Bernd Turowski

Endovascular Treatment of Symptomatic Carotid Stenosis Using Stent Placement Long-Term Follow-Up of Patients With a Balanced Surgical Risk/Benefit Ratio

Background and Purpose— Carotid endarterectomy (CEA) is not necessarily beneficial in all patients with symptomatic high-grade (≥70%) internal carotid artery (ICA) stenosis. Independent risk factors modulate both the individual stroke risk under medical treatment and the combined stroke and death risk after CEA. Endovascular stenting of symptomatic ICA stenosis may be an alternative to CEA in patients with a balanced surgical risk/benefit ratio. Methods— We included 43 patients (71% men; median age, 67 years) with a recently symptomatic ICA stenosis with ≥70% luminal narrowing in whom the individual sum of medical and surgical risk factors suggested a balanced surgical risk/benefit ratio (risk-modeling appraisal derived from the European Carotid Surgery Trial). After stenting of the stenosed ICA with distal balloon protection, the mean±SD follow-up, including clinical and ultrasonographic examinations, was 20±11.8 months, with a median number of examinations of 5 per patient. Results— Recanalization of ICA stenoses was technically successful in 40 of 43 procedures (93%). Within the 30-day postinterventional period 1 death occurred (2.5%), and the combined stroke and death rate within follow-up was 5%. Except for 1 asymptomatic ICA occlusion, no restenosis ≥70% occurred during follow-up. Conclusions— ICA stenting in symptomatic patients with a balanced surgical risk/benefit ratio is technically feasible, with a low periprocedural risk of stroke or death. Furthermore, the risk of future stroke and rate of significant restenosis during long-term follow-up appears to be low, suggesting that ICA stenting may be useful in carotid revascularization and stroke prevention.

Cisplatin tumor concentrations after intra-arterial cisplatin infusion or embolization in patients with oral cancer

One neoadjuvant course of intra‐arterial high‐dose cisplatin (cis‐diamminedichloroplatinum [CDDP]) tumor perfusion combined with intravenous sodium thiosulfate (STS) (cisplatin neutralizer) infusion is part of a multimodality concept for treatment of oral cancer. Recently, crystalline cisplatin embolization has been described as a novel treatment variant with increased tumor response rates.

