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Biomedical subjects

E C Halperin

Publications and source records attributed to E C Halperin.

At least 55 records · Page 3Linked to original sources
PubMed1994

Management of pineal non-germinoma germ cell tumor with residual teratoma and normal alpha-fetoprotein.

A 16-year-old white male presented with multiple abnormal extraocular movements secondary to an enhancing pineal tumor. Subtotal resection of the lesion revealed a mixed malignant germ cell tumor. The preoperative serum alpha-fetoprotein (AFP) was markedly elevated at 155 IU/L. The patient subsequently received radiotherapy and adjuvant chemotherapy consisting of cisplatin rotating monthly with vincristine and cyclophosphamide, with dramatic tumor regression and return of AFP to normal. Eighteen months later the persistence of a substantial tumor mass despite a normal AFP raised concern for residual active tumor. Histological examination of the resected lesion revealed benign teratoma and fibrous tissue. Repeat management of mixed malignant germ cell tumors, which demonstrate a persistent mass following an initial response to treatment.

Adolescent↗
PubMed1994

Arteriovenous malformation mimicking recurrent medulloblastoma.

Magnetic resonance imaging (MRI) is becoming the method of choice for evaluation of central nervous system tumors. However, the sensitivity of this modality raises concern that new lesions in patients previously diagnosed with a brain tumor may not necessarily represent recurrent disease. We report a patient previously treated with surgery, radiotherapy, and chemotherapy for a medulloblastoma who developed a new lesion in the floor of the fourth ventricle. Histologic review following excision revealed an arteriovenous malformation.

Brain Neoplasms↗
PubMed1994

Cyclophosphamide, doxorubicin, vincristine, and prednisone for primary central nervous system lymphoma: short-duration response and multifocal intracerebral recurrence preceding radiotherapy.

The activity of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) in the treatment of primary central nervous system lymphoma (PCNSL) prior to radiotherapy was studied in six patients. Primary lesions were reduced by 80% or more on contrast-enhancing cross-sectional area in four patients and to a lesser extent in two others after two cycles of chemotherapy. The primary lesion sites demonstrated no contrast enhancement in the three patients who completed four cycles of therapy. However, concurrent with response at the primary disease sites, multiple lesions occurred at distant, noncontiguous CNS parenchymal sites in five patients after two to four cycles of chemotherapy. Median survival was 8.5 months for the six enrolled patients and 16.5 months for the four patients completing craniospinal radiotherapy. PCNSL is highly responsive to standard systemic non-Hodgkin's lymphoma chemotherapy regimens, but the pattern and rapidity of relapse suggest mechanisms of failure including inherent or rapidly evolving antineoplastic drug resistance and perhaps limited drug delivery to occult sites of disease in the brain.

Aged↗
PubMed1994

Techniques of experimental animal radiotherapy.

Animal research is a crucial component of the generation of new knowledge in human and veterinary medicine. Total body irradiation, whole brain irradiation, total lymphoid irradiation, and local field irradiation of experimental animals are powerful tools for immunology, oncology, studies of normal tissue radiation tolerance, and medical physics. Animal radiotherapy requires specialized techniques. Because of necessarily smaller field sizes, beam localization must be particularly precise. Care must be taken to obtain optimum and accurate dose distribution. This requires consultation with a medical physicist. Optimum dose distribution may be obtained, depending upon the circumstance, by use of either a single beam or two parallel opposed beams with or without bolus. To ensure a proper dose to the animal target volume, care must be paid to the selection of beam energy and the use of radiation attenuators. Beams may be shaped by custom-made lead alloy blocks. Radiation dose rate may be modified by changing the linear accelerator output or the distance from the beam source to the animal, or by attenuating the beam. Reliable targeting of animals requires, for fields other than total body irradiation, anesthesia-utilizing agents such as ether, ketamine, and pentobarbital. The objective of this report is to review the techniques of experimental animal radiotherapy.

Anesthesia↗
PubMed1993

Final results of a study of escalating doses of hyperfractionated radiotherapy in brain stem tumors in children: a Pediatric Oncology Group study.

