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Primary central nervous system tumors in adults

Current Treatment Options in Neurology volume 1, pages 377–394 (1999)Cite this article

Opinion statement

It is important that before treatment is initiated, the precise diagnosis of brain tumor has been made and fits with the clinical, radiographic, and histologic findings. With low-grade gliomas, maximal surgical resection should be attempted. We delay radiation therapy unless the patient has significant neurologic symptoms that could be alleviated by treatment. Patients with glioblastoma multiforme (GBM) and anaplastic astrocytoma should undergo maximum surgical resection, postoperative radiation therapy, and adjuvant chemotherapy with bischloroethylnitrosourea (BCNU) or intensive procarbazine, chloroethylcyclohexylnitrosourea (CCNU), and vincristine (PCV) therapy, respectively. Patients with anaplastic oligodendroglioma (AO) and mixed anaplastic oligodendroglioma-astrocytoma(A OA) should undergo maximal surgical resection, postoperative radiation therapy, and intensive adjuvant PCV therapy. Meningiomas are usually managed with surgery alone; radiation therapy is used if the meningioma is malignant or recurs. Tamoxifen or hydroxyurea may be useful for recurrent meningiomas. Patients with primary central nervous system (CNS) lymphoma undergo biopsy; surgical resection of the tumor is not necessary. We treat immunocompetent patients with multimethod therapy. Patients with AIDS and primary CNS lymphoma receive radiation alone. Because the prognosis for primary CNS lymphomas has not changed significantly in the past 20 years, patients with these tumors should be enrolled in clinical trials if possible. Novel approaches, such as targeting angiogenesis, using signal transduction or invasion, or employing genes affecting growth control, are being pursued.

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References and Recommended Reading

  1. Surawicz TS, McCarthy BJ, Kupelian V, et al.: Descriptive epidemiology of primary brain and CNS tumors: results from the central brain tumor registry of the United States, 1990–1994. Neuro-Oncolog 1999, 1:14–25.

    CAS  Google Scholar 

  2. Burger PC, Scheithauer BW, Lee RR, O’Neill BP: An interdisciplinary approach to avoid the overtreatment of patients with central nervous system lesions. Cancer 1997, 80:2040–2046. This is an outstanding review of lesions that might in some cases mimic high-grade gliomas. Very useful tables are included, and the approach is thoughtful and practical.

    PubMed  Article  CAS  Google Scholar 

  3. Forsyth PAJ, Petrov E, Mahallati H, et al.: Prospective study of postoperative magnetic resonance imaging in patients with malignant gliomas. J Clin Oncol 1997, 15:2076–2081. This prospective study of postoperative magnetic resonance changes in patients with malignant glioma concludes that the optimal window in which to image patients is 3 to 5 days after surgery.

    PubMed  CAS  Google Scholar 

  4. Verhoef M, Hagen N, Pelletier G, Forsyth P: Unconventional therapy in neurological diseases: use in brain tumor patients. Neurology 1999, 52:617–622.

    PubMed  CAS  Google Scholar 

  5. Posner JB: Neurological Complications of Cancer. Philadelphia: F.A. Davis Co.; 1995:61.

    Google Scholar 

  6. Barker FG, Chang SM, Huhn SL, et al.: Age and the risk of anaplasia in magnetic resonance-nonenhancing supratentorial cerebral tumors. Cancer 1997, 80:936–941. According to this prospective study, the probability that a nonenhancing tumor seen on magnetic resonance scanning is malignant increases as a function of age.

    PubMed  Article  Google Scholar 

  7. Mason W, Krol G, DeAngelis L: Low-grade oligodendroglioma responds to chemotherapy. Neurology 1996, 46:203–207.

    PubMed  CAS  Google Scholar 

  8. Berger MS, Deliganis AVK, Dobbins J, et al.: The effect of extent of resection on recurrence in patients with low grade cerebral gliomas. Cancer 1996, 74:1784–1791.

    Article  Google Scholar 

  9. Mork SJ, Lindegaard KF, Halvorsen TB, et al.: Oligodendroglioma: incidence and biological behavior in a defined population. J Neurosurg 1985, 63:881–889.

