Spine Tango in Turkish: Development of a Local Registry System

AIM

Successfully established registry systems, rather than personal efforts to collect data, are required to record, analyze, compare and secure patient related data. Unfortunately, our country does not have such patient registry systems for spinal pathologies and surgeries at this time. In order to fill this gap in patient management in Turkey, the authors adopted already established Spine Tango registry system in a unique way answering the requirements of our health system. This article aims to present the adaptation process of Spine Tango forms for use in Turkish and describe the first implementation with 50 patients treated for spinal pathologies in a tertiary referral center.

MATERIAL AND METHODS

In 2011, an effort was initiated by the first author to translate the original Spine Tango forms into Turkish. Funding for this project was provided by authors themselves. With the assistance of a Spine Tango team, the translation process was completed. The Turkish forms were then used in an academic institution with a high spinal workload. A local solution was developed by the authors using commercially available software and mobile instruments. This system was tested with 50 spine patients from June 2012 to January 2013.

RESULTS

The analysis of the data gathered using the new Turkey Spine Tango registry system was successful.

CONCLUSION

In an environment of exponentially increasing medical data, successfully established registry systems have the potential to facilitate patient management. The authors recommend the use of Turkish Spine Tango forms for clinics performing spinal interventions.

Primary Intracerebral Alveolar Soft Part Sarcoma in an 11-Year-Old Girl: Case Report and Review of the Literature

Alveolar soft part sarcoma (ASPS), a rarely observed tumor, is a soft tissue sarcoma with an unidentified cell origin. It constitutes 0.5–1.0% of all soft tissue sarcomas. It may appear in various parts of the body, but mostly observed in the trunk and the extremities. It has a high metastasis potential. To the best of our knowledge, only three cases of primary intracranial ASPS without a demonstrable lesion elsewhere is encountered. An 11-year-old girl was operated because of fronto-parietal mass lesion by craniotomy. Pathological examination revealed ASPS and no primary focus was detected. In spite of radiotherapy and chemotherapy as an adjuvant therapy, after 45 months she had a second operation for recurrence of the tumor. Since it is possible to observe metastases in late phases, up to 30 years, the patients must be followed up for a long period. Although radiotherapy and chemotherapy followed by surgery is the most accepted treatment strategy, the prognosis is still poor.

Gamma Knife radiosurgery for arteriovenous malformations in pediatric patients

OBJECTIVE

The authors present the results of Gamma Knife stereotactic radiosurgery performed in a series of children with arteriovenous malformations (AVMs).

METHODS

Between June 2005 and January 2014, 75 patients 18 years old or younger received Gamma Knife radiosurgery for AVMs. Of these, 58 patients were eligible for further analysis. The median age of the population was 12 years; 41% presented with hemorrhage, 34% with neurological insult, and 24% patients were diagnosed incidentally. The median AVM volume was 3.5 cm(3). The median radiosurgery-based AVM score (RSBAVMS) was 0.86. The median follow-up period was 32 months.

RESULTS

Single session Gamma Knife radiosurgery resulted in complete AVM obliteration in 40 (68.9%) patients. There were 35 (60.3%) excellent outcome (complete obliteration with no new deficits) in this series. During the follow-up period, nine (15.51%) patients experienced new deficits and three (5.1%) patients experienced intracranial hemorrhage. The annual rate of developing new deficits and hemorrhage was calculated as 5.45 and 1.8%, respectively. Volume, gender, RSBAVMS, and nidus type factor were factors associated with excellent outcome.

CONCLUSIONS

Radiosurgery was successful in majority of patients with minimal morbidity. Gamma Knife radiosurgery for AVMs can be a safe and successful method in pediatric patients.

Hyperbaric oxygen in epidural fibrosis: is there a potential for treatment?

AIM

To investigate the effects of hyperbaric oxygen treatment on epidural fibrosis formation in an experimental laminectomy model.

MATERIAL AND METHODS

Twenty-four Wistar rats underwent L5-L6 total laminectomy and divided into three groups. Animals in the control group received no further treatment while animals in short and long term groups received 2,5 ATM ABS of hyperbaric oxygen for 3 and 7 days, respectively. The amount of epidural fibrosis was analyzed histologically at the end of 42 days of follow up.

