Radio & Chemo Therapy after Brain Tumor Surgery

[Ivaturi]

Hi,

My brother underwent surgery for a GradeIII Tumor in Brain (Anaplastic Oligodendroglioma). What is the best treatment possible for him? His case details are below. He is in New Delhi, India. In Rajiv Gandhi Cancer Research Institute, they are planning IMRT with concomittant Temozolomide capsules.

Regards,
-prasad
========================

Age: 50 yrs
Neuro No: *****

DIAGNOSIS: LEFT TEMPORAL ANAPLASTIC OLIGODENDROGLIOMA GRADE III

HISTORY:
This 50 year old gentleman presented with history of a single episode of seizure on 29th Spet, 2007 at 9am, sudden onset unresponsiveness, clenching of teeth, blinking of eyes, tonic movements, no history of post ictal deficits, no history of headache. No history of memory dysfunctions.

ON EXAMINATION:
Vitals stabl
HMF - mild dysfunction in verbal and visual memory
Cranial nerve - Fundus - No pailledema
Motor/Sensory - No deficits
Reflexes - Normal
Plantars - downgoing
No positive cerebellar sugns

INVESTIGATIONS:
Blood Group - A+ve
Hemogram/Biochemistry - Normal
MRI - T1 hypo intense T2 hyper intense lesion in the left temporal lobe, ill defined boundaries extending into the vascular cortex. The lesion is not enhancing on contrast. Suggestive of low grade glioma.

TREATMENT GIVEN:
On 11th Oct, 2007, he underwent left fronto temporal craniotomy and decompression of tumor. Tumor tissue was yellowish, rubbery, and moderately vascular. Tumor extending into deep insular cortex was not decompressed. Medial temporal extension of the tumor tissue decompressed.

POST OP COURSE:
Post op CT Scan - showed residual tumor in the let insualr with a small tumor bed haematoma with mild hemispheric edema.
HPR - 1512/07 - Anaplastic Oligodendroglioma grade 3

COURSE IN THE HOSPITAL:
Post operative period was uneventful. No fresh neurological deficits. Wound was healthy.

AT DISCHARGE:
Patient was concious, oriented, aferbile. No fresh neurological deficits; wound was healthy.

DISCUSSION:
This patient was diagnosed to a left temporal mass lesion extending into insula with mild uncal herniation. Patient underwent left temporal craniotomy and decompression of the tumor (except the insular part). Post operative course was uneventful. Histopathology report was Anaplastic Oligodendroglioma Grade III. Patient was advised to undergo chemotherapy and radiotherapy and was referred to Oncology Center. Patient was concious, oriented, without any neurological deficits at the time of discharge.

ADVICE AT DISCHARGE:
1. Tab. Eptoin 100mg 1-1-1 to continue
2. Tab. Biosprolol fumerate 5 mg 1/2-0-0
3. Syp. Oral Glycerol 30 ml tid x 1 week
4. Cap. B-Complex 0-1-0 x 1 month
5. Refer to Oncology Center for adjuvant chemotherapy and radiotherapy
6. Review after 3 months in NS OPD on Monday at 9am
===================================================

NIMHANS HISTOPATHOLOGICAL EXAMINATION

Age: 50 years
Sex: M
Neuropath No: *****
Neuro No: N ******
Unit: Dr BACM

Nature of Specimen:
Received bits of whitish aggregate measuring 1x0.5x0.3cm.
Bottle 1 (Tumor tissue): Received 2 grey brown, nodular bits of tissue, larger measuring
3x2.5x2cm with foci of hemorrhage and necrosis.
Bottle 2 (Tumor tissue): Received multiple grey-brown irregular to nodular bits of tissue
together measuring 5x4.5x2cm.

Frozen Section Report: Low Grade Astrocytoma

Histopathology Report:
Anaplastic oligodendroglioma - grade iii: temporal
There is evidence of progression from a grade II neoplasm. Focal calcification is seen.

