<p> Floeth 1</p><p>Data supplement MS # 200202394</p><p>Floeth et al.</p><p>Tumor-free survival of 7 years after gene therapy for recurrent glioblastoma</p><p>Clinical note</p><p>Figure 2: Initial CT-scan before first tumor resection.</p><p>CCT without and with contrast medium from August 1995 demonstrates a right frontal mass lesion with focal contrast enhancement and strong perifocal edema.</p><p>Figure 3: Histological and immunohistochemical features . a: Histological investigation of the primary tumor showed a diffusely growing cellular astrocytic glioma consisting of pleomorphic neoplastic astrocytes including so-called gemistocytes (H&E stain). b: The tumor also demonstrated focal areas of necrosis (nec.) (H&E stain). c: Immunohistochemistry for glial fibrillary acidic protein (GFAP) was positive in the gemistocytic tumor cells. In addition, there were small anaplastic glioma cells, which were</p><p>GFAP-negative. d: Immunostaining for the proliferation-associated Ki-67 antigen using the</p><p>MIB1 monoclonal antibody demonstrated a high proliferative activity with more than 10%</p><p>MIB1-positive tumor cells. The immunohistochemical sections were counterstained with hematoxylin.</p><p>Figure 4: Follow-up with morphologic and metabolic imaging.</p><p>Time course preoperative (Screen), week 9, year 2 and year 6.5 after gene therapy treatment showing enhancement in MR scans (upper line) and amino-acid uptake in IMT-SPECT scans Floeth 2</p><p>(lower line). In addition to the morphologic follow-up with MR imaging, we performed metabolic follow-up with IMT (3-[123I]iodo--methyl-L-tyrosine) SPECT imaging.</p><p>In line with the preoperative MRI, metabolic imaging by IMT-SPECT performed 5 days before treatment showed an increased amino-acid uptake within the right fronto-parietal area that was highly suggestive of tumor tissue. In contrast, IMT-SPECT at week 9 revealed no elevated amino-acid uptake while MRI showed a strong ring-shaped enhancement around the resection cavity. The negative IMT-SPECT results at this time point argue against a neoplastic origin of the MR enhancement because malignant glioma tissue usually shows an increased uptake of amino acids.8 The radiological follow-up revealed a complete disappearance of the MR enhancement within one year and no evidence of tumor relapse for now 6.5 years after treatment.</p><p>Thus, we assume that the transient ring-shaped “flare” enhancement was due to a local inflammatory immune reaction and a disruption of the blood-brain barrier with subsequent perifocal contrast leakage. This was probably induced by the multiple traumatic injections of the gene therapy treatment and an immunologic reaction against the locally injected xenogenic mouse fibroblast vector producer cells. </p><p>8 Langen KJ, Pauleit D, Coenen HH. [123I]Iodo--Methyl-L-Tyrosine: uptake mechanisms</p><p> and clinical applications. Nucl Med Biol 29:625-631, 2002).</p><p>Corresponding and reprint author:</p><p>Frank-Willi Floeth, M.D.</p><p>Department of Neurosurgery</p><p>Heinrich-Heine-University of Düsseldorf</p><p>Moorenstraße 5</p><p>40225 Düsseldorf, Germany</p><p>Tel/Fax: 0049-211-811-6278 Floeth 3</p><p>E-Mail: [email protected]</p>