Andrew Lozen

Brain metastases from breast cancer during pregnancy.

Background: Brain metastasis during pregnancy is a rare occurrence. In particular, there have only been three prior cases regarding breast cancer metastasis. We report a patient with breast cancer metastasis to the brain during pregnancy and review the literature. Case Description: The patient was a 35-year-old female with a history of breast cancer (estrogen receptor/progesterone receptor negative, human epidermal growth factor receptor 2/neu positive, status post-neoadjuvant docetaxel/carboplatin/trastuzumab/pertuzumab therapy, status post-bilateral mastectomies), and prior right frontal brain metastases (status post-resection, capecitabine/lapatinib/temozolomide therapy, and cyberknife treatment). Patient was found to be pregnant at 9 weeks’ gestation while on chemotherapy; the patient elected to continue with the pregnancy and chemotherapy was discontinued. At 14 weeks’ gestation, she returned with recurrent right frontal disease. She was taken for a craniotomy at 16 weeks’ gestation, which confirmed metastases. Six weeks later, patient returned with worsening headaches and fatigue, with more recurrent right frontal disease. She was started on decadron and chemotherapy (5-fluorouracil, adriamycin, and cyclophosphamide). Serial magnetic resonance imaging (MRI) demonstrated enlarging right frontal lesions. She underwent a craniotomy at 27 weeks’ gestation, and chemotherapy was discontinued promptly. Starting at 30 weeks’ gestation, she received whole brain radiation for 2 weeks. Subsequently, she delivered a baby girl via cesarean section at 32 weeks’ gestation. At 6 weeks follow-up, an MRI brain demonstrated no new intracranial disease, with stable postoperative findings. Conclusion: There is a lack of guidelines and clinical consensus on medical and surgical treatment for breast cancer metastases in pregnant patients. Treatment usually varies based upon underlying tumor burden, location, gestational age of the fetus, and patients preference and symptomatology.

Marsupialization and distal obliteration of a lumbosacral dural ectasia in a nonsyndromic, adult patient

Dural ectasia is frequently associated with connective tissue disorders or inflammatory conditions. Presentation in a patient without known risk factors is rare. Moreover, the literature regarding the treatment options for symptomatic dural ectasia is controversial, variable, and limited. A 62-year-old female presents with intractable, postural headaches for years. A lumbar puncture revealed opening pressure 3 cm of water. A computed tomography myelogram of the spine demonstrated erosion of her sacrum due to a large lumbosacral dural ectasia. An initial surgery was attempted to reduce the size of the expansile dura, and reconstruct the dorsal sacrum with a titanium plate (Depuy Synthes, Westchester, PA, USA) to prevent recurrence of thecal sac dilatation. Her symptoms initially improved, but shortly thereafter recurred. A second surgery was then undertaken to obliterate the thecal sac distal to the S2 nerve roots. This could not be accomplished through simple ligation of the thecal sac circumferentially as the ventral dura was noted to be incompetent and attempts to develop an extradural tissue plane were unsuccessful. Consequently, an abundance of fibrin glue was injected into the thecal sac distal to S2, and the dural ectasia was marsupialized rostrally, effectively obliterating the distal thecal sac while further reducing the size of the expansile dura. This approach significantly improved her symptoms at 5 months follow-up. Treatment of dural ectasia is not well-defined and has been variable based on the underlying manifestations. We report a rare patient without risk factors who presented with significant lumbosacral dural ectasia. Moreover, we present a novel method to treat postural headaches secondary to dural ectasia, where the thecal sac is obliterated distal to the S2 nerve roots using an abundance of fibrin glue followed by marsupialization of the thecal sac rostally. This method may offer an effective therapy option as it serves to limit the expansile dura, reducing the cerebrospinal fluid sump and the potential for intracranial hypotension.