PURPOSE: In September 1984, the Pediatric Oncology Group began accrual to a Phase I/II study designed to assess the efficacy and toxicity of sequentially escalated doses of hyperfractionated (twice daily) radiotherapy in children with poor-prognosis brain stem tumors. Pediatric Oncology Group Study #8495 closed in June 1990 with a total of 136 patients on study. We report here the outcome of patients treated at the third and final dose level (75.6 Gy), and compare the results to those obtained at the 66 and 70.2 Gy dose levels. METHODS AND MATERIALS: Patients eligible for study were those between 3 and 21 years of age with previously untreated tumors arising in the midbrain, pons or medulla. Histological confirmation of diagnosis was not mandatory provided that the clinical and radiological findings were typical for brain stem glioma. Treatment consisted of radiotherapy delivered to local fields. At the third dose level, fraction sizes of 1.26 Gy were given twice daily, with a minimum interfraction interval of 6 hr to a dose of 75.6 Gy in 60 fractions over 6 weeks. Between 5/89 and 6/90, 41 patients were accrued to the study. Two were excluded from analysis leaving 39 evaluable patients, 21 male and 19 female, whose ages ranged from 3 to 15 years (median 7.5 years). RESULTS: Following treatment, neurological improvement was reported in 30/39 (77%) of the patients. On central review of imaging studies in 29 patients, one patient was found to have had a complete response to radiotherapy, five a partial (> 50% response), and only three had non-responding or progressive disease. The median time to disease progression was 7 months; median survival time was 10 months; survival at 1 year was 39.9% (SE 8.3%) and at 2 years, 7% (SE 4.8%). The pattern of failure was local in all patients; in addition six had evidence of leptomeningeal seeding. Morbidity of treatment included an enhanced skin reaction (21%), otitis media and/or externa (26%), and steroid use > 3 months (62%). Intralesional necrosis was a frequent finding (45%) on imaging studies performed at a median time of 6 weeks post treatment. CONCLUSION: The results of treatment in terms of progression-free survival and overall survival are not significantly different (at p = .55 and p = .46, respectively) from those obtained at the two previous dose levels. There is no evidence that higher doses of hyperfractionated radiotherapy given as in this study improve the outlook of patients with poor-risk brain stem gliomas.

Adolescent↗
PubMed1993

The management of desmoid tumors.

PURPOSE: To determine the efficacy of different treatment modalities for desmoid tumors. MATERIALS AND METHODS: We reviewed the treatment of 40 patients with histologically confirmed desmoid tumors seen at Duke University Medical Center between 1974 and 1990. RESULTS: Radiotherapy was administered to 16 patients (Group I)--14 with recurrent disease s/p surgery and in two as initial treatment. The average size of the irradiated lesions was 9.3 +/- 3.9 X 8.4 +/- 3.5 cm. With a median follow-up of 57.5 months and a median administered dose of 5400 cGy (mean 5286 cGy, range 4960-5620 cGy), local control has been obtained in 15/16 patients (94%). Complete regression (5/16), partial regression (5/16), or stable disease (5/16) was produced in 15 patients while one patient failed and was salvaged via gross total resection. Continued regression has been seen up to 60 months after treatment. Fourteen patients underwent primary gross total resection and two underwent subtotal resection (Group II). None received post-operative radiotherapy. Three of 14 patients (21%) recurred after gross total resection. All three were salvaged with subsequent gross total resection. After subtotal resection, 2/2 patients recurred. With a mean follow-up of 52 months, 14 patients are without evidence of disease, one is dead with disease (unrelated cause of death), and one was lost to follow-up after recurrence. Eight patients have been treated with combinations of chemotherapy, NSAIDS, anti-estrogens, and immunotherapy with mixed results (Group III). A subset of seven patients with retroperitoneal disease taken from all three groups had large tumor burden (mean size 17 X 15 cm), an infiltrative nature, as well as a difficult location. The disease was surgically resectable in three patients. One is without evidence of disease 9 years after gross total resection alone. Disease has been stabilized with radiotherapy in the other two patients after multiple unsuccessful surgical resections. Of four patients with unresectable disease, two are dead of disease, one died of unrelated causes with disease, and regression of disease was obtained in the other with Gamma-interferon after unsuccessful treatment with tamoxifen and vincristine, doxorubicin, and cyclophosphamide chemotherapy. CONCLUSION: Gross total resection is the indicated initial therapy, if it can be performed without significant disfigurement. Radiotherapy is also excellent for obtaining local control, even in patients with a large burden of recurrent disease. Doses in the range of 50 to 55 Gy give a chance of local control equal to that obtained with higher doses previously reported.

