Neuro-oncology: clinical research and applied technology in the mid-1990s.
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Brain Neoplasms↗
Biomedical subjects
P C Phillips
Publications and source records attributed to P C Phillips.
Surveillance scanning of children with medulloblastoma.
BACKGROUND: The standard follow-up care for children with medulloblastoma includes regular clinical evaluations and surveillance scanning of the central nervous system with computed tomography or magnetic resonance imaging. The evaluations and scanning assess the response of the tumor to treatment, detect any recurrence of disease, and monitor any complications of treatment. We compared the effectiveness of a periodic history taking and physical examination with that of surveillance scanning in detecting recurrent tumors. METHODS: We reviewed the medical records, including 794 scanning reports or scans, of 86 children with posterior fossa medulloblastoma who were followed regularly between 1980 and 1991. Recurrent tumors were classified as symptomatic if neuroimaging studies had been prompted by clinical symptoms or signs and as radiographic if the tumor had been detected by imaging in an asymptomatic patient. RESULTS: Twenty-three of the 86 children (27 percent) had a recurrence of tumor. Four recurrences (17 percent) were detected on scanning only, and 19 (83 percent) were associated with symptoms arising a median of four months after the previous scan. The median and range of survival after a recurrence of the tumor were 5 months and < 1 to 38 months, respectively, for a symptomatic recurrence and 20 months and 10 to 32 months, respectively, for a radiographic recurrence (P = 0.03). No patient survived after a recurrence. The longer survival of patients with recurrent tumors detected by scanning most likely reflects the small number of patients and lead-time and length biases associated with screening. CONCLUSIONS: Among children with medulloblastoma, surveillance scanning is of little clinical value. Scanning detected a minority of recurrences, and no patient who had a recurrence survived.
Adolescent↗
Transforming growth factor-alpha-Pseudomonas exotoxin fusion protein (TGF-alpha-PE38) treatment of subcutaneous and intracranial human glioma and medulloblastoma xenografts in athymic mice.
Epidermal growth factor receptor (EGFR) is amplified or overexpressed in many malignant gliomas and other primary brain tumors but is low or undetectable in normal brain. In the present study, this differential expression has been exploited for targeted brain tumor therapy using a TGF-alpha-Pseudomonas exotoxin recombinant toxin, TGF-alpha-PE38. In vitro experiments demonstrate that the cytotoxicity of this fusion protein is primarily determined by tumor EGFR expression and that TGF-alpha-PE38 cytotoxicity is abolished by pretreatment with excess epidermal growth factor. Treatment with i.p. TGF-alpha-PE38 in nude mice bearing glioblastoma or medulloblastoma s.c. xenografts produced tumor regression and growth delay. For intracranial xenograft implants treated with i.p. TGF-alpha-PE38, significant increases in median survival were noted only for tumors with the highest EGFR expression. However, intracranial tumors treated with a single intratumoral injection of TGF-alpha-PE38 showed increased survival in all xenografts tested. These results indicate that TGF-alpha-PE38 is active against primary human brain tumors ranging from moderate to high EGFR expression. For intracranial tumors, however, the higher survival rates produced by intracranial injection of TGF-alpha-PE38 than by continuous i.p. administration suggest that increased drug clearance or impaired drug delivery reduces the efficacy of systemic TGF-alpha-PE38. Direct delivery of TGF-alpha-PE38 into brain tumors by controlled-release biodegradable polymers or intratumoral implanted catheters, or intrathecal administration into the colony stimulating factor of patients with leptomeningeal metastasis, may represent clinically useful applications of recombinant toxin therapy in tumors with high EGFR expression.
Animals↗
Cognitive deficits in long-term survivors of childhood medulloblastoma and other noncortical tumors: age-dependent effects of whole brain radiation.
Twenty-four children, aged 1.5-20 yr at diagnosis, with noncortical brain tumors, primarily medulloblastoma, have been followed for 3-4 yr for intellectual status. All the children received craniospinal irradiation, and 19 of 24 received chemotherapy as well. For the group as a whole. Full Scale IQ fell from 104 at baseline to 91 at final follow-up. Children younger than 7 yr at diagnosis showed a significant decrease in IQ as early as year 1, and all changes from baseline to years 3 and 4 were significant. In contrast, children older than 7 yr at diagnosis did not show a significant IQ change from baseline to year 3 or 4. The Spearman correlation coefficient between IQ change and age at diagnosis from baseline to year 4 was 0.57 (P = 0.003). This study supports the hypothesis that children treated with whole brain radiation at a younger age have more severe cognitive impairment than those treated at a later age. Limitations in sample size and duration of observations do not permit us to identify whether a true plateau occurs 2-4 yr after irradiation versus a continued progressive decline in intellectual performance. Moreover, we cannot at this time distinguish between a true dementing process versus failure to acquire new cognitive skills at a rate comparable to age-matched peers.
