The limited value of cytoreductive surgery in elderly patients with malignant gliomas.
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Aged↗
Biomedical subjects
F W Kreth
Publications and source records attributed to F W Kreth.
Interstitial implant radiosurgery for cerebral metastases.
The effectiveness of interstitial implant radiosurgery (IRS) as an alternative or adjuvant treatment to radiotherapy (WBRT) or surgery of cerebral metastases remains unclear. In a retrospective study (1982-1991) we analysed four therapeutic regimes after stereotactic biopsy: IRS with a tumour dose of 60 Gy in combination with WBRT (40 Gy/5 x 2 Gy/week--38 patients), IRS only (tumour dose 60 Gy--22 patients), WBRT only (40 Gy/5 x 2 Gy/week--49 patients), and IRS only for recurrent cerebral metastases (tumour dose 60 Gy--21 patients). Low-activity iodine-125 seeds were used exclusively. IRS was performed in the case of circumscribed, mostly solitary metastases < or = 4 cm in diameter. Patients undergoing combined treatment had the best survival, with a median survival time of 17 months in comparison with 12 months after IRS alone and 7.7 months after WBRT. The median survival of patients with recurrent metastases after IRS was 6 months. A comparison of treatments in the multivariate analysis showed that IRS + WBRT was not superior to IRS alone. The metastases could be locally controlled in every case. There were no radionecroses requiring treatment. Most favourable determinants after IRS or IRS + WBRT were a solitary metastasis and a long time interval between diagnosis of the primary and diagnosis of the cerebral metastases. Our results demonstrate the effectiveness of IRS. For a single cerebral metastasis, IRS as a minimally invasive method offers major advantages.
Brain Neoplasms↗
Surgical resection and radiation therapy versus biopsy and radiation therapy in the treatment of glioblastoma multiforme.
There has been considerable controversy over the concept of treating glioblastoma multiforme with cytoreductive surgery. Therefore, a retrospective study of cases treated between 1986 and 1991 was conducted to analyze and compare the results of stereotactic biopsy followed by radiation therapy performed in 58 patients with those of surgical resection plus radiation therapy in 57 patients. In both groups, conventionally fractionated radiation (1.7 to 2.0 Gy/day) was delivered, with a total dose of 50 to 60 Gy. Biopsy was performed only in patients with tumors judged to be inoperable. These patients carried a higher surgical risk and were in worse neurological condition than the patients in the resection group. The median survival time for the resection group was 39.5 weeks, as compared with 32 weeks for the biopsy group. This difference was not significant. The most important prognostic factor was the patient's age. The treatment variable biopsy versus resection did not reach prognostic relevance. In patients with midline shift who underwent biopsy, the Karnofsky Performance Scale score decreased in more patients during radiation therapy. The clinical status 6 weeks after surgery, however, showed no significant differences between the two groups. The comparable survival times for the two groups place doubt on the concept of treating glioblastoma multiforme with cytoreductive surgery. Presently, radiation therapy is the most effective treatment for patients with glioblastoma. There is no question that decompressive surgery followed by radiation therapy should be performed whenever necessary for sever space-occupying lesions and when it will not cause new neurological deficits.
Aged↗
[Interstitial radiosurgery of low grade glioma].
In this retrospective study the outcome of 324 patients with low-grade gliomas (WHO-Grade II) is evaluated, who from 1979 to 1991 underwent stereotactic biopsy and interstitial radiosurgery (Iodine-125). The patients were selected for interstitial radiosurgery if the tumor was unifocal, well-circumscribed and in diameter < or = 4 cm. Of these patients 251 had astrocytomas, 29 had oligodendrogliomas, and 44 had oligoastrocytomas. All patients presented with progressive neurological deficit or showed evidence of CT/MRI confirmed tumor growth. The preoperative performance status was > or = 70%. Diffusely infiltrative, non-delineated gliomas and gliomas crossing the midline were excluded. Five-year survival rates were 65% for astrocytomas, 80% for oligoastrocytomas and 58% for oligodendrogliomas. In the multivariate analysis age was a significant factor predicting survival. Patients who received temporary implants had a significantly better outcome than those with permanent implants. Radiation toxicity (3.1%) was seen mostly among the permanent implants. No patients required reoperation due to radionecrosis. The findings in this subgroup of gliomas indicate that interstitial radiosurgery using Iodine-125 is effective in controlling tumor growth and is well tolerated. Patients with differentiated and circumscribed gliomas particularly benefit from the treatment.
Adolescent↗
[Stereotactic interstitial radiosurgery and percutaneous radiotherapy in treatment of cerebral metastases].