Adolescent↗
PubMed1993

A double-blind, randomized, prospective trial to evaluate topical vitamin C solution for the prevention of radiation dermatitis. CNS Cancer Consortium.

PURPOSE: The object of this study was to ascertain the value of topical ascorbic acid in the prevention of radiation dermatitis. METHODS AND MATERIALS: Patients with primary or metastatic brain tumors were eligible. Patients applied a topical solution, twice per day prior to and throughout the course of radiotherapy, to the left and right sides of the head. The radiotherapist and the patient were blinded as to the contents of the solutions. The bottle for one side of the head contained topical ascorbic acid solution. The bottle for the other side of the head contained only vehicle. During and after the course of treatment the radiotherapist scored the skin reaction on both the left and right sides of the irradiated head using a skin reaction scale. The data were analyzed with a matched pair analysis. Since each patient received both treatments (ascorbic acid and control solutions) the statistical analysis concentrated on the paired difference in scores based on the probability of a "preference" for the treatment or control. RESULTS: Eighty-four patients entered the study. Sixty-five were suitable for analysis. In 10 patients there was a preference for ascorbic acid solution (15%), in 20 patients there was a preference for placebo (31%), and there was a preference for neither in 35 patients (54%). Ascorbic acid solution could be considered to have an effect if the percentage of preferences favoring ascorbic acid over placebo, among those subjects with a preference, significantly exceeded the 50% expected by chance. The observed percentage of preferences for ascorbic acid was only 33% (10 of 30 with a preference; p = .10, two-sided sign test). Patient age, race, sex, and total dose of irradiation had no detectable influence on the comparative skin toxicity scores. CONCLUSION: There is no discernible benefit to ascorbic acid lotion, in the manner in which we used it in this trial, for the prevention of radiation dermatitis.

Adolescent↗
PubMed1993

Concerning the inferior portion of the spinal radiotherapy field for malignancies that disseminate via the cerebrospinal fluid.

PURPOSE: Many radiotherapists widen the inferior aspect of the craniospinal irradiation field to encompass the sacroiliac joints and "cover the sacral nerve roots." This is commonly referred to as a "spade" field. Other therapists, however, reject the notion of widening the bottom of the field--feeling that straight field borders are adequate. We have evaluated this controversy by an anatomical study. METHODS AND MATERIALS: Twenty-five skeletons were measured to ascertain the distance between the outermost portions of the posterior pedicles of L3, L4, and L5; the distance between the outermost portions of the intervertebral foramina between L3-L4, L4-5, and L5-S1 through which the spinal nerves pass; and the width of the most lateral portions of the posterior and anterior foramina of S1 and S2 through which the sacral spinal nerves would pass. Twenty-two cranial spinal irradiation simulator films of patients with medulloblastoma were used to measure the distance between the outermost portions of the posterior pedicles of L3, L4, and L5 and the foramina of S1 and S2. These measurements were then corrected for film magnification. RESULTS: Skeleton measurements showed that the mean width between the outer portions of the posterior pedicles of L3 and 4.1 cm, for L4 it was 4.4 cm, and for L5 it was 5.1 cm. Measurements of the mean maximum width of the intervertebral foramen for nerve root exit at the bottom of L3 was 4.1 cm, for L4 4.4 cm, and for L5 4.7 cm. The mean distance between the outermost portions of the intervertebral foramen for nerve root exit at the front of S1 was 5.9 cm while it was 5.0 cm for the back of S1. The mean distance between the outermost portions of the anterior foramen of S2 was 5.7 cm and 4.8 cm for the back. Measurements from the 22 simulation films show that the mean maximum width between the outer portion of the posterior pedicles of L3 was 3.3 cm, for L4 3.5 cm, and for L5 3.8 cm. The mean maximum width of the intervertebral foramen for nerve root exit at the bottom of S1 was 4.4 cm and 4.5 cm for S2. CONCLUSIONS: While the caudal end of the craniospinal field needs to be widened by 1.2 to 1.8 cm to encompass the increase in distance between nerve root exits as one moves inferiorly down the spine, coverage of the sacroiliac joints is not necessary.

