Treatment results of two-stage operation for the patients with esophageal cancer concomitant with liver dysfunction

PURPOSE

The aim of this study was to clarify the usefulness of two-stage operation for the patients with esophageal cancer who have liver dysfunction.

METHODS

Eight patients with esophageal cancer concomitant with liver dysfunction who underwent two-stage operation were analyzed. The patients initially underwent an esophagectomy, a cervical esophagostomy and a tube jejunostomy, and reconstruction with gastric tube was performed after the recovery of patients' condition.

RESULTS

The average time of the 1(st) and 2(nd) stage operation was 410.0 min and 438.9 min, respectively. The average amount of blood loss in the 1(st) and 2(nd) stage operation was 433.5 ml and 1556.8 ml, respectively. The average duration between the operations was 29.8 days. The antesternal route was selected for 5 patients (62.5%) and the retrosternal route was for 3 patients (37.5%). In the 1(st) stage operation, no postoperative complications were observed, while, complications developed in 5 (62.5%) patients, including 4 anastomotic leakages, after the 2(nd) stage operation. Pneumonia was not observed through two-stage operation. No in-hospital death was experienced.

CONCLUSION

A two-stage operation might prevent the occurrence of critical postoperative complications for the patients with esophageal cancer concomitant with liver dysfunction.

The suprapineal recess of the third ventricle: an anatomic study with magnetic resonance imaging

PURPOSE

The suprapineal recess (SPR) is a small, backward extension of the third ventricle. Few radiological studies have investigated the morphology of the SPR. Here, we explore the SPR with magnetic resonance (MR) imaging.

METHODS

A total of 124 patients underwent thin-slice MR imaging examinations with T2-weighted imaging and the constructive interference steady-state (CISS) sequence. Imaging data were transferred to a workstation for analysis.

RESULTS

The pineal gland (P) was delineated in 99% of the patients on T2-weighted imaging and 100% of the patients on the CISS sequence. In contrast, the SPR was identified in 27% of the patients on T2-weighted imaging and 82% of the patients on the CISS sequence. The location of the P relative to the lowest point of the splenium was roughly classified into two types. Of them, the anterior P location was the more frequent type and observed in 73% of the patients. The angle formed by the roof and floor of the SPR showed remarkable interindividual diversity. A membranous posterior extension with variable length, spanning between the posterosuperior margin of the P and Galenic complex was found in 55% of the identified SPRs on T2-weighted imaging and 45% on the CISS sequence.

CONCLUSIONS

The SPR is a distinct structure with diversity in appearance among individuals but commonly extends posterior to the P. High-resolution MR imaging is useful for delineating the SPR in vivo.

Osteochondroma Presenting as a Calcified Mass in the Sellar Region and Review of the Literature

Objective Osteochondroma (OC) is the most common benign bone neoplasm. It infrequently occurs in the cranial cavity as a calcified lesion and very rarely presents in the sellar region. The present study summarizes the knowledge about OCs of the sellar region. Methods We searched the literature search for the clinical appearance of OCs and other calcified pathologies occurring in the sellar region. Results A total of 21 English-language articles published from 1961 to 2015 documented cases of calcified lesions in the sellar region including cerebral aneurysm, chondroid chordoma, chondroma, craniopharyngioma, OC, odontome, osteoma, pituitary adenoma, pituitary stone, Rathke cleft cyst, retinoblastoma, schwannoma, and xanthogranuloma. Among them, six were OC cases: three in the parasellar region and three in the sellar-suprasellar region. Patients with sellar-suprasellar OCs presented with visual loss and hypopituitarism; patients with parasellar OCs did not show these symptoms. OCs appeared as irregular and multilobulated calcifications on X-ray and computed tomography. On magnetic resonance imaging, OCs showed variable intensity on T1-weighted sequences and consistently heterogenous intensity on T2. Four patients underwent transcranial tumor resection, and the transsphenoidal route was selected for one. Five of the six resulted in a partial resection or internal decompression with a satisfactory outcome. Conclusions Calcified tumors occurring in the sellar region may be OCs, especially if they appear as irregular multilobulated calcification.

Distant lymph node metastases caused by esophageal cancer invasion to the lamina propria: a case report

Background

Pathological examination after endoscopic submucosal dissection revealed that a 62-year-old male had esophageal squamous cell carcinoma with lamina propria mucosal invasion and lymphatic permeation.

Case presentation

The patient underwent subtotal esophagectomy and reconstruction as an additional therapy. At 3 years and 4 months after esophagectomy, enlargement of abdominal para-aortic lymph nodes metastases was detected by computed tomography scanning. A total of 50.4 Gy of radiation and two cycles of 5-fluorouracil plus cisplatin were administered. The lymph node metastases were markedly reduced by chemoradiotherapy; however, at 1 year and 1 month later (4 years and 5 months after esophagectomy), left adrenal gland recurrence was found. Although resection was performed, the patient died from cancer progression at 5 years and 4 months after esophagectomy.

Conclusions

This case demonstrates that esophageal squamous cell carcinoma with invasion to the lamina propria and lymphatic permeation has the potential to cause distant metastases.

