Combined Modality Therapy of Central Nervous System Tumors

631 Pages·2003·32.574 MB·English

by  Susan Preston-Martin (auth.), Zbigniew Petrovich MD, FACR, Luther W. Brady MD, Michael L. J. Apuzzo MD, Michael Bamberg MD (eds.)

Contents I
MEDICAL RADIOLOGY
Radiation Oncology
Softcover Edition
Editors:
L.W. Brady, Philadelphia
H.-P. Heilmann, Hamburg
M. Molls, Munich
1234
Springer-Verlag Berlin Heidelberg GmbH
Z. Petrovich · L.W. Brady · M.L. Apuzzo
M. Bamberg (Eds.)
Combined Modality Therapy
of Central
Nervous System Tumors
With Contributions by
R. Atkinson · J. R. Adler · A. P. Amar · M. L. J. Apuzzo · M. Bamberg · A. Bettini · B. D. Birch
L. W. Brady · S. D. Chang · J. Chen · R. Class · P. Conti · J. L. Daigle · J. D. Day · B. Dykes
J. Flagel · S. C. Formenti · R. A. Freidman · B. George · S. Ghosh · S. L. Giannotta · J. L. Go
A.-L. Grosu · G. Harsh · G. Hsu · D. Huang · D. J. Hyder · B. Jeremic · G. Jozsef · M. G. Kaiser
L. T. Khoo · P. Kim · M. Kocher · R. D. Kortmann · M. D. Krieger · J.E.Lahaniatis
R. S. Lavey · M. L. Levy · M. Liker · D. P. Martin · W. H. McBride · J. G. McComb
P. C. McCormick · C. T. Miyamoto · M. Molls · R.-P. Müller · M. J. Murphy · S. O’Day
A. T. Parsa · Z. Petrovich · S. Preston-Martin · M. Salcman · R. Sawaya · M. Selch
E. M. Thomson · V. C.-K. Tse · J. Voges · M. H. Weiss · H. R. Withers · C. Yu · C.-S. Zee
Foreword by
L. W. Brady, H.-P. Heilmann, and M. Molls
With 226 Figures in 391 Separate Illustrations, 25 in Color and 80 Tables
123
Zbigniew Petrovich, MD, FACR
Professor and Chairman
Department of Radiation Oncology, University of Southern California
Keck School of Medicine
1441 Eastlake Avenue, Room G356
Los Angeles, CA 90033-0804, USA
Luther W. Brady, MD
Hylda Cohn/ American Cancer Society
Professor of Clinical Oncology and Professor
Department of Radiation Oncology, Hahnemann University Hospital
Broad & Vine Sts., Mail Stop 200
Philadelphia, PA 19102, USA
Michael L.J. Apuzzo, MD
Edwin M. Todd/Trent H. Wells, Jr.
Professor of Neurological Surgery and Professor of Radiation Oncology
Keck School of Medicine of the University of Southern California
Los Angeles, CA 90033, USA
Michael Bamberg, MD
Professor
Department of Radiotherapy, Eberhard-Karls-Universität
Hoppe-Seyler-Strasse 3
72076 Tübingen, Germany
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors: A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Molls · K. Sartor
Continuation of
Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
Library of Congress Cataloging-in-Publication Data
Combined modality of central nervous system tumors / Z. Petrovich ... [et al.] (eds.);
with contributions by R. Adkinson ... [et al.]; foreword by L. W. Brady and H.-P. Heilmann.
p. ; cm. -- (Medical radiology)
Spine title: Combined modality therapy of central nervous system tumors.
Includes bibliographical references and index.
ISBN 978-3-540-00627-5 ISBN 978-3-642-56411-6 (eBook)
DOI 10.1007/978-3-642-56411-6
1. Central nervous system--Cancer--Treatment. I. Title: Combined modality therapy of
central nervous system tumors. II. Petrovich, Zbigniew. III. Series.