Adolescent↗
PubMed1993

Malignant glioma--timing of response to radiation therapy.

PURPOSE: The response of malignant gliomas to radiation was examined retrospectively in 71 patients with newly diagnosed supratentorial malignant gliomas. Questions asked included frequency, timing and clinical significance of response. METHODS AND MATERIALS: After surgery, all were treated with whole brain plus boost radiotherapy followed 8 weeks later by chemotherapy. The rate, degree, and timing of response to radiation were determined by comparing postoperative, end of radiation, and prechemotherapy CT scans on each patient. RESULTS: Postoperative residual tumor was evident on 63/71 postoperative scans. Twenty-two of 63 tumors (35%) had a partial or complete response to radiation. Twenty (32%) had responded by the end of radiation; 17 maximally. Six to 8 weeks later, three responding tumors had responded further and two previously stable ones had begun to respond. Only three tumors (5%) responded completely. A greater proportion of anaplastic gliomas than glioblastomas responded to radiation (52% vs. 26%). Protracted or delayed responses were only observed in patients with anaplastic glioma. Patients who responded to radiation did not live significantly longer than non-responders. However, tumor progression prior to chemotherapy was associated with significantly shorter survival. CONCLUSION: This CT scan-based analysis demonstrates that malignant gliomas are only moderately radioresponsive tumors and also demonstrates that response to radiation, if it is going to occur, is usually evident by the end of treatment.

Adolescent↗
PubMed1993

Comparison of serial PET and MRI scans in a pediatric patient with a brainstem glioma.

Profound clinical deficits may be associated with insults to the brainstem, making management of patients with brainstem gliomas very complex. Small changes in the radiographic appearance of a brainstem tumor may be associated with significant clinical deterioration. Furthermore, both magnetic resonance imaging and computed tomography are frequently unable to differentiate between therapy-related tissue reactions and progressive tumor. Two clinical scenarios particularly difficult to resolve include: (1) transient radiographic and clinical deterioration following hyperfractionated radiotherapy, and (2) clinical deterioration in a patient who has failed initial therapy, but has stable radiographic findings following a second therapy. We report a child with a pontine glioma whose tumor progression was demonstrated more convincingly with a 18F-deoxyglucose positron emission scan than with magnetic resonance imaging. PET scans may be helpful in confirming that tumor progression is responsible for clinical deterioration in a patient whose MRI scans remain stable.

Brain Neoplasms↗
PubMed1993

Multiple fraction-per-day radiotherapy for patients with brain stem tumors.

Brain stem tumors are among the most resistant brain tumors to therapy. The majority progress within 18 months of diagnosis and treatment. Multiple-fraction-per-day (MFD) radiotherapy would theoretically allow higher total doses of radiotherapy to be delivered in order to improve local tumor control without increasing neurotoxicity secondary to treatment. Seventeen patients with brain stem tumors were evaluated and treated at Duke University Medical Center (DUMC) from 1985 to 1991 with a MFD regimen. Six patients were accrued to Pediatric Oncology Group (POG) Protocol 8495 and were not included in this analysis, leaving eleven patients for review. Local fields were treated with fraction sizes of 110 or 117 cGy twice daily. There were 3 patients who received a total of 60.5-68.2 Gy and 8 who received 70.2-71.5 Gy. Initial and follow-up CT and/or MRI studies were available for review on all but one patient. All patients had progression of disease and have died. Median time to tumor progression was 5.8 months. Median overall survival was 11.2 months. There was no significant influence upon time to tumor progression or survival by total radiation dose received. Patients were classified by imaging group per the criteria of Stroink et al. based on review of their pre-treatment CT or MRI scans. One patient had no initial films available, 2 were in Group II (no contrast was given to separate A or B), 3 in IIA, 4 in IIB, and 1 in III. Autopsy in 3 patients failed to demonstrate histologic evidence of injury attributable to radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Surgery, hyperfractionated craniospinal irradiation, and adjuvant chemotherapy in the management of supratentorial embryonal neuroepithelial neoplasms in children.