Development of fistula between esophagogastric anastomotic site and cartilage portion of trachea after subtotal esophagectomy for cervical esophageal cancer: a case report

A 65-year-old man with cT3N2M0 stage III cervical esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the retrosternal route after neoadjuvant chemoradiotherapy. The anastomosis was located adjacent to the left side of the trachea, and a circular stapler was used for anastomosis. Postoperative anastomotic leakage occurred, and an esophagotracheal fistula between the esophagogastric anastomotic site and cartilage portion of the trachea was observed on postoperative day 44. The patient underwent division of the fistula, direct suturing of the anastomotic leakage site, left pectoralis major muscle flap placement, and tracheotomy. He was discharged home on postoperative day 120 on an oral diet. All previous reports of tracheobronchial fistula describe the occurrence of the fistula at the membranous portion of the trachea. The formation of a fistula between the esophagogastric anastomotic site and cartilage portion of the trachea is considered a possible complication when a high esophagogastric anastomosis is created.

Cerebral cavernous malformations with diffuse manifestation: A benign entity?

PURPOSE

Cerebral cavernous malformations (CCMs) are a distinct cerebrovascular disease. A fraction of CCMs present as diffuse manifestations distributed over the cerebral hemispheres, cerebellum, and brainstem. The purpose of the present study was to explore the clinical picture of such CCMs.

METHODS

This study assessed the appearance of CCMs on magnetic resonance (MR) images, the presence of genetic mutations using the polymerase chain reaction method, and disease course over long-term follow-up in a total of 10 patients with diffuse CCMs.

RESULTS

The 10 patients were Japanese and comprised 5 males and 5 females with a mean age of 48.7years. Three of them presented with seizures, two with headache and intracerebral hemorrhage, two with numbness, and one with dizziness, while the remaining two were asymptomatic. Genetic analysis revealed CCM1 mutations in four patients, CCM2 mutations in three, and a CCM3 mutation in one. In a family with 2 CCM2 patients, the appearance of sustained diffuse CCMs on MR images significantly differed between the 2 patients despite the mutation being identical. During the mean follow-up period of 13.7years, none of the 10 patients showed evidence of neurological deterioration or symptomatic hemorrhage. The appearance of their CCMs on MRI did not show significant changes. Eight patients maintained normal neurological function.

CONCLUSIONS

CCMs with diffuse manifestation is a hereditary disease with satisfactory prognosis. Unrecognized genomic mutations may be involved in the genesis of these CCMs.

Visualization of the olfactory nerve using constructive interference in steady state magnetic resonance imaging

PURPOSE

The olfactory nerve (OlfN) is a small neural structure with inconsistent visualization on neuroimages. The aim of this study was to delineate the intracranial course of the OlfN using constructive interference in steady state magnetic resonance (MR) imaging.

METHODS

A total of 168 patients were enrolled in this study. Following initial examinations with conventional MR sequences, constructive interference in steady-state sequence (CISS) was performed in coronal and axial sections.

RESULTS

On coronal sections, the OlfN was entirely visualized in 90 % of patients on the right and 92 % on the left, coursing along the olfactory sulcus. Complete visualization of the OlfN occurred in 100 % of patients on serial axial images. The OlfN was classified into four portions based on the topographical differences and surrounding structures. The olfactory fossa exhibited considerable variability at the midlevel of the olfactory bulb on coronal images. Characteristic appearance of the OlfN with respect to age range or gender was not observed.

CONCLUSIONS

The OlfN follows a highly consistent course along the olfactory sulcus. Thin-sliced, CISS sequences are useful for consistent visualization of the OlfN.

Expression of PD-L1 and HLA Class I in Esophageal Squamous Cell Carcinoma: Prognostic Factors for Patient Outcome

BACKGROUND

Programmed cell death 1 ligand 1 (PD-L1) and human leukocyte antigen (HLA) class I molecules on malignant cell surfaces are pivotal for tumor immunity. The clinical significance of their expression in patients with esophageal squamous cell carcinoma (ESCC) remains to be determined.

METHODS

PD-L1 and HLA class I protein expression was investigated by immunohistochemical staining of resected specimens from 90 ESCC patients who underwent radical surgery without preoperative therapy. The relationships between the expression of PD-L1 and HLA class I and clinicopathologic factors and patient prognosis were assessed.

RESULTS

High expression of PD-L1 and HLA class I were observed in 17 (18.9 %) and 35 (38.9 %) of 90 cases, respectively. High PD-L1 expression was correlated with the depth of tumor invasion (P = 0.0379), lymph node metastasis (P = 0.0031), recurrence (P = 0.0085), and poor overall survival (OS) (5-year survival rate; low/high: 60.9/28.4 %, P = 0.0110). Among those patients with high expression of HLA class I, high PD-L1 expression was correlated with significantly poorer recurrence-free survival (median survival time, low/high: 102.5/3.1 months, P = 0.0016) and poorer OS (median survival time, low/high: 102.5/13.1 months, P = 0.0027). Multivariate analysis showed that combined high PD-L1/high HLA class I expression was an independent prognostic factor for recurrence-free survival (hazard ratio 2.88, 95 % confidence interval 1.02-7.04, P = 0.0455) and OS (hazard ratio 2.95, 95 % confidence interval 1.03-7.50, P = 0.0447).

CONCLUSIONS

High PD-L1 expression was a significant independent prognostic factor in ESCC patients with high HLA class I expression.