RESULTS

The ratio of severe fibrosis was 57% in the control, 29% in the short HBOT, and 14% in the long HBOT groups. Although there was a clear trend towards having less fibrosis in the HBOT groups, the difference did not reach to the level of statistical significance (p=0.242), probably due to small number of animals used in this preliminary study.

CONCLUSION

Our findings suggest that hyperbaric oxygen treatment may have favorable effects on epidural fibrosis. Further studies with larger cohorts are required to prove our results.

Brain abscess caused by Nocardia cyriacigeorgica in two patients with multiple myeloma: novel agents, new spectrum of infections

OBJECTIVE AND IMPORTANCE

Introduction of high-dose chemotherapy and the novel agents including bortezomib, Lenalidomide, and Thalidomide has provided a significant progress in the treatment of multiple myeloma (MM) with an increase in median overall survival up to 6-8 years. However, the advances in myeloma treatment comes at a price with new spectrum of treatment-related infectious complications which should be taken into consideration while treating these patients.

CLINICAL PRESENTATION

We report here two patients with Ig G λ MM presenting with intracerebral mass lesions in the abscence of constitutional symptoms that would suggest an infectious etiology. Both patients had severe hypogammaglobulinemia and lymphopenia, which was attributed to treatment regimens including bortezomib. Intervention The surgical intervention-revealed abscess in both cases caused by Nocardia cyriacigeorgica, a relatively new pathogen which rarely causes infections in humans and also an unexpected pathogen in myeloma patients.

CONCLUSION

Although every aspect of immune system is known to be affected in MM, humoral immune deficiency is the hallmark of the inherent immune defect in this disease. Introduction of the novel agents, bortezomib in particular seems to have changed the characteristics of the immune dysfunction and the spectrum of the opportunistic infections by causing qualitative and quantitative changes in cellular immunity. The new spectrum of infectious agents might not be limited to hepatitis B and herpes zoster. Monitoring lymphopenia and administration of prophylactic antimicrobial agents accordingly could be considered in patients treated with bortezomib.

Neuroprotective effects of quetiapine on neuronal apoptosis following experimental transient focal cerebral ischemia in rats

OBJECTIVE

This study was undertaken in the belief that the atypical antipsychotic drug quetiapine could prevent apoptosis in the penumbra region following ischemia, taking into account findings that show 5-hydroxytryptamine-2 receptor blockers can prevent apoptosis.

METHODS

We created 5 groups, each containing 6 animals. Nothing was done on the K-I group used for comparisons with the other groups to make sure adequate ischemia had been achieved. The K-II group was sacrificed on the 1st day after transient focal cerebral ischemia and the K-III group on the 3rd day. The D-I group was administered quetiapine following ischemia and sacrificed on the 1st day while the D-II group was administered quetiapine every day following the ischemia and sacrificed on the 3rd day. The samples were stained with the immunochemical TUNEL method and the number of apoptotic cells were counted.

RESULTS

There was a significant difference between the first and third day control groups (K-II/K-III : p=0.004) and this indicates that apoptotic cell death increases with time. This increase was not encountered in the drug groups (D-I/D-II : p=1.00). Statistical analysis of immunohistochemical data revealed that quetiapine decreased the apoptotic cell death that normally increased with time.

CONCLUSION

Quetiapine is already in clinical use and is a safe drug, in contrast to many substances that are used to prevent ischemia and are not normally used clinically. Our results and the literature data indicate that quetiapine could help both as a neuronal protector and to resolve neuropsychiatric problems caused by the ischemia in cerebral ischemia cases.

The effect of temozolomide on the prevention of epidural fibrosis developing after lumbar laminectomy in rats

AIM

Failed back surgery syndrome is observed in 15% of patients who have undergone surgery for lumbar disk hernia.Excess epidural fibrosis is the etiology in 24% of FBSS cases. This study was conducted with the belief that the antiproliferative effect of temozolomide can prevent epidural fibrosis.

MATERIAL AND METHODS

8 rats (Group I) underwent laminectomy and were then administered saline while 6 rats (Group II) were administered temozolomide at a dose of 18 mg/kg/day for 5 days after the surgery to make up a total of 14 male Wistar rats used. The pathology preparations of subjects sacrificed at the end of week 6 were histopathologically examined with the Hematoxylin-Eosin stain and Trichrome stain. The pathology preparations were assessed with the analysis parameters and scale generated by He et al. The results were analyzed with the Chisquare test.

