Sidedness is not a prognostic factor in an unselected cohort of patients with colon cancer but prognosis for caecal carcinoma is worse - A multivariate analysis of a large single institution database

PURPOSE

Sidedness has emerged as a prognostic factor for metastatic colorectal cancer treated with modern systemic therapies. This study investigates whether it is also relevant for an unselected patient cohort including all stages.

METHODS

All consecutive patients admitted with colon cancer between 1995 and 2018 were retrieved from an institution-held database. Patients were divided into two cohorts. The first cohort included patients without distant metastases who were able to undergo curative resection. The second cohort presented with distant metastases (stage IV). Potentially prognostic factors were subjected to multivariate Cox Regression analysis.

RESULTS

Overall, 1,606 patients met the inclusion and exclusion criteria. An R0-resection was achieved in 1,222 patients without distant metastases. Five-year cause-specific survival rate was 89.3% for this group. There was no difference between right- and left-sided cancers (88.2% vs. 90.1%, p = 0.220). However, prognosis of caecal carcinoma was significantly worse than that of all other sites combined (83.5% vs. 90.2%, p = 0.007). In multivariate analysis, pT-category, pN-category, grading, vascular invasion, emergency operation, adjuvant chemotherapy, and caecal carcinoma remained as independent prognostic factors. In the 384 patients with stage IV-disease, 3-year overall survival for right- vs. left-sided cancers differed only in univariate analysis (17.7% vs. 28.6%, p = 0.013).

CONCLUSION

In non-metastatic colon cancer, location in the caecum is an independent prognostic factor. In unselected patients with stage IV colon cancer, sidedness was not found to be a prognostic factor. Differentiation into right- and left-sided tumors may be simplistic, and further studies on the biological behavior of different colonic sites are warranted.

Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence

Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.

Beyond Total Mesorectal Excision: Compartment-based Anatomy of the Pelvis Revisited for Exenterative Pelvic Surgery

OBJECTIVE

Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes.

BACKGROUND

Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself.

MATERIALS AND METHODS

Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest.

RESULTS

All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated.

CONCLUSIONS

A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.

Significant decrease of the pathological stage I rectal carcinoma in the era of neoadjuvant therapy-A matter of concern

BACKGROUND

Neoadjuvant treatment (nTx) for rectal cancer is commonly reserved for UICC stages II/III. Patients with stage I tumours (T1-2N0M0) are not candidates for nTx. The accuracy of treatment allocation depends on the precision of clinical staging, which is liable to understaging and overstaging. The study aimed at exploring changes in the proportion of stage pI patients with the introduction of nTx over a 26-year period.

MATERIALS AND METHODS

All consecutive patients with histologically proven rectal cancer excluding carcinoma in situ were retrieved from a prospective database of our colorectal unit. Time periods were defined as per the use of nTx: baseline phase 1994-1997; implementation phase 1998-2005 and guideline phase 2006-2019. Trends over time regarding proportion of applied nTx and stage pI tumours were investigated.

RESULTS

Overall, 1468 patients met the inclusion criteria. There were no major differences in patients' characteristics, especially proportion of synchronous metastases (stage IV) over time. nTx was applied to 1.2% of patients without metastases in the baseline phase, to 29.6% in the implementation phase, and to 59.6% in the guideline phase (p < 0.001). Corresponding proportions for patients with stage pI were 31.0%, 26.3% and 14.2%, respectively (p < 0.001).

CONCLUSION

With a stable proportion of stage IV carcinomas indicating no major changes in the patient cohorts, we could document a significant decrease of stage pI patients with increasing use of nTx. This trend clearly signals overtreatment caused by clinical T- and N-staging. More precise criteria are needed to better select patients with rectal cancer for nTx.

Correction to: Long-term results achieved by guideline-based stage-dependent management of anal cancer in a non-HIV population

The authors of the article mentioned above found out errors on the Table 4 concerning the number and survival rates of patients with incomplete radiotherapy.

Nonmelanoma Skin Cancer with Skull Infiltration and Cranial Involvement

BACKGROUND

Skin cancer is an uncommon cause of skull invasion, dural infiltration and brain parenchyma involvement.

CASE REPORT

We report on a series of three elderly patients who presented with squamous cell carcinoma of the scalp with skull bone and cerebral invasion and discuss the diagnostic and therapeutic challenges.

