Giant-cell tumour involving the cranial vault: imaging and treatment

A giant-cell tumour involving the cranial vault was diagnosed in a 37-year-old man who presented with a large swelling at the vertex. The role of imaging in the diagnosis and treatment of this tumour is described. On CT and MRI the appearances were nonspecific and the diagnosis was established by histological examination after removal of the tumour. A preoperative angiogram showed a tumour blush and before surgery, embolisation was performed via the percutaneous and transarterial routes.

Osteosarcoma of the sella

Primary osteosarcoma of the skull is rare. Osteosarcoma arising from the sellar region is extremely uncommon. The case of a 38-year-old man with osteosarcoma of the sella is described, and the literature is reviewed. The patient was treated with surgery followed by aggressive chemotherapy and radiotherapy. Currently he is in remission at 12 months.

Carcinoma of the ear: a case report of a possible association with chlorinated disinfectants

In this report we present a case of squamous cell carcinoma developing in a mastoid cavity after prolonged exposure to the chemical disinfectant, Eusol. The efficacy and safety of Eusol and other chloric acid (hypochlorous acid) derivatives in clinical use is debated.

Angiocentric lymphoma involving the temporal bone in a child

Involvement of the temporal bone in patients with malignant lymphomas is very rare. Most of the reported cases have been clinically asymptomatic and were diagnosed only by post-mortem examinations. We present a nasal, paranasal, nasopharyngeal lymphoma that occurred in a 12-year-old child and also involved the temporal bone. Clinical presentation began with bilateral chronic otitis media. Histopathologically, tumor was found to be an angiocentric lymphoma of B-cell origin. Association with Epstein-Barr virus could not be demonstrated. Despite combination chemotherapy (with cyclophosphamide, vincristine, doksorubicine, prednisolone, L-asparaginase, cytosine arabinoside, metotraxate) and radiotherapy (to 40 Gy), disease progressed locally as well as to cervical lymph nodes and the lungs.

[Giant cell tumor originating in the sphenoid bone: a case report]

The authors report a case of giant cell tumor originating in the sphenoid bone. A 29-year-old woman presented with headache and diplopia. Bilateral ophthalmoplegia developed and MRI showed rapid growth of the tumor in spite of transnasal removal and conventional radiation therapy. The second transnasal surgery was performed 3 weeks after completion of radiotherapy. The symptoms were relieved except for right abducens palsy. Chemotherapy with cisplatin and etoposide was started after the second operation. The patient regained full ocular movement several months after the operation. Clinical remission has continued for four years. We conclude that the combination of repeated operations in the initial phase of rapid tumor growth, irradiation and chemotherapy is important to achieve tumor control.

Giant cell tumors of the jugular foramen

PURPOSE

To review the diagnosis and treatment of giant cell tumors of the jugular foramen.

MATERIALS AND METHODS

A typical case is reported. Symptoms, signs, and diagnostic studies are reviewed. Photomicrographs and angiographic studies showing the differences between these and glomus jugulare tumors are provided. A coherent approach to their management is presented.

RESULTS

These hypervascular, traditionally radioresistant tumors may cause pulsatile tinnitus, conductive hearing loss, and lower cranial nerve paresis. Angiographic studies showed a hypervascular lesion supplied by numerous small branches of the external carotid artery, making embolization difficult. Complete resection was achieved by an infratemporal fossa approach with preoperative embolization.

CONCLUSION

Giant cell tumors of the temporal bone may mimic glomus jugulare tumors with respect to anatomic location, cranial nerve deficits, and vascularity.

[Metastatic calvarial tumor: report of 3 cases]

We report 3 cases of calvarial tumor metastasized from the following malignancies: squamous cell carcinoma of the lung, hepatocellular carcinoma, and clear cell carcinoma of the kidney. All three patients presented with a painful mass as the initial symptom. Although each tumor was successfully extirpated, out-come was not satisfactory because of the malignant nature of the primary sources. The main purpose of treatment of metastatic calvarial tumors was thought to be relief of pain and cosmetic reasons. Metastatic calvarial tumors may reach considerable size as reported here. We stressed that meticulous care should be paid to repair of the dura and reconstruction of subcutaneous soft tissues, since scalp necrosis or cerebrospinal fluid retention may occur following preoperative embolization of feeding arteries and extensive removal of subcutaneous tissues invaded by tumor.

Solitary plasmacytoma of the skull base presenting with unilateral sensorineural hearing loss

Solitary plasmacytoma of the skull base is a rare entity with only a few reported cases in the literature. We review the literature and present our experience with this lesion that produced ipsilateral sensorineural hearing loss, vertigo and ipsilateral sixth nerve palsy.