Adolescent↗
Acute neurotoxicity after intrathecal cytosine arabinoside in two adolescents with acute lymphoblastic leukemia of B-cell type.
BACKGROUND: Two adolescents with acute B-cell leukemia (Burkitt leukemia) had acute severe neurotoxicity after treatment with intrathecal (IT) cytosine arabinoside (AraC) at a dose of 50 mg/day for three consecutive days. RESULTS: A 16-year-old boy had a rapidly ascending myelopathy and encephalopathy 20 hours after receiving the third dose of IT AraC. He remained quadriplegic and required ventilatory assistance for 10 months until his death from progressive tumor. A 12-year-old girl had acute encephalopathy, seizures, and focal neuroimaging abnormalities in the cerebellum and brain stem within 32 hours of the third AraC dose and 8 hours after IT methotrexate (MTX, 12 mg). Her clinical neurologic deficits resolved during the ensuing month. Patient 1 represents the first report to the authors' knowledge of acute severe neurotoxicity after AraC administered as the only IT drug. In Patient 2, IT AraC neurotoxicity may have been potentiated by the single dose of MTX. CONCLUSION: IT AraC administered for 3 or more consecutive days may lead to profound neurologic dysfunction and require discontinuation of therapy.
Adolescent↗
Folliculo-stellate cells in the human anterior pituitary express cytokeratin.
Recent studies have suggested that the anterior pituitary is derived not from Rathke's pouch, but instead from neuroectoderm. To address this controversy and the differentiation of the adenohypophysis, we evaluated folliculo-stellate cells from 7 human pituitaries using a panel of immunohistochemical stains. The panel included antibodies to a low molecular weight cytokeratin (CK-8), a broad spectrum of cytokeratins (AE 1/AE 3), S-100 protein, vimentin, and glial fibrillary acid protein. The most intense immunostaining was observed with the antibody to broad spectrum cytokeratins. Less intense immunohistochemical staining of folliculo-stellate cells was observed with the antibodies against glial fibrillary acidic protein and S-100 protein. Immunoblotting of anterior pituitary tissue obtained from 3 autopsied patients showed that cytokeratins identified in the anterior pituitary were of low molecular weight (40 to 56 Kd). These results indicate that folliculo-stellate cells show epithelial differentiation, and support the hypothesis that the anterior pituitary is derived from Rathke's pouch.
Blotting, Western↗
Intrathecal 4-hydroperoxycyclophosphamide: neurotoxicity, cerebrospinal fluid pharmacokinetics, and antitumor activity in a rabbit model of VX2 leptomeningeal carcinomatosis.
Dissemination of tumor to the leptomeninges and cerebrospinal fluid represents a common pattern of metastasis for many cancers; however, few chemotherapeutic agents are available for intrathecal (i.t.) use and treatment results are often poor. We studied the neurotoxicity and pharmacokinetics of i.t. 4-hydroperoxycyclophosphamide (4-HC) in the rabbit and the activity of i.t. 4-HC in a VX2 rabbit model of leptomeningeal carcinomatosis to evaluate the potential use of 4-HC in the treatment of leptomeningeal tumors. Toxicity studies examined 4-HC doses ranging from 0.5 to 6.0 mumol administered by intraventricular injection weekly for 4 to 8 weeks. Clinical or histological neurotoxicity was not observed in rabbits treated with < 1.0 mumol 4-HC for 4 weeks. Clinical toxicity, characterized by lethargy, weight loss, seizures, or death, was apparent at doses > 2.0 mumol. Vasculitis of superficial arteries was observed in rabbits treated with > 1.0 mumol 4-HC. In cerebrospinal fluid pharmacokinetic studies, the mean drug half-life after intraventricular or intralumbar administration was 24.3 and 18.2 min. Regional inequities in drug exposure were apparent as area under the clearance curve values for cerebrospinal fluid distant from the injection site were lower than those of proximate sites (P < 0.001). Weekly intraventricular treatment of VX2 leptomeningeal tumor-bearing rabbits with 0.5 or 1.0 mumol of 4-HC resulted in an increased life span of 22.5 and 35%, respectively. These results indicate that i.t. 4-HC, at doses lower than those producing neurotoxicity in the rabbit, is effective treatment for VX2 leptomeningeal carcinomatosis.