CONCLUSION

A major factor of delayed diagnosis of this potentially life-threatening skin cancer feature is patients' neglecting.

Prognosis in patients with synchronous colorectal cancer metastases after complete resection of the primary tumor and the metastases

BACKGROUND

Synchronous metastases are considered a negative prognostic factor in patients with metastatic colorectal cancer (CRC). We investigated the outcomes of stage IV CRC patients undergoing complete gross resection (R0/1) of both the primary tumor and the metastases under the guidance of a multidisciplinary team (MDT).

METHODS

All CRC patients with synchronous metastases were retrieved from a prospective database. Patients treated from 2006 to 2017 who underwent complete resection were analyzed. Various factors, including multiple metastatic sites and complex procedures, were investigated. Univariate and multivariate overall survival (OS) calculations were performed.

RESULTS

Of 330 consecutive patients with synchronous metastases, 101 (30.6%) achieved an R0/1 status including 12 (11.9%) patients with multiple metastatic sites. Complex procedures were necessary in 45 (44.6%) patients. Five-year OS was 53.0% for the R0/1 patient group. Multivariate analysis could not detect factors associated with prognosis.

CONCLUSIONS

With modern treatment, the prognosis of patients with synchronous CRC metastases can be improved. Decisions made by a MDT offered one-third of patients a potentially curative approach to their stage IV disease. Despite the treatment of a high rate of patients with complex metastases necessitating complex procedures, we achieved a favorable 5-year OS rate.

Very Rare Amelanotic Lentigo Maligna Melanoma with Skull Roof Invasion

BACKGROUND

Lentigo malignant melanoma is a melanoma subtype of chronic sun-damaged skin in elderly Caucasians. Amelanotic variants of lentigo malignant are extremely rare.

CASE PRESENTATION

This is a case report of an 80-year-old male patient who presented with a non-pigmented exophytic tumour of his bald head. After complete surgical excision under the suspicion of squamous cell carcinoma, three-dimensional histologic examination confirmed an amelanotic lentigo malignant melanoma with a tumour thickness of 1.76 mm, resected R0. Five years later he developed the first relapse, the other year a satellite metastasis was surgically removed. One year later, this patient had developed a large relapsing lentigo malignant melanoma with skull roof invasion. There was no evidence of distant metastatic spread. Amelanotic lentigo malignant melanoma is a very rare tumour.

CONCLUSIONS

Serial excision or slow Mohs and Mohs micrographic surgery are the treatments of choice especially in the head and neck area. These tumours may be locally very aggressive as it is shown by skull invasion in the present case.

Outcome for stage II and III rectal and colon cancer equally good after treatment improvement over three decades

PURPOSE

This study aimed to investigate the outcome for stage II and III rectal cancer patients compared to stage II and III colonic cancer patients with regard to 5-year cause-specific survival (CSS), overall survival, and local and combined recurrence rates over time.

METHODS

This prospective cohort study identified 3,355 consecutive patients with adenocarcinoma of the colon or rectum and treated in our colorectal unit between 1981 and 2011, for investigation. The study was restricted to International Union Against Cancer (UICC) stages II and III. Postoperative mortality and histological incomplete resection were excluded, which left 995 patients with colonic cancer and 726 patients with rectal cancer for further analysis.

RESULTS

Five-year CSS rates improved for colonic cancer from 65.0% for patients treated between 1981 and 1986 to 88.1% for patients treated between 2007 and 2011. For rectal cancer patients, the respective 5-year CSS rates improved from 53.4% in the first observation period to 89.8% in the second one. The local recurrence rate for rectal cancer dropped from 34.2% in the years 1981-1986 to 2.1% in the years 2007-2011. In the last decade of observation, prognosis for rectal cancer was equal to that for colon cancer (CSS 88.6 vs. 86.7%, p = 0.409).

CONCLUSION

Survival of patients with colon and rectal cancer has continued to improve over the last three decades. After major changes in treatment strategy including introduction of total mesorectal excision and neoadjuvant (radio)chemotherapy, prognosis for stage II and III rectal cancer is at least as good as for stage II and III colonic cancer.

