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We conducted a clinical trial to determine if prophylactic anticonvulsants in brain tumour patients (without prior seizures) reduced seizure frequency. We stopped accrual at 100 patients on the basis of the interim analysis.
One hundred newly diagnosed brain tumour patients received anticonvulsants (AC Group) or not (No AC Group) in this prospective randomized unblinded study. Sixty patients had metastatic, and 40 had primary brain tumours. Forty-six (46%) patients were randomized to the AC Group and 54 (54%) to the No AC Group. Median follow-up was 5.44 months (range 0.13 -30.1 months).
Seizures occurred in 26 (26%) patients, eleven in the AC Group and 15 in the No AC Group. Seizure-free survivals were not different; at three months 87% of the AC Group and 90% of the No AC Group were seizure-free (log rank test, p=0.98). Seventy patients died (unrelated to seizures) and survival rates were equivalent in both groups (median survival = 6.8 months versus 5.6 months, respectively; log rank test, p=0.50). We then terminated accrual at 100 patients because seizure and survival rates were much lower than expected; we would need ≥ 900 patients to have a suitably powered study.
These data should be used by individuals contemplating a clinical trial to determine if prophylactic anticonvulsants are effective in subsets of brain tumour patients (e.g. only anaplastic astrocytomas). When taken together with the results of a similar randomized trial, prophylactic anticonvulsants are unlikely to be effective or useful in brain tumour patients who have not had a seizure.
A variety of lymphomas can involve the central nervous system (CNS) at different phases of their evolution, both in immunocompetent and immunocompromised individuals. They represent a heterogeneous group of malignancies, with variable clinical and behavioral characteristics, and require different therapeutic approaches. In this chapter, the therapeutic management of these malignancies will be analyzed separately in three main entities: primary CNS lymphomas (PCNSL), secondary CNS lymphomas (SCNSL), and other, less common, forms of CNS lymphomas.
Primary diffuse large B-cell lymphoma (DLBCL) of the CNS shows diffuse parenchymal growth with dense cuffing in perivascular spaces. The latter is best appreciated towards the periphery of the tumor. Large areas of necrosis may be present, especially in those treated with steroids prior to biopsy. Towards the periphery of the tumor the neoplastic cells are often admixed with astrocyte gliosis. Cytologically, the neoplastic cells resemble those of DLBCL encountered elsewhere. Similarly, the immunophenotype of primary CNS DLBCL is similar to those outside the CNS and is positive for B-cell markers (CD20, CD79a, and PAX-5). Strong IRF4/MUM1 staining is seen in 90% of cases. CD10 is expressed by a minority of cases, while many express BCL-6. BCL-2 is often expressed. As these lymphomas (by definition) occur in immunocompetent patients, Epstein–Barr virus (EBV) is generally absent.
Many lymphomas involving the CNS in immunocompromised patients are EBV-positive and show features of DLBCL, many with an immunoblastic morphology. Burkitt lymphoma, a common lymphoma in the immunocompromised patient, may involve the CNS.
Cancer-related intracerebral bleeding is an uncommon cause of hemorrhage and represents only a fraction of all non-traumatic intracranial hemorrhages (ICHs). The mechanisms of intratumoral hemorrhage remain unclear, but include tumor necrosis, rupture of tumor blood vessels and invasion of parenchymal blood vessels by tumor. Metastatic brain tumors can cause intracerebral hemorrhage. Brain metastases from any primary tumor can cause bleeding, but the different primaries have a wide variability in their tendency to bleed. A tumor embolus may cause an aneurysm that can lead to potentially fatal intraparenchymal or subarachnoid hemorrhages. The clinical presentation of intratumoral hemorrhage is often indistinguishable from spontaneous ICH from more typical etiologies such as hypertension. Radiotherapy should be administered according to the appropriate protocol regardless of whether the tumor is associated with hemorrhage. The prognosis of a hemorrhagic neoplasm is primarily determined by the prognosis of the underlying malignancy.
Andrés J. M. Ferreri, Medical Oncology Unit, Department of Oncology, San Raffaele H. Scientific Institute Via Olgettina 60, 20132, Milan, Italy,
Lisa M. DeAngelis, Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275, York Avenue, New York, NY, 10021, USA,
Andrew Wotherspoon, Department of Histopathology, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK,
Andreas Rosenwald, Institute of Pathology, University of Würzburg, Josef-Schneider-Str, 2, Würzburg, 97080, Germany,
German Ott, Institute of Pathology, University of Würzburg, Josef-Schneider-Str, 2, Würzburg, 97080, Germany
A variety of lymphomas can involve the central nervous system (CNS), at different phases of their evolution, in both immunocompetent and immunocompromised individuals. They represent a heterogeneous group of malignancies, with variable clinical and behavioral characteristics, requiring different therapeutic approaches. In this chapter, the therapeutic management of these malignancies will be analyzed separately in three main entities: primary CNS lymphomas (PCNSL), secondary CNS lymphomas (SCNSL) and other, less common, forms of CNS lymphomas.
The vast majority of CNS lymphomas are diffuse large B-cell lymphomas (DLBCL) that share the morphological and immunophenotypic characteristics similar to those of DLBCLs encountered elsewhere. They may show a perivascular growth pattern. The perivascular infiltrate is associated with increased reticulin fibres and the periphery of areas of involvement frequently shows astrocyte gliosis. Many immunocompromised patients show features similar to Burkitt's lymphoma, while others show a more immunoblastic morphology.
Rare cases of small lymphocytic, lymphoplasmacytic and T-cell lymphoma similar to those seen in tissue outside the CNS have been described. Secondary involvement by lymphoma originating elsewhere is also encountered.
Immunophenotypically CNS lymphomas recapitulate the staining pattern of similar lymphomas encountered outside the CNS. The DLBCLs are positive for CD20 and CD79a with expression of bcl-2 protein. A proportion express CD10 and bcl-6, but they are usually negative for CD5 and CD23. Large B-cell lymphomas in immunocompromised patients frequently contain Epstein–Barr virus (EBV).
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