Endovascular therapy for surgical diseases of the cranial base

Endovascular therapy for surgical diseases of the cranial base is in many ways a survey of the field of interventional neuroradiology (or endovascular neurosurgery). As the multidisciplinary focus to the treatment of various cranial base diseases has become increasingly complex, the role of endovascular therapy as both a primary and secondary treatment modality has expanded. A comprehensive review of this role is presented.

Radiation therapy in the management of paragangliomas of the temporal bone

The use of radiation therapy for the treatment of paragangliomas of the temporal bone remains controversial. Few studies exist that provide sufficient information on staging the long-term follow-up to clarify this issue. A retrospective study was undertaken of 38 patients with temporal bone paragangliomas treated with radiation therapy between 1956 and 1991. All patients received radiation therapy, either as a primary modality (14 patients), in combination treatment with surgery (13 patients), or as salvage therapy (11 patients). Mean disease stage (Fisch classification system) for each group was C2, B, and C1, respectively. The follow-up period ranged from 1 to 27 years (median 11.5 yr). Local control was achieved in 79% of the primary radiation therapy group, 100% of the combined treatment group, and 91% of the salvage therapy group. Complications resulting from radiation therapy were few and minor. This study demonstrates that the use of radiation therapy for temporal bone paragangliomas offers effective local control as a primary treatment modality, in combination with surgery, and as salvage therapy with few long-term complications.

Management of posterior cranial fossa meningiomas

Posterior cranial fossa meningiomas are relatively common extra-axial tumors with important relationships to the cochleovestibular system, facial nerve, and/or cranial base. Nevertheless, objective reporting of auditory and vestibular function is rare for this patient population, and a full discussion of the nonsurgical management is all but totally discounted in the otolaryngology literature. Nine cases (8 operative cases) are presented, with the purpose of correlating neurotologic function with precise anatomic tumor location, available by magnetic resonance imaging and computed tomography. The usefulness of this information for diagnosis and meaningful scrutiny of the operative results is discussed. A comprehensive review of posterior fossa meningiomas in terms of epidemiology, etiology, and pathology, as well as nonsurgical treatment alternatives, is provided.

[The value of MRT in primary extramedullary plasmacytoma involvement of the head-neck area]

Six patients with a primary extramedullary plasmocytoma in the head and neck were examined using MR imaging. The morphological appearance of these lesions was described to support the radiologist in the differential diagnosis of this rare lesion. All tumours appeared as oval-shaped and sharply delineated without any signs of infiltration. After contrast media application a distinct central inhomogeneity could be proved in all cases. Furthermore, demoscopical, clinical and therapeutical problems were discussed based on the literature.

[Hemangiopericytoma of the infra-temporal fossa. Apropos of a clinical case]

We observed the case of a young woman with haemangiopericytoma in the subtemporal fossa. Diagnosis problems and the access route were discussed. Good exposure was achieved at the price of minor aesthetic and functional impairment. The prognosis of these potentially malignant tumors is uncertain.

Multimodality management of a case of primary osteogenic sarcoma of the zygoma

Craniofacial osteogenic sarcomas are rare primary malignant bone tumors and very few cases involving zygomatic bone were reported in literature. We present our experience of multimodality management of a case of primary osteogenic sarcoma of zygoma. Wide radical excision of the tumor including the parotid gland was done followed by three cycles of adjuvant chemotherapy and fifty Gy of external radiotherapy. The patient is disease-free at two years follow-up. Till 1970s, craniofacial osteogenic sarcomas were managed mainly by radical surgery with a high local failure rate. With the advances made in the field of radiotherapy and chemotherapy, multimodality therapy is playing a major role in the treatment of these aggressive tumors with better overall and disease-free survival.

The difficult scalp and skull wound

Scalp and skull defects can be very difficult to reconstruct. Whereas small defects may require only primary closure, skin graft, or small rotation flaps, large defects involving full-thickness scalp can be much more problematic. These large defects may require free-tissue transfer for adequate soft-tissue coverage. The calvaria also may require reconstruction. If the underlying bone is not infected, it can be left in situ and covered with well-vascularized tissue. The bone should be removed only if it is infected. Calvarial reconstruction should then be delayed for 3 to 6 months. If the tissue has been irradiated, only selected defects are appropriate for coverage with local scalp flaps because adjacent tissues may have underlying damage. With a methodic, accurate assessment of the defect, successful reconstruction can be expected.