RESULTS

No significant difference was found between the two groups in terms of bone and cartilage regeneration, arachnoidal fibrosis, and inflammatory and fibroblast cell densities. Epidural fibrosis formation was significantly less and there was no grade III fibrosis in the Temozolomide group. This was found to be statistically significant (p=0.0302). No side effect of dural or intradural damage was observed.

CONCLUSION

Temozolomide was found to be effective in preventing epidural fibrosis. However, further research is required to determine its effectiveness in local applications and the appropriate dose range.

Role of vena cava inferior filter on neurosurgical deep venous thrombosis

AIM

The patients who undergo neurosurgical procedures are at high risk for perioperative deep vein thrombosis and pulmonary embolism. Pharmacological prophylaxis with mechanic prophylaxis is a safe and effective way of preventing deep vein thrombosis and pulmonary thromboembolism in neurosurgery. However, pharmacological prophylaxis may increase the risk of hemorrhage after cranial or spinal operations.

MATERIAL AND METHODS

Patients with vena cava inferior filter were retrospectively examined between 2003 and 2010.

RESULTS

Approximately 1600 patients per year are operated in our clinic. Deep vein thrombosis incidence is % 1.2 - 2.3 in our department. Vena cava inferior filter is used on 13 patients who operated for various diagnoses, during the 2003 - 2010 period. None of these patients had new pulmonary thromboembolism after inserting vena cava inferior filter but two of them died cause of initial respiratory distress.

CONCLUSION

We think that vena cava inferior filter in is safe and effective method for pulmonary thromboembolism prophylaxis, especially for patients with high bleeding risk and who cannot be anticoagulated. Further prospective studies with larger series are needed for evaluating long term complications and benefits.

Establishment of a primary pleomorphic xanthoastrocytoma cell line: in vitro responsiveness to some chemotherapeutics

BACKGROUND

Anaplastic pleomorphic xanthoastrocytoma is an aggressively growing, malignant, and eventually fatal tumor of the central nervous system. Testing chemotherapeutic drug sensitivity under in vitro conditions would be a useful strategy to determine sensitive or resistant drugs for fatal brain cancers.

OBJECTIVE

To establish primary cell cultures of excised tumor tissue from pleomorphic xanthoastrocytoma-bearing patients and to test their sensitivity against various anticancer chemotherapy drugs.

METHODS

Prepared suspensions of the excised tumor tissue from a patient who had a recurrent grade 3 pleomorphic xanthoastrocytoma was cultured in culture dishes until cells began to grow. Immunofluorescent and immunohistochemical visualizations were performed using confocal and light microscopy. MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay in comparison with ³H-thymidine incorporation assay was used to test cellular toxicity of several anticancer drugs.

RESULTS

We established vigorously growing primary cells of the tumor. Drug sensitivity testing was conducted successfully.

CONCLUSION

Primary cell cultures of surgically removed tumor tissues may be useful in studies of cancer biology and chemotherapeutic drug sensitivity for recurrent malignant brain tumors, particularly for anaplastic pleomorphic xanthoastrocytoma.

Effectiveness of single posterior decompressive laminectomy in symptomatic lumbar spinal stenosis: a retrospective study

AIM

The best method for surgical intervention in symptomatic lumbar stenosis is not clear. The present study aims to assess first year outcomes and complication rates of patients treated with single posterior decompressive laminectomy.

MATERIAL AND METHODS

Patients requiring surgery for severe, symptomatic, lumbar spinal stenosis were evaluated retrospectively. Oswestry disability index scores as well as the complications attributable to surgery were recorded before, at the sixth month and at the twelfth month of the surgery.

RESULTS

Eighty patients were enrolled to the study. The mean age of the population was 63,14 ± 11,57. Neurogenic claudication was the most common finding (65%). Of the patients, 67.5% had severe spinal stenosis. The mean ODI score at the baseline was relatively high than in the literature and was measured as 74.30 ± 5.38. At the end of the 6 months follow-up period, all patients' ODI scores significantly improved. Moreover, this improvement continued till the end of the 12 month. The mean change in ODI at the end of the first year was 41.80% ± 12.73.

CONCLUSION

In selected cases of symptomatic lumbar spinal stenosis, single posterior decompression using laminectomy is safe and effective.

