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Treatments may improve outlook for patients with primary brain tumors

Primary tumors of the brain comprise a diverse group of neoplasms. Although relatively uncommon -- within an incidence of five to 10 cases per 100,000 people -- primary tumors may be particularly difficult to treat, often with devastating consequences for patients.

Unfortunately, the prognosis of malignant glioma, the most common group of primary brain tumors, remains particularly grim. Despite treatment, glioblastoma multiforme has a median survival of less than one year. Tremendous efforts are being made in many centers to improve this outlook. At Ellis Fischel Cancer Center, several innovative treatments are available for patients with these tumors.

Craniotomy
Treatment for malignant glioma initially involves a craniotomy to resect the maximum amount of tumor possible. Goals of cranio-tomy include obtaining a tissue diagnosis, debulking tumor mass effect and decreasing tumor burden.

For lesions not amenable to resection due to tumor location, age or infirmity of the patient, stereotactic biopsy can be used to obtain a tumor specimen for histological diagnosis.

Chemotherapy
Because malignant glioma tumors tend to infiltrate into the surrounding normal brain, even aggressive resection surgery cannot be curative. Therefore, other treatments, such as chemotherapy and radiation are necessary to control tumor growth. Chemotherapy has been used in patients with these tumors with limited success, but newer concepts may offer hope for this disease.

One novel chemotherapy treatment involves the use of polymer wafers impregnated with the chemotherapeutic agent carmustine (BCNU). The wafers are implanted into the cavity created when a malignant glioma is resected. Once implanted in the brain, the wafer dissolves, releasing carmustine into the surrounding tissue.

In a phase III, multicenter, randomized, double-blind trial with patients who have recurrent malignant glioma, polymer wafers improved six-month survival rates and prolonged median survival with low complication rates.¹

Another treatment for malignant glioma that may prolong survival is the use of high-dose chemotherapy followed by progenitor cell rescue. This treatment, which is available at Ellis Fischel, allows the use of very high doses of drugs that may be effective in the treatment of malignant glioma.

A number of potentially active drugs can be used, such as thiotepa and carboplatin. Patients are infused with peripheral progenitor blood cells 72 hours after the completion of chemotherapy. The entire treatment can be accomplished in less than three weeks. This treatment seems to improve the quality of life of patients compared to standard chemotherapy and seems most effective in patients with anaplastic astrocytoma.

A third chemotherapy treatment is interferon, a protein that can affect the growth of a wide variety of cells and has been shown to influence the expression of tumor cell surface antigens.

In an ongoing clinical trial at Ellis Fischel, patients are pretreated with alpha interferon before surgery and also receive interferon with their postoperative chemotherapy in an effort to improve tumor response to chemotherapy. So far, this therapy has been well tolerated by patients.

Teleradiotherapy
Conventional teleradiotherapy is effective in prolonging survival in patients with malignant glioma, but doses are limited by its deleterious effects on a normal brain. While it is known that gliomas are infiltrative, most gliomas recur locally. Therefore, it seems reasonable that increased radiation doses may be useful in improving tumor control.

Stereotactic radiosurgery
Stereotactic radiosurgery allows a radiation boost to the local tumor site. Radiosurgery involves the attachment of a frame to the patient's head, which permits the precise localization of the tumor in space using computer technology after computerized tomographic scanning. Then, a linear accelerator is used to generate beams of photons focused at the tumor, which results in high doses to the tumor but much lower doses to surrounding normal structures. Radiosurgery is accomplished on an outpatient basis and typically is well tolerated by patients.

Patients with malignant glioma and their families face a most difficult challenge as they confront this disease. They deserve frank discussion about the nature of their disease, as well as the treatment options available.

For more information regarding brain tumor treatment, please call Dr. Colapinto at (573) 882-4908, or e-mail him at ted_colapinto@surgery.missouri.edu.

References

1. Brem H., Piantadosi S., Burger P.C., et al. Placebo controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. Lancet 345:1008 1012, 1995.