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Mark Bernstein, Tom Marotta, Patricia Stewart, Jennifer Glen, Lothar Resch and Mark Henkelman

✓ Changes in normal rat brain were studied acutely, and at 3, 6, 9, and 12 months following interstitial brachytherapy with high-activity 125I seeds. An 80-Gy radiation dose was administered to an area with a 5.5-mm radius. Effects were measured with magnetic resonance (MR) imaging (with and without gadolinium enhancement), leakage of horseradish peroxidase(HRP), electron microscopy, and light microscopy. Significant histological damage was seen at radiation doses above 295 Gy, and breakdown of the blood-brain barrier was observed only in tissue receiving a dose of 165 Gy or greater. Blood-brain barrier breakdown increased up to the 6-month time point, and thereafter appeared to stabilize or decrease. The area of blood-brain barrier disruption indicated by gadolinium-enhanced MR imaging was greater than that indicated by leakage of HRP.

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Randall C. Florell, David R. Macdonald, William D. Irish, Mark Bernstein, Steven A. Leibel, Philip H. Gutin and J. Gregory Cairncross

✓ Interstitial irradiation is a promising treatment for malignant glioma. Longer than expected survival periods following treatment of recurrent tumor have led to the use of brachytherapy as an adjuvant treatment. The impact of patient selection on survival data was studied among candidates for this therapy. Consecutive, conventionally treated adults with newly diagnosed supratentorial tumors were identified retrospectively at a center where experience with glioma is population-based. Based on imaging and performance status, two surgeons and a radiation oncologist designated each patient as either eligible or ineligible for adjuvant brachytherapy. The survival and prognostic factors in the eligible and ineligible groups were analyzed. Overall, the patients eligible for brachytherapy (32% of the series) lived significantly longer than the ineligible patients (16.57 vs. 9.30 months), were younger, and had larger resections and better function. For glioblastoma, 40% of patients were eligible, and lived much longer than those who were ineligible (13.90 vs. 5.80 months). It is concluded that better outcome following adjuvant brachytherapy for glioma is at least in part the result of patient selection. Randomized trials of comparably selected patients will be necessary to demonstrate conclusively that longer survival is also a result of treatment.

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Mark Bernstein and Andrew G. Parrent

✓ A series of 300 consecutive stereotactic biopsies for intra-axial brain lesions performed by one neurosurgeon was critically analyzed regarding complications of the procedure. Complications were incurred by a total of 19 patients (6.3%). Five patients (1.7%) died following the procedure, all due to intracranial hypertension: one from subarachnoid hemorrhage, one from intracerebral hemorrhage, and three from increased edema without hemorrhage. The three patients who died without hemorrhage all had marked intracranial hypertension at the time of biopsy. All five patients who died harbored a glioblastoma multiforme. The surviving 14 patients (4.7%) with complications suffered increased neurological deficit due to hemorrhage. In 10 (3.3%), the deficit was mild and/or transient; in the other four (1.3%), a major deficit was incurred which markedly affected the remainder of the patient's life. Therefore, mortality or major morbidity was seen in 3.0% of patients and minor morbidity in 3.3%. Stereotactic biopsy is a very effective procedure with a complication rate significantly lower than that of craniotomy (particularly in the population of patients selected for stereotactic biopsy), but in a small number of patients the outcome is devastating.

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Mark Bernstein, Alfonso Villamil, George Davidson and Charles Erlichman

✓ Radiological and clinical evidence of acute necrosis in a meningioma following one cycle of chemotherapy with 5-fluorouracil, folinic acid, and levamisole was observed in a patient being treated for invasive rectal carcinoma. The possible mechanisms and implications of this occurrence are discussed.

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R. Loch Macdonald, Michael G. Fehlings, Charles H. Tator, Andres Lozano, J. Ross Fleming, Fred Gentili, Mark Bernstein, M. Chris Wallace and Ronald R. Tasker

✓ This study was conducted to determine the safety and efficacy of multilevel anterior cervical corpectomy and stabilization using fibular allograft in patients with cervical myelopathy. Thirty-six patients underwent this procedure for cervical myelopathy caused by spondylosis (20 patients), ossified posterior longitudinal ligament (four patients), trauma (one patient), or a combination of lesions (11 patients). The mean age (± standard deviation) of the patients was 58 ± 10 years and 30 of the patients were men. The mean duration of symptoms before surgery was 30 ± 6 months and 11 patients had undergone previous surgery. Prior to surgery, the mean Nurick grade of the myelopathy was 3.1 ± 1.4. Seventeen patients also had cervicobrachial pain. Four vertebrae were removed in six patients, three in 19, and two in 11 patients. Instrumentation was used in 15 cases. The operative mortality rate was 3% (one patient) and two patients died 2 months postoperatively. Postoperative complications included early graft displacement requiring reoperation (three patients), transient dysphagia (two patients), cerebrospinal fluid leak treated by lumbar drainage (three patients), myocardial infarction (two patients), and late graft fracture (one patient). One patient developed transient worsening of myelopathy and three developed new, temporary radiculopathies. All patients achieved stable bone union and the mean Nurick grade at an average of 31 6 20 months (range 0–79 months) postoperatively was 2.4 ± 1.6 (p < 0.05, t-test). Cervicobrachial pain improved in 10 (59%) of the 17 patients who had preoperative pain and myelopathy improved at least one grade in 17 patients (47%; p < 0.05). Twenty-six surviving patients (72%) were followed for more than 24 months and stable, osseous union occurred in 97%. These results show that extensive, multilevel anterior decompression and stabilization using fibular allograft can be achieved with a perioperative mortality and major morbidity rate of 22% and with significant improvement in pain and myelopathy.

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Mark Bernstein and Beverly C. Walters

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Joseph Bampoe, Paul Ritvo and Mark Bernstein

Quality-of-life assessments in neurooncology are becoming more relevant with the proliferation of intensive research into brain tumors and their therapy. In this review, the authors examined several aspects and problems associated with the past, present, and future applications of quality-of-life assessments in neurooncology.

The inadequacy of the almost exclusive use of physical functioning assessments, image-documented tumor response to therapy, and patient survival time as endpoints when evaluating therapeutic regimens is becoming increasingly apparent. In therapies in which outcome using traditional endpoints are only marginally different, specific (neurological) toxicity and social and psychological outcomes must be evaluated as well to determine valid treatment options. Also becoming widely accepted is the consideration of patient values of specific health states in justifying treatment resources. There is ongoing research in brain tumor patients to address these issues.