Langerhans cell histiocytosis with seborrheic eczema of the scalp and extensive calvarial involvement

INTRODUCTION

Langerhans cell histiocytosis (LCH) is a multisystem disorder of unknown etiology and characterized by accumulation of histiocytes in various tissues.

CASE REPORT

A 3-year-old, previously healthy girl presented with progressive flattening of the parietal convexity for 6 months and seborrheic eczema of the scalp. At presentation, the patient showed no neurological deficit. The eczemas were extensively distributed over the scalp, but not found in any other site of the body. Blood examination revealed a marked increase in soluble interleukin-2 receptor levels. Neuroimages revealed multiple calvarial defects that were replaced by well-demarcated, enhancing extracerebral masses. A biopsy surgery confirmed the diagnosis as LCH.

CONCLUSION

LCH may cause progressive calvarial defects. If seborrheic eczemas are concurrent, they may suggest prompt histological verification and treatments be initiated.

A possible venous connection between the cranial and nasal cavity

PURPOSE

The foramen cecum (FC) is a fine bony canal with the aperture located immediately anterior to the crista galli (CG). The venous structures in the regions of the FC and CG have been inconsistently described and are not well understood. Here we explore these veins using magnetic resonance imaging.

MATERIALS AND METHODS

We enrolled 101 patients who underwent contrast examinations and exhibited intact skin, skull, dura mater, and intracranial dural sinuses. Imaging data were obtained as thin-sliced, seamless sagittal sections and were transferred to a workstation for analysis.

RESULTS

In 84 % of the patients, tubular-shaped venous extensions arose from the rostral end of the falx cerebri and were confirmed to lie in the FC. These extensions were supplied by the superior sagittal sinus or the frontal cortical vein, and were classified into four types: rudimental slight projections, short and straight extensions, long and straight channels, and long and tortuous channels. Furthermore, 27.7 % of the patients exhibited a distinct venous channel between the venous extension in the FC and the median vestibular submucosa of the nasal cavity. Among these channels, 81.5 % were connected to the vein lying in the FC via a short channel that vertically pierced the CG.

CONCLUSIONS

The FC contains tubular-shaped venous extensions that are supplied by the rostral end of the superior sagittal sinus or the frontal cortical vein. The cranial cavity, FC, and nasal cavity may be connected by a venous channel.

Malignant Peripheral Nerve Sheath Tumor Manifesting as Severe Buttock Pain

A 28-year-old woman presented with complaints of severe buttock pain exacerbating for 2 weeks. Physical examination found numerous café-au-lait macules and axillary freckles. Neurological examination revealed sensory loss at the S3-S5 dermatome and significant vesicorectal dysfunction. Magnetic resonance imaging revealed an enhanced intraspinal mass at S1-S2, with bony erosion on the dorsal aspect of the sacrum. Intraoperatively, the rostral part of the tumor was found to involve a filament of the cauda equina. The tumor protruded extraspinally through an irregular-shaped defect in the dorsal dura and bony erosion. Total resection was achieved. The histological appearance was consistent with malignant peripheral nerve sheath tumor and loss of neurofibromin. Malignant peripheral nerve sheath tumor should be included in the differential diagnosis of spinal tumor in a patient with neurofibromatosis type 1.

Cerebrospinal fluid drainage through the diploic and spinal epidural veins

The aim of this study was to quantitatively evaluate the function of the cranial diploic and spinal epidural veins as cerebrospinal fluid (CSF) drainage pathways by measuring lipocalin-type prostaglandin D synthase (PGDS) and cystatin C (CysC) dissolved in the blood of these veins. This was a prospective study involving 51 consecutive patients, 31 males and 20 females, who underwent 41 cranial and 10 spinal surgeries. Intraoperatively, peripheral venous blood and diploic venous blood, or peripheral venous blood and spinal epidural venous blood samples were simultaneously collected and immediately centrifuged. For all samples, dissolved albumin (for reference), PGDS and CysC were measured using an enzyme-linked immunosorbent assay. The diploic vein/peripheral vein ratios in five cranial locations and epidural vein/peripheral vein ratios were calculated and statistically evaluated for the three biomarkers. For PGDS, the diploic vein/peripheral vein ratio was significantly increased in the frontal (P = 0.011), temporal (P = 0.028), parietal (P = 0.046) and skull base (P = 0.039), while it did not reach statistical significance for CysC. For patients older than 45 years, the diploic vein/peripheral vein ratio for PGDS was significantly decreased in the frontal region (P = 0.028), and the epidural vein/peripheral vein ratio for CysC was significantly decreased (P = 0.014). These results show that the diploic veins constitute CSF drainage pathways with heterogeneous functional intensity at different cranial locations. Compared with the diploic veins, spinal epidural veins seem to drain less CSF. The cranial diploic and spinal epidural veins may jointly function as an alternative, age-related trans-dural CSF drainage system.

Schwannoma of the nasal septum presenting as a multicentric neuronal tumour

PROBLEM

Schwannomas (neurilemmomas) are benign primary tumours that arise from Schwann cells. Schwannomas arising from the nasal septum are exceptionally rare. Here, we report a unique case of schwannoma of the nasal septum presenting as a multicentric neuronal tumour.

RESULTS

A 40-year old male sustained intermittent left tinnitus. Magnetic resonance imaging revealed masses near the nasal septum and upper cervical cord in addition to a tumour in the left cerebellopontine (CP) angle. The tumour in the nasal septum was completely resected by endoscopic endonasal surgery and diagnosed as a typical schwannoma. The CP angle tumour was treated with stereotactic radiosurgery, while the asymptomatic cord lesion showed no significant growth and remains under observation.

