Extended orbital exenteration for sinonasal malignancy with orbital apex extension: surgical technique and clinical analysis

OBJECT

The majority of sinonasal malignancies present with advanced disease, and cure rates are generally poor. Surgical extirpation remains the mainstay of treatment. In cases of sinonasal malignancy with orbital apex extension, gross-total tumor resection requires orbital exenteration and bony skull base resection around the orbital apex to provide sufficient margins. In this retrospective study, the authors describe their surgical strategy in and technique for orbital exenteration with orbital apex resection in patients at Tokyo Medical and Dental University who had sinonasal malignancy with orbital apex extension. They also analyzed the clinical features of and the results in these patients.

METHODS

Between February 2001 and August 2012 at the authors' institution, sinonasal malignancy with orbital apex extension was treated using craniofacial tumor resection with orbital exenteration including skull base bone around the orbital apex. The authors describe this technique and analyze the surgical indications, extent of resection, primary tumor location, outcome, pathological findings, and neoadjuvant and adjuvant therapies of the patients who underwent the technique.

RESULTS

The patients consisted of 12 men and 3 women with a mean age of 47.7 years (range 14-79 years). The longest postoperative follow-up was 9.5 years, and the shortest was 0.67 year (mean 3.0 years). Tumor originated at the ethmoid sinus in 6 patients (40%), maxillary sinus in 5 (33%), nasal cavity in 2 (13%), and orbital cavity and maxillary bone in 1 patient each (7%). Histological analysis of tumor specimens revealed squamous cell carcinoma in 9 patients (60%), rhabdomyosarcoma in 2 (13%), and small cell carcinoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, and Ewing sarcoma in 1 patient each (7%). Two patients experienced recurrences at 1 and 5 months after treatment; these patients died at 5 and 10 months after surgery, respectively. Estimated 5-year recurrence-free survival (RFS) was 86.7%, and estimated 5-year overall survival (OS) was 86.2%; there was no perioperative mortality. None of the patients had new neurological deficits as a result of the surgery, but 5 patients suffered infectious complications from the graft transplanted into the cavity after resection. There were no other perioperative complications.

CONCLUSIONS

These authors are the first to describe a technique for extended orbital exenteration with orbital apex skull base resection. The technique provided sufficient margins for gross-total resection of the sinonasal malignancy with orbital apex extension. The estimated 5-year OS and RFS rates were high, and the perioperative complication rate was acceptably low, demonstrating the safety and efficacy of this technique.

Uncoupling Action of Antibiotic Sporaviridins with Rat-liver Mitochondria

The effects of the glycoside antibiotic sporaviridins (SVDs) on oxidative phosphorylation of rat-liver mitochondria were examined. SVDs released state 4 respiration, dissipated transmembrane electrical potential, and accelerated ATPase activity. These facts demonstrated that SVDs are potent uncouplers of oxidative phosphorylation. During the uncoupling caused by SVDs, large amplitude swelling and oxidation of intramitochondrial NAD(P)H occurred, suggesting that SVDs greatly enhanced nonspecific permeability of the inner mitochondrial membrane. It is suggested that the uncoupling action of SVDs might be caused by dissipation of proton electrochemical potential due to an increase in the permeability of inner mitochondrial membrane.

Combined extradural subtemporal and anterior transpetrosal approach to tumors located in the interpeduncular fossa and the upper clivus

BACKGROUND

Central skull base lesions in the interpeduncular fossa and the upper clival regions can be challenging to access because of their location anterior to the brainstem. We have modified the anterior transpetrosal approach by combination with the extradural subtemporal route to increase the surgical corridor.

METHODS

Thirty-seven patients underwent surgical treatment via the anterior transpetrosal approach from 2002 to 2012. The combined surgical approach was primarily applied when the tumors arose from the upper clival portion and extended to the interpeduncular fossa. The combined approach was used in seven of these patients, comprising four patients with petroclival meningiomas, one patient with sphenoclival meningiomas, one patient with trigeminal schwannoma, and one patient with an epidermoid cyst extending from the interpeduncular fossa to the prepontine cistern.

