama City, Japan. yujiue@wakayama-med.ac.jp
Gamma knife radiosurgery (RS) has been introduced as a modern therapy
for brain tumors. However, the effects of RS for neuroepithelial tumors
are still obscure. The present study investigates the radiological and
histological changes after RS to elucidate the biological effect. There
were seven cases (two males and five females), ranging from 4 to 71
years with a mean age of 33 years. Two cases were located in the
brainstem, another two in the cerebellum, and one each in the thalamus,
the hypothalamus, and the frontal lobe. Histologically, two cases had
gangliogliomas, four astrocytomas (1 pilocytic, 1 fibrillary, 2
anaplastic), and one glioblastoma. RS was performed after surgery with a
central dose of 30-36 Gy. All cases were evaluated radiologically on MRI
before and after RS. Four cases (3 astrocytomas and 1 glioblastoma)
which neurologically deteriorated after RS were reoperated. These cases
were examined using HE and immunohistochemical studies with antibodies
of CD34, alpha-smooth muscle actin (SMA), p53, p21 and MIB-1 on the
sections before and after RS. MRI demonstrated perifocal edema and
intratumoral hypointensity on T2 weighted imaging (T2WI), suggesting
radionecrosis in most of the cases within 6 months after RS. In the
central part of the RS, destructive changes were observed in the tumor
cells and endothelial cells: decrease in the tumor cell population,
coagulation necrosis, and fibrinoid degeneration of vascular walls were
revealed. In the peripheral part, however, some tumors contained viable
tumor cells intermingled with blood vessels showing endothelial and
pericytic proliferations. The increase of MIB-1 staining index was found
in only one case. The p21 immunoreactivity was increased in endothelial
cells, although the p53 immunoreactivity was unchanged. These results
suggested that radionecrosis occurred earlier and more frequently in
neuroepithelial tumors after RS than after conventional radiation.
2
UI - 11560039
AU - Pedachenko IeH; Hlavats'kyi OIa; Popadynets' II
TI -
[Prognosis of brain death in the surgical treatment of supratentorial
glial tumors]
SO - Lik Sprava 2001 May-Jun;(3):87-9
Results are presented of prognostication of death of the brain in
surgical treatment of 1056 patients with glioma of supratentorial
localization. Prognostically unfavourable factors for development of
vital disturbances are determined, the main ones being advanced age, low
quality of life before surgery, vascular and hypertensive type of the
disease course, high degree anaplasia, the ability of the tumor to store
a contrast, deep localization of the tumor, its partial resection.
Predominance of the sum of unfavourable signs over favourable ones
suggested to us a high risk of operation which came to be lower with the
use of microsurgical techniques.
3
UI - 11922695
AU - Haines SJ
TI -
Moving targets and ghosts of the past: outcome measurement in brain
tumour therapy.
SO - J Clin Neurosci 2002 Mar;9(2):109-12
AD - Department of Neurological Surgery, Medical University of South
Carolina, Charleston 29425, USA.
Evaluation of novel therapies for brain tumours should logically
consider quality and quantity of patient survival as primary endpoints.
The urgency of the problem, however, frequently leads investigators to
use surrogate endpoints and historical controls in order to more rapidly
evaluate outcome. To examine the impact of the use of surrogate
endpoints and historical controls on the evaluation of innovative brain
tumour therapy, selective literature review of three content areas
(intraarterial chemotherapy for malignant glioma, interstitial
brachytherapy for malignant glioma and stereotactic radiosurgery for
cerebral metastasis and malignant glioma) was carried out. The impact of
surrogate outcome measures and use of historical controls was assessed
by comparing the results of trials using these methods and randomised
clinical trials. In the evaluation of both intraarterial chemotherapy
and interstitial brachytherapy, promising results in early phase trials
were not confirmed in randomised clinical trials. This result can be
explained by selection bias and predicted by the use of controls
carefully selected from large treatment data bases. In the evaluation of
stereotactic radiosurgery, early phase trials are promising, but
randomised clinical trials have not yet been done. Prior experience
suggests that the early promising results with stereotactic radiosurgery
should be subjected to randomised clinical trial validation before being
considered proven. Careful selection of controls for early phase trials
is necessary if erroneous conclusions are to be avoided. Copyright 2002,
Elsevier Science Ltd. All rights reserved.
4
UI - 12057797
AU - Jaing TH; Wang HS; Hung IJ; Tseng CK; Yang CP; Hung PC; Lui TN
TI -
Intracranial germ cell tumors: a retrospective study of 44 children.
SO - Pediatr Neurol 2002 May;26(5):369-73
AD - Division of Hematology, Chang Gung Children's Hospital, Taoyuan, Taiwan.
This 16-year retrospective study review sought to determine the factors
influencing prognosis and treatment results of all patients with primary
intracranial germ cell tumors treated at our hospital who were younger
than 17 years of age at the time of diagnosis. A total of 44 patients
were treated during the study period, including 32 males and 12 females
with a male:female ratio of 2.67:1. The median age at diagnosis was 12
years and 5 months of age (range = 2-16 years). The 44 intracranial germ
cell tumors consisted of 27 pure germinomas (61.4%) and 17
nongerminomatous germ cell tumors, including 10 mixed germ cell tumors
(22.7%), three yolk sac tumors (7.8%), two immature teratomas (4.5%),
and two choriocarcinomas (4.5%). Univariate analysis of prognostic
factors using Kaplan-Meier survival estimates revealed that only
histologic tumor type was correlated with outcome (P < 0.005). The
projected 5-year overall survival and event-free survival rate of
patients with germinomas vs those with intracranial germ cell tumors
were 92.6%, 92.6% vs 47.3%, and 42.1%, respectively. Our analysis
suggests that radiation involving the spinal axis has limited usefulness
in patients with intracranial germ cell tumor, although better results
have been obtained for germinomas using radiotherapy in this study.