Nodular epitheloid sarcoma of the upper limb. A case report and review of the literature

Epitheloid sarcoma is a rare malignant soft tissue sarcoma. We present a 36-year-old male patient with a primary tumour on his wrist and subcutaneous spread in a sporotrichoid pattern along the upper extremity. Early surgical treatment with micrographic control of all margins provides best long term outcome as long as a solitary lesion is present. In case of cutaneous and internal spread of the disease treatment options are only palliative. Early diagnosis, therefore, is most crucial.

Acne inversa (Hidradenitis suppurativa): A review with a focus on pathogenesis and treatment

Acne inversa (AI) is a disabilitating chronic inflammatory disease with major negative impact on quality of life and significant co-morbidities. This is an important link to insights into immune dysfunction, which stimulated therapeutic approaches like tumor necrosis-α inhibitor therapy. This new off-label drug treatment is particularly beneficial when used in combination with wide excision of inflamed skin and subcutaneous tissue. Retinoids have been reported to be helpful in secondary prevention. The standard of therapy in advanced cases is surgery with wide excisions and healing by secondary intention. This treatment results in significant reduction of complaints and achieves satisfactory body contouring.

[CT-findings in penetrating captive bolt injuries to the head and brain: analysis of the trauma-related CT-findings and review of the literature]

Penetrating gunshot injuries to the head and brain are rare in Germany and the rest of Western Europe. Due to the small number of cases over here no consistent diagnostic and therapeutic standards exist in this respect. Thus these kinds of injuries present a great challenge to the attending physicians. Most of these violations are a result of a suicidal attempt or an accident. Beside violations by firearms also penetrating injuries to the head and brain due to captive bolt devices, as used in slaughtery business for the "humane" killing of animals, occur from time to time. The impact on the head differs from that caused by firearms because no projectile is leaving the barrel and the used bolt, as a fix part of the device, does not remain in the affected tissue. That implies characteristic results within the radiological imaging that might be pathbreaking for the further treatment, because the origin of such a head injury is often unknown during primary care. Consequently the knowledge of these specific findings is central to the radiologist to make the appropriate diagnosis. Based on some clinical examples the trauma-related CT-findings are introduced and a short overview of the relevant literature is also given.

Giant tricholemmal squamous cell carcinoma with cranial infiltration

Tricholemmal squamous cell carcinoma is a rare variant of squamous cell carcinoma thought to follow a more benign course. The authors present the case of a 67-year-old man with a giant tricholemmal squamous cell carcinoma on his scalp. Further investigations demonstrated a skull destruction and cranial invasion. Curative treatment was impossible, but tumor mass reduction and wound closure by sandwich split-thickness skin mesh graft transplantation using a dermal template was performed. Problems of advanced squamous cell carcinoma on the scalp are discussed.

Enhancement of liver parenchyma after injection of hepatocyte-specific MRI contrast media: a comparison of gadoxetic acid and gadobenate dimeglumine

PURPOSE

To compare enhancement of liver parenchyma in MR imaging after injection of hepatocyte-specific contrast media.

MATERIALS AND METHODS

Patients (n = 295) with known/suspected focal liver lesions randomly received 0.025 mmol gadoxetic acid/kg body weight or 0.05 mmol gadobenate dimeglumine/kg body weight by means of bolus injection. MR imaging was performed before and immediately after injection, and in the delayed phase at approved time points (20 min after injection of gadoxetic acid and 40 min after injection of gadobenate dimeglumine). The relative liver enhancement for the overall population and a cirrhotic subgroup was compared in T1-weighted GRE sequences. An independent radiologist performed signal intensity measurements. Enhancement ratios were compared using confidence intervals (CIs).

RESULTS

The relative liver enhancement in the overall population was superior with gadoxetic acid (57.24%) versus gadobenate dimeglumine (32.77%) in the delayed-imaging phase. The enhancement ratio between the contrast media was statistically significant at 1.75 (95% CI: 1.46-2.13). In the delayed phase, the enhancement of cirrhotic liver with gadoxetic acid (57.00%) was comparable to that in the overall population. Enhancement with gadobenate dimeglumine was inferior in cirrhotic liver parenchyma (26.85%).

CONCLUSION

In the delayed, hepatocyte-specific phase, liver enhancement after injection of gadoxetic acid was superior to that obtained with gadobenate dimeglumine.

Panniculitis Ossificans of the Lower Leg

The authors present a rare case of panniculitis ossificans (PO) in a 30-year-old woman. Differential diagnoses and treatment are discussed. PO is an important differential diagnosis to sarcomas.