[DNLM: 1. Central Nervous System Neoplasms--therapy. 2. Combined Modality
Therapy. WL 358 C731 2000]
RC280.N43 C66 2000
616.99’4806--dc21 00-055628
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Contents V
Foreword
The Surveillance Research Program of the American Cancer Society’s Department of
Epidemiology and Surveillance Research reported in CA – A Cancer Journal for Clinicans in
January/February 2000 that the estimated number of new primary malignant tumors in-
volving the central nervous system in the year 2000 was 16,500 patients: 9,500 males and
7,000 females. The cancer deaths in 2000 for brain and other nervous system primary
tumors were estimated at 13,000: 7,100 males and 5,900 females. Input into this data also
came from the National Cancer Institute: SEER Cancer Incidence Public-Use Database,
1973–1996, August 1998 Submission to the United States Department of Health and Human
Services of the Public Health Service, Bethesda, Md, 1999.
With the advances that have been made in the treatment of solid tumors by combined
integrated multimodal programs of management including surgery, radiation therapy and
chemotherapy, more patients are now being diagnosed with metastatic disease involving
the brain. It has been estimated that more than 150,000 patients per year in the USA have
brain metastasis as a part of their primary presentation or identified in subsequent follow-
up. More than 50% of all patients with primary malignant tumors of the brain have high-
grade gliomas of the brain. With the increase in primary malignant tumors among older
patients over the past decade, there have been major developments and increased interest in
new technologies in the treatment of these tumors. In general, primary brain neoplasms
spred invasively without forming a natural capsule and present symptoms based on expan-
sion of the tumor and surrounding edema within the skull.
The management of primary malignant tumors of the brain remains a very significant
and difficult problem in clinical practice. The lack of major response to treatment by the
high-grade gliomas of the brain has been discouraging and clearly indicates the need for
innovative new approaches in the management of these tumors.
The present volume represents a concerted effort on the part of the authors to present
data with regard to basic science evaluation and translation into clinical practice of tech-
niques based on combined, integrated multimodal programs of management. The data
brought together in this book clearly indicate the progress that has been made but, also,
clearly indicate the need for additional innovative efforts in terms of management.
It is the Editors’ firm belief that this volume represents the first publication of new inno-
vative programs for combined treatment of primary malignant tumors of the brain as well
as addressing the issues of the growing incidence of brain metastasis from solid tumors that
are better controlled now by combined, integrated programs of management.
Philadelphia L. W. Brady
Hamburg H.-P. Heilmann
Munich M. Molls
1234
Contents VII
Preface
Respice, Adspice, Prospice:
Consider the Past, the Present, the Future
Neoplastic involvement of the nervous system presents unique problems to the specialist
therapeutic community. No other neoplasms have the capability of functional disruption with
relatively small tumor burdens or challenge traditional surgical or oncologic principles more.
There has been a natural evolution toward application of combined therapies which has
been particularly evident with increasing sophistication in the closing decades of the
twentieth century. In surgery, the specialty of neurological surgery has been completely
reinvented thanks to the introduction of the operating microscope, modern imaging, novel
stereotactic principles, and the computer as a functional and practical operative tool.
Similar refinements have been seen in the field of radiation oncology, with computerized
planning and the introduction of stereotactic imaging-directed radiosurgery by rotational
and fixed beam methods. Concurrently, the practical emergence of cellular and molecular
biology as a diagnostic probe and therapeutic companion to more traditional treatment
methods is offering exciting new possibilities for the management of problems that have
been persistently enigmatic. More information is available regarding the efficacy and
application of chemotherapeutic methods to a broad spectrum of these neoplasms.
Therefore, in general overview the remarkable escalation in technical ability, information
base and knowledge within the past two decades allows new capabilities and possibilities in
management protocols. This is particularly exciting regarding central nervous system neo-
plasms, which in general lend themselves to combined, multimodality management for
optimization of outcome and the satisfying of the all-important requirement for functional
preservation.
Given these considerations, this multidimensional text has been composed and carefully
assembled to present a view of the past, present, and future in the management of central
nervous system neoplasms. It also has an international perspective presented in order to
convey the current body of knowledge related to epidemiology, pathology, molecular biol-
ogy, and therapeutic principles as a basis for individual attention to the principal categories
of neoplastic problems affecting the nervous system – extraaxial, and intraaxial, cranial and
spinal, adult and pediatric, primary and metastatic. Sophisticated perspectives of the
surgeon, radiation oncologist, oncologist, and oncology nurse are presented in an effort to
define modernity in the field for those desiring a succinct but substantive overall view.