5
UI - 12073541
AU - Sipos L; Vitanovics D; Afra D
TI -
[Treatment of recidive malignant gliomas with temozolomide]
SO - Orv Hetil 2002 May 26;143(21):1201-4
AD - Orszagos Idegsebeszeti Tudomanyos Intezet, Budapest.
INTRODUCTION: The prognosis of malignant gliomas despite of the recent
advances of diagnostical and therapeutical techniques remains poor. The
majority of gliomas following total removal and postoperative
radiotherapy recurs. In case of recurrencies reoperation is rarely
possible and chemotherapy is the last treatment modality. METHODS: Forty
patients with recurrent malignant gliomas had been treated with
temozolomide (Temodal). The treatment had to be stopped in four cases.
RESULTS: Complete remission was observed in 3, partial in 11,
progressive disease in 4 and stable disease in 50% of the cases with CT
and/or MR images. The mean progress free interval was 6.25 and the mean
survival time 9 months. According to the primary histology the mean
survival time for glioblastoma patients was 6.8 and for anaplastic
astrocytoma or mixed oligoastrocytoma patients 12.2 months. CONCLUSIONS:
Due to its low toxicity and relatively long survival time after
recurrency temozolomide seems to be a promising drug in the treatment of
recurrent malignant gliomas.
6
UI - 12122942
AU - Afra D; Sipos L; Vitanovics D
TI -
[Chemotherapy of recurrent supratentorial malignant gliomas (phase II
study)]
SO - Ideggyogy Sz 2002 Jan 20;55(1-2):38-44
AD - Orszagos Idegsebeszeti Tudomanyos Intezet, Budapest.
At the Hungarian National Institute of Neurosurgery 73 recurrent
supratentorial malignant tumours were treated by chemotherapy during the
last ten years. Chemotherapy was applied after postoperative
radiotherapy but in some cases following reoperation only. All cases
were clinically and by CT or MRI verified recurrences. Forty-three
patients received BCNU-DBD (dibromodulcitol) treatment (23 anaplastic
astrocytoma--AA, and 20 glioblastoma multiforme--GM): day 1. BCNU 150
mg/sq.m. in i.v. infusion, day 2. dibromdulcitol 1000 mg/sq orally was
given. This course was repeated every six weeks, altogether 2-8 times.
Sixteen patients with AA responded with complete or partial regression
but only 6 did with GM. Median survival was 14 and 7 months, the
difference proved to be significant, p = 0.0091. PCV combination
(procarbazine, CCNU, vincristine) was applied to 16 patients with AA and
14 cases with recurrent oligodendroglioma (O). Treatment started with
vincristine 1.5 mg/sq.m. i.v. (2.0 mg maximum), the next day CCNU 100
mg/sq.m. was given, followed by procarbazine 60 mg/sq.m. on days 8-22.
and finished by the same dose of vincristine on day 30. The course was
repeated after one month, mostly six times. Six patients with AA did not
respond; in cases of oligodendroglioma all but one responded with
complete or partial improvement. It is remarkable that no significant
difference was found between the survivals of BCNU-DBD or PCV treated AA
patients. Chemotherapy of supratentorial malignant glioma recurrences
with nitroso-ureas and their combination proved to be efficacious. It
also seems, that in recurrent cases lower grade gliomas show better
response rate than glioblastomas.
7
UI - 12118029
AU - Kleinberg L; Grossman SA; Carson K; Lesser G; O'Neill A; Pearlman J;
TI -
Phillips P; Herman T; Gerber M
Survival of patients with newly diagnosed glioblastoma multiforme
treated with RSR13 and radiotherapy: results of a phase II new
approaches to brain tumor therapy CNS consortium safety and efficacy
study.
SO - J Clin Oncol 2002 Jul 15;20(14):3149-55
AD - Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore,
MD 21231-2410, USA. kleinla@jhmi.edu
PURPOSE: The objectives of this phase II study were to determine
survival, safety, pharmacokinetics (PK), and pharmacodynamics (PD) of
2,4-[[(3,5-dimethylanilino)carbonyl]methyl]phenoxy]-2-methylpropionic
acid (RSR13, efaproxiral) 100 mg/kg per day administered with standard
cranial radiotherapy (RT) for the treatment of glioblastoma multiforme
(GBM). RSR13, a synthetic allosteric modifier of hemoglobin, is a
radiation-enhancing agent that noncovalently binds to hemoglobin,
reduces oxygen-binding affinity, and increases oxygen unloading to
hypoxic tissue. PATIENTS AND METHODS: Fifty patients with newly
diagnosed GBM (Karnofsky performance status >or= 60) were enrolled onto
this multicenter phase II study. Patients received daily RSR13 100 mg/kg
intravenously infused for 30 minutes immediately before cranial RT (60
Gy in 30 fractions). Supplemental oxygen was given during RSR13 infusion
and continued until after the RT treatment was completed. RT was given
within 30 minutes of the end of RSR13 infusion. PK and PD determinations
were performed. RESULTS: The median survival for the RSR13-treated
patients was 12.3 months with 1-year and 18-month survival rates of 54%
and 24%, respectively. Twenty-four percent of patients had greater than
grade 2 toxicity, which was generally transient and self-limited. A
significant PD effect on hemoglobin-oxygen binding affinity was
demonstrated for most patients. CONCLUSION: RSR13 (100 mg/kg)
administered immediately before cranial RT is well tolerated and is
pharmacodynamically active. Median survival in excess of 1 year is
favorable.