Effects of different surgical techniques on cephalic index and intracranial volume in isolated bilateral coronal synostosis model

BACKGROUND

Bilateral coronal synostosis (brachycephaly) is the most common single-suture synostosis that may lead to functional deficits such as mental retardation. This increases the importance of volume gain during surgery. This study was designed to understand the differences in volume gain, cranial index (CI), and aesthetic outcomes when additional osteotomies or rotations are applied on the frontoparietal segment.

METHODS

Acrylic brachycephaly models were prepared. Frontoparietal osteotomy was standard in all models. Frontoparietal segment was fixed: to the same position in surgical control model, after 1.2-cm advancement in advancement model, after 180-degree rotation without advancement in rotation model, after 180-degree rotation plus a horizontal osteotomy and 1.2-cm advancement in rotation plus angled advancement model, and after a horizontal osteotomy without rotation and 1.2-cm advancement and in angled advancement model.

RESULTS

Intracranial volume changes (in milliliters) and CIs were as follows between groups: control group, 828/94.1; surgical control group, 830/93.8; advancement model, 900/84.5; rotation model, 834/89.1; rotation plus angled advancement model, 897/82.7; angled advancement model, 902/81.8.

CONCLUSIONS

Advancement of the frontoparietal segment is the keystone of surgery in brachycephaly treatment. Making an additional horizontal osteotomy can angle this segment and may supply additional volume gain. Rotation of the frontoparietal segment does not provide additional volume or CI gain but increase better aesthetic outcomes.

An unusual ventriculoperitoneal shunt complication: spontaneous knot formation

This article aims to describe an extraordinary complication of a ventriculoperitoneal shunt system that formed a knot spontaneously and lead to a shunt malfunction. A 3-year-old male patient was operated due to posttraumatic hydrocephalus. After an uneventful follow-up period of 34 months, he presented with shunt malfunction. During the shunt revision surgery, the peritoneal catheter was found to form a loop over itself. There are various complications of ventriculoperitoneal shunt systems. Migration to body cavities is among the most interesting ones. This is the fifth report describing this rare complication. Hydrocephalic patients should be closely followed up after shunt surgery for various extraordinary complications.

Split cord malformation: experience from a tertiary referral center

AIM

To present clinical, radiological, and follow-up features of 34 cases with spinal split cord malformation (SCM) treated in a tertiary referral center between April 2000 and March 2012.

METHODS

A total of 59 patients were treated due to SCM between April 2000 and March 2012 at the Gazi University Faculty of Medicine, Division of Pediatric Neurosurgery. Data for each patient were evaluated retrospectively, and age, sex, clinical findings, radiological findings, complications, and surgical results were recorded. Patients with a follow-up period of less than 6 months, patients harboring an open spinal dysraphism, and patients who had had their index surgery in another clinic were excluded, thus leaving a total of 34 patients for further analysis.

RESULTS

There were 19 females and 15 males ranging in age from 2 months to 15 years (mean 5.04 years). In this cohort, skin stigma was the most common reason (76.5%) to seek medical care. Of the cases, 22 (64.7%) had lumbar SCM and 12 (35.3%) had thoracic SCM. There were no cervical SCM. Twenty-one (61.8%) of the cases had type 1 SCM and 13 (38.2%) had Type 2 SCM. Of the patients, 21 (61.8%) had a detectable neurological deficit at initial evaluation. There were no differences between patients with and without a neurological deficit regarding age, sex, type, and level of SCM. Overall evaluation of patients regarding their final neurological status revealed that 16 (47.1%) patients improved, 4 (11.8%) deteriorated, and 14 (41.2%) remained stable.

CONCLUSIONS

In our opinion, all patients diagnosed with either type of SCM should be surgically treated to prevent further neurological deterioration. The results of this study, together with previously published data, confirm the effectiveness and safety of surgical intervention in SCM.

Myogenic and melanotic differentiated medulloblastoma: case report

Medulloblastoma is the most common malignant tumor of childhood and usually arises from the cerebellar vermis. Several histological types of medulloblastoma have been described. Myogenic and melanotic differentiated medulloblastoma are seldom seen. We present a case diagnosed as myogenic medulloblastoma with focal areas of melanotic differentiation. A 4-year-old boy was admitted due to headache, nausea and vomiting for a month. MRI revealed a heterogeneous enhanced posterior fossa tumor rising from the fourth ventricle. He was operated and pathological examination of the specimen revealed myogenic medulloblastoma with myogenic and melanotic differentiation. According to our knowledge there are six cases reported in the literature so far. Oncogenic factors in medulloblastoma development are controversial. Presence of multiple differentiation patterns supports a pluripotent origin for these tumors.