Direct ethanol injection for skull metastasis from hepatocellular carcinoma. The techniques and consequences of a therapeutic trial

The frequency of skull metastasis from hepatocellular carcinoma (HCC) is increasing together with the recent progress in the management of the primary lesion. Cases are often complicated with poor general conditions or metastasis to the other organs, and not readily indicated for surgery. A direct injection of ethanol to the lesion could be one of the therapeutic options to cope with this complicated situation. To evaluate the feasibility of this technique, we planned a therapeutic trial in a patient with HCC associated with lumbar and skull metastasis, the latter metastasis repeated twice during the past one year. A total of 10 ml of ethanol was injected into the skull metastasis percutaneously under ultrasound (US) guidance. US guidance was very useful in determining the sites of injections and the distribution of ethanol as well as monitoring the blood flow within the tumor vessels. The patient transiently complained of local pain at the injection sites, but there were no other adverse effects. Four days after the injection, the lesion was resected by surgery, which confirmed the pathologic diagnosis as well as the nearly-total necrosis of the tumor. This technique is simple, safe and repeatable with low cost. The technical details and the histologic effects are described.

Preoperative superselective embolization of skull-base meningiomas: indications and limitations

We evaluated the clinical significance of preoperative superselective embolization for skull-base meningiomas. The subjects consisted of 20 patients with skull-base meningiomas, and were classified into a preoperative embolized group and a non-embolized group. The volume of blood transfused during the operation, the length of the operative procedure and the neurological outcome were compared between the two groups. The results showed that, in tumors smaller than 6 cm, the blood lost during the operation was significantly less in the embolized group. In tumors larger than 6 cm, there was not difference in blood lost, perhaps because larger meningiomas tend to have tiny blood vessels that are unsuitable for preoperative embolization. There was no difference in the length of the operation between the two groups. The embolized group tended to show a better clinical outcome than the non-embolized group.

[Cranial metastases from a follicular carcinoma of the thyroid. A clinical case report and review of the literature]

Follicular carcinoma, in association with other prognostic factors, identifies a class of "high-risk" patients in which a more aggressive treatment is indicated. In fact, in patients operated on for follicular carcinoma bone metastases, also many years after primary surgery, are reported. A case of skull metastases in a young women occurred 3 years after a near total lobectomy for follicular thyroid carcinoma is described. After six years the patient underwent total thyroidectomy, resection of skull metastases, radiometabolic therapy with I131 180 m Ci; now she is disease free at three years of follow-up. The biology of metastases in thyroid follicular carcinoma, risk factors and diagnostic and therapeutic controversies are analyzed. Good prognostic factors are considered age < 45 years, good degree of differentiation of primary tumor, small size of bone metastases and early appearance after primary diagnosis. The conclusions is drawn that bone metastases are the worst prognostic factors. In case of single lesion, surgical treatment allows good results.

Otalgia. An isolated symptom of malignant infratemporal tumors

OBJECTIVE

This study aimed to review a series of 18 patients with malignant infratemporal fossa tumors who presented with otalgia as the primary symptom.

STUDY DESIGN

This was a retrospective case analysis.

SETTING

All patients were evaluated and treated at a tertiary care academic medical institution.

PATIENTS

Eighteen patients evaluated for otalgia in a normal-appearing ear, between July 1988 and July 1996, who were found to have a malignant infratemporal fossa tumor participated.

INTERVENTIONS

Diagnostic testing included radiographic evaluations and tissue sampling through fine-needle aspiration cytology. Treatment methods were histology dependent.

MAIN OUTCOME MEASURES

The time between the onset of otalgia and the tumor diagnosis was recorded. Overall treatment outcomes were reviewed.

RESULTS

The period between the onset of otalgia and tumor diagnosis ranged from 4-21 months with a mean of 7.5 months. Adenoid cystic carcinoma was the most commonly seen tumor in this series of patients.

CONCLUSIONS

The infratemporal fossa is a relatively protected region that may be the site of malignant neoplasms causing the isolated symptom of otalgia.

Giant cell tumor of the sphenoid bone: long-term follow-up of two cases after chemotherapy

BACKGROUND

Giant cell tumors rarely occur in the sphenoid bone. When they do occur in the base of the skull, surgical treatment is frequently difficult and therefore, the use of adjuvant therapy is important. However, there remains no optimal management regimen for giant cell tumors of the sphenoid bone.

CASE DESCRIPTION

Two cases of a giant cell tumor involving the sphenoid bone that responded well to chemotherapy using adriamycin after a partial removal of the tumor are presented. In the first patient, the tumor was partially removed via a transcranial subfrontal approach and a transnasal transsphenoidal approach. In the second patient, the tumor was partially removed through a transcranial subfrontal approach. Both tumors demonstrated histologic features typical of giant cell tumors. The patients subsequently received adjuvant chemotherapy using adriamycin alone in the first patient, and chemotherapy combined with radiotherapy in the second patient. Partial regression of the tumors was later confirmed on a computed tomography (CT) scan after chemotherapy. In both patients, tumors have been stable for more than 12 years despite an incomplete removal of the tumors.