RESULTS

The combined approach permitted excellent visualization of the interpeduncular fossa in addition to the upper clivus and the lateral aspect of the brain stem. Mobilization of the temporal lobe by the entire epidural dissection of the lateral wall of the cavernous sinus facilitates access via the subtemporal route. The transient symptom of the temporal lobe in the dominant site may be the only drawback for this combined approach, although it may disappear immediately after the surgery.

CONCLUSION

The present approach combines Dolenc's approach and Kawase's approach, providing a wide exposure to lesions of the interpeduncular fossa and the clivus.

Retinoic acids up-regulate functional eosinophil-driving receptor CCR3

Eotaxins and their receptor CCR3 have a definitive role for tissue accumulation of eosinophils both under homeostatic and pathologic conditions. However, physiological stimuli that can up-regulate CCR3 in blood-derived human eosinophils have not been recognized. As a prior gene microarray study revealed up-regulation of CCR3 in eosinophils stimulated with retinoic acids (RAs), the expression of functional CCR3 was examined. We found that 9-cis RA and all-trans RA (ATRA) significantly induced surface CCR3 expression regardless of the presence of IL-3 or IL-5. Pharmacological manipulations with receptor-specific agonists and antagonists indicated that retinoic acid receptor-α activation is critical for CCR3 up-regulation. RA-induced CCR3 was associated with its functional capacity, in terms of the calcium mobilization and chemotactic response to eotaxin-1 (CCL11). Our study suggests an important role of vitamin A derivatives in the tissue accumulation of eosinophils.

Neural decoding of visual imagery during sleep

Visual imagery during sleep has long been a topic of persistent speculation, but its private nature has hampered objective analysis. Here we present a neural decoding approach in which machine-learning models predict the contents of visual imagery during the sleep-onset period, given measured brain activity, by discovering links between human functional magnetic resonance imaging patterns and verbal reports with the assistance of lexical and image databases. Decoding models trained on stimulus-induced brain activity in visual cortical areas showed accurate classification, detection, and identification of contents. Our findings demonstrate that specific visual experience during sleep is represented by brain activity patterns shared by stimulus perception, providing a means to uncover subjective contents of dreaming using objective neural measurement.

Controlling pain after total knee arthroplasty using a multimodal protocol with local periarticular injections

BACKGROUND

Measures for pain management after total knee arthroplasty (TKA) are important for early improvement in the quality of life after operation and early postoperative rehabilitation. We investigated the benefits and safety analgesic effect of locally injected drugs around the total knee prosthesis.

METHODS

60 patients undergoing TKA for osteoarthritis were divided randomly into three groups.Group A (20 knees; control group), this group did not receive multimodal drug cocktailtherapy; group B (21 knees), received intra-articular injection of a multimodal drug cocktail; and group C (19 knees), received localperiarticular injection of a multimodal drug cocktail. All analgesics administered in the first 24 h after surgery were recorded. The evaluation items included assessment of pain using a 100-point visual analogue scale (VAS) after the patients awoke on the day of the operation and on postoperative day 1, the dose of diclofenac sodium suppository, the number of days for acquiring assisted ambulation with a walking cane, and side effects. Assessment of flexion angles was conducted at postoperativeweek 1 and at theconclusion of the study.

RESULTS

The VAS scores on the day of surgery and the amounts of diclofenac sodium used indicated good pain relief in groups B and C; the level of pain control was higher in group C than in group B. No cardiac or central nervous system toxicity was observed.

CONCLUSIONS

Periarticular injection with multimodal drugs can significantly reduce the requirements for analgesia, with no apparent risks, following TKA.

Ozone microbubble treatment at various water temperatures for the removal of residual pesticides with negligible effects on the physical properties of lettuce and cherry tomatoes

In this study, the effects of ozone microbubbles (OMCB) treatment at various water temperatures on the removal of residual fenitrothion (FT) pesticides and on the physical properties of lettuce and cherry tomatoes was examined. The residual FT percentage in lettuce and cherry tomatoes was shown decreased by using higher water temperatures, particularly at 30 °C, resulting in a decrease within the range of 32% to 52%, after the 20-min treatment. In addition, bubbling OMCB treatment did not alter the color and pulling strength of lettuce and cherry tomatoes. These results indicate that bubbling OMCB treatment at 30 °C is a highly effective method for the removal of FT residues in lettuce and cherry tomatoes, with relatively little effect on crop quality.