Los Angeles Z. Petrovich
M. L. Apuzzo
Philadelphia L. W. Brady
Tübingen M. Bamberg
1234
Contents IX
Contents
1 Epidemiology of Primary Brain Tumors
S. Preston-Martin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Pathology of CNS Tumors
R. Atkinson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3 Molecular Biology
R. Class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4 Biological Principles of Radiotherapy in the Central Nervous System
J.L. Daigle, W.H. McBride, and H.R. Withers . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5 Principles of Physics of External Beam Radiotherapy
G. Jozsef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6 Principles of Physics of Stereotactic Radiosurgery
C. Yu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
7 Imaging of Intracranial and Spinal Neoplasms
C. S. Zee, P. Kim, J.L. Go, and P. Conti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8 Surgical Management of Pituitary Adenomas
M.D. Krieger, A.P. Amar, and M.H. Weiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9 Radiotherapy for Pituitary Adenomas
A.-L. Grosu, M. Kocher, J. Voges, R.-P. Müller, and M. Molls . . . . . . . . . . . 167
10 Craniopharyngiomas: Surgical Management
L.T. Khoo, J. Flagel, M. Liker, and M.L. Levy . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
11 Radiation Therapy for Craniopharyngioma
M. Selch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
12 Management of Vestibular Schwannomas
S. Ghosh and S. Giannotta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
13 Surgical Therapy and Problems in the Treatment of Meningioma
B. George . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
14 Radiotherapy for Meningioma
Z. Petrovich, G. Jozsef, C.-S. Zee, and C. Yu . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
15 Management of Low-grade Gliomas: A Surgical Perspective
L.T. Khoo and M.L.J. Apuzzo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
16 Radiotherapy in the Management of Low-grade Gliomas
R.D. Kortmann, B. Jeremic, and M. Bamberg . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
1234
X Contents
17 Surgical Therapy and Problems in the Treatment of Malignant Gliomas
M. Salcman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
18 Radiation Therapy Principles for High-Grade Gliomas
C.T. Miyamoto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
19 The Role of Stereotactic Radiosurgery in the Management
of Primary Brain Tumors
D. Huang, J. Chen, C. Yu, and Z. Petrovich . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
20 Frameless Stereotactic Radiosurgery
S.D. Chang, M.J. Murphy, D.P. Martin, and J.R. Adler, Jr. . . . . . . . . . . . . . . . 387
21 Treatment of Brain Metastasis
Z. Petrovich, C. Yu, and M.L.J. Apuzzo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
22 Management of Skull Base Tumors
J.D. Day and R.A. Freidman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
23 Treatment of CNS Lymphomas
S.C. Formenti and A. Bettini . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
24 Chemotherapy in Adult CNS Tumors
S. O’Day and B. Dykes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
25 Immunotherapy for Primary Brain Tumors
J.E. Lahaniatis and L.W. Brady . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
26 Prospects for Gene Therapy for Brain Tumors
V.C.-K. Tse and G. Harsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
27 Radiation Therapy in the Management of Pediatric Brain Tumors
R.S. Lavey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
28 Surgical Management of Pediatric Patients with CNS Tumors
M.D. Krieger, J.G. McComb, and M. Levy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
