"Slipped capital femoral epiphysis in a 25-year-old hypogonadic man with a large cranial chondroma: causality or coincidence? "

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a hip disorder frequently occurring in adolescence. In adults it is rare and so far very few cases have been documented.

CASE PRESENTATION

This report presents a 25-year-old patient diagnosed with an anterior fossa giant chondroma, hypogonadotropic hypogonadism, and SCFE. The patient underwent surgical and hormonal therapy. His symptoms revealed, and he became a father.

CONCLUSIONS

Every patient diagnosed with SCFE in adulthood should undergo endocrinological assessment based on physical examination and laboratory tests.

Primary yolk sac tumor of pterygopalatine fossa with loss of vision: A case report

INTRODUCTION

Primary yolk sac tumor (YST) is an infrequently-diagnosed malignant extragonadal germ cell tumors. It is likely to recur locally and may present with widespread metastases once diagnosed. Primary YST of the head is uncommon but can cause severe complications, such as loss of vision once the tumor mass invades the optic nerve.

PATIENT CONCERNS

A 20-month-old boy presented to the general clinic of the local children's hospital with a complaint of swelling of left face for 1 year and proptosis of the left eye for over 2 weeks as stated by his parents. Initially, he did have some vision, as he could walk by himself, but a special ophthalmologic examination was not performed.

DIAGNOSES

Cranial computed tomography and magnetic resonance imaging revealed a large tumor accompanied by peripheral bone destruction in the left pterygopalatine fossa that extended to sphenoid, ethmoid, left maxillary sinuses, left nasoethmoid, and left orbit. The optic nerve was invaded on both sides. Chest and abdominal imaging were normal. A primary diagnosis of Langerhans cell hyperplasia was made. However, blood tests on the second day of hospitalization revealed significantly elevated serum alpha-fetoprotein levels. On the third day, the boy lost his eyesight, with loss of pupillary and no light sensation during flashlight stimulation on both sides.

INTERVENTIONS

Nasal endoscopy was performed on the fourth day, the vast majority of soft tissue mass was resected for biopsy. Histopathological examination revealed features of endodermal sinus tumor. A final diagnosis of primary YST of pterygopalatine fossa was made. Because the mass could not be resected completely, he received combined chemotherapy with bleomycin, etoposide, and carboplatin for 6 cycles over six months.

OUTCOMES

The patient recovered with significant tumor shrinkage and without secondary metastasis after 18 months but left permanently blind.

CONCLUSION

The worst complication of loss of vision after Primary YST of pterygopalatine fossa alerts us that close physical examination during the initial investigation should be performed, which is especially important in young children who cannot express complaints well. Early detection and treatment with surgical resection and chemotherapy may contribute to satisfactory outcomes and avoidance of visual impairment.

Basal Ganglia Germ Cell Tumors With or Without Sellar Involvement: A Long-Term Follow-Up in a Single Medical Center and a Systematic Literature Review

BACKGROUND

Basal ganglia germ cell tumors (BGGCTs) represent an extremely rare subset of tumors about which little is known. Some patients suffer from tumor dissemination, such as sellar involvement. This study aimed to evaluate the independent prognostic risk factors of patients with BGGCTs with or without sellar involvement.

METHODS

Sixteen patients were diagnosed with BGGCTs at Peking Union Medical College Hospital from January 2000 to December 2020. A literature review was performed on the online databases Medline and PubMed, and 76 cases in the 19 retrieved articles were identified at the same time. The data regarding biochemical tests, radiological examinations, and outcomes during follow-up were analyzed.

RESULTS

Of 92 patients in this study, seven patients were clinically diagnosed as germinomas, with the remaining 85 patients receiving surgery. Fifty-two patients suffered from multifocal lesions or tumor dissemination. The patients with BGGCTs demonstrated a significant male predilection. The patients with delayed diagnosis more likely had cognitive disturbance (p = 0.028), mental disturbance (p = 0.047), and diabetes insipidus (p = 0.02). Multivariate analysis demonstrated that the independent poor prognostic risk factors of patients with BGGCTs were delayed diagnosis [odd ratio (OR) 2.33; 95% CI 1.02-5.31], focal radiotherapy (OR 4.00; 95% CI 1.69-9.49), and non-pure germinoma (OR 4.64; 95% CI 1.76-12.22).

CONCLUSIONS

The delayed diagnosis, focal radiotherapy, and non-pure germinoma were associated with a poorer prognosis for patients with BGGCTs with or without sellar involvement.

Epithelioid and spindle cell rhabdomyosarcoma with FUS-TFCP2 or EWSR1-TFCP2 fusion: report of two cases

The WHO Classification of Tumors of Soft Tissue and Bone divides rhabdomyosarcoma (RMS) into alveolar, embryonal, pleomorphic, and spindle cell/sclerosing types. Advances in molecular diagnostics have allowed for further refinement of RMS classification including the identification of new subtypes. Very rare RMS with epithelioid and spindle cell morphology, female predominance, marked osseous predilection, ALK expression, EWSR1/FUS-TFCP2 gene fusions, and highly aggressive clinical behavior have recently been recognized with only 23 cases reported in the English language literature. Herein, we report two additional cases with detailed clinicopathologic description and molecular confirmation. In brief, two young women presented each with a primary bone tumor-one with a frontal bone tumor and another with an osseous pelvic tumor. Both tumors showed epithelioid to spindle cell morphology, ALK expression, and EWSR1/FUS-TFCP2 gene fusions. Both patients died of disease less than 17 months from diagnosis despite administration of multiple lines of aggressive treatment. In addition, we review the literature and discuss differential diagnostic and potential treatment considerations.