Interventional neuroradiology of the head and neck

Vascular interventions are important and helpful for treatment of various pathologies of the head and neck. Interventional neuroradiology of the head and neck includes image-guided biopsies, vessel occlusion, and local chemotherapy. Knowledge of anatomy, functional relationships between intra- and extracranial vessels, and pathology are the basis for therapeutic success. The interventional neuroradiologist is responsible for appropriate selection of patients based on clinical information, indications, and risk assessment. Neuroradiologic imaging, especially CT and MR imaging, and appropriate analysis of angiographic findings help ensure indication for treatment and plan an intervention. Technical equipment, including an angiographic unit, catheters, needles, embolizing materials, and so forth, are important. Knowledge of hemodynamics is relevant to avoid complications and to find the optimal technique for solving the clinical problem. Indications for image-guided biopsies are preverterbal fluid-collections, spinal and paraspinal inflammations and abscesses, deep cervical malignancies, vertebral body, and skull base tumors. Special care should be taken to preserve critical structures in this region, including spinal nerve roots, cervical plexus, main peripheral nerves, and vessels. Indications for vessel occlusion are emergency situations to stop bleeding in vascular lesions (traumatic, malformation, or tumors) by reduction of pressure, preoperative reduction of blood flow to minimize the surgical risk, palliative occlusion of feeding vessels to produce tumor necrosis, or potential curative (or presurgical) occlusion of vascular malformations. Pressure reduction to support normal coagulation, such as epistaxis, in hereditary hemorrhagic telangiectasia can be achieved by proximal vessel occlusion with large particles or platinum coils. Prevention of intraoperative bleeding requires occlusion of the microvascular bed with small particles. Examples of these interventions are: a hemangioma of the hard palate, a juvenile angiofibroma, a hemangiopericytoma, a malignant meningioma, a malignant fibrous histiocytoma, and a glomus tumor. Effective treatment of vascular malformations, such as AV fistulas or angiomas, needs exact occlusion of the fistula or the angiomatous nidus, which is demonstrated in the case of an AV angioma of the base of the tongue. Chemotherapy with local intra-arterial cisplatin combined with intravenous administration of sodium thiosulfate as antidote is indicated as an adjuvant modality in a multimodal regimen of oropharyngeal squamous cell carcinoma or as palliative treatment of recurrent and otherwise untreatable malignant tumors of the head and neck. Examples are a carcinoma of the alveolar ridge, a squamous cell carcinoma of the floor of the mouth, and a nasopharyngeal lymphoepithelioma. Palliative treatment of a bleeding oropharyngeal cancer is another example of interventional treatment. Selective treatment, either occluding or pharmacologic, may be preoperative, palliative, or curative. The objective is reduction of surgical risk, improvement of quality of life, or curative therapy of a lesion. Thus, the interventional treatment should not be associated with morbidity or mortality. Major complications, such as cerebral stroke, blindness, or cranial nerve palsies, can result from application of inappropriate techniques or poor evaluation of angiographic findings and should be avoided in the majority of cases. Sometimes collateral lesions are unavoidable. These include inflammation, necrosis, and nerve damage. Based on neuroradiologic experience, most of those risks are predictable. The benefits, risks, and expected damages of neuroradiologic interventions must be balanced during the informed consent procedure with the patient. Avoiding complications, handling unavoidable problems, and dealing with complications is a skill founded on knowledge and experience. Continuing education is a firm basis to push the limits of interventions and expand benefits without increasing risk for the patient. Nevertheless, state-of-the-art external carotid intervention should, in skilled hands, have a permanent morbidity far below 1% and no mortality.

Chemoembolization of oral and oropharyngeal cancer using a high-dose cisplatin crystal suspension and degradable starch microspheres.

The aim of the study was to achieve intensification of intraarterial chemotherapy of head and neck cancer with high-dose cisplatin by establishing a new method of chemoembolization which can be routinely used without the earlier drawbacks of the method (low drug dosage due to early occlusion of the small head and neck vessels, danger of local damage). Thirty two patients with previously untreated oral and oropharyngeal squamous cell carcinomas of all stages were treated by at least one superselective chemoembolization via femoral approach using a new preparation format of 150 mg/m(2) cisplatin which is an aqueous crystal suspension. In defined cases, combination with the delivery of degradable starch microspheres (DSM). Systemic neutralization with sodium thiosulfate. Primary end points were tolerance and response. Subsequent treatment was surgery or radiation. Chemoembolization succeeded in all 37 interventions to date. Overall response after one cycle was 64.7% using the cisplatin crystal suspension only (n=17) and 86.6% using additional DSM chemoembolization (n=15), as assessed 3 weeks after treatment. Systemic toxicity was extremely low, local side-effects (pain, swelling, small necrosis) were pronounced after additional delivery of DSM. There have been three complications (tracheotomy due to swelling, temporary facial paralysis twice due to embolization of the geniculate ganglion). Using the high-dose cisplatin crystal suspension, chemoembolization can routinely be used in the head and neck area as neoadjuvant therapy. Response was better than with former comparable regimens. The additional delivery of DSM was complicated, restricted to certain areas and unreliable in the dosage needed and might be omitted, therefore.

Spinal subdural haematoma mimicking tethered cord after posterior fossa open surgery

We report the MRI findings in a girl aged 3 years and 10 months who developed a spinal subdural haematoma after posterior fossa open surgery for cerebellar malignant rhabdoid tumour. Emergency surgery was performed immediately because of increased intracranial pressure. Control MRI 48xa0h after surgery showed a spinal subdural haematoma without clinical signs of paresis or bladder dysfunction. Spinal subdural haematoma is rare, and only few cases have been reported, especially in children. This report suggests that silent (without clinical symptoms) postoperative spinal acute subdural haemorrhage can occur after posterior fossa surgery.