Animals↗
Colloid cysts of the third ventricle: immunohistochemical evidence for nonneuroepithelial differentiation.
The histogenesis of colloid cysts (CCs) of the third ventricle has been a subject of controversy. We examined, using immunohistochemical techniques, four CCs for the presence of cytokeratins (CKs), glutathione S-transferase isoenzymes (GST-pi, GST-mu), and glial fibrillary acidic protein. Antibodies to both low molecular weight CKs (anti-CK8) and to a mixture of CKs (AE1/AE3) were used. For comparison, normal fetal and adult choroid plexus, ependyma, and nasal mucosa were also examined. The epithelium lining all four CCs showed positive immunostaining for the CKs and GST-pi but not for GST-mu or glial fibrillary acidic protein. Fetal and adult nasal mucosa showed a pattern of immunohistochemical staining almost identical to that of CCs. In contrast, fetal and adult choroid plexus tissue showed positive immunostaining for GST-pi and low molecular weight CKs but not for the CK mixture (AE1/AE3). Fetal and adult ependyma were negative for both CKs and GST-pi. These results suggest that CCs differentiate along nonneural lines distinct from the neuroepithelial differentiation of the choroid plexus and ependyma.
Adult↗
Leptomeningeal dissemination of optic pathway gliomas in three children.
We treated three children with optic pathway gliomas who had progressive disease associated with metastatic spread to the leptomeninges. One patient had radiographic resolution of leptomeningeal disease after treatment with intravenous carmustine and oral mercaptopurine but died of progressive pulmonary fibrosis. The second patient was treated with intravenous thiotepa, and the leptomeningeal disease remained stable. The third patient was treated with intravenous vincristine sulfate, cyclophosphamide, cisplatin, and etoposide and had a significant size reduction of the leptomeningeal lesion. Although leptomeningeal dissemination is a seemingly rare event, it is important that all children with optic pathway gliomas be considered for this possibility, particularly after the onset of new, atypical neurologic symptoms.
Antineoplastic Agents↗
Abnormal cerebral glucose metabolism in long-term survivors of childhood acute lymphocytic leukemia.
Chemotherapy and radiation treatment of the central nervous system may cause delayed neurotoxicity in children with acute lymphocytic leukemia. We evaluated 12 long-term survivors of childhood leukemia using [18F]fluorodeoxyglucose positron emission tomography, computed tomography scans, clinical neurological examinations, and neuropsychological tests. Regional cerebral metabolic rate for glucose (rCMRGlc) values for white matter were lower in the older long-term survivors (greater than 18 years old) treated with cranial radiation and intrathecal chemotherapy than in normal control subjects or survivors who had been treated with intrathecal chemotherapy alone. The ratio of white matter: cortex rCMRGlc values was lower than control values in the long-term survivors treated with cranial radiation and intrathecal chemotherapy, regardless of age, but not in those treated with intrathecal chemotherapy alone. By contrast, thalamic rCMRGlc values were lower than control values in older survivors regardless of treatment, and the ratio for thalamus:cortex rCMRGlc values was lower in all the treatment groups than in the control subjects. The highest rCMRGlc values were found in the youngest children, indicating an important effect of age on cerebral glucose metabolism. No neuropsychological deficits were identified in patients treated only with intrathecal chemotherapy; however, lower IQ scores were found in the long-term survivors who had been treated with cranial radiation and intrathecal chemotherapy. Treatment of the central nervous system with cranial radiation and intrathecal chemotherapy may cause prolonged alterations in white-matter and thalamic rCMRGlc, which may permit the identification and assessment of neurotoxicity in long-term survivors of acute lymphocytic leukemia by [18F]fluorodeoxyglucose positron emission tomography.
Adolescent↗
PET imaging of brain tumors.
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Biological Transport↗
Osteoblastic metastases from astrocytomas: a report of two cases.