Extradural chondroma presenting as lumbar mass with compressive neuropathy

The identification of a soft tissue chondroma within the spine represents a rarity and is typically not included within the differential diagnosis for patients with sensory complaints of the leg. The authors describe 46-year-old female presenting with 3-week history of decreased sensation and paresthesias of the left leg. Magnetic resonance imaging of the lumbar spine demonstrated an L3 extradural soft tissue mass. She underwent an uncomplicated excision through an L3 laminectomy and exhibited complete resolution of symptoms. Pathologic examination revealed benign cartilaginous tissue; however, the authors recommend long-term follow-up for such lesions as the potential for malignant transformation is unknown.

Ipsilateral pedicle screw placement with contralateral percutaneous facet screws: Early results with an alternative in lumbar arthrodesis

Transforaminal lumbar interbody fusion (TLIF) is a widely used method of surgical treatment for a variety of lumbar spinal disorders. Bilateral transpedicular instrumentation is routinely used in conjunction with an interbody graft to provide additional stability. In this technical note, we describe our fusion construct using ipsilateral pedicle screw placement on the side of TLIF and contralateral facet screw placement. We performed this construct at six levels in four patients. Suggested advantages include: low morbidity, small incision and lower cost. Outcomes parameters included radiographic evidence of solid union at four months and improvement in Oswestry Disability Index. A mean improvement from a preoperative score of 73 to 26 after surgery was observed at one-year follow-up. There were no instrument-related complications. In conclusion, this hybrid screw system minimizes contralateral dissection and is an attractive alternative to standard bilateral pedicle screw fi xation.

Delayed hydrocephalus associated with traumatic atlanto-occipital dislocation: Case report and literature review

Background: Traumatic atlanto-occipital dislocation (AOD) is a rare but often fatal injury. Consequently, long-term data regarding surviving patients have been limited. In particular, the occurrence of hydrocephalus is not well-documented. Case Description: A 33-year-old male sustained AOD as a consequence of a motor vehicle collision. Although he did well initially after an occipitocervical fusion, 1 month after his operation, he exhibited signs of increased intracranial pressure (bilateral abducens nerve palsies, worsening headaches, and fatigue). He was found to have hydrocephalus, which was responsive to shunting. Conclusion: Manifestations of hydrocephalus after AOD can be variable, ranging from interval ventricular dilatation to pseudomeningoceles and syringomyelia. In addition, the timing of presentation can be acute, requiring emergent external ventricular drainage, or delayed, requiring ongoing vigilance. Consequently, as more patients survive this once thought to be fatal injury, caution for hydrocephalus is stressed.

Traumatic spondyloptosis at the cervico-thoracic junction without neurological deficits.

Background: There have been rare cases of traumatic cervical spondyloptosis without neurological compromise. We report another case and provide a review of the literature, with a focus on appropriate management. Case Description: A 60-year-old male rode his bicycle into a stationary semi-truck. He reported initial bilateral upper extremity paresthesias that resolved. Imaging demonstrated C7 on T1 spondyloptosis. Traction did not achieve reduction and a halo was applied. Subsequently, he underwent posterior decompression C6-T1, reduction via bilateral complete facetectomies at C7, and fixation from C4 to T2 fixation. Afterward, an anterior C7-T1 fixation occurred, where exposure was performed through a midline sternotomy. Postoperatively, he woke up with baseline motor and sensory examination in his extremities. He did exhibit voice hoarseness due to paralysis of the left vocal cords. He was discharged home 3 days after surgery. At 6 months follow-up, there was a progressive improvement of the left vocal cords to slight paresis; dynamic X-rays demonstrated no instability with good fusion progression. Conclusion: Traumatic cervical spondyloptosis without neurological compromise is a rare and challenging scenario. There is a concern for neurologic compromise with preoperative traction, but if specific posterior elements are fractured, the spinal canal may be wide enough where the concern for disc migration is minimal. For patients who have not been reduced preoperatively, a posterior approach with initial decompression to widen the canal, before reduction, appears safe. This scheme may avoid an initial anterior approach for decompression, necessitating a 3-stage procedure if circumferential stabilization is pursued.

Unilateral atlanto-axial fractures in near side impact collisions: An under recognized entity in cervical trauma.