CONCLUSION

Endoscopic endonasal surgery is useful for the resection of schwannomas of the nasal septum. Schwannomas of the nasal septum may present as multiple neuronal tumours.

Cranial arachnoid protrusions and contiguous diploic veins in CSF drainage

BACKGROUND AND PURPOSE

Studies have suggested that arachnoid villi or granulations found in the walls of the cranial dural sinuses, olfactory mucosa, and cranial nerve sheaths function as outlets for intracranial CSF. However, their role as CSF outlets has not yet been verified. Here we show that arachnoid protrusions and contiguous diploic veins provide an alternative drainage route for intracranial CSF.

MATERIALS AND METHODS

Four hundred patients with intact skull, dura mater, and dural sinuses underwent MR imaging to explore arachnoids protruding into the skull and diploic veins. Patients with symptoms of increased intracranial pressure or intracranial hypotension were excluded. For 15 patients undergoing craniotomy, both peripheral and diploic venous blood was collected. Albumin and the CSF-specific biomarkers were measured by enzyme-linked immunosorbent assay.

RESULTS

With MR imaging, arachnoid protrusions into the skull and contiguous diploic veins were consistently identified throughout the cranium with their characteristic appearance depending on the cranial region. In addition, elevated amounts of prostaglandin D synthase and cystatin C were confirmed in diploic veins compared with peripheral venous blood.

CONCLUSIONS

Diploic veins are distributed ubiquitously throughout the cranium. A portion of the intracranial CSF may be drained through arachnoid protrusions and contiguous diploic veins.

The superior ophthalmic vein: delineation with high-resolution magnetic resonance imaging

OBJECTIVE

To delineate the superior ophthalmic vein (SOV) with high-resolution magnetic resonance (MR) imaging.

METHODS

This retrospective study enrolled 302 consecutive outpatients, 101 patients, 51 males and 50 females, who underwent coronal T2-weighted imaging and 201 patients, 99 males and 102 females, who underwent three-dimensional (3D) phase-contrast (PC) MR angiography.

RESULTS

Coronal T2-weighted imaging clearly delineated the intraorbital course of SOV on serial images in all 101 subjects. The SOV could be topographically divided into three segments in relation to the superior rectus muscle. The SOV crossed over the optic nerve at the level of the anterior ethmoidal foramina in 87% of right orbits and 71% of left orbits. The mean outer diameter of the SOV at the crossing point was 1.7 mm on both sides, but the SOVs were asymmetric in the same individual in 75% of the subjects. 3D PC MR angiography showed that the bilateral SOVs were symmetrical in 16% of subjects, larger in the right orbit in 18%, and larger in the left orbit in 13%, and were unidentified in 52%. The SOV showed a consistent lateral course to the ophthalmic artery.

CONCLUSIONS

The SOV consistently courses lateral to the ophthalmic artery, but tends to show bilateral asymmetry in the outer diameter. The superior rectus muscle, anterior ethmoidal foramen, and anterior ethmoidal artery are valuable landmarks to identify the SOV during transcranial orbital surgery. Combination of high-resolution MR imaging and 3D PC MR angiography is useful for delineating the SOV.

Cervical spondylosis: Evaluation of microstructural changes in spinal cord white matter and gray matter by diffusional kurtosis imaging

INTRODUCTION

We investigated microstructural changes in the spinal cord, separately for white matter and gray matter, in patients with cervical spondylosis by using diffusional kurtosis imaging (DKI).

METHODS

We studied 13 consecutive patients with cervical myelopathy (15 affected sides and 11 unaffected sides). After conventional magnetic resonance (MR) imaging, DKI data were acquired by using a 3T MR imaging scanner. Values for fractional anisotropy (FA), apparent diffusion coefficient (ADC), and mean diffusional kurtosis (MK) were calculated and compared between unaffected and affected spinal cords, separately for white matter and gray matter.

RESULTS

Tract-specific analysis of white matter in the lateral funiculus showed no statistical differences between the affected and unaffected sides. In gray matter, only MK was significantly lower in the affected spinal cords than in unaffected spinal cords (0.60±0.18 vs. 0.73±0.13, P=0.0005, Wilcoxon's signed rank test).

CONCLUSIONS

MK values in the spinal cord may reflect microstructural changes and gray matter damage and can potentially provide more information beyond that obtained with conventional diffusion metrics.

Laparoscopic gastrectomy for gastric cancer with peritoneal dissemination after induction chemotherapy

Gastric cancer with peritoneal dissemination may be diagnosed as unresectable. More recently, as a result of progress in chemotherapy, some patients with peritoneal dissemination have exhibited extended survival. We report on our experience with three patients in whom induction chemotherapy allowed for totally laparoscopic total gastrectomy (TLTG). All three patients were diagnosed as having advanced gastric cancer with peritoneal dissemination using staging laparoscopy. As induction chemotherapy, S-1 combined with cisplatin was administered to two patients and trastuzumab plus capecitabine combined with cisplatin to one patient. TLTG was performed in all patients and there were no postoperative complications. Adjuvant chemotherapy was initiated within 3 weeks after surgery in all three patients. Laparoscopic gastrectomy undertaken after induction chemotherapy was found to be effective and safe; this treatment has the potential to achieve good treatment outcomes in patients with stage IV gastric cancer.