PRACTICAL APPLICATION

The bubbling OMCB has a potential of reducing the FT reduces on vegetables with no adverse effect on the sensory quality of vegetables.

Chronic encapsulated expanding hematoma in nonfunctioning pituitary adenoma

The diagnosis and treatment of pituitary macroadenomas with entire hematoma fluid accumulation are problematic. Such lesions are often difficult to completely resect, and recurrence is not uncommon. We present five cases of pituitary macroadenomas entirely composed of hematoma fluid and investigated their histopathology to clarify the mechanism of the hematoma fluid accumulation. Five patients with pituitary adenoma and significant intra-tumor hematoma underwent transsphenoidal resection and were retrospectively reviewed for their clinical status, findings on magnetic resonance imaging (MRI), intraoperative findings, and histopathology. The specific surgical techniques used to address these cases were also reviewed. All patients were diagnosed with nonfunctioning pituitary adenomas by histopathological examination. MRI showed all tumors extended to the cavernous sinus. Histopathology showed tumor tissues were located between the thick granulation tissue and the pseudocapsule of the tumor. The thick granulation tissues were composed of collagenous layers, neovascular vessels, and necrotic red blood cells, indicating repeat hemorrhage from the granulation tissues. The boundary between adenoma and normal pituitary gland was identified during surgical removal in four patients and was not identified in the other patient who showed a recurrence 2 years later. Clinical and histopathological findings indicate hematoma fluid accumulation in the present cases is caused by repeat hemorrhage from the reactive granulation tissues and can be regarded as a chronic encapsulated expanding hematoma. In these cases, the boundary between adenoma and normal pituitary gland should be identified before puncturing the hematoma fluid to minimize the risk of tumor recurrence.

Clinical Course and Autopsy Findings of a Patient with Clival Chordoma Who Underwent Multiple Surgeries and Radiation during a 10-Year Period

The management of clival chordoma remains problematic. We present the case of a 48-year-old woman with clival chordoma who underwent multiple surgeries and radiation therapy, including gamma knife stereotactic radiosurgery (GK-SRS), during a 10-year clinical course. The tumor was initially removed by gross total resection via the trans-sphenoidal approach, followed by external linac radiation therapy. The tumor recurred at the clivus 5 years after the initial operation. After repeated trans-sphenoidal removal of recurrent tumors, she twice underwent GK-SRS for a tumor remnant adjacent to the brainstem. Although this part of the tumor was controlled by GK-SRS, there was further tumor extension toward the sphenoid and maxillary sinuses. Ultimately, lower cranial nerve dysfunction developed due to tumor extension into the lower part of the clivus and the patient died of respiratory failure. Autopsy revealed the tumor to extend from the lower clivus to the bilateral middle fossae. The lower part of the tumor extended to the nasal cavity and to the posterior wall of the pharynx, resulting in compression of the upper pharyngeal region. The tumor around the jugular foramen compressed the lower cranial nerves bilaterally. Tumor cells did not, however, invade the intradural space microscopically. Although chordoma is not biologically malignant, this tumor can show massive extension with destruction of bony structures and extracranial invasion of connective tissues. Therefore, the optimal treatment strategy is to remove the tumor mass as extensively as possible, including normal bony structures and connective tissues surrounding the tumor, using skull base surgical techniques.

Removal of residual pesticides in vegetables using ozone microbubbles

The removal of fenitrothion (FT) pesticide residues from vegetables by immersion in ozone-microbubbled solution was demonstrated. FT-treated lettuce, cherry tomatoes, and strawberries were immersed in ozone-microbubbled, ozone-millibubbled, and dechlorinated water. After that the percentage of residual FT in the vegetables was determined. Residual FT was efficiently removed from lettuce by immersing it in ozone-microbubbled solution containing more than 1.0 ppm dissolved ozone, or continuously generated ozone-microbubbled solution containing 2.0 ppm dissolved ozone. Similarly, for cherry tomatoes and strawberries, the continuously generated ozone-microbubbled solution containing 2.0 ppm dissolved ozone was highly effective. These results showed that ozone microbubbles effectively removed residual pesticides not only from leafy vegetables but also from fruity vegetables.