The spread of primary central nervous system (CNS) neoplasms beyond the confines of the neuraxis is a relatively uncommon observation. Extraneural metastases involving bone are quite rare, and have been observed almost exclusively in cases of medulloblastoma, high-grade (III-IV) astrocytoma, and glioblastoma multiforme. To date there has been only one case reported of bone metastasis from a "well-differentiated" astrocytoma. We now report two cases of astrocytoma in children with diffuse osteoblastic metastases and a fulminant clinical course. These cases demonstrate that due to the potential morphologic heterogeneity of these neoplasms, an initial biopsy diagnosis of low-grade astrocytoma does not always imply a benign clinical course.
Adolescent↗
Cisplatin, ara-C and etoposide (PAE) in the treatment of recurrent childhood brain tumors.
Sixteen patients with recurrent childhood brain tumors were treated with intravenous cisplatin, cytosine arabinoside and etoposide (PAE), daily for three days every three to four weeks. Objective responses were observed in 6 of 15 evaluable patients and an additional six patients had stable disease for greater than 6 months. The tumor-specific response rate for astrocytoma/glioma was 3 of 7 and for medulloblastoma was 2 of 4. The mean progression-free interval was 11.0 months and the hazard rate for progression was 0.085 per patient-month of observation. The most common toxicities were neutropenia and thrombocytopenia. Clinically significant ototoxicity was identified in 7 patients. The activity of PAE chemotherapy for recurrent childhood brain tumors warrants further investigation.
Adolescent↗
Multidrug resistance gene (MDR1) expression in human brain tumors.
Multidrug resistance for many types of cancer outside the central nervous system (CNS) has been found to be due to the overexpression of the multidrug resistance gene MDR1, of which the gene-product P-glycoprotein acts as a membrane-bound efflux pump for many anticancer drugs. To examine whether brain tumors overexpress the MDR1 gene, 25 brain-tumor specimens were subjected to Northern blot analysis: 10 gliomas, eight meningiomas, three schwannomas, one malignant lymphoma, and three tumors metastatic to the brain. Ten fresh-frozen autopsy specimens of various parts of normal brain were also analyzed. Blots were hybridized with 32P-labeled Chinese hamster complementary deoxyribonucleic acid (cDNA) and 32P-labeled human MDR1 cDNA. The MDR1 gene messenger ribonucleic acid (mRNA) was detected in two tumors using the Chinese hamster probe (one sphenoid wing meningioma and one metastatic prostate tumor) and in one CNS lymphoma using the human probe. Intact mRNA could not be extracted from the fresh-frozen autopsy specimens of normal brain. Seventeen tumors were examined for P-glycoprotein by immunohistochemical staining using murine monoclonal antibody C219: eight gliomas, eight meningiomas, and one craniopharyngioma. The neoplastic cells from two gliomas and three meningiomas and the blood vessels within six gliomas and two meningiomas stained positively for P-glycoprotein. Seven of 10 normal brain specimens stained positively for P-glycoprotein in blood vessels but no specimen demonstrated staining of parenchymal cells. This study demonstrates that the MDR1 gene can be detected in normal brain, and in malignant, benign, and metastatic lesions. P-glycoprotein can be present in tumor blood vessels even when it is not seen in neoplastic cells. Although the role of P-glycoprotein in tumor blood vessels needs to be further examined and more clearly defined, drug resistance in malignant primary brain tumors may result from characteristics not solely of neoplastic cells but also tumor vasculature.
ATP Binding Cassette Transporter, Subfamily B, Mem↗
Antineoplastic drug resistance in brain tumors.