Plasmacytoma of the skull mimicking an epidural hematoma: A case report

RATIONALE

Plasmacytoma as the 1st presentation of skull tumors is a rare disorder. When it is combined with brain trauma or dramatic changes in intracranial pressure, patients are more prone to misdiagnosis.

PATIENT CONCERNS

A 67-year-old woman complaining of a headache presented with a history of head trauma for the past 1 hour. Emergency head computed tomography initially suggested an epidural hematoma.

DIAGNOSIS

Emergency surgery was performed to remove the intracranial hematoma, but a tumor-like mass was found during surgery, and pathologic assessment confirmed plasmacytoma. Surgery was difficult because of bleeding. The tumor was radically removed.

INTERVENTIONS AND OUTCOMES

The patient underwent whole-brain radiotherapy and chemotherapy. She died 40 months after the surgery.

LESSONS

Epidural lesions found after a head injury may be assumed to be an epidural hematoma, leading to unnecessary surgery. Diseases such as hematomas, meningiomas, eosinophilic granulomas, bone metastases, and osteosarcomas must be considered.

Clinical implications, diagnosis, and treatment of a giant frontoethmoid osteoma

Osteomas are benign, asymptomatic fibro-osseous tumors that are most commonly observed in the paranasal sinuses and sometimes are found in imaging examinations that were taken for other reasons. Giant osteomas are rarely found in the frontal and ethmoid sinuses but, when they are, they may cause intracranial and orbital complications. The aims of this case report are to describe a frontoethmoid osteoma in a 40-year-old woman, discuss the characteristics of this lesion through cone beam computed tomography (CBCT) imaging, and review the options for treatment. A CBCT examination performed for the purpose of orthodontic diagnosis revealed the presence of a large, well-defined, lobular, hyperdense mass that occupied a sizeable area of the frontal sinus and extended to the ethmoid sinus. The patient did not report any pain. Based on the physical and imaging characteristics of the mass, the location and size of the lesion, and the patient's age, the diagnosis was a giant frontoethmoid osteoma. Due to its enhanced field of view, CBCT may enable earlier diagnosis of lesions that affect the maxillofacial region.

Ewing sarcoma of the head and neck: The Mayo Clinic experience

BACKGROUND

Treatment options of Ewing sarcoma of the head and neck include surgery, radiotherapy (RT), and chemoradiotherapy. However, local control can be challenging.

METHODS

We conducted a retrospective review of all patients with head and neck Ewing sarcoma treated from 1972 to 2015 at a single tertiary care hospital.

RESULTS

Seventeen patients met criteria (median 21 years, range 5-58 years; 5 women). Mean follow-up was 10.4 years (range 2.2-39 years). Tumors occurred commonly in the cervical spine (5/17), the skull (3/17), and the paranasal sinuses (3/17). A total of 14 of 17 patients underwent surgical resection, 9 with gross total resection. After multimodality therapy, the 5-year overall survival (OS) and recurrence-free survival (RFS) was 87% and 75%, respectively.

CONCLUSION

Combined multimodal treatment resulted in a 5-year OS and RFS of 87% and 75%, respectively. Aggressive surgical resection with adjuvant chemoradiotherapy should be considered. Although negative margin surgery is the goal, subtotal resection may be acceptable in the setting of adjuvant treatment.

Ossifying Fibroma of the Skull: Clinical and Therapeutic Study

Aims and Backround

Ossifying fibroma is a tumor with benign course that rarely affects the cranial bones.

Methods

The authors report 5 cases of ossifying fibroma of the skull and analyze the clinical course and treatment of this lesione.

Results

3 patients were females and 2 males. The mean clinical history was 3.2 years. 4 patients underwent total removal and 1 partial. At mean follow-up of 19 years, all patients who underwent total removal showed improvement of neurological deficit, whereas the patient who underwent partial removal had clinical regrowth.

Conclusion

The authors conclude that total removal of fibroma should be extended to normal bone and in cases in which total removal is not possible the residue should be checked for regrowth by serial MRI.

Extraskeletal presentation of Ewing's Sarcoma

The case of a 27-year-old Hispanic female who presented with an occipito-parietal tumor after suffering trauma to the area. A physical examination revealed no tenderness to palpation and with evidence of healing ulcerations. The biopsy was consistent with a synovial sarcoma. A wide excision of the mass (15cm x 14cm x 6cm) followed by a pericranial flap was performed. A follow-up CT showed recurrence involving the parietal sagittal sinus. After a second biopsy the mass was determined to be a small-cell sarcoma, consistent with Ewing's sarcoma. Chemotherapy included 8 cycles of doxorubicin, vincristine, and cyclophosphamide, with alternating cycles of etoposide and ifosfamide. A year later, a second wide excision of the mass was performed, followed by bilaminate skin substitute and skin graft placement for reconstruction of the soft-tissue defect. After chemotherapy, a follow-up PET scan showed no signs of re-uptake in any soft tissue or skeletal structures. After 2 years, the patient remains in complete remission.

Skull Metastasis from the Liver: Case Report and Literature Review

BACKGROUND

Calvarial metastasis from liver cirrhosis in the absence of a primary focus is exceptionally rare. Few reports of metastases from hepatocellular carcinoma of an unknown primary focus have been published.

CASE DESCRIPTION

A 66-year-old man with a history of Schistosoma japonicum infection presented to our hospital with a mass over the left occipital region associated with headache and dizziness. Imaging revealed a 6 × 5-cm lesion supplied principally by the left occipital artery. The metastatic tumor was removed via super-selective embolization and craniotomy. Pathology revealed that circulating tumor cells from the liver had metastasized to the calvaria. Postoperatively, no primary foci was found over 9 months of follow-up.