Late complication after tropic storm accident: subcutaneous and intracranial actinomycetoma

We report a 53-year-old farmer who developed subcutaneous and cerebral masses 24 years after penetrating trauma during a tropic storm. Computed tomography scans, magnetic resonance imaging and histopathology disclosed actinomycetoma, a disease that rarely develops after trauma and is only occasionally seen with intracranial manifestation. Clinically, the cutaneous manifestation resembled acne keloidalis nuchae or dissecting folliculitis of the scalp. He was treated by neurosurgery and antibiosis.

Successful treatment of relapsing disseminated coccidioidomycosis with cutaneous involvement with posaconazole

A 52-year-old woman with pulmonary sarcoidosis on immunosuppressive therapy developed pulmonary infiltrates and cutaneous granulomatous abscesses after a trip to the USA in April 2005. A hyphomycete was identified, further characterized by a gene probe as Coccidioides spp. and then definitively identified as Coccidioides posadasii by polymerase chain reaction and sequencing. Antibodies towards Coccidioides spp. were detected. The infection was successfully treated with posaconazole (Noxafil), 2 x 400 mg/d.

[Medicamentous thrombolysis in acute occlusions of extremity arteries]

Local catheter-directed thrombolysis for thromboembolic extremity artery or bypass occlusions is a promising therapeutic option with comparatively low complication rates if the severity of the ischemia does not require an urgent surgical revascularization. This therapeutic decision has to be made by the vascular team under consideration of individual circumstances and contraindications. Apart from an adequate dosage, a strict intrathrombotic application of the fibrinolytic agent and careful clinical monitoring, including surveillance of the coagulation system is necessary. If needed, the thrombolysis therapy can be combined with interventional thrombaspiration and balloon dilatation or surgical correction of an underlying lesion.

[Necrosis of the femoral head in late pregnancy. Necessity of early diagnosis]

Limping and groin pain can issue diagnostic problems during late pregnancy. Differential diagnosis of two idiopathic syndromes, transient osteoporosis and osteonecrosis of the femoral head, is made possible by MRI in the early stages. This case is reported to demonstrate the need to distinguish between those syndromes early so as to prevent further joint damage.

Magnetic resonance imaging of bone metastases in patients with nonseminomatous germ cell tumors

OBJECTIVE

To investigate the role of magnetic resonance imaging (MRI) of bone metastases in nonseminomatous germ cell tumors.

METHODS AND MATERIALS

There were 5 consecutive patients with bone metastases from nonseminomatous germ cell tumors treated between 2003 and 2006 who underwent imaging studies, including MRI. The characteristic imaging findings are discussed in the light of the clinical course.

RESULTS

Of the 5 patients, 3 had symptoms related to bone involvement at diagnosis. All patients received conventional x-ray of their bony lesions, but only 1 of them was considered abnormal. Skeletal MRI was obtained in all patients. A bone scan was available in 3 cases with spinal involvement. It was normal in 1 case and detected only a minority of the lesions visible on MRI in the other 2 cases. Follow-up MRIs were available in all patients. A partial resolution of bone involvement during chemotherapy was observed in only 1 of them. In 2 cases, there was a slight progression of a diffuse alteration of the bone marrow during treatment. In 1 patient, severe spinal bone marrow changes were visible on MRI 2 years after cessation of treatment without evidence of disease recurrence.

CONCLUSIONS

MRI may disclose bone metastases in nonseminomatous germ cell tumors, which otherwise may be missed. MRI findings of bone lesions during treatment do not directly reflect the course of the disease and have to be interpreted with caution using clinical information.

Efficacy and safety of gadodiamide (Gd-DTPA-BMA) in renal 3D-magnetic resonance angiography (MRA): a phase II study

PURPOSE

To determine the most efficacious dose of gadodiamide for three-dimensional (3D) contrast-enhanced (CE) magnetic resonance angiography (MRA) of the renal arteries on a patient level based on the sensitivity in detecting the main hemodynamically relevant (> or =50% or occlusion) renal artery stenosis (RAS) using intra-arterial digital subtraction angiography (IA DSA) as the gold standard.