Single institutional experience of the treatment of angiosarcoma of the face and scalp

OBJECTIVE

Angiosarcoma is a rare malignant neoplasm with a poor prognosis. A retrospective study was performed to accumulate radiotherapy (RT) data.

METHODS

Data from 17 patients with angiosarcoma of the face and scalp (AFS) who were treated with definitive RT between January 1999 and July 2011 were retrospectively analysed. The total radiation dose was 70 Gy, and the fractional doses were 2.0-2.5 Gy. Combined with RT, chemotherapy using docetaxel alone, recombinant interleukin-2 immunotherapy alone and both of these was performed in 10, 4 and 2 patients, respectively. Three patients underwent limited surgery before RT.

RESULTS

The response rate was 82%, and the median overall survival (OS) rate was 26 months. Locoregional relapse alone, distant metastasis alone and both of these were confirmed in 4, 5 and 4 patients, respectively. Patients treated with docetaxel showed a better prognosis (p=0.0477), a distant metastasis-free rate (p=0.0063) and a better in-field control rate, although the last was not statistically significant (p=0.1645).

CONCLUSION

Definitive RT combined with docetaxel chemotherapy provided an effective approach for treating AFS.

ADVANCES IN KNOWLEDGE

Since patients treated with chemoradiotherpy using docetaxel showed better OS and distant metastasis-free rates than those who did not receive docetaxel, it was warranted to continue use of docetaxel. In chemoradiotherapy at a dose of 70 Gy using docetaxel, 2-year in-field control rate was 67%.

Solitary epicranial neurofibroma with NF1-related germline mutation: case report

A 33-year-old male became aware of a painless soft mass in the left occipital region. His medical and family history were unremarkable for neurofibromatosis type 1 (NF1) or other genetic disorders. Physical examination showed no signs of NF1. Neurological and ophthalmological examinations found no abnormality. Cranial computed tomography showed an isodense mass located subcutaneously with irregular deformities in the adjacent occipital bone. Magnetic resonance (MR) imaging demonstrated that the lesion, 7.5 × 5.5 cm in diameter, was hypointense both on T1- and T2-weighted images and intensely enhanced after gadolinium infusion. The patient requested to remove the large mass. The subcutaneous tumor was well circumscribed, encapsulated, and less vascular, and resected en bloc. The histological diagnosis was neurofibroma without findings of cell atypia, whereas genomic exploration identified abnormal gains in NF1 gene, and resultant absence of neurofibromin, a protein coded on NF1 gene. Solitary neurofibromas in "clinically" non-NF1 patients may originate from the genomic changes in NF1 gene.

Convexity en plaque meningioma manifesting as subcutaneous mass: case report

A 67-year-old woman sensed a slowly growing, painless hard mass in the left parietal region. Cranial computed tomography showed focal bony erosion and homogeneous sclerotic change at the affected site. Magnetic resonance (MR) imaging revealed an enhanced subcutaneous mass and irregularly thickened dura mater. Intraoperatively, the subcutaneous tumor was found to be strongly adhered to the temporalis muscle. The outer table was eroded adjacent to the subcutaneous tumor, whereas the bony structures of the inner table were intact. The dura mater underneath had irregular-shaped, yellowish convolutions both on the outer and inner surfaces. The patient underwent total tumor resection with sufficient normal margins. The histological diagnosis was World Health Organization (WHO) grade I meningioma, with finger-like outward extensions through the dura mater and overlying skull, and infiltration among into the temporalis muscle fibers. Meningiomas may form a subcutaneous mass without intracranial growth.

Detection of antiferromagnetic ordering in heavily doped LaFeAsO(1-x)H(x) pnictide superconductors using nuclear-magnetic-resonance techniques

We studied double superconducting (SC) domes in LaFeAsO(1-x)H(x) by using 75As and 1H nuclear-magnetic-resonance techniques and unexpectedly discovered that a new antiferromagnetic (AF) phase follows the double SC domes on further H doping, forming a symmetric alignment of AF and SC phases in the electronic phase diagram. We demonstrated that the new AF ordering originates from the nesting between electron pockets, unlike the nesting between electron and hole pockets, as seen in the majority of undoped pnictides. The new AF ordering is derived from the features common to high-Tc pnictides; however, it has not been reported so far for other high-Tc pnictides because of their poor electron doping capability.

Intramedullary primitive neuroectodermal tumor presenting with rapidly-progressive cauda equina syndrome

A 39-year-old male presented with gait disturbances with rapid deterioration for 2 weeks. Neurological examination found paraparesis, sensory loss in the L1-S5 dermatomes, and vesicorectal dysfunction. Magnetic resonance (MR) imaging revealed a fusiform intramedullary tumor at T12-L1 levels with heterogeneous enhancement. The patient underwent microsurgical tumor resection. A myelotomy exposed a highly vascular tumor that was subtotally resected. Histological examination demonstrated hypercellular tumor accompanied by significant cell atypism and mitotic figures. Immunohistochemical staining was positive for glial fibrillary acidic protein, S-100 protein, synaptophysin, and INI-1, consistent with primitive neuroectodermal tumor (PNET). Postoperatively, the patient underwent irradiation to the whole craniospinal axis. He experienced local recurrence 7 months after surgery. MR imaging performed at 10 months revealed holocord progression and intracranial dissemination. The patient died 13 months after the onset of the disease. PNET should be considered in the differential diagnosis of an intramedullary spinal cord tumor.