CONCLUSIONS

A calvarial mass may be an initial manifestation of hepatocellular carcinoma. Early diagnosis is important. A calvarial metastasis from the liver, although very rare, should be included in the differential diagnosis of a patient with both cirrhosis and skull mass.

Domain Modeling and Application Development of an Archetype- and XML-based EHRS. Practical Experiences and Lessons Learnt

BACKGROUND

Access to patient data within the hospital or between hospitals is still problematic since a variety of information systems is in use applying different vendor specific terminologies and underlying knowledge models. Beyond, the development of electronic health record systems (EHRSs) is time and resource consuming. Thus, there is a substantial need for a development strategy of standardized EHRSs. We are applying a reuse-oriented process model and demonstrate its feasibility and realization on a practical medical use case, which is an EHRS holding all relevant data arising in the context of treatment of tumors of the sella region. In this paper, we describe the development process and our practical experiences.

METHODS

Requirements towards the development of the EHRS were collected by interviews with a neurosurgeon and patient data analysis. For modelling of patient data, we selected openEHR as standard and exploited the software tools provided by the openEHR foundation. The patient information model forms the core of the development process, which comprises the EHR generation and the implementation of an EHRS architecture. Moreover, a reuse-oriented process model from the business domain was adapted to the development of the EHRS.

RESULTS

The reuse-oriented process model is a model for a suitable abstraction of both, modeling and development of an EHR centralized EHRS. The information modeling process resulted in 18 archetypes that were aggregated in a template and built the boilerplate of the model driven development. The EHRs and the EHRS were developed by openEHR and W3C standards, tightly supported by well-established XML techniques. The GUI of the final EHRS integrates and visualizes information from various examinations, medical reports, findings and laboratory test results.

CONCLUSION

We conclude that the development of a standardized overarching EHR and an EHRS is feasible using openEHR and W3C standards, enabling a high degree of semantic interoperability. The standardized representation visualizes data and can in this way support the decision process of clinicians.

Embolization of cranial/spinal tumours and vascular malformations with hydrogel microspheres: An experience of 69 cases

Objective: To evaluate polymethyl methacrylate hydrogel microspheres (HMs) as an embolization material in the management of hypervascular craniofacial and spinal lesions.

Material and Methods: Sixty-nine patients with vascular lesions of the craniofacial and spinal regions underwent embolization with HM. The pathologies included craniofacial tumours (n=38), cranial arteriovenous malformations (AVMs) (n=7), dural AVM (n=1), cavernous carotid fistula (n=1), spinal tumours (n=7), spinal AVMs (n=6), orbital lesions (n=4) and scalp AVMs (n=5). Surgery was done in 56 patients. The blood loss at surgery, tumour shrinkage, surgical cleavage and ease of removal of tumour was noted from the records. Histopathology was available in 39 patients. A follow-up of 3 months to 6 years was available in 13 patients in whom embolization was the sole treatment. Surgical and histopathological findings were correlated with angio-embolization findings.

Results: HMs were easy to inject through the microcatheter with good control. Good devascularization was obtained in 61 patients and partial in 8 patients. Two patients developed complications due to presence of anastomoses between intra- and extracranial circulation and 1 patient due to tumor swelling. Histopathology showed presence of HMs in all the lesions, with minimal inflammatory reaction in 2 patients. Patients with spinal lesions treated with embolization only stabilised in neurologic deficits.

Conclusion: HMs are highly suitable as embolization agents in the management of craniofacial and spinal hypervascular lesions.

Cutaneous squamous cell carcinoma of the scalp in the immunocompromised patient: review of 53 cases

OBJECTIVE

We analyzed outcomes from immunocompromised patients with scalp squamous cell carcinoma (SCC) treated with surgical excision with and without radiation in order to explore 3-year disease-free survival and overall survival.

STUDY DESIGN

The study design was a retrospective chart review.

SETTING

This study was conducted in a private practice setting.

SUBJECTS AND METHODS

The study included 53 immunocompromised patients with an average age of 63.2 years, with scalp squamous cell carcinoma. Pre-operative imaging dictated the extent of resection. Patients with bony involvement received wide local excision including full-thickness craniectomy and cranioplasty. Patients without bony involvement underwent wide local excision and outer-table calvarial resection. All patients were recommended to have post-operative radiation. Patients were followed for a minimum of 3 years.

RESULTS

A total of 53 patients were included in the study. Six patients had pre-operative CT showing bone involvement and were treated with full-thickness craniectomy along with post-operative radiation. Fourteen patients without bone involvement on pre-operative CT were found to have positive bone involvement on final pathology. Forty-five patients underwent post-operative radiation. Patients treated with adjuvant radiation demonstrated a 3-year survival of 80 % and the overall survival was 62 %. In the surgery-only group, the 3-year survival was 62.5 % and the overall survival was 32.5 %.

CONCLUSIONS

Immunocompromised patients with scalp SCC have a poor prognosis. Early detection and treatment are crucial. Based on our results, we recommend wide local excision with at least outer-table calvarial resection, and post-operative radiation. Despite aggressive therapy, patients may still have distant, local, or regional recurrence.

LEVEL OF EVIDENCE

level 2b (retrospective cohort).

Vertigo by Breast Cancer Metastasis 33 Years after Treatment

A 76-year-old woman complained of vertigo for two years. She manifested left deafness, loss of caloric response, and right-beaten nystagmus. An imaging study revealed a tumorous lesion located from the clivus to the left temporal bone with inner ear destruction. A tumor biopsy was performed endonasally and the patient was diagnosed with adenocarcinoma mimicking breast cancer. She had undergone surgery for breast cancer 33 years previously, and the current biopsy specimen showed identical pathology. Breast cancer may metastasize to the skull base; however, metastasis 33 years after surgery is very rare.