29 Chemotherapy in Pediatric Patients
D.J. Hyder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
30 Surgery for Primary and Metastatic Tumors of the Spine
A. T. Parsa, B. D. Birch, M. G. Kaiser, and P. McCormick . . . . . . . . . . . . . . . . 503
31 Radiotherapy of Tumors of the Spine
Z. Petrovich, M. Liker, and G. Jozsef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
32 Management of Rare Central Nervous System Tumors
G. Hsu and R. Sawaya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
33 Toxicity of Therapy and Quality of Life in Patients Treated for CNS Tumors
S.C. Formenti and Z. Petrovich . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
34 Complexity of Nursing in Patients Undergoing Treatment
for CNS Tumors
E.M. Thomson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
1234
Epidemiology of Primary Brain Tumors 1
1 Epidemiology of Primary Brain Tumors
Susan Preston-Martin
CONTENTS newly diagnosed with a benign or malignant ner-
vous system tumor in 1998 (CBTRUS 1998)]. Only
1.1 Introduction 1
about half of the patients with malignant brain tu-
1.2 Descriptive Epidemiology 2
mors are still alive 1 year after diagnosis (Davis
1.2.1 Variation in Inclusion Criteria 2
1.2.2 Pathologic Classification 2 1999). Although the incidence of brain tumors, par-
1.2.3 Distribution by Age and Change in Age Curves ticularly the more lethal subtypes, increased in re-
and Rates Over Time 3 cent decades (Greig et al. 1990; Modan et al. 1992;
1.2.4 Distribution by Gender, Race, and Geography 4 Desmeules et al. 1992), it appears that trends in
1.2.5 Social Class 5
childhood brain tumors (Smith 1998; Black 1998)
1.2.6 Survival 6
1.2.7 Summary of Descriptive Epidemiology 6 and adult tumors (Legler et al. 1999) increased due
1.3 Suggested Causes of Human Brain Tumors 7 to the introduction of diagnostic improvements, in-
1.3.1 Ionizing Radiation 7 cluding computerized tomography (CT) scans in the
1.3.2 Nonionizing Radiation 7
mid-1970s and magnetic resonance imaging (MRI)
1.3.3 Occupational Exposures 7
in the mid-1980s. This issue and the recent explosion
1.3.4 Pesticides 8
1.3.5 Nitroso Compounds 8 of epidemiologic and molecular genetic studies of
1.3.6 Other Dietary Factors 9 brain tumors has focused attention on this impor-
1.3.7 Prior Head Trauma, Infection, tant human cancer, which up until only a few decades
or Other Medical Conditions
ago was relatively little studied. Despite this surge of
1.3.8 Predisposing Genetic Syndromes
interest, the etiology of the majority of nervous sys-
and Familial Occurrence 11
1.3.9 Other Suggested Risk Factors 11 tem tumors remains unknown. Inherited syndromes
1.4 Pathogenesis of Nervous System Tumors 11 that predispose affected individuals to brain tumor
1.4.1 Molecular Genetic Characteristics 12 development and/or the presence of nervous system
1.4.2 Possible Interactions of Genetic
tumors in other family members appear to be present
and Environmental Factors 12
in fewer than 5% of brain tumor patients. Some envi-
1.5 Prospects 13
References 14 ronmental agents, in particular ionizing radiation, are
clearly implicated in the etiology of brain tumors, but
also appear to account for few cases. Numerous other
physical, chemical, and infectious agents that have
1.1 long been suspected risk factors have not yet been
Introduction established as etiologically relevant.
This review will focus on tumors of the brain, cra-
It was estimated that in 1999, 16,800 individuals in nial nerves, and cranial meninges, which account for
the United States would be diagnosed with a malig- 95% of all central nervous system (CNS) tumors.