[Primary rhabdomyosarcoma of the temporal bone]

A case of rhabdomyosarcoma of the temporal bone in a six-year-old girl is reported. Updated literature and the main therapeutical approaches are reviewed.

Adjunctive treatment of cranial base malignacies

The indications for skull base tumor surgery have increased in recent years primarily because of improving surgical techniques and adjunctive treatment modalities. In this article we review current and future adjunctive treatment for cranial base malignancies. Surgically clear tumor margins are often difficult to achieve in skull base surgery because of unacceptable morbidity to surrounding structures. Current phase I and II trials of adjunctive radiation and chemotherapy are discussed. Future advances in radiation therapy and chemotherapy are introduced.

Squamous cell carcinoma of the external auditory canal. Therapeutic prognosis based on a proposed staging system

OBJECTIVE

To determine the adequacy of the proposed TNM staging system and evaluate the therapeutic modalities used at our institution in an attempt to synthesize guidelines for therapy of primary squamous cell carcinoma (SCC) of the temporal bone.

DESIGN

Case series of 22 patients with previously untreated or residual SCC of the temporal bone treated between 1970 and 1990. Mean follow-up of the surviving patients was 124.5 months (range, 46 to 210 months).

SETTING

University of Texas M. D. Anderson Cancer Center, Houston, an ambulatory and hospitalized care referral center.

PATIENTS

The hospital charts of 41 patients with carcinoma of the temporal bone seen between 1970 and 1990 were retrospectively reviewed. Twenty-two of these patients had previously untreated or residual SCC of the external auditory canal and were chosen for this study. Information was collected regarding symptoms, tumor location, treatment methods, pathologic diagnosis, and patient outcomes.

MAIN OUTCOME MEASURE

Accuracy of proposed staging system in predicting 5-year survival. Effect of surgery alone, radiotherapy alone, and surgery combined with radiotherapy on survival.

RESULTS

Using the Pittsburgh staging system, the conditions of eight patients (36%) were staged at T1, four (18%) were staged at T2, six (27%) were staged at T3, and four (18%) were staged at T4. (The 19 patients with either recurrent disease or non-SCC were also treated, but their conditions were not staged). Statistical validation is impossible owing to the small sample sizes. Combination therapy with surgery and radiotherapy provided a higher 5-year survival rate than surgery or radiotherapy alone. Extrapolation of our data confirms that a staging system is useful in planning therapy. Surgical resection followed by radiotherapy is the preferred treatment for SCCs of the external auditory canal.

Intratumoral embolization of intracranial and extracranial tumors: technical note

A new technique of intratumoral embolization is described. An intratumoral injection of N-butylcyanoacrylate is performed either perioperatively by direct puncture of the tumor or preoperatively through the nose or through the skin. The indications for this technique are hypervascularized tumors, such as juvenile angiofibroma, hemangiopericytoma, or paraganglioma. This technique has been applied in 21 patients with excellent results in terms of devascularization.

Malignant change in cutaneous neurofibromas--case reports

Neurofibromatosis is the most common single gene disorder to affect the nervous system, with an estimated incidence of 1 in 3000 live births. Neurofibromatosis (NF) may be classified into von Recklinghausen NF (NFI) and bilateral acoustic NF (NFII) based on the distribution of lesions. The most common lesion associated with the von Recklinghausen type is the neurofibroma. Various complications are associated with neurofibromatosis, the most feared of which is malignant change in the neurofibroma. This article describes the study of 7 cases of proven malignant change in neurofibromas with regards to presentation, clinical progress and treatment followed by a review of the present literature.

Primary Ewing's sarcoma of the skull base with intracerebral extension--case report

A 32-year-old female presented with an uncommon primary Ewing's sarcoma of the skull involving the middle cranial fossa with an extremely unusual extension into the cerebral parenchyma. She was treated with surgical excision, irradiation, and chemotherapy. Two years after surgery she demonstrated no evidence of local recurrence or distant metastasis. Ewing's sarcoma of the skull may achieve a better survival rate under adequate management than this lesion in other sites.