Recurrent squamous cell carcinoma of the temporal bone: critical analysis of cases with a poor prognosis

PURPOSE

Temporal bone squamous cell carcinoma (TBSCC) is an uncommon, aggressive malignancy with a significant recurrence rate. We reviewed our experience with recurrent TBSCCs.

MATERIALS AND METHODS

Clinicopathological and therapeutic variables potentially associated with disease-free survival (DFS) and disease-specific survival (DSS) were assessed in 17 TBSCC patients who died of their disease after treatment.

RESULTS

TBSCC recurrences were treated with surgery in 12 cases (palliative in 11, with curative intent in 1) and palliative chemotherapy in 5; the median DFS and DSS were 6 and 16 months, respectively. The mean DFS and DSS were longer in patients who had primary lateral temporal bone resection (LTBR) rather than subtotal temporal bone resection (STBR) (p=0.0173 and p=0.03, respectively). Patients given non-surgical palliative treatment for recurrences had a longer mean DSS than those who underwent surgery (trend toward significance, p=0.09).

CONCLUSIONS

Our results reflect the aggressive nature of TBSCC recurrences. Our findings seem to support the use of non-surgical treatments (chemotherapy, radiotherapy, or specialist palliative care) in patients with loco-regionally advanced recurrent TBSCC. Salvage surgery might be considered for early recurrences when radicality is still achievable. Precise guidelines for the rational follow-up of surgically-treated TBSCCs need to be shared between tertiary centers.

Malignant tumors of temporal bone in Songklanagarind Hospital: management and results

OBJECTIVE

To evaluate the clinical course and treatment in patients with carcinoma of temporal bone

MATERIAL AND METHOD

The authors retrospectively reviewed the patients treated for primary carcinoma of temporal bone in Otolaryngology Head and Neck Surgery department, at Songklanagarind Hospital between 2002 and 2013. Thirty-two patients, including 10 cancer ofpinna and 22 carcinoma of the External Auditory Canal (EAC), were included in this study. The treatment modality was lateral temporal bone resection and postoperative radiotherapy and palliative radiotherapy for advanced stage tumors (T4). Twelve patients were excluded due to difference in modality. Twenty patients remained in the study.

RESULTS

Twenty patients had carcinoma of EAC, early stage (T1, T2) 36.4% and late stage (T3, T4) 63.6%. The overall survival of this group was 46.9%. The median survival period was 22 months (0.286-0.769, 95% CI).

CONCLUSION

The complete resection is the treatment of choice in primary cancer of temporal bone. Postoperative radiotherapy for a microscopic residual tumor is highly recommended. The most important thing is early diagnosis.

L-carnitine treatment in a seriously ill cancer patient with severe hyperthyroidism

OBJECTIVE

To report a case of vaccine-induced Graves' disease successfully managed with L-carnitine and propranolol and without antithyroid drugs (ATDs). ATDs sometimes need to be used at low doses or can be contraindicated/refused. One of the ancillary compounds available is L-carnitine. L-carnitine is a naturally occurring quaternary amine, which acts by impairing thyroid hormone access to the cell nucleus.

REPORT

A 32-year-old Chinese woman with a synovial sarcoma received radiotherapy, chemotherapy and experimental immunotherapy. Two months after the start of immunotherapy, she developed autoimmune hyperthyroidism [thyroid-stimulating immunoglobulins (TSI)=152%, normal values <140]. Left untreated, hyperthyroidism worsened (TSI=248%), so that for 3 months she took L-carnitine (1-4 g/d) and propranolol (20-80 mg/d). Though the hyperthyroidism worsened biochemically (FT4>50 pg/ml, FT3>20 pg/ml, TSI=501%), it was tolerated very well clinically. Fearing a life-threatening thyroid storm, she agreed to have, while still hyperthyroid, total thyroidectomy. The operation was uneventful.

CONCLUSIONS

This case expands previous observations involving two more patients who survived thyroid storms while being treated with L-carnitine (combined with low doses of ATD). Taking also into account that tissue concentrations of L-carnitine decrease in hyperthyroidism, there is room for wide therapeutic use of L-carnitine in several hyperthyroidism settings.

[Intracranial tumor behavior of plasma cell neoplasms. Report of 2 cases and literature review]

BACKGROUND

Multiple myeloma is a plasmatic cell neoplasm that is characterized by skeletal destruction, renal failure, anemia and hypercalcemia. The skull plasmacytomas represent less than 1% of the head and neck tumors, they can be the primary lesion or occur as a secondary manifestation of multiple myeloma in 20-30% of the patients, or they can even manifest several years later after the diagnosis of plasmacytoma. Although some of the lesions may be surgically accessible, the aggressive natural behavior will complicate the evolution of the patients. We present two cases of Mexican women with intracranial plasmacytomas, one of them associated with multiple myeloma.

CLINICAL CASES

The first case was a 24 year-old woman diagnosed with a multiple myeloma with plasmacytic-plasmablastic bone infiltration that was removed in 90%. She presented a local recurrence that required a second intervention for removal. The second case was a 62 year-old female with a malignant intracranial tumor of plasma cells that was totally resected. Both patients received adjuvant treatment based on chemotherapy and radiation therapy with favorable results. The patients died at 5 and 1.5 years respectively due to renal failure secondary to systemic disease.

CONCLUSIONS

We propose chemotherapy and radiation therapy as an essential part of treatment for this condition, as the aggressive behavior of the neoplasms can complicate the evolution, despite being surgically accessible.