8
UI - 12049471
AU - Company FZ
TI -
Stereotactic synchrotron microbeam radiotherapy.
SO - Australas Phys Eng Sci Med 2002 Mar;25(1):16-21
AD - School of Engineering and Industrial Design, University of Western
Sydney, Kingswood, NSW. f.company@nepean.uws.edu.au
Highly collimated synchrotron x-ray beams with high fluence rate may be
used in stereotactic radiotherapy of brain tumours. Several
monochromatic x-ray beams having uniform microscopic thickness ie
(microplanar beams) are directed to the center of the tumour from
varying directions, delivering lethal dose to the target volume while
sparing normal cells. This proposed technique takes advantage of the
hypothesised repair mechanism of capillaries between closely spaced
microplanar beam zones. The sharply dropping lateral dose profile of a
microplanar beam provides low scattered dose to the off-target interbeam
volume. In close proximity to the target volume, relatively high
secondary electron doses close to the edge of the beams overlap and
produce a high dose region between angled beams. This allows precise
targeting and prevents gradual blurring of the higher and lower dose
margins in the target volume. The advantages of stereotactic microplanar
beam radiotherapy will be lost as the dose between microplanar beams
exceeds the tolerance dose of the dose limiting tissues. Therefore to
minimize the risks of delayed radiation damage it is essential to
optimize the interbeam doses inside a human head phantom. The EGS4 Monte
Carlo code is used to calculate the lateral dose profiles and depth dose
of a 100 keV single microplanar beam in the phantom. A general equation
for absorbed dose as a function of depth and lateral distances is
derived for the single beam. Several microplanar beams are directed into
the target volume at the center of the phantom. Using the equation,
maximum dose on the beam axis (primary + total scattered dose) and the
minimum interbeam dose (total scattered dose) are calculated at
different depths and an isodose map of the phantom is obtained. A
stereotactic microplanar beam radiotherapy model is proposed for a 10 mm
diameter (approximately spherical) tumour at the center of the phantom.
9
UI - 12135190
AU - Chao TY
TI -
Primary brain lymphoma.
SO - Zhonghua Yi Xue Za Zhi (Taipei) 2002 Apr;65(4):135-7
10
UI - 12145066
AU - Talke P; Caldwell JE; Brown R; Dodson B; Howley J; Richardson CA
TI -
A comparison of three anesthetic techniques in patients undergoing
craniotomy for supratentorial intracranial surgery.
SO - Anesth Analg 2002 Aug;95(2):430-5, table of contents
AD - Department of Anesthesia and Perioperative Medicine, University of
California, San Francisco, California 94143, USA.
talkep@anesthesia.ucsf.edu
Several anesthetic techniques have been used successfully to provide
anesthesia for resection of intracranial supratentorial mass lesions.
One technique used to enhance recovery involves changing anesthesia from
vapor-based to propofol-based for cranial closure. However, there are no
data to support a beneficial effect of this approach in the immediate
postoperative period after craniotomy. We evaluated 3 anesthetic
techniques in 60 patients undergoing elective surgery for supratentorial
mass lesions. Patients were randomly assigned to three anesthesia study
groups: propofol infusion, isoflurane inhalation, and these two
techniques combined. In the combination group, once the dura was closed,
isoflurane was discontinued and propofol infusion simultaneously
started. We studied intra- and postoperative hemodynamics and several
recovery variables for 2 h after the end of anesthesia. Baseline and
average intraoperative blood pressure and heart rate values did not
differ among the groups. Heart rate and blood pressure increased
similarly in all groups in response to intubation and pin placement and
postoperatively. None of the recovery event times (open eyes,
extubation, follow commands, oriented, Aldrete score) or psychomotor
test performance differed significantly. We conclude that the sequential
administration of isoflurane and propofol did not provide earlier
recovery and cognition than the intraoperative use of isoflurane alone.
IMPLICATIONS: We evaluated three anesthetic techniques with and without
propofol in patients undergoing elective surgery for supratentorial mass
lesions by using a prospective, randomized clinical study design and
found that the three anesthetics did not differ in intra- or
postoperative hemodynamic stability or early postoperative recovery
variables.
11
UI - 11887580
AU - Sawamura Y; de Tribolet N
TI -
Neurosurgical management of pineal tumours.
SO - Adv Tech Stand Neurosurg 2002;27():217-44
AD - Hokkaido University Hospital, Sapporo, Japan.
12
UI - 11955412
AU - Zhan S; Li Z; Lin Z; Xu Z; Lin X; Li G; Shu H; Zhou D; Tang K
TI -
[Application of neuroendoscopy in brain surgery]
SO - Zhonghua Wai Ke Za Zhi 2002 Mar;40(3):187-90
AD - Department of Neurosurgery, Guangdong Provincial People's Hospital,
Guangzhou 510080, China.
OBJECTIVE: To investigate the effect of neuroendoscope on surgery.
METHODS: 315 patients were treated with neuroendoscope. Endoscopic
neurosurgery (EN) was used in 219 patients, endoscope-assisted
microneurosurgery (EAM) in 72, and endoscope-controlled
microneurosurgery (ECM) in 24. RESULTS: 201 (91.8%) of the 219 patients
underwent EN effectively. In 72 patients who underwent EAM there was
less retraction during tumor removal and visual control was improved. 21
(87.5%) of the 24 patients underwent ECM effectively. No severe
complications were observed. CONCLUSION: Neuroendoscopy can reduce
tissue trauma, improve visualization during tumor removal, and reduce
complications.