[Enoch Choi, MD]

Radiation and chemo are indicated for high grade oligodendroglioma.  With respect to radiation therapy, from the 2 studies cited below, doses of 60 to 65 Gy in 30 to 35 fractions are recommended based upon extrapolation from studies in patients with high-grade gliomas.  When chosen, temozolomide is generally preferred over the PCV chemotherapy regimen. No randomized controlled studies exist comparing PCV and temozolomide in patients with oligodendrogliomal tumors, so this is based on ease of use and toxic side effects.  See the last study I cite below to see that there is controversy whether or not adjuvant chemotherapy improves survival, suggesting that delaying chemo until progression is one possible reasonable course of action.  Only your brother's oncologist can tell you for sure.


TI Phase III trial of chemotherapy plus radiotherapy compared with radiotherapy alone for pure and mixed anaplastic oligodendroglioma: Intergroup Radiation Therapy Oncology Group Trial 9402.
AU Cairncross G; Berkey B; Shaw E; Jenkins R; Scheithauer B; Brachman D; Buckner J; Fink K; Souhami L; Laperierre N; Mehta M; Curran W
SO J Clin Oncol. 2006 Jun 20;24(18):2707-14.
CONCLUSION: For patients with AO and AOA, PCV plus RT does not prolong survival. Longer progression-free survival after PCV plus RT is associated with significant toxicity. Tumors lacking 1p and 19q alleles are less aggressive or more responsive or both.

AD University of Calgary, Calgary, Alberta, Canada; e-mail: jgcairnx @ ucalgary.ca
PMID 16782910



TI Adjuvant procarbazine, lomustine, and vincristine improves progression-free survival but not overall survival in newly diagnosed anaplastic oligodendrogliomas and oligoastrocytomas: a randomized European Organisation for Research and Treatment of Cancer phase III trial.
AU van den Bent MJ; Carpentier AF; Brandes AA; Sanson M; Taphoorn MJ; Bernsen HJ; Frenay M; Tijssen CC; Grisold W; Sipos L; Haaxma-Reiche H; Kros JM; van Kouwenhoven MC; Vecht CJ; Allgeier A; Lacombe D; Gorlia T
SO J Clin Oncol. 2006 Jun 20;24(18):2715-22.
CONCLUSION: Adjuvant PCV chemotherapy does not prolong OS but does increase PFS in anaplastic oligodendroglioma. Combined loss of 1p/19q identifies a favorable subgroup of oligodendroglial tumors. No genetic subgroup could be identified that benefited with respect to OS from adjuvant PCV.

AD Departments of Neurology and Pathology, Daniel den Hoed Cancer Center/Erasmus University Hospital, Rotterdam, The Netherlands. email:  m.vandenbent @ erasmusmc.nl




Although adjuvant chemotherapy either immediately before or after radiation therapy prolongs the disease-free interval, it does not improve overall survival.  The evidence for use of temozolomide is shown the following study:

TI Correlations between O6-methylguanine DNA methyltransferase promoter methylation status, 1p and 19q deletions, and response to temozolomide in anaplastic and recurrent oligodendroglioma: a prospective GICNO study.
AU Brandes AA; Tosoni A; Cavallo G; Reni M; Franceschi E; Bonaldi L; Bertorelle R; Gardiman M; Ghimenton C; Iuzzolino P; Pession A; Blatt V; Ermani M
SO J Clin Oncol. 2006 Oct 10;24(29):4746-53. Epub 2006 Sep 5.
CONCLUSION: TMZ is active in anaplastic oligodendroglial tumors treated at first recurrence. In this setting, 1p/19q allelic loss is an important predictive and prognostic factor. Further studies on MGMT promoter methylation should be performed in randomized trials to test its correlation with survival.

AD Department of Medical Oncology, Bellaria Hospital, Via Altura 3, Bologna, Italy. email:  aa.brandes @ yahoo.it


This review of the literature is current as of August 2007.

Dr. Enoch Choi, MD
Palo Alto, CA

[Ivaturi]

Dear Doctor,

Thanks for your quick response. I am wondering if there are any clinical trials of late providing good results. I am praying if only some miracle is available.

Coincidentally, I am a resident of San Jose, CA - I am here in India to accompany my brother through
his treatment. I shall meet you in person when I get back to US.

Regards,
-prasad

[Enoch Choi, MD]

Prasad,  those 2 trials are the most recent I've found.  Your best bet is to email the authors, listed at the end of the citation.

Good luck to your brother.  Will be happy to meet when you're back here.

I re-read the end of your initial post, and it sounds like with evidence of progression, chemo makes more sense.