Tumor-intrinsic and tumor-extrinsic factors impacting hsp90- targeted therapy

In 1994 the first heat shock protein 90 (Hsp90) inhibitor was identified and Hsp90 was reported to be a target for anticancer therapeutics. In the past 18 years there have been 17 distinct Hsp90 inhibitors entered into clinical trial, and the small molecule Hsp90 inhibitors have been highly valuable as probes of the role of Hsp90 and its client proteins in cancer. Although no Hsp90 inhibitor has achieved regulatory approval, recently there has been significant progress in Hsp90 inhibitor clinical development, and in the past year RECIST responses have been documented in HER2-positive breast cancer and EML4-ALK-positive non-small cell lung cancer. All of the clinical Hsp90 inhibitors studied to date are specific in their target, i.e. they bind exclusively to Hsp90 and two related heat shock proteins. However, Hsp90 inhibitors are markedly pleiotropic, causing degradation of over 200 client proteins and impacting critical multiprotein complexes. Furthermore, it has only recently been appreciated that Hsp90 inhibitors can, paradoxically, cause transient activation of the protein kinase clients they are chaperoning, resulting in initiation of signal transduction and significant physiological events in both tumor and tumor microenvironment. An additional area of recent progress in Hsp90 research is in studies of the posttranslational modifications of Hsp90 itself and Hsp90 co-chaperone proteins. Together, a picture is emerging in which the impact of Hsp90 inhibitors is shaped by the tumor intracellular and extracellular milieu, and in which Hsp90 inhibitors impact tumor and host on a microenvironmental and systems level. Here we review the tumor intrinsic and extrinsic factors that impact the efficacy of small molecules engaging the Hsp90 chaperone machine.

Venous lacunae presenting with unusual upward protrusion: an anatomic study using high-resolution magnetic resonance imaging

PURPOSE

This study aims to investigate the distribution and anatomic features of venous lacuna presenting with unusual upward protrusion (VLUUP) using high-resolution magnetic resonance (MR) imaging.

METHODS

This retrospective study included 59 consecutive outpatients who underwent MR imaging with gadolinium. Acquired imaging data were transferred to a workstation for analysis.

RESULTS

The 30 male and 29 female subjects were aged from 10 to 76 years. A total of 46 VLUUPs located parasagittally were identified in 36 of the 59 patients, 24 on the right, and 22 on the left; 29 patients had one VLUUP, 4 patients had two, and 3 patients had three. Most VLUUPs (93 %) were distributed in the posterior third of the frontal region and the remainder (7 %) in the middle third. There were no VLUUP found in the anterior third of the frontal region or the parietal or occipital regions. The mean longitudinal and lateral dimensions of the VLUUPs and distance from the midline to the medial margin of the VLUUP were 9.7 mm (3.1-27.6), 6.9 mm (3.1-11.5), and 14.3 mm (1.6-43.5), respectively.

CONCLUSIONS

The VLUUPs carry a higher risk of injury when making a bony window in or involving the parasagittal posterior frontal region. High-resolution MR imaging is useful for delineating the VLUUPs.

Genomic causes of multiple cerebral cavernous malformations in a Japanese population

Cerebral cavernous malformation (CCM) is a hamartomatous vascular disease affecting the central nervous system. A fraction of CCM are thought to arise in association with genomic mutations in the cerebral cavernous malformation 1 (CCM1) (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10) genes. In the present study, 18 Japanese patients with multiple CCM (10 with familial type and eight with sporadic type), underwent genomic analysis for CCM1, CCM2 and CCM3 mutations with blood samples and surgical specimens. MRI showed CCM in the cerebral hemisphere in 17 patients, the cerebellum in 10, the brainstem in 10 and the spinal cord in eight. CCM2 mutations were the most prominent, followed by CCM1 and CCM3. CCM1, CCM2 and CCM3 mutations were not identified in seven patients. Among the 10 patients with familial CCM, CCM1, CCM2 and CCM3 mutations were found in two, three and one patient, respectively, whereas four patients lacked these mutations. Among the eight patients with sporadic CCM, these mutations were found in one, three, and one patients, respectively, whereas three patients lacked these mutations. Most of the patients had a stable course during the follow-up period. Genomic mutations other than CCM1, CCM2 and CCM3 may be frequent in patients with multiple CCM in the Japanese population.

Carotid cavernous sinus fistula caused by dental implant-associated infection

A 61-year-old woman presented with painful ophthalmoplegia, Tolosa-Hunt syndrome. The patient had undergone a placement of dental implant 5 months before the presentation and had a local maxillary sinusitis 1 month later. She had not been aware of any preceding head trauma or infection. On examination, the patient showed serious right oculomotor nerve paresis and retro-orbital pain. Blood examination showed normal findings. Magnetic resonance imaging identified abnormal structure in the right cavernous sinus with flow void signals. Angiography revealed a carotid cavernous sinus fistula fed by the intracavernous branches of the internal carotid artery on both sides, right internal maxillary and middle meningeal arteries, and left ascending pharyngeal artery. The patient underwent coil embolization via both external carotid arteries. We assumed that local maxillary sinusitis caused by dental implant might spread hematogenously into the sphenoid and cavernous sinuses and formed a carotid cavernous sinus fistula, which presented with Tolosa-Hunt syndrome. Implant-associated infection has to be managed promptly with adequate manner before it spreads.