13
UI - 12128295
AU - Desai KI; Nadkarni TD; Muzumdar DP; Goel AH
TI -
Surgical management of colloid cyst of the third ventricle--a study of
105 cases.
SO - Surg Neurol 2002 May;57(5):295-302; discussion 302-4
AD - Department of Neurosurgery, King Edward Memorial Hospital, Seth G. S.
Medical College, Parel, Mumbai, India.
BACKGROUND: Colloid cyst of the third ventricle is a relatively rare
intracranial tumor. It generates tremendous interest for the
neurosurgeon because of its benign nature, deep location, and an
excellent prognosis when diagnosed early and excised. METHOD: A
retrospective analysis of 105 cases of third ventricle colloid cyst
treated between 1967 to 1998 was conducted. The clinical presentation,
radiological findings, different surgical approaches, and outcome were
analyzed. The transcallosal and transcortical-transventricular
approaches were predominantly used. Memory and psychological assessment
were carried out both pre- and postoperatively. A computerized
tomography (CT) scan was performed during follow-up. RESULTS: The male
to female ratio was 1.5:1. The age of the patients ranged from 10 to 68
years. Headache was the most common symptom. Papilledema and short-term
memory disturbances were the most common signs. In 5 patients the
colloid cyst was detected incidentally.Surgery for colloid cyst was
performed in 93 patients. Transcallosal and
transcortical-transventricular approaches were performed in 62 and 30
patients, respectively. In 1 patient the cyst was excised through the
subfrontal lamina terminalis approach. Total excision was achieved in 90
patients, while partial cyst excision was done in three patients.
Moderate to severe lateral ventricular enlargement was found in 76
patients at presentation. A ventriculoperitoneal shunt was the only
surgical procedure performed in 7 patients. In 16 patients colloid cyst
excision was conducted after cerebrospinal fluid (CSF) diversion via a
shunt. No surgical treatment of any kind was performed in 5 patients.
Five patients died. Eighty-six patients came for follow-up, with a range
from 1 month to 25 years (average 3 years and 8 months).
Postoperatively, transient recent memory deficits occurred in 14
patients, while a permanent recent memory loss was noted in 2 patients.
There was no incidence of postoperative disconnection syndrome or
behavioral disturbance. A CT scan was performed in 44 patients during
follow-up. Recurrence was detected in 1 patient in whom the cyst had
been partially excised. CONCLUSIONS: Colloid cyst, although a benign
tumor, is surgically challenging because of its deep midline location.
Early detection and total excision of the colloid cyst carries an
excellent prognosis.
14
UI - 12128299
AU - Ausman JI
TI -
Colloid cysts of the third ventricle: some comments.
SO - Surg Neurol 2002 May;57(5):305
15
UI - 11995420
AU - Metzger AK; Lewin JS
TI -
Optimizing brain tumor resection. Low-field interventional MR imaging.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):651-7, ix
AD - Departments of Neurological Surgery, Radiation Oncology, University
Hospitals of Cleveland, Case Western Reserve University, Cleveland,
Ohio, USA.
In this article, the authors describe their strategy for intraoperative
MR image guidance of tumor resection at low-field (0.2 T) strength. It
is their opinion that intraoperative imaging is most useful in assessing
the resection of intrinsic, infiltrating brain tumors; boundaries of the
tumor cannot be clearly distinguished with the surgeon's eyes, and
therefore, this discussion predominantly applies to the surgical
resection of gliomas.
16
UI - 11995421
AU - Alexander E 3rd
TI -
Optimizing brain tumor resection. Midfield interventional MR imaging.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):659-72
AD - Department of Surgery, Division of Neurosurgery, University of
Massachusetts Medical Center, Worcester, Massachusetts, USA.
The development of the intraoperative MR imager represents an important
example of creative vision and interdisciplinary teamwork. The result is
a remarkable tool for neurosurgical applications. MRT allows surgical
manipulation under direct visualization of the intracranial contents
through the eye of the surgeon and through the volumetric images of the
MR imaging system. This technology can be applied to cranial and spinal
cases, and forseeably can encompass application to the entire gamut of
neurosurgical efforts. The author's experience has been that this device
is easy and comfortable for the surgeon to use. Image acquisition,
giving views in the plane of choice, lasts no more than 2 to 60 seconds
(depending on the imaging method), and does not increase the duration of
a given procedure substantially. The author believes that the
information received through intraoperative MR imaging scanning
ultimately will contribute to decreasing the duration of surgery. Future
possibilities include combining the intraoperative MR imager with other
technologies, such as the endoscope, focused ultrasound, robotics, and
the evaluation of brain function intraoperatively. The development of
the intraoperative MR imager marks a significant advance in
neurosurgery, an advance that will revolutionize intraoperative
visualization as fully as the operating microscope. The combination of
intraoperative visualization and precise surgical navigation is
unparalleled, and its enhancement of surgical applications will be
widespread. Considering the remarkable potential of the intraoperative
MR imager for neurosurgical applications, optimal magnet design, image
quality, and navigational methods are necessary to capitalize on the
advantages of this revolutionary tool. The intraoperative MR imaging
system that the author's team has developed and used has combined these
features, and allows the performance of open surgical procedures without
the need of patient or magnet repositioning. By using advanced
navigational tools and computer technology, it represents an integration
of frameless stereotactic methods with real-time interactive imaging.
The midfield imager provides sufficient spatial and temporal resolution
and image quality to assess anatomy and pathology adequately, to monitor
a surgical procedure, and make image-based decisions. The intraoperative
use of this unique system is not limited to biopsies or limited-access
procedures. The entire range of neurosurgical procedures can be
performed, if the requisite instrumentation is available. Much work
remains to be done, however. The team did not develop this system only
to enable the performance of current neurosurgical procedures. Forty
years ago, the operating microscope enabled not only the performance of
undreamt-of procedures but opened the door to entire new subspecialties.