[Repeated catamenial pneumothorax with pleural and diaphragmatic endometriosis; report of a case]

A 31-year-old female with 2 episodes of right pneumothorax related to onset of menstruation was reported. Thoracoscopy revealed the presence of some cystic lesions in the diaphragm. Partial resection of the diaphragm including the lesions was performed. Histologial findings of the resected diaphragm showed stromal endometriosis. One month after operation, she had a recurrent right pneumothorax related to onset of menstruation. A pinhole perforation of the lower lobe was noted at 2nd surgery. Microscopic examination of the resected lung disclosed endometrial stroma in the macroscopically normal lung tissue. Since air leakage from chest tube continued after surgery, the hormonal therapy with a gonadotropin-releasing hormone analogue was started, and she was discharged from the hospital 3 weeks after hormonal therapy. Report of the demonstration of endmetriosis in the visceral pleura and diaphragm is very rare and the present case is very suggestive is considering the mechanism of the development of this disease.

Possible role of cyclooxygenase-2 in developing chronic subdural hematoma

Inflammatory cytokines are reportedly involved in the pathogenesis of chronic subdural hematomas (CSH), and the angiogenesis of hematomas has particularly been in focus. Cyclooxygenase-2 (COX-2) is an essential enzyme for the synthesis of prostaglandin E2 (PGE2). The COX-2-PGE2 pathway has been shown to influence angiogenic factors such as vascular endothelial growth factor (VEGF). We investigated the association of COX-2 expression in the dura mater and outer membrane with the pathogenesis of CSH, and suggested a treatment strategy on the basis of this association. Hematoma fluid and serum samples obtained from 37 patients, and samples of the dura mater and outer CSH membrane obtained from 13 patients during the operation were examined in this study. The concentrations of PGE2 in relation to COX-2 in the hematoma fluid were significantly higher than those in the serum. Immunohistochemical analyses revealed COX-2-positive cells in the outer membrane of CSHs. There was a linear and significant relationship between PGE2 concentration in hematoma fluid and the interval from trauma to initial surgery. COX-2 may play a crucial role during the development of CSHs. Our study might lead to the development of anti-COX-2 treatment options that aim to minimize repeat surgery and choose medical therapy by reducing CSH morbidity and recurrence rate in patients with CSH.

In vivo kinematic analysis of a high-flexion, posterior-stabilized, mobile-bearing knee prosthesis in deep knee bending motion

The objective of this study was to evaluate the kinematics of a high-flexion, posterior-stabilized, mobile-bearing total knee arthroplasty (TKA) in weight-bearing, deep knee bending motion. Thirteen patients implanted with the Legacy Posterior Stabilized Flex (Zimmer, Warsaw, IN) mobile-bearing TKA were examined during a deep knee bending motion using fluoroscopy. Femorotibial motion was determined using a 2-dimensional to 3-dimensional registration technique, which used computer-assisted design models to reproduce the position of metallic implants from single-view fluoroscopic images. The average flexion range of motion between the metallic implants was 116 degrees . The average rotation of the femoral component was 9.3 degrees external rotation. The mean kinematic pathway was early rollback, lateral pivot with external rotation, and bicondylar rollback. We found that the kinematic pattern of the Legacy Posterior Stabilized Flex mobile-bearing TKA was different than normal knee kinematics.

[Giant left atrial myxoma with ossification on having a fever; report of a case]

A 37-year-old female with a fever had a medical examination, and was pointed out cardiac murmur. She was referred to our hospital for a further examination. Blood cultures were positive for Streptococcus milleri group. Thoracic echocardiogram demonstrated a giant left atrial tumor, arising from the portion of the interatrial septum, and mitral insufficiency. We removed the tumor completely and performed mitral annuloplasty. The tumor was diagnosed as myxoma with ossification by histopathological examination. She discharged from our hospital 25 days after the operation without complication and does not recur for 3 years. We consider our case as extremely rare, because it revealed giant left atrial myxoma with ossification and mitral insufficiency at the same time.