Visualization of the ophthalmic artery by phase-contrast magnetic resonance angiography: a pilot study

OBJECTIVE

This study aimed at investigating whether phase-contrast (PC) magnetic resonance (MR) angiography is useful for visualizing the ophthalmic artery (OA).

METHODS

This prospective study enrolled 196 consecutive outpatients who underwent three-dimensional PC MR angiography. The basal image parallel to the anteroposterior dimension of the OA was extracted for analysis from the imaging data.

RESULTS

The 99 male and 97 female subjects were aged from 10 years to 80 years (mean 47.9 years). The OAs were supplied only by the external carotid system or in combination with the internal carotid artery (ICA) in 18 subjects (9.2%). The bilateral OAs were symmetrical in 12%, asymmetrical in 87%, and unidentified in 1%. The contour of the proximal segment of the OAs could be classified into straight, curved, and tortuous types. The ICA-OA angle defined by the angle between the approximate line of the proximal OA and the vertical line was also variable. The first bend of the OA corresponded to the anastomosis site with the external carotid system. The proximal medial bend was the origin of the posterior ethmoidal artery, and the distal medial bend was the origin of the anterior ethmoidal artery.

CONCLUSIONS

According to the results the OA not only possesses three characteristic bends, but also shows prominent individual variability and commonly shows bilateral asymmetry. The contour of the OA may be regulated by the anchor effect at the bend sites. PC MR Angiography is useful for visualizing the main trunk of the OA.

Effects of denervation at ileocecal junction and ileocecal resection in dogs

BACKGROUND

To investigate neural regulation at the ileocecal junction (ICJ) and motility changes after ileocecal resection (ICR). Previous studies showed normal basal motility at the ICJ directly by force transducers in dogs, but these observations were limited to normal contractile activity.

METHODS

Continuous strain gauge recordings of stomach, terminal ileum, ileocecal sphincter (ICS), and colon were performed in dogs. The dogs were divided into four groups, namely control (CONT), extrinsic denervation at ICJ (ED), intrinsic denervation at ICJ (ID), and ICR groups. Colonic activity was recorded 2 h before a meal, in the early postprandial period (first 2 h), and in the late postprandial period (4-6 h after a meal). The meal lasted 5 min.

KEY RESULTS

Motility index was significantly increased at the ICS (P = 0.0056) and proximal colon (P = 0.0059) after feeding. However, such changes were not observed in the ED and ID groups. The amplitude of contractions at proximal colon in the interdigestive state was significantly decreased by ED. In the ID and ICR groups, the numbers of nonmigrating contractions were significantly decreased (P < 0.05), and colonic migrating motor complex (CMMC) ratio was significantly higher than that of the CONT group (P < 0.001). The dogs in these two groups had diarrhea.

CONCLUSIONS & INFERENCES

Gastrocolonic response at the ICJ may require both intrinsic and extrinsic innervation. When ID was performed, CMMC ratio increased. As a result, intraluminal water absorption may have decreased. ID may be one of the causes of diarrhea after ICR.

Characteristics of neck and shoulder pain (called katakori in Japanese) among members of the nursing staff

BACKGROUND

The characteristics of neck and shoulder pain (NSP), called katakori in Japanese, have not been well documented to date. The aim of this study was to clarify the characteristics of NSP through a questionnaire survey of members of the nursing staff.

METHODS

The study population consisted of 484 nursing staff members of Gunma University Hospital in Japan. The questionnaire involved information on age, body mass index (BMI), gender, psychological stress at work, musculoskeletal pain at other anatomic sites (elbow/wrist, lumbar and knee), smoking history, and hypertension. If subjects had NSP, they were asked about any coexisting symptoms, the utilization of health services, and the precise location of NSP.

RESULTS

The total study population included 393 persons after 91 persons were excluded for various reasons. The point prevalence of NSP was 68.1% (268 of 393). Age, BMI, smoking history, and hypertension showed no significant trend for the prevalence of NSP in the univariate analyses. The occurrence of NSP was significantly higher in subjects with psychological stress, elbow/wrist pain, lumbar pain, and knee pain, respectively. A multivariate logistic regression analysis showed that gender, psychological stress, elbow/wrist pain, and lumbar pain were significantly associated with the occurrence of NSP. One hundred fifty-eight of those with NSP (58.9%) reported coexisting symptoms, and the most common was headache. Fifty-seven (21.2%) of the subjects with NSP had consulted medical or health practitioners, and bone setting was the most common service provider. The most common area of NSP was the superior part of the trapezius.

CONCLUSIONS

This study confirmed that NSP, katakori in Japanese, is a prevalent problem in a nursing staff, and several factors associated with NSP were identified.

The Virchow-Robin spaces: delineation by magnetic resonance imaging with considerations on anatomofunctional implications

INTRODUCTION

The Virchow-Robin spaces (V-R spaces) are well-known, but not systematically understood fluid-filled perivascular spaces that allow the convexity and basal perforating vessels to penetrate deep into the cerebral parenchyma.