The entire landscape of neurosurgery will change at a fundamental level
as the full ramifications of this exciting idea come to fruition. The
holy grail of image-guided surgery is a seamless interface between the
eye and hand in the purest sense (i.e., the mind's eye and hand).
Ideally, this seamless interface represents effortless flow between the
procedural goal compared with the present situation and the manipulation
of the tools available to accomplish the task, whether they be the
scalpel, drill, laser, ultrasonic aspirator, phased array focused
ultrasound, microrobot, or high-dose irradiator. As in the realm of
high-performance military jet fighters, the physical limits of the human
being demarcate the confining boundary of the system. Those limits are
much tighter around the domain of tool manipulation, where the surgeon
will yield, early on, to the enhanced performance of robotics and other
technical adjuncts. The era of large open magnet imaging systems for
surgical procedures then will come to a close; however, the grander era
of the surgeon's integration of precision-guided, multimodality
therapeutics will just be beginning. The future will be very bright,
indeed.
17
UI - 11995422
AU - Tummala RP; Chu RM; Liu H; Truwit CL; Hall WA
TI -
Optimizing brain tumor resection. High-field interventional MR imaging.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):673-83
AD - Department of Neurosurgery, University of Minnesota School of Medicine,
Minneapolis, Minnesota, USA.
High-field strength iMRI guidance is an effective tool for brain tumor
resection. Although its use lengthens the average time for a craniotomy,
the reward is a more extensive tumor excision compared with conventional
neurosurgery without an increased risk to the patient (Table 4).
Although intraoperative patient transfer into and out of the magnet is
cumbersome, the possibility for complete resection, especially for a
low-grade glioma, makes the effort worthwhile. The cost and technical
support required for this system presently limits its use to only a few
sites worldwide. As with any technology, further refinements will make
this system less expensive and more attainable. Practical consideration
aside, high-field strength iMRI is presently [table: see text] the most
effective tool available for brain tumor resection. Because of its
novelty, future studies are necessary to determine if this technology
lowers the incidence of and extends the duration to tumor recurrence as
the preliminary data in children suggests. These are the ultimate
measures of efficacy for any brain tumor treatment. Based on the rapid
advancement of technology, will today's high-field strength
interventional magnet become tomorrow's low-field system? Very
high-field strength designs may improve diagnostic capabilities through
higher resolution, but their interventional applications may be hindered
by increased sensitivity for clinically insignificant abnormalities and
decreased specificity for clinically relevant lesions. As new technology
is developed, clinicians must continue to explore and refine the
existing high-field strength iMRI to make it cost-effective and widely
applicable.
18
UI - 11995423
AU - Jolesz FA; Kikinis R; Talos IF
TI -
Neuronavigation in interventional MR imaging. Frameless stereotaxy.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):685-93, ix
AD - Department of Radiology, Brigham and Women's Hospital, Harvard Medical
School, Boston, Massachusetts, USA. jolesz@bwh.harvard.edu
The main thrust of diagnostic MR imaging is to discern normal and
pathologic patient morphology and function. Intraprocedural imaging,
however, serves a different goal: to furnish the surgeon or
interventionalist with updates on intraoperative changes and how they
may modify preintervention data. Although researchers have not
established whether MR image-guided therapy can improve clinical
outcomes and reduce complication rates definitively, the intraoperative
and preoperative data generated will improve the ability of every
neurosurgeon to navigate in the surgical field more accurately.
19
UI - 11995424
AU - Liu H; Hall WA; Truwit CL
TI -
Neuronavigation in interventional MR imaging. Prospective stereotaxy.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):695-704
AD - Departments of Radiology, Biomedical Engineering, University of
Minnesota School of Medicine, Minneapolis, Minnesota, USA.
liuxx105@umn.edu
A practical MR imaging-based guidance/control methodology has been
developed successfully and validated for improving the performance of
stereotactic neurosurgerical procedures such as brain lesion biopsy. The
use of the device and method in 40 routine MR-guided procedures has
revealed its potential as an alternative approach. Superior to the
traditional stereotactic systems, which rely on the old images, the new
method, based on prospective guidance, can provide good and acceptable
targeting accuracy in the presence of brain shift. Furthermore, the use
of MR monitoring of the overall neurosurgical procedure provides another
independent assurance for the success of a complicated surgery. The
advantages of the new surgical guidance system and method are simple and
compatible with the existing capabilities of conventional MR scanners.
More importantly, it allows a more effective surgical guidance in the
presence of brain shift during the typical neurosurgery. Another
important advantage of the guidance method and device is the performance
of a truly MR-guided neurosurgical procedure in a conventional, short
bore high field MR scanner. Surgical procedures using the guidance
system and method have been accepted by radiologists and neurosurgeons
as an attractive MR-based stereotactic approach. It can be expected that
this guidance scheme will be a useful addition to the MR-based
stereotactic system for neurosurgery, and animal research, in which
cumbersome stereotactic frames have been used.
20
UI - 11995425
AU - Hall WA; Liu H; Martin AJ; Truwit CL
TI -
Minimally invasive procedures. Interventional MR image-guided
neurobiopsy.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):705-13
AD - Departments of Neurosurgery, Radiation Oncology, Radiology, University
of Minnesota School of Medicine, Minneapolis, Minnesota, USA.
hallx003@tc.mn.edu
Neurobiopsy using intraoperative MR imaging represents a natural
progression from stereotaxis in the method with which neurosurgeons
perform brain biopsy.