[Clinical and serial angiographic study in patients with subarachnoid hemorrhage of unknown etiology with special reference to the clot distribution of perimesencephalic nonaneurysmal subarachnoid hemorrhage]

We investigated 22 cases with subarachnoid hemorrhage (SAH) of unknown etiology by the initial digital subtraction angiography (DSA). The computed tomography (CT) scans were obtained within 24 hours from onset. Patients were divided into two groups according to SAH distribution in CT on admission; perimesencephalic SAH (PMSAH) and non-PMSAH. The category of patients belonging to the PMSAH group was subdivided into typical or extended pattern of PMSAH. Typical PMSAH pattern of CT is defined as that having the center of clot immediately anterior to the upper brainstem with no definite extension into the anterior interhemispheric fissure (IFH) or sylvian fissure. Extended PMSAH pattern includes the extension of SAH into the anterior IHF or sylvian fissure with the center of the clot similarly located anterior to the upper brainstem. The number of patients with typical PMSAH, extended PMSAH or non-PMSAH was 2, 6, or 14, respectively. Follow-up DSA was obtained in 20 Spatients. The 2nd DSA revealed the lesions as bleeding sources in 3 patients with non-PMSAH. Eight patients further underwent the 3rd DSA, which identified bleeding sources in 3 patients with non-PMSAH. No bleeding sources were detected by serial DSA in PMSAH patients. Patients with extended PMSAH may be managed like those with typical PMSAH. The 3rd DSA is required if the 2nd DSA fails to identify the bleeding source in non-PMSAH. The 2nd DSA may be necessary in PMSAH patients because of the possible identification of bleeding sources. Optimal diagnostic protocol to confirm the bleeding sources should be established in SAH patients of unknown etiology.

[Mediastinal lymph node carcinoma of unknown primary site; report of a case]

A 44-year-old woman was admitted to our hospital because of mediastinal mass. Serum levels of carcinoembryonic antigen (CEA) were found to be elevated. No preoperative examination could detect the primary lesion. The tumor was resected through right thoracotomy. Histological examination revealed poorly differentiated adenocarcinoma. She was diagonosed as metastatic mediastinal lymph node carcinoma of unknown primary site. She received radiotherapy and chemotherapy and is desease free 29 months after operation. Good results may be obtained by multimodality therapies for cancer in mediastinal lymph node of unknown primary site.

[The usefulness of whole body FDG-PET/CT in patients with brain metastasis]

In patients presenting with brain metastases, the evaluation for extracranial metastases is important to determine the therapeutic strategies and predict the patients outcome. We investigated the findings of whole-body FDG-PET/CT in 30 patients with metastatic brain tumors. The patients were divided into two groups consisting of 16 patients with precocious or synchronous metastases (PS group), or 14 patients with metachronous metastases (M group), according to the brain metastatic patterns. In all patients of the PS group, the primary site was the lung. In one patient of the PS group, the primary lesion was detected neither by FDG-PET/ CT nor by contrast-enhanced CT or MRI in one patient of the PS group. The primary site of another patient in the PS group was confirmed only by FDG-PET/CT. The sensitivity of FDG-PET/CT in search of primary site was 93.3%, while that of conventional modalities was 87.5%. Maximum standardized uptake value (SUV) of the primary lesions did not show statistically significant difference between groups with single and multiple metastatic brain lesions. SUV also failed to show a statistically significant difference between groups with and without extracranial metastatic lesions. In patients comprising the M group, breast cancer was the most frequent primary site. 3 patients in the M group showed no definite hypermetabolic lesions including the primary sites. Two of them have been clinically independent for more than 20 months. 22 (73.3%) of all patients presented extracranial metastases when brain lesions were found. FDG-PET/CT is a useful modality in detecting the primary cancer and evaluating extracranial systemic metastases. It is important to establish a refined clinical staging system and predict the patient's prognosis based upon the findings of FDG-PET/CT in patients with brain metastasis.

Development of large deformation in 62Cr

The structure of neutron-rich isotopes 60Cr and 62Cr was studied via proton inelastic scattering in inverse kinematics. The deformation lengths (delta) for 60Cr and 62Cr were extracted as 1.12(16) and 1.36(14) fm, respectively, providing evidence for enhanced collectivity in these nuclei. An excited state at 1180(10) keV in 62Cr was identified for the first time. We adopted 4;{+} as its spin and parity, leading to the rapid increase of the Ex(4;{+})/E_{x}(2;{+}) ratio, which indicates the development of large deformation in 62Cr near N=40. Importance of the admixture of the gd-shell component above N=40 is also discussed by comparing with a modern shell model calculation.