Neuroprotective effects of gabapentin on spinal cord ischemia-reperfusion injury in rabbits

Object

Extensive research has been focused on neuroprotection after spinal cord trauma to alleviate the effects of secondary injury. This study aims to investigate the neuroprotective effects of gabapentin in an experimental spinal cord ischemia reperfusion injury.

Methods

Thirty-two adult male New Zealand white rabbits received spinal cord ischemic injury using the aortic occlusion model. Animals were divided into 4 groups (sham, control, low-dose, and high-dose treatment groups; 8 rabbits in each group). High (200 mg/kg) and low (30 mg/kg) doses of gabapentin were administered to the animals in the treatment groups after spinal cord ischemic injury. Neurological status of the animals, ultrastructural findings in injured tissue samples, and levels of tissue injury markers in these 2 groups were compared with findings in the animals that did not receive the ischemic procedure (sham-operated group) and those that received normal saline after administration of ischemia.

Results

Regarding levels of tissue injury marker levels after ischemic injury, animals in the gabapentin-treated groups demonstrated better results than animals in the other groups. The ultrastructural findings and caspase-3 activity were similar. The treatment groups demonstrated better results than the other groups.

Conclusions

Gabapentin demonstrated significant neuroprotection after early phases of ischemic injury. Further studies with different experimental settings including neurological outcome are required to achieve conclusive results.

Radiological and histopathological comparison of microporous polysaccharide hemospheres and oxidized regenerated cellulose in the rabbit brain: a study of efficacy and safety

AIM

Topical hemostatic agents are widely used in brain surgery but they have some disadvantages such as foreign body reaction, being a focus for infection and causing artifacts in radiological examinations. The purpose of this study is to compare the effectiveness and safety of microporous polysaccharide hemospheres (MPH) with a well known agent, oxidized regenerated cellulose (ORC), histopathologically and radiologically.

MATERIAL AND METHODS

Standard brain lesions (4x1mm) were created in 24 hemispheres in 12 New-Zealand rabbits. Animals were divided into three groups; control, ORC and MPH. Twenty-four hours later, all rabbits magnetic resonance brain imaging. After imaging, the animals were sacrificed and the brains were removed for histopathological analysis.

RESULTS

Histopathological analysis showed no significant difference between the groups. Radiological examination showed no significant difference between the MPH and ORC groups in terms of edema but the edema in control group was significantly prominent than MPH and ORC groups (p < 0.001).

CONCLUSION

A new agent (MPH) provides safe and effective hemostasis in the brain in this study. The most important advantage of microporous polysaccharide hemospheres is their rapid clearance from the surgical field and therefore having the potential of causing less imaging artifacts.

Intraoperative neurophysiological monitoring during surgery for tethered cord syndrome

AIM

The tethered cord syndrome refers to a variety of lesions that can cause the conus medullaris to be low-lying or incapable of movement within the spinal canal. Permanent or temporary neurological complications were reported following surgical release. In this report, peri- and postoperative results in cases with tethered cord syndrome that were followed by multimodal intraoperative neurophysiological monitoring (MIONM) methods are presented.

MATERIAL AND METHODS

An IONM system (Nicolet CR Endeavor) was used for monitoring during tethered cord surgery. Somatosensory evoked potentials (SEPs), motor evoked potentials (MEPs), direct nerve root/rootlet stimulation, free-run electromyography (EMG) and F-waves were used during tethered cord surgery of 10 cases to prevent possible nerve injuries.

RESULTS

MEP and SEP recordings did not change in any of the cases during surgery. The nervous tissue was identified and differentiated from connective tissue in three cases when motor responses were elicited with direct stimulation of nerve roots. None of the cases had neurological deficits following the operation.

CONCLUSION

Direct nerve root/rootlet stimulation should be one of the components of MIONM during surgery for tethered cord syndrome to prevent postoperative neurological deficits.