21
UI - 11995427
AU - Broaddus WC; Gillies GT; Kucharczyk J
TI -
Minimally invasive procedures. Advances in image-guided delivery of drug
and cell therapies into the central nervous system.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):727-35
AD - Division of Neurosurgery, Virginia Commonwealth University/Medical
College of Virginia, Richmond, USA. wbroaddu@hsc.vcu.edu
Image-guided transparenchymal delivery of drugs is an emerging
neurosurgical modality that holds the promise of delivering various
agents directly across the blood-brain barrier. Potential large-scale
applications for convection-enhanced delivery of drugs through the
interstitial space include the delivery of chemotherapeutic agents and
gene therapy vectors for the treatment of brain tumors and the delivery
of neurotrophic factors and neurotransmitters for the treatment of
neurodegenerative disorders. The related technique of direct
intraparenchymal injection of cells provides a means for transplanting
neural stem cells into the brain for the treatment of degenerative
diseases. Significant advances in catheter design, infusion strategies,
and imaging technology have brought these procedures into the mainstream
of human clinical testing, with clinical applications potentially on the
near horizon.
22
UI - 11995429
AU - Straube T; Kahn T
TI -
Thermal therapies in interventional MR imaging. Laser.
SO - Neuroimaging Clin N Am 2001 Nov;11(4):749-57
AD - Klinik und Poliklinik fur Diagnostische Radiologie, Universitatsklinikum
Leipzig AoR, Leipzig, Germany.
Laser ablation of cerebral tumors is an alternative to surgical excision
and radiosurgery; however, more clinical testing is necessary. Various
MR parameters can be used during laser ablation to detect structural as
well as temperature changes in near real-time for diagnostic and
therapeutic applications. Unfortunately, MR-guided ablation does not
solve the problem of defining a precise target in high-grade tumors of
the central nervous system.
23
UI - 10439748
AU - Jansen GF; van Praagh BH; Kedaria MB; Odoom JA
TI -
Jugular bulb oxygen saturation during propofol and isoflurane/nitrous
oxide anesthesia in patients undergoing brain tumor surgery.
SO - Anesth Analg 1999 Aug;89(2):358-63
AD - Department of Anesthesiology, Academic Medical Centre, University of
Amsterdam, The Netherlands.
We investigated, in brain tumor patients, the jugular bulb venous oxygen
partial pressure (PjO2) and hemoglobin saturation (SjO2), the arterial
to jugular bulb venous oxygen content difference (AJDO2), and middle
cerebral artery blood flow velocity (Vmca) during anesthesia, and the
effect of hyperventilation on these variables. Twenty patients were
randomized to receive either isoflurane/ nitrous oxide/fentanyl (Group
1) or propofol/fentanyl (Group 2). At normoventilation (PacO2 35 +/- 2
mm Hg in Group 1 and 33 +/- 3 mm Hg in Group 2), SjO2 and PjO2 were
significantly higher in Group 1 than in Group 2 (SjO2 60% +/- 6% and 49%
+/- 13%, respectively; P = 0.019) (PjO2 32 +/- 3 and 27 +/- 5 mm Hg,
respectively; P = 0.027). In Group 2, 5 of 10 patients had SjO2 < 50%,
and 3 of these patients had SjO2 < 40% and AJDO2 > 9 mL/dL. All patients
in Group 1 had SjO2 > 50%. During hyperventilation, there were no
differences in SjO2, PjO2, or AJDO2 between the two groups. On
hyperventilation, there was no correlation between the relative
decreases of Vmca and 1/AJDO2 (r = 0.21, P = 0.41). The results indicate
during propofol anesthesia, half of the brain tumor patients showed
signs of cerebral hypoperfusion, but not during isoflurane/nitrous oxide
anesthesia. Furthermore, during PacO2 manipulations, shifts in Vmca are
inadequate to evaluate brian oxygen delivery in these patients.
Implications: During propofol anesthesia at normoventilation, 50% of
brain tumor patients showed signs suggesting cerebral hypoperfusion, but
this could not be demonstrated during isoflurane/nitrous oxide
anesthesia. During PacO2 manipulations, consecutive measurements of the
cerebral blood flow velocity may be inadequate to assess cerebral
oxygenation.
24
UI - 12053159
AU - Lopes M; Duffau H; Capelle L; Meningaud JP; Herve C
TI -
[Proposing surgical management to a patient with low-grade glioma:
controversies and ethical consequences]
SO - Neurochirurgie 2002 May;48(2-3 Pt 1):69-74
AD - Service de Neurochirurgie, Hopital de la Salpetriere, 47-83, boulevard
de l'Hopital, 75651 Paris Cedex 13, France.
manuel.lopes@psl.ap-hop-paris.fr
The therapeutic controversies surrounding low-grade glioma result mainly
from the lack of certainty about their histological definition, and,
from our imperfect knowledge of the natural history of the disease.
Heterogeneous surgical management is the consequence of this situation,
which renders difficult to propose the best attitude to each individual
patient, thus raising ethical questions, because the absence of a
consensus. Performing prospective studies able to analyse these
different modalities is mandatory whenever we want to be enable to give
to our patients the best answer in their precise case, and furthermore
to justify back our acts too.
25
UI - 12128128
AU - Uy NW; Woo SY; Teh BS; Mai WY; Carpenter LS; Chiu JK; Lu HH; Gildenberg
TI -
P; Trask T; Grant WH; Butler EB
Intensity-modulated radiation therapy (IMRT) for meningioma.