Interventional neuroradiology of lesions of the skull base

Preoperative embolization has been incorporated definitively into the multidisciplinary therapy strategy for lesions of the skull base. Clinical and anatomic knowledge of the pathology of the skull base, as well as experience with embolization, is the basis for therapeutic success. Clinical knowledge will lead to adequate patient selection, whereas profound anatomic knowledge and mastery of endovascular techniques will avoid predictable complications. Provided these conditions are taken into consideration, embolization of lesions of the skull base yields convincing therapeutic and technical results. Preoperative embolization of skull base tumors should not be associated with mortality or morbidity because most of these diseases are histologically benign and the interventional procedure is done as a preoperative step and not as a curative one. Major complications such as cerebral stroke, blindness, or cranial nerve palsies are results of the application of inappropriate techniques or of poor evaluation of angiographic findings, and should be avoided in the majority of cases. Minor complications are related to inadvertent occlusion of cutaneous, muscular, or osseous branches of the ECA. They are sometimes unavoidable and may include pain, skin necrosis, and trismus. Nevertheless, state-of-the-art external carotid embolization should--in skilled hands--have a permanent morbidity below 1% and no mortality.

Chondrosarcoma of the skull base

Chondrosarcomas are relatively rare tumors of the skull base. This article surveys the clinical and pathologic features of these lesions. In recent years there have been remarkable advances in both the imaging and treatment of these lesions. Both CT scanning and MR imaging are usually necessary for the complete evaluation of these tumors because of the involvement of both soft tissue and bony structures at the skull base. New surgical techniques and the use of high-energy proton beam irradiation have improved the prognosis for patients with these lesions.

Devascularization of craniofacial tumors by percutaneous tumor puncture

PURPOSE

To present and evaluate a devascularization technique for hypervascular tumors of the head and neck by direct tumor puncture.

METHODS

Tumor puncture was performed percutaneously or via natural orifices (nose and mouth). In one case, an intrasellar tumor was embolized via a transseptosphenoidal surgical approach. The embolization material used was NBCA, lipiodol, and tungsten in the majority of tumors (14 out of 17) and alcohol for 3 metastases of the calvarium. We used this technique to embolize 10 nasopharyngeal fibromas, 4 tumors of the calvarium (3 metastases and 1 hemangiopericytoma), 1 intrasellar hemangiopericytoma, and 2 glomus tumors. Reflux of blood was obtained in every case after direct puncture of the tumor. Direct injection of contrast agent into the tumor revealed local parenchymography followed by local and regional venous drainage without extravasation.

RESULTS

Total devascularization was obtained in 14 cases, and devascularization greater than 90% was obtained in 3 cases. Thirteen tumors were totally resected without requiring blood transfusion. During surgery, the limits of the exsanguinated tumor were very well defined in every case by the black staining induced by tungsten. Of the 4 tumors embolized but not operated on (3 metastases and 1 glomus tumor), 2 metastases needed retreatment after 6 and 8 months of remission, respectively. The other metastasis is still in remission after 3 months, and the volume of the glomus tumor decreased by 80% remains unchanged after 8 months.

CONCLUSION

This technique was initially used to devascularize tumors with difficult or dangerous intravascular access, but in view of the hemodynamic and surgical results obtained, we believe that the indications for this technique can be extended to hypervascular tumors accessible to conventional embolization.

[15O]H2O positron emission tomography determination of cerebral blood flow during balloon test occlusion of the internal carotid artery

PURPOSE

To determine the utility of [15O]H2O positron emission tomography (PET) for the quantitative determination of cerebral blood flow in patients undergoing balloon test occlusion of the internal carotid artery.

METHODS

Twenty-two [15O]H2O PET cerebral blood flow studies were completed on 20 patients for whom temporary or permanent occlusion of the internal carotid artery was being considered because of skull base tumor or internal carotid artery aneurysm. In each study, cerebral blood flow was determined during temporary balloon internal carotid artery occlusion, and again after deflation and removal of the balloon from the internal carotid artery.

RESULTS

Patients were divided into three groups based on clinical and cerebral blood flow response to balloon test occlusion. Studies were classified as group I when associated with no clinical symptomatology and with a cerebral blood flow decrease of less than 10 mL/100 g per minute (16 of 22 patients); as group II when there was no clinical symptomatology and cerebral blood flow fell to 25 to 35 mL/100 g per minute on the occluded side (5 of 22); and as group III when the patient was clinically unable to tolerate test occlusion and had a cerebral blood flow of less than 20 mL/100 g per minute on the occluded side (1 of 22). Neurologic sequelae developed in none of the eight group I patients later undergoing permanent internal carotid artery occlusion. Cerebral infarction developed subsequently in the one group II patient who underwent internal carotid artery occlusion.

