Effects of iodine-125 brachytherapy on the proliferative capacity and histopathological features of glioblastoma recurring after initial therapy.

OBJECTIVE: To determine the effect of initial therapy (surgery and external beam radiation) on the proliferative capacity of glioblastoma and whether adjunctive high focused doses of radiation therapy can further reduce the proliferative capacity of the tumor. This would provide a rationale for attempting to further control local tumor growth with the different forms of high-dose focused radiation available. METHODS: Patients with glioblastoma were initially treated within a randomized, controlled study with or without iodine-125 (125 I) brachytherapy after initial surgical resection and external beam radiation (50 Gy in 25 fractions). Specimens from 24 consecutive patients later reoperated for "recurrence" were used to determine the effects of 125 I brachytherapy on the histological features and proliferating cell nuclear antigen index of the tumor tissue. RESULTS: 125 I brachytherapy reduced histological features prognostic for tumor progression, i.e., cellularity, pleomorphism, vessel hyperplasia, and degree of mitosis (P < 0.05). The degree of mitosis (marker for the mitotic or "M" phase) and proliferating cell nuclear antigen index (market for the late G1 and S phase) provide complementary data on the cell kinetics of the tumor. Proliferating cell nuclear antigen immunostaining was lower in the 125 I brachytherapy group (34.6 +/- 8.2%, mean +/- standard error) compared with the control nonimplant group (68.2 +/- 3.5%). 125 I brachytherapy produced a dramatic reduction in mitotic figures (mean histological score = 0.0 +/- 0.0). CONCLUSION: Adjunctive treatment of glioblastoma with discrete high doses of radiation therapy delivered by 125 I brachytherapy allows further control of the proliferative capacity of the tumor.

The detection and management of intracranial hypertension after initial suture release and decompression for craniofacial dysostosis syndromes.

We performed a retrospective study of 107 consecutive patients with syndromic forms of craniosynostosis (craniofacial dysostosis) seen by the craniofacial team at the Hospital for Sick Children between 1986 and 1992. There were 51 patients with Crouzon's syndrome, 33 with Apert's syndrome, 8 with Pfeiffer syndrome, 11 with Saethre-Chotzen syndrome, and 4 with kleeblättschadel anomaly. Six patients developed raised intracranial pressure (ICP) after initial suture release and decompression (Apert's syndrome, three patients; Pfeiffer syndrome, one patient; Saethre-Chotzen syndrome, two patients). Raised ICP was considered in those children who returned with a bulging fontanelle, progressive frontal bone protrusion, intermittent headaches, irritability, and vomiting. The diagnosis of raised ICP was based on papilledema (four patients), progressive macrocephaly (one patient), and ICP monitoring (one patient). No child in this group had hydrocephalus requiring cerebrospinal fluid diversion. Once raised ICP was detected in these children, a second operation was immediately performed to reduce the ICP with the intention of expanding the volume of the cranial cavity. The second procedures included: anterior cranial vault and upper orbital reshaping (four patients), posterior cranial vault reshaping (one patient), and total cranial vault reshaping (one patient). There were no perioperative complications in these patients, although one patient showed subsequent recurrence of raised ICP requiring further cranial vault re-expansion. At follow-up, ranging from 3 to 7 years, all six patients were asymptomatic without evidence of raised ICP. In our series, raised ICP occurred in 6% of the children with a craniofacial dysostosis syndrome after initial suture release and decompression.(ABSTRACT TRUNCATED AT 250 WORDS)

Lhermitte-Duclos disease mimicking adult-onset aqueductal stenosis. Case report.

Lhermitte-Duclos disease is a rare lesion characterized by enlarged cerebellar folia containing abnormal ganglion cells. This case report describes a 51-year-old woman who was initially misdiagnosed as having adult-onset aqueductal stenosis. There were no abnormal findings on computerized tomography (CT), but subsequent magnetic resonance (MR) imaging showed a midline cerebellar lesion extending to the brain stem. This is a unique case of Lhermitte-Duclos disease arising within the cerebellar vermis. The characteristic feature of an enlarged cerebellar hemisphere is absent on CT scans; thus MR imaging is needed to confirm the diagnosis. If diagnosed late, this generally benign lesion becomes difficult to resect totally and has a poorer prognosis. Only two reports have mentioned the MR imaging characteristics of Lhermitte-Duclos disease; both described only T2-weighted images. This case illustrates the full spectrum of MR imaging features of this disease. Both T1- and T2-weighted studies showed enlarged cerebellar folia within the lesion. The T1-weighted image showed a mixed iso- and hypodense signal and the T2-weighted image a homogeneously increased signal; with gadolinium administration the lesion did not enhance. The latter feature supports the theory that this disease is a hamartoma rather than a tumor.