nant primary nervous system tumor and 13,100 of These tumors are unique because of their location
these would die from the disease (Landis 1999). within the bony structure of the cranium. Symptoms
When benign as well as malignant brain tumors are depend on location of the tumor. Furthermore, his-
included, the incidence is over twice that for malig- tologically benign tumors can result in similar
nant brain tumors alone [34,345 individuals were symptomatology and outcome as malignant tumors
because growth of both normal and tumor tissue is
confined to the cranial space. For this reason, some
S. Preston-Martin, PhD
cancer registries voluntarily include both benign
Professor, Department of Preventive Medicine, University of
Southern California School of Medicine, 1441 Eastlake and malignant intracranial tumors. For simplicity,
Avenue, MS #44, Los Angeles, CA 90089, USA this group of tumors will be called “brain tumors” or,
Z. Petrovich et al. (eds.), Combined Modality Therapy of Central Nervous System Tumors
© Springer-Verlag Berlin Heidelberg 2003
2 S. Preston-Martin
when benign tumors are excluded, “brain cancer.” les County Japanese and Koreans) to a low of 0% (in
The term “central nervous system tumors “ (or can- Setifi, Algeria; Parkin et al. 1992). Rates vary consid-
cer) indicates that tumors of the spinal cord and spi- erably across registries as well as across specific pop-
nal meninges are included along with brain tumors, ulation groups within a country. For example, the
and “nervous system tumors” indicates that tumors rates of histologic verification range from 76 to 95%
of the peripheral nerves are also included. This re- in Switzerland, 27 to 91% in Canada, 45 to 87% in
view will first discuss the descriptive epidemiology Brazil, 52 to 98% in Japan, and 63 to 99% in the Unit-
of CNS tumors including the change of incidence ed States (Parkin et al. 1992). Such wide variation
rates in different age groups over time – patterns of suggests that caution in the interpretation of these
occurrence by gender, race, geography, and social rates is warranted. In general, for relatively inaccessi-
class – and median survival. Evidence relating to a ble cancer sites, a higher rate of microscopic confir-
number of other suggested risk factors will be sum- mation increases the likelihood that a neoplasm ac-
marized and prospects for future research explored. tually existed and that it was correctly classified. In
For each topic, reference will be made only to a few some registries, however, a high rate of microscopic
of the numerous relevant papers but will include a confirmation of brain tumors may indicate that clin-
recent paper with a comprehensive bibliography. ically or radiologically diagnosed tumors may have
been missed. With the advent of radiosurgery, this is
an increasing limitation.
1.2
Descriptive Epidemiology 1.2.2
Pathologic Classification
1.2.1
Variation in Inclusion Criteria The histologic groups of tumors which occur within
the central nervous system and their corresponding
The descriptive epidemiology of CNS tumors has ICD-O codes are shown in Table 1.1. A modification
been difficult to study because of the wide variation of this scheme is proposed for classification of pedi-
in specific tumors included in published rates. Quan- atric brain tumors (Rorke et al. 1985). In both chil-
titatively, the most important variation is estimated dren and adults, neuroepithelial tumors (still more
to be approximately 50% and relates to the inclusion commonly called gliomas) are the most common
or exclusion of benign tumors (Davis 1996). This major histologic type; these are predominantly ma-
critical difference has often been ignored in compar- lignant tumors that arise in the glial cells which com-
isons across geographic areas. Although reporting of prise the supporting structure for the brain. In Los
malignant tumors alone eases geographical compar- Angeles, neuroepithelial tumors account for 59% of
isons, it is unfortunate that incidence rates for be- primary tumors of the brain and cranial meninges
nign nervous system tumors are not also reported. among men and 42% among women. Over 80% of
For this reason, benign tumors will not be excluded neuroepithelial tumors are astrocytic gliomas (i.e.,
from descriptive data shown here for Los Angeles astrocytomas and glioblastoma multiforme). Astro-
County. It should be noted that pineal and pituitary cytic tumors that are grades I and II are generally
tumors, included in some standard definitions of classified as astrocytomas, those that are grade III
brain and central nervous system tumors, are not are classified as anaplastic astrocytomas, and those
included. In fact, as will become clear from discus- with grade IV are classified as glioblastomas. The
sions of analytic studies below, more is known about possibility that this practice is not followed consis-
the etiology of benign histologic types such as men- tently is suggested, however, by the considerable geo-
ingiomas than about the etiology of neuroepithelial graphic variation in the relative proportions of as-
tumors which are more common than meningiomas trocytic tumors that are classified as glioblastomas.
and are usually malignant. This variation is seen, for example, among the vari-
Another variation relates to whether or not clini- ous United States registries in the SEER Program. In
cally diagnosed tumors are included. The micro- comparison with the other SEER registries, Connect-
scopic confirmation rate of brain and nervous sys- icut has a considerably higher proportion of tumors
tem cancers included in the latest edition of Cancer classified as glioblastomas, and a correspondingly
Incidence in Five Continents varies widely across lower proportion of astrocytomas (Velema and
geographic areas from a high of 99% (e.g., Los Ange- Percy 1987).
12132434