SO - Int J Radiat Oncol Biol Phys 2002 Aug 1;53(5):1265-70
AD - Department of Radiology/Section of Radiation Oncology, The Methodist
Hospital and Baylor College of Medicine, Houston, TX, USA.
PURPOSE: To assess the safety and efficacy of intensity-modulated
radiation therapy (IMRT) in the treatment of intracranial meningioma.
METHODS AND MATERIALS: Forty patients with intracranial meningioma
(excluding optic nerve sheath meningiomas) were treated using IMRT with
the NOMOS Peacock system between 1994 and 1999. Twenty-five patients
received IMRT after surgery either as adjuvant therapy for incomplete
resection or for recurrence, and 15 patients received definitive IMRT
after presumptive diagnosis based on imaging. Thirty-two patients had
skull base lesions, and 8 had nonskull base lesions. The prescribed dose
ranged from 40 to 56 Gy (median 50.4 Gy) at 1.71 to 2 Gy per fraction,
and the volume of the primary target ranged from 1.55 to 324.57 cc
(median 20.22 cc). The mean dose to the target ranged from 44 to 60 Gy
(median 53 Gy). Follow-up ranged from 6 to 71 months (median 30 months).
Acute and chronic toxicity were assessed using Radiation Therapy
Oncology Group (RTOG) morbidity criteria and tumor response was assessed
by patient report, examination, and imaging. Overall survival,
progression-free survival, and local control were calculated using the
Kaplan-Meier method. RESULTS: Cumulative 5-year local control,
progression-free survival, and overall survival were 93%, 88%, and 89%,
respectively. Two patients progressed after IMRT, one locally and one
distantly. Each was treated with IMRT after multiple recurrences of
benign meningioma over many years. Both were found to have malignant
meningioma at the time of relapse after IMRT, and it is likely their
tumors had already undergone malignant change by the time IMRT was
given. Defined normal structures generally received a significantly
lower dose than the target. The most common acute central nervous system
(CNS) toxicity was mild headache, usually relieved with steroids. One
patient experienced RTOG Grade 3 acute CNS toxicity, and 2 experienced
Grade 3 or higher late CNS toxicity, with one possible treatment-related
death. No toxicity was observed with mean doses to the optic
nerve/chiasm up to 47 Gy and maximum doses up to 55 Gy. CONCLUSION: IMRT
is a promising new technology that is safe and efficacious in the
primary and adjuvant treatment of intracranial meningiomas. A history of
local aggression may indicate malignant degeneration and predict a
poorer outcome. Toxicity data are encouraging, but the potential for
serious side effects exists, as demonstrated by one possible
treatment-related death. Larger cohort and longer follow-up are needed
to better define efficacy and late toxicity of IMRT.
26
UI - 12128129
AU - Merchant TE; Kiehna EN; Miles MA; Zhu J; Xiong X; Mulhern RK
TI -
Acute effects of irradiation on cognition: changes in attention on a
computerized continuous performance test during radiotherapy in
pediatric patients with localized primary brain tumors.
SO - Int J Radiat Oncol Biol Phys 2002 Aug 1;53(5):1271-8
AD - Department of Radiation Oncology, St. Jude Children's Research Hospital,
Memphis, TN 38105, USA. thomas.merchant@stjude.org
PURPOSE: To assess sustained attention, impulsivity, and reaction time
during radiotherapy (RT) for pediatric patients with localized primary
brain tumors. METHODS AND MATERIALS: Thirty-nine patients (median age
12.3 years, range 5.9-22.9) with primary brain tumors were evaluated
prospectively using the computerized Conners' continuous performance
test (CPT) before and during conformal RT (CRT). The data were modeled
to assess the longitudinal changes in the CPT scores and the effects of
clinical variables on these changes during the first 50 days after the
initiation of CRT. RESULTS: The CPT scores exhibited an increasing trend
for errors of omission (inattentiveness), decreasing trend for errors of
commission (impulsivity), and slower reaction times. However, none of
the changes were statistically significant. The overall index, which is
an algorithm-based weighted sum of the CPT scores, remained within the
range of normal throughout treatment. Older patients (age >12 years)
were more attentive (p < 0.0005), less impulsive (p < 0.07), and had
faster reaction times (p < 0.001) at baseline than the younger patients.
The reaction time was significantly reduced during treatment for the
older patients and lengthened significantly for the younger patients (p
< 0.04). Patients with a shunted hydrocephalus (p < 0.02), seizure
history (p < 0.0006), and residual tumor (p < 0.02) were significantly
more impulsive. Nonshunted patients (p < 0.0001), those with more
extensive resection (p < 0.0001), and patients with ependymoma (p <
0.006) had slower initial reaction times. CONCLUSION: Children with
brain tumors have problems with sustained attention and reaction time
resulting from the tumor and therapeutic interventions before RT. The
reaction time slowed during treatment for patients <12 years old. RT, as
administered in the trial from which these data were derived, has
limited acute effects on changes in the CPT scores measuring attention,
impulsiveness, and reaction time.
27
UI - 12128138
AU - Krempien RC; Schubert K; Zierhut D; Steckner MC; Treiber M; Harms W;
TI -
Mende U; Latz D; Wannenmacher M; Wenz F
Open low-field magnetic resonance imaging in radiation therapy treatment
planning.