    PubMed  CAS  Google Scholar 

  10. Shaw EG, Daumas-Duport C, Scheithauer BW, et al.: Radiation therapy in the management of low grad supratentorial astrocytomas. J Neurosurg 1989, 70:853–861.

    PubMed  CAS  Google Scholar 

  11. Leighton G, Fisher B, Bauman G, et al.: Supratentorial low-grade glioma in adults: an analysis of prognostic factors and timing of radiation. J Clin Oncol 1997, 15:1294–1301.

    PubMed  CAS  Google Scholar 

  12. Karim ABMF, Cornu P, Bleehen D, et al.: Immediate postoperative radiotherapy in low grade glioma improves progression free survival but not overall survival: preliminary results of an EORTC/MRC randomized phase III study [abstract]. Proc ASCO 1998, 17:400a.

    Google Scholar 

  13. Doubilet P, Weinstein MC, McNeil BJ: Use and misuse of the term “cost effectiveness” in medicine. N Engl J Med 1986, 314:253–256.

    PubMed  CAS  Article  Google Scholar 

  14. Scott JN, Rewcastle NB, Hagen NA, et al.: Which GBM patient will become a long-term survivor? A population-based study. Ann Neurol 1999, 46:183–188. This paper examines the incidence of long-term survival i a population with glioblastoma multiforme.

    PubMed  Article  CAS  Google Scholar 

  15. WalkerMD, Green SB, Byar DP, et al.: Randomized comparisons of radiotherapy and nitrosources for the treatment of malignant glioma after surgery. N Engl J Med 1980, 303:1323–1329. This classic paper shows that chemotherapy does not prolong median survival but increases the likelihood that patients with malignant glioma will survive for 18 months.

    PubMed  CAS  Article  Google Scholar 

  16. Green SB, Byar DP, Walker MD, et al.: Comparisons of carmustine, procarbazine and high-dose methylprednisolone as additions to surgery and radiotherapy for the treatment of malignant glioma. Cancer Treat Rep 1983, 67:121–132.

    PubMed  CAS  Google Scholar 

  17. Fine HA, Dear KBG, Loeffler JS, et al.: Meta-analysis of radiation therapy with and without adjuvant chemotherapy for malignant gliomas in adults. Cancer 1993, 71:2585–2597.

    PubMed  Article  CAS  Google Scholar 

  18. Hildebrand J, Sahmoud T, Mignolet F, et al.: Adjuvant therapy with dibromodulcitol and BCNU increases survival of adults with malignant gliomas. Neurology 1994, 44:1479–1483.

    PubMed  CAS  Google Scholar 

  19. Levin VA, Silver P, Hannigan J, et al.: Superiority of post-radiotherapy adjuvant chemotherapy with procarbazine, CNNU and vincristine (PCV) over BCNU for anaplastic gliomas: NCOG 6G61 final report. Int J Radiat Oncol Biol Phys 1990, 18:321–324.

    PubMed  CAS  Google Scholar 

  20. BremH, Piantadosi S, Burger PC, et al.: Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. Lancet 1995, 345:1008–1012. Class I data show that implantation of intramural polymers to continue chemotherapy prolongs survival in patients with recurrent glioblastoma multiforme.

    PubMed  Article  CAS  Google Scholar 

  21. Prados MD: Phase II and III trials with temozolomide, including clinical trials in patients with brain tumors [abstract]. Proc Am Assoc Cancer Res 1999, 40:754. This is an early report on the usefulness of temozolomide in patients with brain tumor.

    Google Scholar 

  22. Wisoff JH, Boyett JM, Berger MS, et al.: Current neurosurgical management and the impact of the extent of resection in the treatment of malignant gliomas of childhood: a report of the Children’s Cancer Group trial No. CCG-945. J Neurosurg 1998, 89:52–59.

    PubMed  CAS  Google Scholar 

  23. Rostomily RC, Keles GE, Berger MS: Radical surgery in management of low-grade and high-grade gliomas. In Clinical Neurology. Edited by Yung WKA. London: Baillière Tindall; 1996:345–369.