Supratentorial embryonal neuroepithelial tumors are undifferentiated neoplasms. We have used this term in preference to the controversial classification primitive neuroectodermal tumors (PNET). These lesions in children are malignant neoplasms which are usually fatal within 2 years of diagnosis in spite of therapy with surgery, radiotherapy, and chemotherapy. We have adopted an aggressive approach to the treatment of these tumors with surgical resection, hyperfractionated craniospinal irradiation of 30.6-43.9 Gy followed by a tumor boost to a total dose of 50-63.7 Gy, and adjuvant chemotherapy with cyclophosphamide, vincristine, and cis-platinum. We have treated five children, aged 4-18 years, with this approach. In contrast to the results reported in the literature, four children are alive without evidence of tumor from 4.3 to 8.0 years following diagnosis. One has suffered a tumor relapse at 2.3 years following diagnosis but remains alive. The basis of our therapeutic strategy for childhood supratentorial embryonal neuroepithelial tumors and the implications of our clinical results are discussed.

Adolescent↗
PubMed1993

125I embedded in an orbital prosthesis for retreatment of recurrent retinoblastoma.

The application of radiation therapy in the retreatment of unilateral recurrent retinoblastoma presents a very difficult dilemma in which consideration must be given to preservation of vision in the remaining eye while tumoricidal doses of irradiation are delivered. A technique is described in which a methylmetraculate eye sphere carrying a single Iodine-125 seed was used to deliver local irradiation to the orbital tissues in a patient with multiple episodes of recurrent retinoblastoma. The tissue dose at 2 mm depth was 2630 cGy while the dose to the retina of the remaining eye and to the optic chiasm was negligible.

Brachytherapy↗
PubMed1993

An analysis of radiotherapy data from the CNS cancer consortium's randomized prospective trial comparing AZQ to BCNU in the treatment of patients with primary malignant brain tumors. The CNS cancer consortium.

The CNS Cancer Consortium has conducted a phase III study comparing diaziquone (AZQ) with carmustine (BCNU) in the treatment of adults with primary anaplastic glial brain tumors. Patients eligible for this study were 18 years of age or older at the time of biopsy, subtotal resection, or gross total resection of an anaplastic glial brain tumor. Within 3 weeks of surgery, patients received whole brain radiotherapy at 1.7 to 2 Gy per fraction to a total whole brain dose of 42-48 Gy. This was followed by a boost to the tumor bed as ascertained by computed tomography (CT), angiography, and/or magnetic resonance imaging (MRI) of 1.7 to 2 Gy per fraction to a dose of 12-19 Gy. The recommended cumulative dose to the tumor bed was therefore 55-61 Gy. At 8 weeks following radiotherapy, patients were randomized to receive either AZQ at 15 mg/day for 3 days i.v. every 4 weeks or BCNU at 200 mg i.v. every 8 weeks. Chemotherapy was continued for at least 1 year unless death occurred, treatment failure was declared, or toxicity necessitated alteration of therapy. In the 249 randomized patients, there was no difference between the AZQ- and BCNU-treated patients in age, sex distribution, race, tumor histology, type of surgical resection, or Karnofsky performance status (KPS). Age and KPS at the initiation of therapy and tumor histology were the best overall predictors of survival. The type of chemotherapy (AZQ vs BCNU) was not predictive of survival. Two-year Kaplan-Meier survival was 22% in the AZQ-treated patients and 25% in BCNU-treated patients. In an analysis of radiotherapy administered we found that, within the range of doses required for this study, there was no influence of whole brain dose, boost dose, total dose, or size of the boost field on survival. The institution providing radiotherapy (teaching hospital vs nonteaching facility) did not influence survival.

Adult↗