CONCLUSION

Based on the above findings, postoperative adjuvant chemotherapy using adriamycin may be effective for incompletely resected giant cell tumors of the sphenoid bone.

Extrapontine myelinolysis caused by electrolyte imbalance during the management of suprasellar germ cell tumors. Report of two cases

Extrapontine myelinolysis (EPM) is caused by marked fluctuation of the serum electrolyte level. Patients with suprasellar germ cell tumors frequently present with diabetes insipidus, which is often aggravated by administration of steroid hormone. In addition, cisplatin-based chemotherapy is sometimes accompanied by marked serum electrolyte fluctuation because it needs massive hydration to prevent renal damage. Two children with suprasellar germ cell tumors in whom EPM developed secondary to profound hyponatremia and was rapidly corrected are described. The central pons was spared in both cases. Clinically the children showed transient neurological deficits including confusion, pseudobulbar palsy, and deterioration of consciousness. MRI demonstrated bilateral symmetrical, high-signal-intensity (HSI) lesions on T2-weighted images (T2WI) at the basal ganglia and adjacent cerebral cortex. Follow-up T1WI a few months later revealed newly developed HSI lesions in the basal ganglia. The patients gradually improved, but the neurological deficits did not completely disappear. During the perioperative management of suprasellar germ cell tumors, EPM should be considered when a patient has a significant electrolyte imbalance and neurological deficits, especially confusion and pseudobulbar palsy.

Osteosarcoma of the maxillofacial bones in Kenyans

Osteosarcoma (OS) is a highly malignant tumour and is the most common primary neoplasm of bone; although rare, especially in the maxillofacial skeleton. This article presents 14 Kenyan cases of OS of the maxillofacial bones seen between January 1991 and July 1997: 11 in the mandible, two in the maxilla and one in the right zygomatic arch. Patients ranged in age from one week to 50 years (Mean = 29.7), with an equal gender distribution. While pain and rapid swelling were the commonest clinical features, the radiographic and histopathological characteristics were as varied as has been described elsewhere. Generally, effective management of most of the cases was poor due to late presentation for treatment.

[Late metastasis of clear cell renal cancer to the tonsillar palate]

The authors present a rare case of metastases from clear cell renal cancer to palate tonsillar and temporal bone. In their opinion, by patients with this dis periodical ENT-examination it's necessary. Clinical manifestations, surgical management and therapeutic results are described.

[Mastoid osteosarcoma]

A case of osteogenic sarcoma of the mastoid region of the temporal bone in a 28-year-old male is reported. The rarity of the site is emphasized and the fundamental clinical and therapeutic features are discussed. The literature is reviewed.

[Temporo-sphenoidal giant cell tumors, apropos of a case]

The authors report an extremely rare case: a bony giant cell tumour in the temporo-sphenoidal region presenting with hearing loss and vertigo. The main characteristics of these tumours are given, together with a literature review. This is the 5th published case of this tumour in the temporo-sphenoidal region. The treatment of these tumours is essentially surgical, and the authors emphasise the use of Sekhar's approach.

Testing the hypothalamic-pituitary-adrenal axis in survivors of childhood brain and skull-based tumors

The objective of this study was to determine whether a low dose of ACTH (0.2 microg/kg) improves the sensitivity of ACTH testing in detecting hypothalamic-pituitary-adrenal (HPA) axis abnormalities in survivors of childhood brain and skull-based tumors. Twenty-two children who had undergone treatment for brain or skull-based tumors were enrolled in a prospective study to extensively evaluate the HPA axis. Five tests of the adrenal axis were evaluated in each patient, including determination of basal serum cortisol, a standard ACTH test (250-microg i.v. bolus), a low dose ACTH test (0.2 microg/kg i.v. bolus), an insulin tolerance test, and a single dose metyrapone test. Cortisol responses to both ACTH tests were nearly identical. Two patients (9%) failed the low dose ACTH test, whereas three (14%) failed the standard ACTH test; five of the children (23%) failed the insulin tolerance test, and five (23%) had abnormal responses to metyrapone. One child who initially passed the metyrapone test failed the test 19 months later after becoming symptomatic. All children with abnormal metyrapone test results had low levels of basal cortisol secretion. In this study, the low dose ACTH test did not improve the sensitivity of ACTH testing for evaluation of the HPA axis. We conclude that a single morning basal cortisol level is a good screen for testing the HPA axis in children. We recommend confirming HPA axis dysfunction with the single dose metyrapone test, although this test also has limitations.