    Google Scholar 

  24. NazzaroJM, Neuwelt EA: The role of surgery in the management of supratentorial intermediate and high-grade astrocytomas in adults. J Neurosurg 1990, 73:331–344. This is a critical and thoughtful review of the role of surgery in the management of supratentorial malignant gliomas.

    PubMed  CAS  Google Scholar 

  25. Sneed PK, Prados MD, McDermott MW, et al.: Large effect on the survival of patients with glioblastoma treated with radiotherapy and brachytherapy boost. Neurosurgery 1995, 36:898–904.

    PubMed  Article  CAS  Google Scholar 

  26. Shrieve DC, Alexander E, Wen PY, et al.: Comparison of stereotactic radiosurgery and brachytherapy in the treatment of recurrent glioblastoma multiforme. Neurosurgery 1995, 36:275–284.

    PubMed  Article  CAS  Google Scholar 

  27. CairncrossJG, Macdonald DR, Ludwin S, et al.: Chemotherapy for anaplastic oligodendroglioma. J Clin Oncol 1994, 12:2013–2021. This landmark phase II study established that anaplastic oligodendrogliomas respond to chemotherapy.

    PubMed  CAS  Google Scholar 

  28. Peterson K, Paleologos N, Forsyth P, et al.: Salvage chemotherapy for oligodendroglioma. J Neurosurg 1996, 85:597–601.

    PubMed  CAS  Article  Google Scholar 

  29. CairncrossJG, Ueki K, Zlatescu MC, et al.: Specific genetic predictors of chemo-therapeutic response and survival in patients with anaplastic oligodendrogliomas. J Natl Cancer Inst 1998, 90:1473–1479. A remarkable correlation was found between dilation of 1p and chemoresponsiveness in malignant oligodendrogliomas, raising the possibility that 1p may be a marker for chemosensitivity in malignant oligodendrogliomas or for “true” oligodendrogliomas.

    PubMed  Article  CAS  Google Scholar 

  30. Goodwin JW, Crowley J, Eyre HJ, et al.: A phase 2 evaluation of tamoxifen in unresectable or refractory meningiomas: a Southwest Oncology Group study. J Neurooncol 1993, 15:75–77. This clinical trial shows some efficacy of tamoxifen in meningioma, although the doses used were small.

    PubMed  Article  CAS  Google Scholar 

  31. Schrell UMH, Rittig MG, Anders M, et al.: Hydroxyurea for treatment of unresectable and recurrent meningiomas. II. Decrease in the size of meningiomas in patients treated with hydroxyurea. J Neurosurg 1997, 86:840–844. This paper reports a reasonable response in a very small number of patients treated with hydroxyurea.

    PubMed  CAS  Google Scholar 

  32. GrunbergSM, Weiss MH, Spitz IM, et al.: Treatment of unresectable meningiomas with the antiprogesterone agent mifepristone. J Neurosurg 1991, 74:861–866. This report generated much excitement about mifepristone in the treatment of meningiomas; three fourths of patients developed tumor regression or stable disease.

    PubMed  CAS  Google Scholar 

  33. Chamberlain MC: Adjuvant combined modality therapy for malignant meningiomas. J Neurosurg 1996, 84:733–736.

    PubMed  CAS  Google Scholar 

  34. Couldwell WT, Fukushima T, Giannotta SL, Weiss MH: Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 1996, 84:20–28. This is a careful case series of petroclival meningiomas, some of which extend into the cavernous sinus, highlighting controversies in management.

    PubMed  CAS  Google Scholar 

  35. Goldsmith BJ, Wara WM, Wilson CB, Larson DA: Postoperative irradiation for subtotally resected meningiomas: a retrospective analysis of 140 patients treated from 1967–1990. J Neurosurg 1994, 60:195–201.

    Google Scholar 

  36. Maire JP, Caudry M, Guerin J, et al.: Fractionated radiation therapy in the treatment of intracranial meningiomas: local control, functional efficacy, and tolerance in 91 patients. Int J Radiat Oncol Biol Phys 1995, 33:315–321. This large series analyzes factors important in local control.