[Metastasis to the temporal bone may cause acute peripheral vestibular syndrome and impaired hearing]

Metastasis to the petrous apex of the temporal bone may cause acute peripheral vestibular syndrome and impaired hearing or be asymptomatic. Contrast computed tomography should be performed to exclude pathology in the temporal bone in patients with vestibulocochlear deficit, a history of cancer and no findings on cerebral magnetic resonance imaging. We describe a case of a 61-year-old man with metastatic prostatic carcinoma to the temporal bone.

Alveolar ethmoidal rhabdomyosarcoma in a young adult male

We report a 22-year-old man who presented with a 3 week history of left-sided headache, orbital pain and epiphora progressing to diplopia. He was being treated by his general practitioner with a β-blocker and simple analgesia for possible diagnosis of cluster headaches. Initial examination revealed a reduction in visual acuity and poor abduction and upward gaze. Routine blood tests were normal. CT imaging was reported as a left ethmoid sinusitis with extension into a left orbit subperiosteal abscess. No pus was obtained on frontal sinus trephine and a biopsy was taken, which proved to be an alveolar-type rhabdomyosarcoma. The patient has completed a full course of chemoradiotherapy and has responded well to the treatment. His vision is back to normal and an MRI has shown complete regression of tumour.

Diffuse symmetric meningioma en plaque mimicking metabolic disease of bone

A 50-year-old African American woman with right proptosis and decreased vision demonstrated symmetric, bilateral thickening of the sphenoid wings, calvarium, and skull base on computed tomography. Histopathologic evaluation of the hyperostotic lesion was consistent with meningotheliomatous meningioma. The patient underwent uncomplicated right frontal orbital craniectomy with postoperative radiation. The presentation of en plaque meningioma, when diffuse and symmetric, can mimic a metabolic disease of bone.

[A case of malignant paraganglioma presenting with skull metastases]

A non-functioning paraganglioma is usually benign, however, it may cause distant metastases. There is no histological appearance for the diagnosis of malignancy or absolute criteria for predicting malignant potential. Bony metastases from paraganglioma are known to occur, but, skull metastases are very rare. We report a case of intracranial metastases from a renal paraganglioma. A 61-year-old male presented with temporal headache and exophthalmos on the left side. Seven years prior, he underwent surgery to remove a mass in the right renal hilum, which was diagnosed as renal cell carcinoma at that time. Computed tomography and magnetic resonance imaging showed a ring-like enhanced mass in the left middle fossa, which destroyed the sphenoid bone and the lateral wall of the orbit. Another osteolytic lesion was revealed in the occipital bone. The fragile tumor was totally resected. Histopathological study revealed the Zellballen pattern with extensive coagulation necrosis. No apparent nuclear atypia or mitosis were present. Immunohistochemistry showed reactivity for synaptophysin and chromogranin A in the tumor cells. Review of the surgical specimen of the previously resected renal tumor revealed the same pathological and immunohistochemical findings as those of chief cells in the middle fossa tumor. Thus, this tumor was diagnosed as a malignant paraganglioma metastasized from renal paraganglioma. After six cycle chemotherapy with cyclophosphamide and vincristine, his condition was stable for two years, however, he died four years after the diagnosis of malignancy.

Metastatic skull tumors: MRI features and a new conventional classification

Skull metastases are malignant bone tumors which are increasing in incidence. The objectives of this study were to characterize the MR imaging features, locations, and extent of metastatic skull tumors to determine the frequency of the symptomatic disease, and to assess patient outcomes. Between September 2002 and March 2008, 175 patients undergoing routine head MR imaging were found to have metastatic skull tumors. Contrast-enhanced study with fat suppression was used in some cases when required. Classification of metastases was simplified to three yes/no questions: first, with regard to location (either in the calvarium or in the cranial base); second, with regard to distribution within the plane of the cranial bone (either “circumscribed” meaning clearly demarcated and confined to one bone, or “diffuse” and likely to spread across a suture to another bone); and third, with regard to invasion (“intraosseous” in cranial bones only, or “invasive” spreading from the skull, either out into the scalp or inward to the dura and perhaps further in). Primary sites were breast cancer (55%), lung cancer (14%), prostate cancer (6%), malignant lymphoma (5%), and others (20%). The mean time from primary diagnosis to skull metastasis diagnosis was 71 months for cases of breast cancer, 26 months for prostate cancer, 9 months for lung cancer, and 4 months for malignant lymphoma. Calvarial circumscribed intraosseous metastases were found most frequently (27%). The patients were mainly asymptomatic. However, some patients suffered from local pain or cranial nerve palsies that harmed their quality of life. Treatment, mainly for symptomatic cases, was by local or whole-skull irradiation. Metastatic skull tumors are not rare, and most are calvarial circumscribed intraosseous tumors. MR images contribute to understanding their type, location, and multiplicity, and their relationship to the brain, cranial nerves, and dural sinuses. Radiation therapy improved the QOL of patients with neurological symptoms.

Gangliocytomas of the sellar region--a review

Gangliocytomas are benign, slow growing neuronal tumors and are found for the most part in children and young adults. They are most often localized in either the spinal cord or the cerebral hemispheres. Gangliocytomas in the sellar region are extremely rare and only 43 such tumors (including 4 own cases) have ever been described in the literature. Although these tumors are genuine rarities without any epidemiological importance, they do provide some interesting information on tumorigenesis of pituitary adenomas: 65% of the sellar gangliocytomas are associated with a pituitary adenoma. 74% of patients with these tumors suffered hormonal oversecretion of at least one of the pituitary hormones (mostly growth hormone). With only one exception, the hypothalamic releasing hormone corresponding to the hormonal oversecretion syndrome could be demonstrated in the gangliocytoma immunohistochemically. Ultrastructural studies could demonstrate close cell to cell contacts between adenoma and gangliocytome cells. All these data support the hypothesis that chronic overstimulation by hypothalamic releasing hormones play a role in the development of hormone secreting pituitary adenomas. However, in contrast to sellar gangliocytemas, extrahypothalamic tumors secreting excessive hypothalamic hypophysiotropic hormones have never been associated with a pituitary adenoma. They have only been associated with pituitary cell hyperplasia. Therefore, the hypothesis can be made that hypothalamic releasing hormones only promote but do not initiate tumorigenesis of pituitary adenomas.