Malignant change in an intradiploic epidermoid cyst

We describe a unique case of an intra-diploic epidermoid cyst of the parietal and occipital right bone in a 43 year-old man. The tumor remained quiescent for 12 years and then spontaneously showed malignant changes with intra-cerebral involvement. Fatal outcome occurred one year after surgery, radiation therapy and chemotherapy because of a recurrence. Malignant transformation of the epithelium in epidermoid cyst is very rare. Our case is the first one where this transformation occurred spontaneously without previous surgery.

Verrucous carcinoma of maxillary antrum

Verrucous carcinoma of the paranasal sinuses is a rare malignant tumour. It occurs most frequently in the oral cavity and larynx. We present a case of extensive verrucous carcinoma of the maxillary sinus. This paper discusses the clinical and histological features and modes of treatment. All previous reports of verrucous carcinoma cases of paranasal sinuses are reviewed.

Giant cell tumor of sphenoid-diverse presentation: report of two cases

Two rare cases of giant cell tumors of the sphenoid bone are presented. We discuss their imaging, unpredictable biological behavior and management together with a review of the pertinent literature.

Preoperative endovascular embolization of craniospinal hemangioblastomas

PURPOSE

To determine whether hemangioblastomas, highly vascular tumors requiring surgery that is potentially complicated by excessive bleeding, can be embolized safely by using interventional techniques that furnish a more avascular surgical field.

METHODS

Nine hemangioblastomas involving either the cerebellum or the spinal cord were embolized preoperatively. In each case the feeding artery was selectively catheterized with a microcatheter and the hypervascular tumor nidus was devascularized with polyvinyl alcohol particles.

RESULTS

Two patients who had undergone recent attempts as surgical resection at another institution had repeat surgery after endovascular embolization rendered the tumor nidus avascular. At surgery, the tumor was completely removed in one case and markedly debulked in the other. In all nine cases, blood loss after embolization was reported to be less than expected by experienced surgeons. In addition, manipulation and removal of the tumor was reported to be subjectively easier in these embolized tumors. The embolization procedure caused no permanent complications; however, one patient with a posterior fossa hemangioblastoma and hydrocephalus worsened clinically within 12 hours of embolization. This event was thought to be caused by obstructive hydrocephalus resulting from tumor swelling. Emergency craniotomy, ventricular decompression, and surgical resection of the tumor produced complete resolution of the signs and symptoms.

CONCLUSIONS

Our results indicate that preoperative embolization of hemangioblastomas is a safe procedure that is useful in aiding surgical resection of these highly vascular tumors.

Chondrosarcoma of the jaw and facial bones

BACKGROUND

Osteosarcomas of the jaw frequently have chondroblastic differentiation, causing confusion with chondrosarcomas.

METHOD

Clinicopathologic features and results of treatment were analyzed for a series of 56 patients (27 males and 29 females from 1.5 to 88 years of age) with chondrosarcoma of jaw and facial bones. Twelve patients (21.4%) were younger than 20 years.

RESULTS

The major symptom was nasal obstruction or a painless mass; the median interval from the first symptom until initial treatment was 1 year. Of the 56 chondrosarcomas, 25(44.6%) involved the alveolar portion of the maxilla and maxillary sinus; 23 (41.1%) involved the nasal septum, ethmoid, and sphenoid; 6 (10.7%) involved the mandible; and 2 (3.6%) involved the nasal tip. Of the 19 patients with radiographic studies, 15 (78.9%) had an expanding soft tissue mass with varied matrix calcification and destruction of bone and 2 had a purely lytic lesion. The lesion was difficult to assess in the two others. Most tumors had a lobulated growth pattern of hyaline cartilage. Hypercellularity, nuclear pleomorphism, and binucleation were common features. Forty-three tumors were grade 1, 13 were grade 2, and none were grade 3. Modalities of treatment were known for 51 of the 56 patients. Forty-six patients (90.2%) had surgical treatment, 2 (3.9%) had combination radiation therapy and chemotherapy, 1 (2%) had radiation therapy alone, and 2 (3.9%) had biopsy only. Follow-up adequate for analysis was obtained for 42 patients. Of these, 14 (33.3%) had local recurrence; uncontrolled recurrence developed in 9 (21.4%) patients. No distant metastases were documented. Overall actuarial survival at 5, 10, and 15 years was 80.7%, 65.3%, and 56%, respectively. Survival was analyzed for location, size, and histologic grade of tumor. No statistically significant differences were found.

CONCLUSIONS

Chondrosarcomas of the jaw and facial bones are extremely rare, locally aggressive tumors.