MATERIALS AND METHODS

This prospective, randomized, double-blind, parallel-group, multicenter study included 273 patients referred to IA DSA for suspected RAS. Patients underwent 3D CE MRA after injection of 0.01, 0.05, 0.1, or 0.2mmol/kg of body weight gadodiamide (0.5mmol/ml). The images were assessed for location and degree of RAS by independent blinded readers (MRA: three readers, IA DSA: one reader). Hypothesis testing for a significant trend in sensitivity across dose groups was based on the one-sided Cochran-Armitage style trend test for each independent MRA reader.

RESULTS

The lowest dose group (0.01mmol/kg) proved non-efficacious in detecting hemodynamically relevant (i.e., > or =50% or occlusion) RAS. A statistically significant dose trend (p<0.001) was shown for each of the three independent readers. Depending on reader, the sensitivity obtained with 0.05, 0.1, and 0.2mmol/kg was 63.9-86.1%, 75.8-91.4% and 80.6-90.6%, the specificity was 66.7-73.9%, 59.3-75.0%, and 59.3-75.0% and accuracy was 67.8-78.9%, 75.4-77.4%, and 76.3-81.0%, for the three dose groups, respectively. There were eight non-severe adverse events (AEs). Three serious AEs occurring in one patient were judged not related to gadodiamide by the on-site investigator.

CONCLUSION

A significant dose trend between the four doses examined was observed. The lowest dose (0.01mmol/kg) differed significantly from those of the other three doses. Based on the analysis of the primary and secondary endpoints, 0.1mmol/kg gadodiamide appears to be the most suitable dose in diagnosing hemodynamically relevant RAS. The present study also demonstrated gadodiamide to be safe and well tolerated.

Perforation of Aortic Root as Secondary Complication after Implantation of Patent Foramen Ovale Occlusion Device in a 31-Year-Old Woman

Transesophageal echocardiography (TEE) revealed a 3-mm-large patent foramen ovale (PFO). No other reason for these neurological events could be found and the patient underwent percutaneous closure of the PFO with a CARDIA Star 03/30 device without periprocedural complications. Four weeks later, the patient underwent a routine control of device without any adverse clinical symptoms. Surprisingly, echocardiography revealed a perforation of the aortic root by an umbrella strut with a small shunt from the aortic root to the right atrium. Magnetic resonance imaging (MRI) confirmed the diagnosis of device malposition. Consecutively, the patient underwent minimal invasive surgery. After removal of the single perforating strut, the bleeding lesion was closed. The patient remained free of any additional complications during the postoperative course and up until now has had uneventful follow-ups.

[Acute abdominal pain due to a ventriculo-peritoneal shunt metastasis of an intracranial germ cell tumor]

INTRODUCTION

Extracranial metastases of pineal germinomas are rare.

CASE REPORT

The case of a metastasis of a primary intracranial germ cell tumor via a temporary-ventriculo-peritoneal shunt as a cause of acute abdominal pain is reported. The germ cell tumor markers were useful in establishing the diagnosis.

CONCLUSIONS

With an appropriate clinical history, intra-abdominal metastases via a temporary ventriculo-peritoneal shunt should be considered in the differential diagnosis of acute abdominal pain.

Enhanced tumor uptake in neuroendocrine tumors after intraarterial application of 131I-MIBG

131I-labeled metaiodobenzylguanidine (MIBG) is an established treatment modality for neuroendocrine tumors. Because of low tumor doses, it has a predominantly palliative character. Our approach was to investigate whether intraarterial application of 131I-MIBG has the potential to enhance tumor uptake.

METHODS

Seventeen patients with primary or metastasized neuroendocrine tumors received intraarterial treatment with 131I-MIBG, and 12 of these patients also had intravenous treatment. Every patient underwent intravenous 131I-MIBG whole-body scanning before therapy. For quantification, a tumor-to-whole-body ratio was calculated from the diagnostic and 24-h posttreatment scans.

RESULTS

Compared with the intravenous application, intraarterial 131I-MIBG treatment provided an up to 4-fold higher tumor uptake. Mean uptake was enhanced by 69%, but this varied widely between patients. We did not observe any immediate complications from catheterization. Carcinoid-related side effects were noted in 7 of 17 patients and were not different from those seen with intravenous application.

CONCLUSION

Intraarterial treatment with 131I-MIBG is a safe alternative to intravenous application and provides a 69% higher mean tumor uptake. We propose to attempt intraarterial MIBG treatment in every patient to assess its potential benefit.

