High-dose BCNU and autologous progenitor cell transplantation given with intra-arterial cisplatinum and simultaneous radiotherapy in the treatment of high-grade gliomas: benefit for selected patients.
ABSTRACT A phase II study of postoperative high-dose carmustine (HDBCNU), intracarotid cisplatin (CDDP), and radical radiotherapy in patients with high-grade glioma was performed. Patients underwent 4-6 consecutive days of blood hematopoietic progenitor cell (HPC) apheresis without prior mobilization. Chemotherapy included intracarotid CDDP, 60 mg/m2, and BCNU, 900 mg/m2. HPC were infused 48 h after HDBCNU. Whole brain irradiation, up to 50 Gy, was started on the 8th day after HPC infusion. With a median follow-up time of 44 months, median overall survival was 15.5 months. Eight patients (23.5%) are alive free of disease 2-6 years after treatment (seven out of 25 patients with glioblastoma multiforme and one out of nine patients with anaplastic astrocytoma). Survival was influenced by young age, good performance and complete surgical resection. Two patients (5.8%) died of therapy-related complications. Acute hematological toxicity of HDBCNU was moderate, with a full recovery on day 26. No acute pulmonary or hepatic toxicity was found. Late severe neurological toxicity was observed in one third of patients surviving beyond 2 years. We conclude that HDBCNU, 900 mg/m2, intracarotid CDDP and radical radiotherapy appear to benefit some patients with high-grade gliomas, and phase III studies should preferentially select young patients with resectable tumors.
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ABSTRACT: As intraoperative MRI expands its presence, its use will undoubtedly increase in glioma surgery. The foregoing discussion makes it clear that its benefits are unsurpassed by any other existing system. Because of their radiographic characteristics and gross appearance, gliomas are particularly suited for intraoperative MRI-guided surgery. It enables us to localize gliomas and define tumor margins precisely when, during surgery, the difference between tumor and brain is not easy to discern. The images generated during surgery serve as a detailed and updated map within which navigation is performed with utmost precision. Its significance is further highlighted when dealing with tumors in eloquent areas of the brain, where uncertainties over the location of tumor in relation to important brain structures can hinder the removal of tumor. By providing accurate positional information and in conjunction with cortical mapping techniques, intraoperative MRI enhances the confidence of the surgeon to go forward with resection or to stop when reaching important cortex. It allows us to perform the resection to the desired limit without causing injury to nearby important structures, thereby preventing postoperative neurologic deficits. The tracking system guides us in targeting each minute part of the tumor with unprecedented accuracy, and the ability to update images makes possible the constant evaluation of the progress of surgery. This near-real-time imaging can eliminate the errors brought about by the brain shifting that occurs throughout surgery. It also serves the important purpose of verifying the presence and position of any remaining tumor in the operative field. By means of sequential imaging, additional resection can be performed on any remaining tumor until imaging shows completion. The unwanted occurrence of finding residual tumor on a postoperative scan is thus practically eliminated. As a result, the surgical goal of complete or optimal resection can be achieved without any guesswork. Ultimately, what this means for the glioma patient is increased likelihood of longer survival brought about by a more thorough tumor resection. Intraoperative MRI addresses many of the surgical challenges posed by gliomas. As it becomes more available, there will come a point when the prevailing persuasion will be that some poorly defined tumors near eloquent cortex should not be operated on without intraoperative MRI. In the final analysis, not only is intraoperative MRI worthwhile but it will, in all likelihood, become a standard of care for many glioma cases.Neurosurgery Clinics of North America 02/2005; 16(1):135-41. · 1.76 Impact Factor