OBJECTIVE

This study aims to delineate anatomical characteristics of the normal V-R spaces by MR imaging with considerations on clinical and anatomofunctional implications of the V-R spaces.

METHODS

In this prospective study with 3T magnetic resonance (MR) imaging, the whole extent of the intracranial V-R spaces was classified into basal, cortical, subcortical, paraventricular, and brainstem segments, on the basis of the topological difference in 105 control subjects. Morphological characteristics in each segment of the V-R spaces are described. For comparison with the neuroimaging appearance, V-R spaces were histologically examined in cadaveric human brains. The physiological functions of the V-R spaces and pathognomonic implications of unusually dilated, but asymptomatic, V-R spaces encountered in five subjects are discussed.

RESULTS

The V-R spaces were found to form a complicated, while anatomically highly consistent, intraparenchymal canal network distributed over the whole cerebral hemispheres and connect the cerebral convexity, basal cistern, and ventricular system.

CONCLUSION

The V-R spaces may be essential for drainage routes of cerebral metabolites, additional buoyancy for the brain, and maintenance of homogenous intracranial pressure. MR imaging may be more advantageous in depicting the V-R spaces than histological examination.

Chondrosarcoma with atypical clinical presentation treated by gamma knife radiosurgery for multiple brain metastases--case report

A 60-year-old male was first treated for World Health Organization (WHO) grade II chondrosarcoma arising from the ring finger manifesting as painful swelling. Four years later, the patient presented with cerebral infarction. Echocardiography revealed a tumor occupying the left atrium. He underwent open heart surgery and the tumor was identified as metastatic chondrosarcoma with malignant transformation to WHO grade III lesion. Five months following the cardiac surgery, the patient suffered generalized seizure. Cerebral magnetic resonance imaging revealed multiple parenchymal lesions. Surgical tumor extirpation confirmed the histological diagnosis as metastatic grade III chondrosarcoma. Gamma knife radiosurgery (GKS) performed postoperatively controlled the parenchymal lesions for more than 10 months without relapse. GKS may be effective for the treatment of brain metastasis from high grade chondrosarcoma.

[A case of intramedullary spinal cord metastasis from breast carcinoma: surgical resection for conus medullaris lesion]

A 46-year-old female presented with gait disturbance and urinary retention which had exacerbated over 3 weeks. The patient had a medical history of breast cancer and brain metastases that had been well controlled by serial chemotherapy and gamma knife irradiation, and had remained independent with Karnofsky performance status (KPS) score of 100 %. On admission, neurological examination detected mild sensorimotor disturbance in the right lower extremity and hypesthesia in the perianal region, in addition to urinary retention and decreased anal tone. Spinal MR imaging demonstrated a well demarcated, heterogeneously enhanced, intramedullary tumor at the L1 level, appearing as isointense on both T1 and T2-weighted images. The patient underwent subtotal tumor resection via hemilaminectomy at the L1 and L2 levels. Postoperatively, the patient's motor weakness and vesicorectal dysfunction showed remarkable improvement, whereas sensory disturbance was only very slightly improved. Histological findings of the tumor were consistent with metastatic breast carcinoma. Surgical resection can be considered for the treatment of intramedullary spinal cord metastasis if the lesion is located in the conus medullaris.

Traumatic pseudoaneurysm arising from the anterior superficial temporal artery in an infant

INTRODUCTION

Pseudoaneurysm arising from the superficial temporal artery (STA) is an uncommon sequela of head and facial trauma. This entity is very rare in the pediatric population. The conventional treatment is surgical excision.

CASE REPORT

A 13-month-old boy presented with a progressively enlarging subcutaneous mass in the left forehead that appeared 1 week after indoor minor head trauma. The mass was hard and prominently expansile and was more than 5 cm in the largest dimension. The mass did not have audible bruit and was not diminished by manual compression of the proximal STA. Cranial computed tomography (CT) did not reveal intracranial hemorrhage or skull fracture in association with the head trauma. CT angiography showed a large aneurysm arising from the anterior branch of the left STA.

RESULT

En bloc extirpation of the aneurysm was performed. Histological examination of the excised specimen showed findings consistent with pseudoaneurysm.

CONCLUSION

In addition to careful observation for a sufficiently long period after the head trauma, neurosurgeons should be aware of the need to start treatment before a traumatic pseudoaneurysm reaches a significant size.

[Case of calvarial fibrous dysplasia presenting with cyst degeneration]

A 49-year-old female developed a painful dysesthesia in the left forehead 10 years after having become aware of a subcutaneous mass accompanied with mild tenderness. Her medical history was unremarkable. Neurological examination showed normal findings with intact facial nerve function. Blood examination was normal. Neuroimaging revealed a cystic bony mass and an adjacent patchy diploic lesion in the left temporal bone. She underwent total tumor resection by frontotemporal craniotomy. Intraoperatively, a bony defect was noted in the lower surface of the patchy lesion communicating with the diploic venous system. A part of the dura mater was invaginated in the bony defect. The patchy lesion was found to communicate with the bony cyst through the diploic structure. Histological appearance of the bony cyst was consistent with the fibrous dysplasia accompanying cyst degeneration. Histological findings of the patchy lesion were identical to those of the bony cyst except for cyst degeneration. We assumed that the diploic venous system and the meningeal vessel might have been associated with the etiology of cyst degeneration in the present case of fibrous dysplasia.