For all neoplasms, extraneural as well as brain, intrinsic, and acquired resistance to antineoplastic drugs constitutes a multifactorial problem. Much information has been generated concerning the individual mechanisms that play a role in drug resistance. The present decade will see a great deal of laboratory research emphasis in two related areas: (1) the molecular biology of resistance, including processes that regulate gene expression for critical detoxifying and transport proteins, and (2) further identification of DNA repair mechanisms in normal and neoplastic cells. In addition to continued research directed toward the identification of specific mechanisms, further study of the interrelationship between these mechanisms will be essential. Finally, there is a growing awareness that in vitro determination of the rank order of mechanisms contributing to resistance for a given drug may be quite different from that determined in vivo. The complexity of this problem is increased for brain tumors in that the understanding of the fundamentals of brain tumor biology is less advanced than for many of the systemic tumors. Ultimately, the identification of resistance mechanisms will lead to the development of clinically useful approaches to reverse cellular resistance and to increase drug sensitivity. Examples of such strategies that have or will find their way into clinical trial include: (1) use of buthionine sulfoximine to reverse glutathione-mediated resistance, (2) use of ethacrynic acid to reverse glutathione S-transferase-mediated resistance, and (3) use of calcium channel blockers and calmodulin inhibitors to reverse MDR. There will also be considerable emphasis on the rational modification of existing antineoplastic agents and the development of new drugs designed to circumvent important resistance mechanisms. For brain tumor treatment, additional strategies to circumvent intrinsic and acquired resistance by increasing drug delivery, such as high-dose chemotherapy with marrow or growth factor rescue and local drug delivery to brain tumors by drug-impregnated biodegradable polymers, will continue to be examined. Previous experience with efforts to augment antineoplastic drug cytotoxicity indicates that this process may decrease the margin of cytotoxicity between normal tissue and tumor, often referred to as the therapeutic index. To avoid serious neurotoxicity as a dose-limiting or treatment-limiting factor for potentially important clinical strategies to modulate drug resistance, it will be important to develop a greater understanding of the relative treatment sensitivities of brain capillary endothelium, glial cells, and neurons, as well as their individual abilities to transport, detoxify, and repair the effects of these drugs.(ABSTRACT TRUNCATED AT 400 WORDS)
ATP Binding Cassette Transporter, Subfamily B, Mem↗
L-methionine uptake by human cerebral cortex: maturation from infancy to old age.
Age-associated changes in amino acid transport from blood to normal frontal cortex were studied using positron emission tomography (PET). Seventeen patients, 1.8-71 yr, were injected intravenously with tracer doses of [11C] L-methionine and a baseline PET scan was obtained. To assess competitive inhibition of [11C]L-methionine uptake, patients received either oral L-phenylalanine or an i.v. infusion of amino acids 1 hr before a second PET study. Uptake of [11C]L-methionine by frontal cortex decreased seven-fold between 1.8 and 71 yr (r = -0.71; p less than 0.05). Blood-to-brain transfer of [11C]L-methionine, at 4.5 yr, exceeded mean adult values by more than five-fold. Competitive inhibition reduced L-methionine uptake in all patients older than 4.6 yr. These developmental changes parallel findings in animals. The neutral amino acid transport system may modulate human brain amino acid levels to meet changing developmental metabolic needs.
Adult↗
High-dose leucovorin reverses acute high-dose methotrexate neurotoxicity in the rat.
Intravenous high-dose methotrexate (HD-MTX) reduces cerebral glucose metabolism and produces behavioral abnormalities and electroencephalographic slowing in an animal model of acute HD-MTX neurotoxicity and in cancer patients undergoing HD-MTX chemotherapy. We used our model of HD-MTX neurotoxicity in the rat to determine if leucovorin (5-formyltetrahydrofolate) reduces this neurotoxicity, and extended our characterization of this model to identify regional as well as global HD-MTX treatment effects and to investigate HD-MTX-induced alterations in regional brain pH. Intravenous high-dose leucovorin reversed the HD-MTX-induced decrease in cerebral glucose metabolism and associated behavioral and electroencephalographic abnormalities in the rat, but low-dose leucovorin was ineffective. The major effect of HD-MTX on cerebral glucose metabolism was a global reduction; however, smaller region-specific treatment effects were identified in auditory, thalamic, and white matter structures. HD-MTX did not alter regional brain pH. These findings suggest a potential clinical role for high-dose leucovorin in severe or prolonged acute HD-MTX neurotoxicity and provide an important justification for the role of positron emission tomography in the early detection of clinical HD-MTX neurotoxicity.
Animals↗
Congenital odontoid aplasia and posterior circulation stroke in childhood.
Head trauma and vigorous physical activity were followed by delayed-onset posterior circulation stroke in a 5-year-old boy with odontoid aplasia and C1-C2 subluxation. Angiography demonstrated vertebral artery narrowing and occlusion of the left anterior-inferior cerebellar and posterior cerebral arteries. Odontoid aplasia and other atlantoaxial dislocations are treatable causes of posterior circulation insufficiency in childhood; these defects may be overlooked without appropriate radiographic study of the cervical spine using flexion-extension views.
Atlanto-Axial Joint↗