    PubMed  Article  CAS  Google Scholar 

  37. Milosevic MF, Frost PJ, Laperriere NJ, et al.: Radiotherapy for atypical or malignant meningioma. Int J Radiat Oncol Biol Phys 1996, 34:817–822. This paper reviews a large single-institution series of patients treated with radiation therapy. It also describes factors determining treatment outcome.

    PubMed  Article  CAS  Google Scholar 

  38. Pendl G, Schrottner O, Eustacchio S, et al.: Stereotactic radiosurgery of skull base meningiomas. Minim Invasive Neurosurg 1997, 40:87–90.

    PubMed  CAS  Article  Google Scholar 

  39. DeAngelis LM: Current management of primary central nervous system lymphoma. Oncology 1995, 9:63–71.

    PubMed  CAS  Google Scholar 

  40. Eby NL, Grufferman S, Flannelly CM, et al.: Increasing incidence of primary brain lymphoma in the US. Cancer 1988, 62:2461–2465.

    PubMed  Article  CAS  Google Scholar 

  41. Hao D, DiFrancesco LM, Brasher PMA, et al.: Is primary CNS lymphoma really becoming more common? A population-based study of incidence, clinicopathological features and outcomes in Alberta from 1975 to 1996. Ann Oncol 1999, 10:1–6.

    Article  Google Scholar 

  42. Abrey LE, DeAngelis LM, Yahalom J: Long term survival in primary central nervous system lymphoma. J Clin Oncol 1998, 16:859–863. This paper reviews a single institution’s experience with multimethod therapy.

    PubMed  CAS  Google Scholar 

  43. Corry J, Smith J, Wirth A, et al.: Primary central nervous system lymphoma: age and performance status are more important than treatment modality. Int J Radiat Oncol Biol Phys 1998, 41:615–620.

    PubMed  Article  CAS  Google Scholar 

  44. DeAngelisLM, Yahalom J, Thaler HT, Kher U: Combined modality therapy for primary CNS lymphoma. J Clin Oncol 1992, 10:635–643. This early report shows encouraging results with multimethod therapy.

    PubMed  CAS  Google Scholar 

  45. Freilich RJ, Delattre JY, Monjour A, et al.: Chemotherapy without radiation therapy as initial treatment for primary CNS lymphoma in older patients. Neurology 1996, 46:435–439.

    PubMed  CAS  Google Scholar 

  46. Forsyth PA, Yahalom J, DeAngelis LM: Combinedmodality therapy in the treatment of primary central nervous system lymphoma in AIDS. Neurology 1994, 44:1473–1479.

    PubMed  CAS  Google Scholar 

  47. Nelson DF, Martz KL, Bonner H, et al.: Non-Hodgkin’s lymphoma of the brain: can high-dose, large volume radiation therapy improve survival? Report on a prospective trial by the radiation therapy oncology group (RTOG): RTOG 8315. Int J Radiat Oncol Biol Phys 1992, 23:9–17.

    PubMed  CAS  Google Scholar 

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Author information

Affiliations

  1. Departments of Clinical Neurosciences and Oncology, University of Calgary and Tom Baker Cancer Centre, 1331 29 Street NW, Calgary, T2N 4N2, Alberta, Canada

    Peter A. J. Forsyth MD

  2. Departments of Oncology and Radiation Oncology, University of Alberta and Cross Cancer Institute, 11560 University Avenue, Edmonton, Alberta, Canada

    Wilson H. Y. Roa MD

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  1. Peter A. J. Forsyth MD
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  2. Wilson H. Y. Roa MD
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Forsyth, P.A.J., Roa, W.H.Y. Primary central nervous system tumors in adults. Curr Treat Options Neurol 1, 377–394 (1999). https://doi.org/10.1007/s11940-996-0002-1

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Keywords

  • Tamoxifen
  • Meningioma
  • Malignant Glioma
  • Radiat Oncol Biol Phys
  • Main Drug Interaction