SO - Int J Radiat Oncol Biol Phys 2002 Aug 1;53(5):1350-60
AD - Department of Clinical Radiology, University of Heidelberg, Heidelberg,
Germany. robertkrempien@med.uni-heidelberg.de
PURPOSE: To evaluate the possibilities of an open low-field magnetic
resonance imaging (MRI) scanner in external beam radiotherapy treatment
(RT) planning. METHODS AND MATERIALS: A custom-made flat tabletop was
constructed for the open MR, which was compatible with standard therapy
positioning devices. To assess and correct image distortion in low-field
MRI, a custom-made phantom was constructed and a software algorithm was
developed. A total of 243 patients (43 patients with non-small-cell lung
cancer, 155 patients with prostate cancer, and 45 patients with brain
tumors) received low-field MR imaging in addition to computed
2001 before the start of the irradiation. RESULTS: Open low-field MRI
provided adequate images for RT planning in nearly 95% of the examined
patients. The mean and the maximal distortions 15 cm around the
isocenter were reduced from 2.5 mm to 0.9 mm and from 6.1 mm to 2.1 mm
respectively. The MRI-assisted planning led to better discrimination of
tumor extent in two-thirds of the patients and to an optimization in
lung cancer RT planning in one-third of the patients. In prostate cancer
planning, low-field MRI resulted in significant reduction (40%) of organ
volume and clinical target volume (CTV) compared with CT and to a
reduction of the mean percentage of rectal dose of 15%. In brain tumors,
low-field MR image quality was superior compared with CT in 39/45
patients for planning purposes. CONCLUSIONS: The data presented here
show that low-field MRI is feasible in RT treatment planning when image
correction regarding system-induced distortions is performed and by
selecting MR imaging protocol parameters with the emphasis on adequate
images for RT planning.
28
UI - 12128139
AU - Palmer MR; Goorley JT; Kiger WS; Busse PM; Riley KJ; Harling OK;
TI -
Zamenhof RG
Treatment planning and dosimetry for the Harvard-MIT Phase I clinical
trial of cranial neutron capture therapy.
SO - Int J Radiat Oncol Biol Phys 2002 Aug 1;53(5):1361-79
AD - Department of Radiology, Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA 02115, USA. mpalmer@caregroup.harvard.edu
PURPOSE: A Phase I trial of cranial neutron capture therapy (NCT) was
conducted at Harvard-MIT. The trial was designed to determine maximum
tolerated NCT radiation dose to normal brain. METHODS AND MATERIALS:
Twenty-two patients with brain tumors were treated by infusion of
boronophenylalanine-fructose (BPA-f) followed by exposure to epithermal
neutrons. The study began with a prescribed biologically weighted dose
of 8.8 RBE (relative biologic effectiveness) Gy, escalated in
compounding 10% increments, and ended at 14.2 RBE Gy. BPA-f was infused
at a dose 250-350 mg/kg body weight. Treatments were planned using
MacNCTPlan and MCNP 4B. Irradiations were delivered as one, two, or
three fields in one or two fractions. RESULTS: Peak biologically
weighted normal tissue dose ranged from 8.7 to 16.4 RBE Gy. The average
dose to brain ranged from 2.7 to 7.4 RBE Gy. Average tumor dose was
estimated to range from 14.5 to 43.9 RBE Gy, with a mean of 25.7 RBE Gy.
CONCLUSIONS: We have demonstrated that BPA-f-mediated NCT can be
precisely planned and delivered in a carefully controlled manner.
Subsequent clinical trials of boron neutron capture therapy at Harvard
and MIT will be initiated with a new high-intensity, high-quality
epithermal neutron beam.
29
UI - 11891728
AU - Madsen SJ; Sun CH; Tromberg BJ; Hirschberg H
TI -
Development of a novel indwelling balloon applicator for optimizing
light delivery in photodynamic therapy.
SO - Lasers Surg Med 2001;29(5):406-12
AD - Department of Health Physics, University of Nevada, Las Vegas, Nevada
89154, USA. steenm@ccmail.nevada.edu
BACKGROUND AND OBJECTIVE: A human glioma spheroid model is used to
investigate the efficacy of different light delivery schemes in
5-aminolevulinic acid (ALA)--mediated photodynamic therapy (PDT). The
results provide the rationale for the development of an indwelling
balloon applicator for optimizing light delivery. STUDY DESIGN/MATERIALS
AND METHODS: Human glioma spheroids were incubated in ALA (100 or 1000
microg /ml-1) for 4 hours and subjected to various light irradiation
schemes. In one set of experiments, spheroid survival was monitored as a
function of light fluence rate (5-200 mW cm-2). In all cases, spheroids
were exposed to fluences of either 25 or 50 J cm-2. In a second study,
the effects of repeated weekly PDT treatments, using sub-threshold
fluences, were investigated. One group of spheroids was subjected to
three treatments using fluences of 12, 12, and 25 J cm-2. Results were
compared to spheroids receiving single treatments of either 12 or 25 J
cm-2. A fluence rate of 25 mW cm-2 was used for all three groups of
spheroids. In all cases, the effect of a given irradiation scheme was
evaluated by monitoring spheroid growth. RESULTS: Low fluence rates
produce greater cell kill than high fluence rates. The minimum effective
fluence rate in human glioma spheroids is approximately 10 mW cm-2.
Repeated weekly PDT treatments with sub-threshold fluences result in
significant cell kill. In spheroids surviving the PDT treatments, growth
is suppressed for the duration of the treatment period. CONCLUSION: The
results of the in vitro studies support the development of an indwelling
balloon applicator for the delivery of light doses in long term
multi-fractionated PDT regimens.
30
UI - 12132939
AU - Parker BC; Shiu AS; Maor MH; Lang FF; Liu HH; White RA; Antolak JA
TI -
PTV margin determination in conformal SRT of intracranial lesions.
SO - J Appl Clin Med Phys 2002 Summer;3(3):176-89
AD - Department of Radiation Physics, The University of Texas M. D. Anderson
Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA.
bparker@mdanderson.org
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