Primary meningeal osteosarcoma: Case report and review of the literature

OBJECTIVE AND IMPORTANCE Primary meningeal osteosarcomas are extremely rare lesions; before this case report, only five cases had been reported in the literature. We encountered a patient with a meningeal osteosarcoma but no evidence of additional tumor at another remote site. CLINICAL PRESENTATION A 56-year-old man presented with progressive weakness of the right leg and the right arm. Computed tomography and magnetic resonance imaging revealed an extracerebral frontoparietal tumor on the left side. INTERVENTION The patient underwent complete resection of the tumor and subsequent radiotherapy of the tumor region. The histological examination showed evidence of the osteosarcoma, which was confined to the meninges. Postoperative adjuvant radiotherapy was administered. There was no tumor recurrence during 3 years of postoperative follow-up. Because the patient had no risk factors or further osteosarcomas, primary meningeal development was assumed. CONCLUSION Despite their rarity, osteosarcomas must be considered in the differential diagnosis of meningeal tumors.

CT-Based Evaluation of Tumor Volume After Intra-Arterial Chemotherapy of Locally Advanced Carcinoma of the Oral Cavity: Comparison with Clinical Remission Rates

PurposeTo assess the volume of locally advanced tumors of the oral cavity and the oropharynx before and after intra-arterial (i.a.) chemotherapy by means of computed tomography and to compare these data with clinically determined treatment response of the same patient population.MethodsEighty-eight patients with histologically proven, advanced carcinoma of the oral cavity and/or the oropharynx (local tumor stages T3/4) received neoadjuvant i.a. chemotherapy with cisplatin as part of a multimodal therapeutic regimen, comprising (1) local chemotherapy, (2) surgery, and (3) combined radio-chemotherapy. Three weeks after the intervention, residual disease was evaluated radiologically by measurement of the tumor volume and clinically by inspection and palpation of the primary tumor according to WHO criteria.ResultsComparison of treatment response according to radiological and clinical criteria respectively revealed complete remission in 5% vs. 8% (p < 0.05), partial remission in 30% vs. 31%, stable disease in 61% vs. 58%, and tumor progression in 5% vs. 2%.ConclusionRadiological volumetry and clinical evaluation found comparable response rates after local chemotherapy. However, in patients with good response after local treatment, volumetric measurement with CT may help to distinguish between partial and complete remission. Thus, radiological tumor volumetry provides precise and differentiated information about tumor response and should be used as an additional tool in treatment monitoring after local chemotherapy.

Reliability of CT-based tumor volumetry after intraarterial chemotherapy in patients with small carcinoma of the oral cavity and the oropharynx

IntroductionThe aim of the study was to evaluate the feasibility and consistency of CT-based tumor volumetry in patients with early carcinoma of the oral cavity and the oropharynx before and after intraarterial (IA) chemotherapy, comparing these data with clinical remission rates.MethodsIncluded in the study were 61 patients (mean age 59.3xa0years; 47 men) with histologically proven small carcinoma of the oral cavity or the oropharynx (local tumor stages T1/2). Patients received IA chemotherapy with high-dose cisplatin as part of a multimodal therapeutic regimen and underwent both clinical and radiological examination before and 4xa0weeks after local chemotherapy.ResultsClinical evaluation of tumor response was possible in all patients (61/61). Radiological assessment of tumor volume was feasible in 42 of 61 patients (69%), but failed in 19 (31%) due to the absence of deep tumoral spread, lack of contrast enhancement or severe dental artifacts. Patients in whom evaluation was possible according to volumetric and clinical criteria revealed comparable remission rates: overall response 54.8% versus 52.4%, stable disease 40.4% versus 47.6%, and tumor progression 4.8% versus 0.0%.ConclusionBecause volume calculation was not feasible in approximately one-third of the patients, it cannot be recommended as a reliable indicator for treatment response in patients with small carcinoma of the oral cavity.