[Diffuse large B-cell lymphoma presenting with hypoglossal nerve palsy and great occipital neuralgia]

A 74-year-old man was hospitalized with hypoglossal nerve paralysis and severe great occipital neuralgia. Enhanced MRI of the head showed tumor on the left petrous bone, which compressed the medulla oblongata. Soluble IL-2 receptor was elevated and malignant lymphoma was clinically diagnosed. PET-CT demonstrated a single hot spot on the spleen. After radiation therapy to the lesion on the petrous bone, splenectomy was performed. Pathological findings established a diagnosis of diffuse large B-cell lymphoma. After chemotherapy consisting of rituximab and THP-COP, complete remission was achieved.

[Tumours of the bony face in children the treated at the Paediatric ENT Clinic in Warsaw]

INTRODUCTION

The tumours of bony face at in children are rare. Among the most commonly found are inflammatory tumours and development anomalies. In histopathology, the most frequent fund are neuroma, fibromas, osteoma, lipomas. In inflammatory tumours there are abscess and inflammatory infiltration. Malignants tumours in this area are rare in children, but are mainly sarcomata or melanoma. Developmental tumours include cyst and fistula.

OBJECTIVE

To analyse tumours of the bony face treated in Paediatric ENT Clinic in Warsaw.

MATERIAL

There were thirty cases of bony face tumours treated in Paediatric ENT Clinic in Warsaw between 2005 and 2007.

RESULTS

One cases (3%) provedto be malignant, and one (3%) locally malignant. Twenty-one cases (70%) were found to be developmental tumours, three cases (10%) of abscesses, and four cases (13%) of benign tumours.

CONCLUSIONS

The most frequently-found tumours of bony face in children are developmental tumours. All tumours must be the subject of histopatological examination. In the case of cancers tumours it has to be established if the tumour is a primary or a metastatic. In the group analysed group the rare tumour were epithelioma, ganglioma.

An unusual association of a sellar gangliocytoma with a prolactinoma

The simultaneous occurrence of a hypothalamic and sellar gangliocytoma with a pituitary prolactinoma is very rare. The explanation for such an association is not known. We describe the case of a woman who had a coexisting adjacent pituitary prolactinoma and gangliocytoma within the same sellar mass. The tumor cells of the gangliocytoma demonstrated expression of enkephalin, a product of proopiomelanocortin known to be a prolactin secretagogue. We postulate that in this patient there may be a link between gangliocytoma enkephalin and prolactin hypersecretion.

Leiomyosarcoma of the Uterus With Sphenoid Bone and Orbital Metastases

A 55-year-old woman presented with a 1-week history of vision loss in the right eye associated with proptosis and diplopia. Past medical history was significant for high-grade leiomyosarcoma of the uterus status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and postoperative pelvic radiation 18 months prior to presentation. Staging studies at the time of initial diagnosis of uterine leiomyosarcoma showed no evidence for metastatic disease. At presentation, CT and MRI showed a well-circumscribed 3.0 cm x 3.6 cm x 2.4 cm mass centered in the right greater sphenoid wing, extending into the middle cranial fossa and the superior and lateral orbital wall. Biopsy of the orbital mass revealed a poorly differentiated high-grade leiomyosarcoma, consistent with recurrent metastatic disease from the uterus. The patient subsequently underwent radiation treatment followed by a left orbital exenteration 6 months after the orbital biopsy. A left thoracostomy was performed 8 months after the orbital biopsy for a metastatic nodule in the left lower lobe of the lung. The clinicopathologic findings of this rare metastatic orbital lesion are presented.

Embryonal rhabdomyosarcoma of the temporal bone

The most common soft-tissue sarcoma in infants and children is rhabdomyosarcoma. The head and neck is the most common site of involvement; temporal bone involvement has been seen in about 7% of reported cases. Multimodality therapy--surgery, multiagent chemotherapy, and radiotherapy-yields sufficiently good results. The author reports a case of embryonal rhabdomyosarcoma of the temporal bone with cranial nerve palsies and extension into the parapharyngeal space in a 4-year-old boy. Despite surgery and chemotherapy, the patient died of his disease within 3 months of presentation.

Skull metastasis from hepatocellular carcinoma

Metastasis to the skull frequently occurs in patients with lung, breast and prostate cancer. However, skull metastases from hepatocellular carcinoma (HCC) have been rarely reported. We review the literature on skull metastasis from HCC and report a case of a 46-year-old male, who was diagnosed as HCC and was operated on by trans-arterial embolization and lobectomy in Oct. 2004. He complained of a painless mass over the left frontal region for two months. Radiograph of the skull revealed an osteolytic mass about 4-5 cm in size over the left frontal region. A cranial computerized tomography demonstrated a destructive lesion with soft tissue mass over the left frontal region. A left frontal craniectomy was performed and tumor was totally removed. The histological diagnosis was cranial metastasis from HCC. Postoperative recovery was uneventful without any neurological deficits. Because of improved and advancing treatment for HCC, survival time for HCC has been lengthened and distant metastases will thus be found to increase. Early diagnosis is essential to treat the primary disease. Skull metastases from HCC should be considered as a differential diagnosis in patients with scalp subcutaneous mass and osteolytic defect on X-ray skull films.