Objective: Nearside impact collisions presenting with lateral mass fractures of atlanto-axial vertebrae contralateral to the impact site represents a rare fracture pattern that does not correlate with previously described injury mechanism. We describe our clinical experience with such fractures and propose a novel description of biomechanical forces involved in this unique injury pattern. The findings serve to alert clinicians to potentially serious consequences of associated unrecognized and untreated vertebral artery injury. Material and Methods: In addition to describing our clinical experience with three of these fractures, a review of Crash Injury Research and Engineering Network (CIREN) database was conducted to further characterize such fractures. A descriptive analysis of three recent lateral mass fractures of the atlanto-axial segment is coupled with a review of the CIREN database. A total of 4047 collisions were screened for unilateral fractures of atlas or axis. Information was screened for side of impact and data regarding impact velocity, occupant injuries and use of restraints. Results: Following screening of unilateral fractures of atlas and axis for direct side impacts, 41 fractures were identified. Cross referencing these cases for occurrence contralateral to side of impact identified four such fractures. Including our recent clinical experience, seven injuries were identified: Five C1 and two C2 fractures. Velocity ranged from 14 to 43 km/h. Two associated vertebral artery injuries were identified. Conclusions: Complexity of the atlanto-axial complex is responsible for a sequence of events that define load application in side impacts. This study demonstrates the vulnerability of vertebral artery to injury under unique translational forces and supports the use or routine screening for vascular injury. Diminished sensitivity of plain radiography in identifying these injuries suggests that computerized tomography should be used in all patients wherein a similar pattern of injury is suspected.

Abstract 5606: Gallium maltolate inhibits brain tumor volume and blood volume in xenograft model.

Purpose: There are limited treatment options for glioblastomas (GBM). Tumor cells have a high requirement for iron; the latter is taken up by cells through transferrin receptor-mediated endocytosis of transferrin-iron. These receptors are highly expressed on GBM cells, which makes them an attractive target for transferrin receptor-directed therapies. Gallium is a group IIIa metal that can function as an iron mimetic by avidly binding to transferrin and incorporating into cells through the transferrin receptor. No studies have been performed to determine the efficacy of gallium-based therapies in brain tumors. Consequently, the goal of this study was to evaluate gallium maltolate in the treatment of a U87 xenograft brain tumor model. Methods: Athymc rats bearing U87 human grade IV astrocytoma cells were studied. Gallium maltolate (50 mg/kg/day, n=5) or saline (n=3) was given intravenously. via an alzet mini pump in the jugular vein. Magnetic resonance imaging (MRI) was performed on days 8 and 18 on a Bruker 9.4 T scanner. Enhancing tumor volumes were determined from the post-contrast T1w images, in all slices showing enhancing tumor. The spin and gradient echo relaxation rate changes were then determined giving estimates of microvascular and total blood volume. ((CBVmicro≈R2=R2MION-R*pre-MION CBVTotal≈ R2* = R2*MION-R2*pre-MION). Results: Gallium maltolate inhibited tumor growth (377132%), as measured by enhancing tumor volume, compared to saline controls (863481%). Treatment shows decrease of CBV micro and CBVTotal compared to the controls. The ratio of R2* /R2, which is a measure of mean vessel diameter, increased in saline treated controls but remained unchanged for the gallium maltolate treated rats. To our knowledge this is the first study performed that uses physiologic MRI measurements to investigate the effects of gallium maltolate on brain tumor xenografts. The differences shown are not statistically significant a result likely due to the small sample sizes, which is being remedied by ongoing additional studies. For the imaging studies included here tissue markers of proliferation (Ki67), hypoxia (HIF1) transferrin receptors, and vascular density (vWF) are being analyzed to provide additional information regarding mechanism of action. In general these results demonstrate, for the first time, that the novel gallium maltolate treatment holds promise for the treatment of malignant brain tumors. Citation Format: Kimberly R. Pechman, Andrew Lozen, Mona Al-Gizawiy, Kathleen Schmainda, Christopher R. Chitambar. Gallium maltolate inhibits brain tumor volume and blood volume in xenograft model. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 5606. doi:10.1158/1538-7445.AM2013-5606