CONCLUSION

During internal carotid artery balloon test occlusion, [15O] H2O PET determination of cerebral blood flow allows rapid quantitative determination of cerebral blood flow throughout the entire brain, predicting the adequacy of collateral flow after permanent occlusion. All patients were able to tolerate the [15O]H2O PET cerebral blood flow determination, and there were no complications of the procedure.

Multiple intracranial metastases with skull and scalp involvement in Ewing's sarcoma

An unusual case of Ewing's sarcoma with multiple intracranial metastases is presented. The treatment of patients with central nervous system metastasis of this rare tumor is discussed and the pertinent literature is reviewed.

Unusual presentations of lymphangioma

L ymphangioma is a rare but potentially life-threatening disease, particularly in children. Three unusual cases of lymphangioma located in the infratemporal fossa, submaxillary gland, and cervicomediastinal regions are presented. These unusual sites illustrate that lymphangiomas may be found at sites distant from the locations of the embryological lymph sacs. The importance of radiological examination is emphasized. Although there are many modes of therapy for this disease, complete surgical excision when possible is advocated. The literature regarding the embryology, presentation, clinical workup, and current modes of therapy for lymphangioma is reviewed.

Post-Paget Osteosarcomas of the Skull. Remarks on Five Cases

We report our experience with 5 cases of post-Paget osteosarcoma of the skull, a rare lesion of the neurocranium. Four patients were treated by surgery and radiotherapy and one by surgery alone. Two patients received chemotherapy. Histologically, the tumor was found to be an osteosarcoma, fibroblastic in 2 cases, mixed in 2, and osteoblastic in 1. Combined treatment (surgery, radiotherapy and chemotherapy) positively influenced survival (median survival, 6 months). The prognosis for post-Paget osteosarcomas of the skull seems to be worse than for primary sarcomas, probably due to their intense vascularization. This facilitates the spread of tumor cells to other organs (as observed in our cases) and reduces the reduced effectiveness of chemotherapy. Although the latter lengthens survival and reduces the incidence of metastases, it is not as efficacious as in primary sarcomas.

[Giant plasmacytoma of the skull which appeared in the clinical course of multiple myeloma--a case report]

A 51-year-old woman with large plasmacytoma occurring from the temporal bone is presented. She has a history of multiple myeloma for 9 years. She manifested marked swelling in the left temporal area with tenderness. Neurological examination revealed no abnormality. She showed monoclonal free light chain (lambda type) in the serum and urine, and had multiple osteolytic lesions in her general bones. T1 WI of MRI exhibited a huge mass showing slightly high intensity in the left middle fossa and infratemporal fossa, and a part of the mass protruded into the extracranial space. The mass was markedly enhanced by Gd-DTPA. Angiography showed a hypervascular mass supplied by the external carotid artery. Biopsy disclosed plasmacytoma. She underwent local irradiation of 30 Gy and chemotherapy of Ranimustine (100 mg) and Cyclophosphamide (400 mg). The tumor reduced its size, and tenderness in her temporal area disappeared.

Osteosarcomas of the skull. Clinical remarks on 19 cases

BACKGROUND

Osteosarcomas are typically long bone tumors and rarely affect the skull, with most articles reporting single cases. As elsewhere in the body, these lesions may be classified as primary or secondary, chiefly post-Paget and post-radiation therapy.

METHODS

The authors reviewed the osteosarcomas of the skull diagnosed at the Division of Neurosurgery of "La Sapienza" University of Rome. The patients were placed into two groups, according to the treatment received (prechemotherapeutic era and chemotherapeutic era). In the last five patients, a diagnostic-therapeutic protocol was adopted.

RESULTS

The most effective investigations are plain radiographs, computed tomography (CT) with bone windows, and magnetic resonance imaging (MRI), with the latter two allowing assessment of the extraosseous extent of the disease. Chemotherapy has changed the prognosis dramatically, achieving cure in some cases (especially in de novo osteosarcomas). Before the age of chemotherapy, the median survival length was 16 months, but since its introduction, five of nine patients in this study are alive 2 years after diagnosis. The onset of metastases, chiefly to the lung, does not necessarily imply a poor prognosis. The authors propose a schedule for the diagnosis and treatment of new cases of osteosarcoma of the skull.

CONCLUSIONS

Plain radiographs, CT targeted on the bone, and MRI are the most important diagnostic tools. Aggressive chemotherapy together with surgery (eventually including local radiation therapy in nontotal macroscopic surgical removal of the lesions) can drastically modify the prognosis of de novo and post-radiation therapy osteosarcomas.