Adenoid cystic carcinoma of the parotid gland presenting as temporal bone neoplasm: a case report

PROBLEM

Temporal bone tumours are rare head and neck cancers that may involve both the parotid and the neck. In cases with concomitant temporal bone and parotid tissue involvement, tumour origin determination can be challenging. A tumour with parotid and temporal bone involvement is usually of temporal origin. The tumour may also be a rare parotid neoplasm with intratemporal invasion through the facial nerve, such as adenoid cystic carcinoma. These are slow-growing, yet locally aggressive tumours marked by late-stage distant metastases.

CASE REPORT

We describe a case of parotid adenoid cystic carcinoma invading the temporal bone via the facial nerve, presenting as primary temporal bone tumour with parotid tissue involvement. We emphasize the significance of intracranial involvement by perineural invasion.

CONCLUSION

Tumours mimicking temporal bone neoplasms can originate from the parotid tissue and invade through the facial nerve. Preoperative fine needle biopsy evaluation is indispensable for malignancy type determination and surgical planning.

Jugular foramen fibromatosis in a 3-month-old male

A 3-month-old male with a chief complaint of episodic choking with feeds and a hoarse cry is presented. Left eye ptosis and asymmetric soft palate elevation were detected on physical examination. Fiberoptic examination showed a left vocal fold paresis and pooling of secretions in the pyriform sinuses. MRI demonstrated an ill-defined lesion at the left jugular foramen extending into the left carotid sheath. A fine needle biopsy revealed spindle shaped cells consistent with fibromatosis. The histopathology of fibromatosis and the differential diagnosis of jugular foramen masses in children will be described. To our knowledge, this represents the earliest reported case of fibromatosis in the jugular foramen.

Primary diffuse large B-cell lymphoma of the dura mater and cranial vault

✓ Primary high-grade lymphoma of the dura mater and cranial vault has rarely been reported. The authors treated a 61-year-old man who presented with a slow-growing scalp mass that involved the cranial vertex. Magnetic resonance imaging revealed an oval mass of the dural type with peripheral edema in the bilateral parietal region, with attachment to the cranial vault and extension to the subgaleal space. After subtotal resection, pathological examination yielded a diagnosis of malignant large B-cell lymphoma. Twenty-three months postoperatively, after undergoing radiation therapy and chemotherapy, the patient is neurologically intact and without systemic dissemination of the malignancy. This is a case of primary malignant B-cell lymphoma of the dura mater with extensive involvement of the skull, which is a very rare event. Imaging-based diagnosis and combined therapy consisting of surgery, radiation therapy, and chemotherapy for the disease are discussed, and the literature on extraaxial malignant lymphomas is extensively reviewed.

Verrucous carcinoma of the temporal bone and maxillary antrum: two unusual presentations of a rare tumor

BACKGROUND

Verrucous carcinoma (VC) is a low-grade variant of squamous cell carcinoma. The involvement of the temporal bone and maxillary antrum is very rare.

PATIENTS AND METHODS

The clinicopathologic features of 2 such tumors are reported, and the pertinent literature is reviewed.

RESULTS

In the 2 patients, the diagnostic procedure was complicated due to initial inconclusive histology. Both were treated with concomitant radiochemotherapy. They were free of disease for 5.8 and 11 years after diagnosis. An additional 15 cases of VC of the temporal bone and 10 cases of maxillary antrum tumors have been reported in the literature. In 10 patients, multiple biopsies were required, and in 7 patients, a definitive histological diagnosis was not obtained before surgery. The disease reappeared in 8 out of 15 patients treated solely with surgery. Only 2 of them were salvaged by reoperation. Radiochemotherapy only (without any surgery) was successfully used in 4 patients.

CONCLUSIONS

VC of the temporal bone or maxillary antrum is an extremely rare tumor. For reliable histological diagnosis, multiple biopsies of deep and ample tissue samples are mandatory. Surgery is a mainstay of therapy; however, radiochemotherapy also represents a viable treatment option with curative potential.

[Kahler's disease presenting with a solitary cranial vault plasmacytoma]

INTRODUCTION

Solitary plasmocytoma is rarely located in the cranial vault. Usually observed, in elderly patients, occurrence during adolescence is extremely rare. We report the case of a 16-year-old patient presenting a cranial vault solitary plasmocytoma which revealed Kahler disease.

CASE REPORT

A 16-year-old patient consulted for a frontal tumefaction becoming painful with diplopia. The cranio-encephalic radiography and the MRI showed a tumoral process involving cranial vault; biopsy revealed a solitary plasmocytoma. Search for multiple myeloma was negative. Six months later, a disease of Kahler was declared.

CONCLUSION

Clinical and biological follow-up of cranial plasmocytoma is necessary, because progression to multiple myeloma is possible as in our observation. Imaging and particularly MRI are needed to specify the axial seat of the tumoral process and its relationship with the nervous and vascular structures.

[Intracranial plasmocytomas: biology, diagnosis, and treatment]

Intracranial plasmocytomas are a rare abnormality in a neurosurgeon's practice. The plasmocytomas may originate from the skull bones or soft tissue intracranial structures; they may be solitary or occur as a manifestation of multiple myeloma, this type being typical of most intracranial plasmocytomas. Progression of solitary plasmocytoma to multiple myeloma is observed in a number of cases. Preoperative diagnosis involves computed tomography or magnetic resonance imaging; angiography is desirable. The final diagnosis of plasmocytoma is chiefly based on a morphological study. Special immunohistochemical studies yield very promising results; these are likely to be of high prognostic value. Intracranial plasmocytomas require a differential approach and a meticulous examination since the presence or absence of multiple myeloma radically affects prognosis. There are well-defined predictors; however, it is appropriate that craniobasal plasmocytomas show a worse prognosis than plasmocytomas of the skull vault and more commonly progress to multiple myeloma. Plasmocytomas respond to radiotherapy very well. The gold standard of treatment for plasmocytoma is its total removal and adjuvant radiation therapy; however, there is evidence for good results when it is partially removed and undergoes radiotherapy or after radical surgery without subsequent radiation. The role of chemotherapy has not been defined today.