The efficacy of interstitial radiosurgery as an alternative or adjuvant to radiotherapy or surgery of cerebral metastases remains unclear. In a retrospective study (1982-1991) we compared 4 therapeutic regimes for cerebral metastases. The first group (n = 38) was treated with interstitial radiosurgery (Iodine-125) with a tumor dose of 60 Gy in combination with percutaneous radiotherapy with 40 Gy. The second group was treated by interstitial radiosurgery alone (n = 22) (tumor dose: 60 Gy). The third group was treated with percutaneous radiotherapy alone with a total dose of 40 Gy (n = 49). The fourth group (n = 21) consisted of recurrent cerebral metastases which were treated by interstitial radiosurgery alone (tumor dose: 60 Gy). Interstitial radiosurgery was performed in cases of circumscribed mostly solitary metastases < or = 5 cm in diameter. Medium survival was 17 months after interstitial radiosurgery in combination with radiotherapy, 12 months after radiosurgery alone and 7.7 months after percutaneous radiotherapy. The medium survival of recurrent metastases after interstitial radiosurgery was 6 months. Prognostically favourable for the outcome following radiosurgery were a Karnofsky Score > or = 70, a solitary metastasis, absence of disseminated disease and a longer time interval between diagnosis of the primary and diagnosis of the cerebral metastases. Interstitial radiosurgery + percutaneous radiotherapy was not superior to interstitial radiosurgery alone in the multivariate analysis. No patient died from a locally treated metastasis. Percutaneous radiotherapy was the treatment of choice for multiple or non-circumscribed cerebral metastases. Our results show that for solitary metastases stereotactic interstitial radiosurgery is a beneficial minimally invasive method.
Adult↗
Iodine-125 interstitial irradiation for cerebral gliomas.
In this retrospective review the outcome of 539 patients is evaluated, who from 1979 through 1991 underwent stereotactic biopsy and interstitial irradiation using iodine-125 implants. Permanent (lost) 125-I implants were used in 345 cases (64%) (1979-1985), temporary (removable) implants in 194 cases (36%) (1985-1991). The patients were selected for interstitial irradiation on the basis of histological classification, location and circumscription of their tumours (106 pilocytic astrocytomas, 251 astrocytomas WHO grade II, 29 oligodendrogliomas, 44 oligo-astrocytomas, 75 anaplastic astrocytomas and 34 glioblastomas). Diffusely infiltrative non-delineated gliomas and gliomas crossing the midline were excluded. Five-year survival rates were 77% for pilocytic astrocytomas, 65% for astrocytomas WHO II, 80% for oligo-astrocytomas, and 58% for oligodendrogliomas. The 2-year survival rates were 36% for anaplastic gliomas and 16% for glioblastomas. Operative morbidity due to stereotactic biopsy, implantation, and explantation of seeds was 3.9%. In the subgroups of patients with astrocytomas (WHO-II), pilocytic astrocytomas and malignant gliomas age was a significant factor predicting survival. Patients with astrocytomas WHO II who received temporary implants had a significantly better outcome than those with permanent implants. Radiation toxicity (3.1%) was seen mostly among the permanent (lost) implants. No patients required re-operation due to radionecrosis. The findings among this subgroup of gliomas indicate that interstitial implant irradiation using 125-I is effective in controlling tumour growth and is well tolerated. Patients with differentiated and circumscribed gliomas particularly benefit from the treatment.
Adolescent↗
[The value of stereotactic biopsy and percutaneous radiation in therapy of glioblastoma multiforme].
The concept of cytoreductive surgery in the treatment of glioblastoma multiforme is controversial. A retrospective study was carried out between 1986 and 1991 to analyze the results of stereotactic biopsy followed by supportive treatment (n = 49), incomplete radiation therapy (less than 40 Gy, n = 26), and complete radiation therapy (greater than or equal to 40 Gy, n = 58) and to compare with those of resection plus irradiation described in the literature. The patients treated with supportive care and an incomplete course of irradiation had a median survival of less than 8 weeks. For the patients who completed the radiation therapy the median survival was 32 weeks. In patients with midline shift the Karnofsky scores worsened more often during the course of radiation therapy, or therapy had to be terminated prematurely. The most important prognostic determinant was the patient's age. A comparison of survival rates in our series with those reported by other authors for patients who received tumor resection with subsequent irradiation yielded no significant difference. This would appear to cast doubt on the concept of cytoreductive surgery. The treatment of choice for patients with glioblastoma multiforme is at present radiation therapy. There is no question about the necessity of decompressive surgery whenever it is required to perform radiation therapy for severe space-occupying lesions and when it can be performed without causing new neurological deficits.
Biopsy, Needle↗