Neuroprotective effects of gabapentin in experimental spinal cord injury

BACKGROUND

Extensive research has focused on neuroprotection after spinal cord trauma to alleviate the effects of secondary injury. This study aims to investigate the neuroprotective effects of gabapentin in experimental spinal cord injury.

METHODS

Thirty-six adult, male Wistar rats received spinal cord injury using the clip compression method. Animals were divided into five groups. High (200 mg/kg) and low doses (30 mg/kg) of gabapentin were administered to the animals in the treatment groups after spinal cord trauma and ultrastructural findings and lipid peroxidation levels of these two groups were compared with the animals that received only laminectomy, only trauma, and trauma and 30 mg/kg methylprednisolone.

RESULTS

Regarding tissue lipid peroxidation levels after trauma, animals in gabapentin groups demonstrated better results than the trauma group. However, these results were no better than the methylprednisolone group. The results regarding the ultrastructural findings were similar. Treatment groups demonstrated better ultrastructural findings than the trauma group. In addition, the results of the high dose gabapentin group were significantly better than the low dose gabapentin group.

CONCLUSIONS

Gabapentin demonstrated similar neuroprotective effects as methylprednisolone in early phase of spinal cord injury. Further studies with different experimental settings including neurological outcome are required to achieve conclusive results.

Effect of a chloride channel inhibitor, 5-nitro-2- (3-phenylpropylamino)-benzoate, on endothelin-1 induced vasoconstriction in rabbit basilar artery

AIM

Endothelin-1 (ET-1) has been implicated in the pathophysiology of cerebral vasospasm. Chloride (Cl-) channels exist in vascular smooth muscle and activation of these channels leads to depolarization and contraction. The aim of the present study was to test the effect of 5-nitro-2-(3-phenylpropylamino)-benzoate (NPPB), a Cl- channel antagonist, on the ET-1-induced cerebral vasospasm in rabbit basilar artery and thus investigate the contribution of Cl- channels.

MATERIAL AND METHODS

Thirty rabbits were divided into five groups and received intra-arterial injection of isotonic saline (Group I, n=6), ET-1 (group II, n=6), ET-1 plus NPPB (Group III, n=6), dimethylsulfate (DMSO4) (Group IV, n = 6) and NPPB (Group V, n=6). Pre and post injection basilar artery diameters were measured in each group and transmission electron microscopic investigations on basilar arteries were performed.

RESULTS

The mean pre-injection and post-injection vessel diameters were 0.8833 mm and 0.7000 mm in ET-1 group, 0.6833 mm and 0.8500 mm in ET-1 + NPPB group. NPPB administered prior to ET-1 injection, prevented the ET-1-induced vasoconstriction. Additionally, NPPB prevents the ET-1 induced changes in vessel wall and neurons in the brain stem.

CONCLUSION

The results of this study add further insights to our armamentarium against cerebral vasospasm.

Intracerebral tension pneumocephalus complicating endoscopic sinus surgery: case report

BACKGROUND

Various forms of intracranial air have been described in the literature.

AIM

This report aims to present clinical, radiological and intraoperative findings of a rare intracranial air entrapment case after endoscopic sinus surgery.

Malignant intracerebral giant nerve sheath tumor in a 14-month-old girl with neurofibromatosis type 1: a case report

INTRODUCTION

Malignant intracerebral nerve sheath tumor (MINST) is extremely rare and the origin is still unclear. The authors present the clinical, radiological, and pathological features of a malignant intracerebral giant nerve sheath tumor.

CASE REPORT

A giant tumor in the right frontotemporoparietal lobes causing a midline shift was detected in a 14-month-old girl who presented with developmental delay, vomiting, and lethargy. The physical examination was consistent with neurofibromatosis type 1 (NF-1). Subtotal resection was performed and the histopathological examination revealed the diagnosis of MINST.

DISCUSSION

There are only six cases of malignant intracerebral nerve sheath tumor in the literature. The presented case is the youngest and the occurrence of MINST in a 14-month-old girl may support the hypothesis of multipotent mesenchymal stem cell origin; however, the tumors which arise from multipotent mesenchymal stem cells may be seen in later stages of life. Another important feature of the presented case is the occurrence of MINST in NF-1.

CONCLUSION

MINSTs are extremely rare tumors with unknown origin. The location, the degree, and the size of the tumor and the general condition of the patient are prognostic factors in MINSTs, like in other malignant tumors.