[Tumors of the craniocervical junction]

In this review, the authors describe the most common tumors of the craniocervical junction and their management. Early recognition is important in view of the unspecific symptomatology and much better surgical results in patients operated before the appearance of neurological deficits. In the last 15 years, different craniobasal approaches have been developed which permit the radical excision of many of these lesions with no or acceptable morbidity. Representative cases are illustrated.

Primary temporal bone angiosarcoma: a case report

We present a rare case of temporal bone angiosarcoma diagnosed in a 26-year-old female patient at 36 week of pregnancy. The patient was referred with a 2 months history of left otalgia and tinnitus with a tender swelling above the mastoid. Cranial imaging studies showed a 7 x 5 x 4 cm hypervascularized mass located in the left middle fossa with lysis of the temporal bone and extension to the subcutis. After the baby was delivered by caesarean section, the patient entered the oncology protocol. Selective embolization of the feeding vessels was followed by gross total surgical resection using a combined supra- and infra-tentorial approach. Pathological findings were those of a poorly differentiated, highly malignant sarcoma with a large epitheloid component and immunohistochemical evidence of endothelial differentiation (CD31, Factor VIII related antigen, CD34), consistent with an angiosarcoma with epitheloid features. No extra-cranial tumor was found after extensive staging. The patient received adjuvant radiotherapy followed by a course of chemotherapy consisting of 6 cycles of paclitaxel. At 15 months follow-up, she developed multiple distant metastasis to a left postauricular lymph node and to the lungs and ribs. The patient was given a second line chemotherapy using doxorubicine and ifosfamide. Despite an initial good response, she died with metastatic disease 26 months after diagnosis. We present a rare case of primary temporal bone angiosarcoma and report our experience with a multimode therapeutic approach combining surgery, radiotherapy and chemotherapy.

Rhabdomyosarcoma of the middle ear and mastoid: a case report and review of the literature

We report a case of rhabdomyosarcoma of the middle ear and mastoid in a 3-year-old boy. The patient was treated according to Intergroup Rhabdomyosarcoma Study IV protocol (chemo- and radiotherapy), and he experienced a complete remission. However 7 months after the completion of treatment, he experienced a recurrence at the primary site that spread to the brain. Despite treatment, the patient died of progressive metastasis to the lung 4 months later.

Small cell neuroendocrine carcinoma in the petrous apex

With the exception of moderately differentiated neuroendocrine carcinoma of the larynx, neuroendocrine carcinomas are very rare head and neck malignancies. We report a case of a small cell neuroendocrine carcinoma in the petrous apex of the temporal bone. This unusual site for this tumour has not yet been reported in the literature. We confirmed the location and extent of the primary tumour by positron-emission tomography scan. The final histopathological diagnosis was of small cell carcinoma, and this was confirmed by immunohistochemistry. We treated this patient with surgery followed by radiotherapy and chemotherapy. After the treatment was completed there was subtotal remission of the tumour, with no distant metastases.

A rare case of periosteal osteoblastoma located in the frontal cranial bone

Periosteal osteoblastoma is an extremely rare bone-forming neoplasm located on the surface of cortical bone. Of the fewer than 30 cases of periosteal osteoblastomas found in the literature, 2 have been reported to be located in cranial bone, and these have not been documented in detail with clinical history, radiographic findings, macroscopic features, and microscopic findings. Although the differential diagnoses of periosteal lesions include parosteal and periosteal osteosarcoma, periosteal chondroma and chondrosarcoma, osteochondroma, osteoid osteoma, periostitis ossificans, and myositis ossificans, an important differential diagnosis both radiologically and pathologically of such a lesion in the cranium is meningioma. We report an unusual case of periosteal osteoblastoma located in the frontal cranial bone that was radiologically consistent with a meningioma. The differential diagnosis of metaplastic meningioma with differentiation toward bone is discussed.

Desmoplastic fibroma of the pediatric skull. Report of three cases

Desmoplastic fibromas are rare bone tumors that have been reported in the adult skull but rarely in that of children. Although desmoplastic fibromas of the pediatric skull are uncommon, their similarity to benign skull lesions and their locally aggressive nature make them an important part of the differential diagnosis. Local recurrence is common after curettage alone but complete resection appears to be curative. Close follow up of incompletely resected lesions is essential. The authors detail three cases of pediatric desmoplastic fibromas of the skull and discuss diagnosis and treatment.

Tumours of the external ear and temporal bone

Symptoms such as hearing impairment, tinnitus, or a disturbance in sense of balance can generally be attributed to non-neoplastic causes, such as otitis media, otosclerosis, or trauma. Less commonly, auricular signs and symptoms are the result of non-neoplastic and neoplastic space-occupying lesions. The external ear can be the site of development of squamous carcinomas and basal-cell carcinomas; the middle ear and inner ear can host metastatic deposits, and primary squamous carcinomas and adenocarcinomas. Most auricular malignant diseases occur in adulthood; only the rhabdomyosarcomas of the middle ear arise in children. Most malignant diseases of the auricular apparatus are treated by a combination of surgery (commonly including radical excision of temporal bone), radiotherapy, and chemotherapy.