Transcatheter closure of atrial septal defects improves right ventricular volume, mass, function, pulmonary pressure, and functional class: a magnetic resonance imaging study

OBJECTIVE

To characterise prospectively by magnetic resonance imaging (MRI) changes in right ventricular (RV) volume, function, and mass after transcatheter closure of atrial septal defects (ASDs) and to evaluate the course of pulmonary pressure and functional class criteria.

METHODS

In 20 patients with secundum-type ASD and dilated RV diameter, MRI was performed to quantify RV end diastolic (RVEDV) and end systolic volumes (RVESV), RV mass, tricuspid annular diameter, and RV ejection fraction before and 6 and 12 months after transcatheter closure of the ASD. RV systolic pressure was measured during follow up by transthoracic echocardiography.

RESULTS

Functional class improved in the majority of patients after ASD closure. RVESV (from 81 (18) ml/m2 to 53 (15) ml/m2, p < 0.001), RVEDV (from 127 (17) ml/m2 to 99 (18) ml/m2, p < 0.001), and RV mass (from 79 (10) g to 63 (8) g, p < 0.01) decreased significantly during follow up, although tricuspid annular diameter did not. RV ejection fraction improved (by 9% compared with baseline, p < 0.05) and RV systolic pressure decreased significantly (from 33 (8) mm Hg to 24 (6) mm Hg, p < 0.001) after closure.

CONCLUSION

MRI studies showed significant improvement of RV volumes, mass, and function after transcatheter closure of ASDs. Restoration of the RV leads to decreased pulmonary pressure resulting in a better functional class in the majority of patients.

Extension of intracranial thrombosis after unilateral dissection of the internal jugular vein

OBJECTIVE

Resection of the internal jugular vein can be necessary in cases of radical neck dissection or even in cases involving benign neoplasms such as glomus tumors. According to the triad described by Virchow (ie, stasis of blood flow, damage to the endothelium, and changes in hemostasis), the development of a thrombosis in the venous vessels superior to the resected internal jugular vein seems to be possible. The aim of this study was to determine the extension of possible intracranial thrombosis after wound healing.

DESIGN

A total of 17 patients requiring resection of the internal jugular vein were evaluated prospectively using magnetic resonance imaging and 2-dimensional (time-of-flight) magnetic resonance angiography after the surgical treatment. Preoperative magnetic resonance images were obtained in all 17 patients for staging purposes as well as to exclude preoperative thrombosis of the internal jugular vein. Sixteen patients had malignant tumors, and 1 patient had a glomus tumor.

RESULTS

Intracranial thrombosis with thrombosis of the sigmoid sinus was found in 4 patients, and thrombosis of the transverse sinus was found in 3 patients. There were no complications such as intracranial hemorrhage or signs of increased intracranial pressure in any patients. There was no evidence of intracranial thrombosis in 10 cases. In these cases, thrombosis of the venous vessels superior to the resected vein ranged from none to complete thrombosis of the superior bulb of the internal jugular vein. After unilateral resection of the internal jugular vein, the venous blood leaves the brain mainly via the venous network of the contralateral side of the neck.

CONCLUSIONS

Although intracranial thrombosis of the sigmoid or transverse sinus seems to occur more frequently than was previously thought, intracranial complications such as venous infarction or increased intracranial pressure appear to be very rare. After unilateral radical neck dissection, the venous blood leaves the brain mainly via the venous system of the other side of the neck and the ipsilateral collateral veins.

Morphological and radiologic evaluation of the human nasopalatine duct

In several mammals, a direct connection between the nasal cavity and the oral cavity is a common finding. The structure is named the nasopalatine duct (NPD). It has been hypothesized to be functional in terms of transportation of odorants from the oral cavity to the nasal cavity. In humans, the NPD exists during embryological development. The connection between the nasopalatine infundibulum and the incisive fossa is typically closed at the time of birth. We present the case of a 24-year-old man who presented with a persistent NPD. By means of a thin, soft tube, it was possible to probe the NPD. Magnetic resonance imaging revealed a bony gap between the hard palate and the alveolar process of the maxillary bone with a length of 16 mm and a width of 6 mm. In light of the literature of the past 500 years, this represents a rare finding of a persistent NPD.