Local chemotherapy for squamous cell cancer of the oral cavity and oropharynx

BACKGROUNDnModern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time.nnnPATIENTS AND METHODSnA total of 289 patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60 years, and 71% of the patients were male.nnnRESULTSnAfter the first cycle 19.3% of the patients presented with complete remission (grade I); 35.4% and 41.5% showed partial remissions (grade II) or stable disease (grade III), respectively. The mean observation time after treatment was 28 months (median: 24.2 months). Of the 137 patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72.5% of these patients were still alive.nnnCONCLUSIONnIntra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.ZusammenfassungHintergrundDie moderne Behandlung von Patienten mit Plattenepithelkarzinomen des Mundes und des Oropharynx beinhaltet zunehmend adjuvante Therapieformen. Die lokale Chemotherapie ermöglicht neben der Applikation einer extrem hohen Medikamentenkonzentration in der Tumorregion eine gleichzeitige Minimierung der Nebenwirkung durch systemische Antagonisierung.Patienten und MethodenIm Rahmen eines multimodalen Therapiekonzepts erhielten 289xa0Patienten mit histologisch gesicherten Karzinomen der Mundhöhle und des Oropharynx eine neoadjuvante i.a. Chemotherapie mit hochdosiertem Cisplatin. Nach TNM-Kriterien waren über 70% der Patienten den Stadienxa0T3 und T4 zuzuordnen. Das Alter zum Zeitpunkt der Intervention lag bei 60xa0Jahren, 71% der Patienten waren Männer.ErgebnisseDer Anteil vollständiger Remissionen (Gradxa0I) nach dem 1. Behandlungszyklus betrug 19,3%, partielle Remissionen konnten bei 35,4% (Gradxa0II) und 41,5% (Gradxa0III) erzielt werden. Der durchschnittliche Beobachtungszeitraum nach Behandlungsende betrug etwa 28xa0Monate (Median 24,2xa0Monate). Von 137xa0Patienten, die einen multimodalen Behandlungszyklus absolvierten, lebten zum Zeitpunkt der Auswertung noch 72,5%; 11% entwickelten ein Lokalrezidiv und 12,4% Lymphknoten- oder Fernmetastasen.SchlussfolgerungDie i.a. Chemotherapie ist ein sicheres Verfahren mit hoher Effektivität und stellt im Rahmen multimodaler Therapiekonzepte zur Behandlung oraler und oropharyngealer Karzinome eine wichtige Option dar.AbstractBackgroundModern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time.Patients and methodsA total of 289xa0patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60xa0years, and 71% of the patients were male.ResultsAfter the first cycle 19.3% of the patients presented with complete remission (gradexa0I); 35.4% and 41.5% showed partial remissions (gradexa0II) or stable disease (gradexa0III), respectively. The mean observation time after treatment was 28xa0months (median: 24.2xa0months). Of the 137xa0patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72,5% of these patients were still alive.ConclusionIntra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.

Lokale Chemotherapie oraler und oropharyngealer Plattenepithelkarzinome

BACKGROUNDnModern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time.nnnPATIENTS AND METHODSnA total of 289 patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60 years, and 71% of the patients were male.nnnRESULTSnAfter the first cycle 19.3% of the patients presented with complete remission (grade I); 35.4% and 41.5% showed partial remissions (grade II) or stable disease (grade III), respectively. The mean observation time after treatment was 28 months (median: 24.2 months). Of the 137 patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72.5% of these patients were still alive.nnnCONCLUSIONnIntra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.ZusammenfassungHintergrundDie moderne Behandlung von Patienten mit Plattenepithelkarzinomen des Mundes und des Oropharynx beinhaltet zunehmend adjuvante Therapieformen. Die lokale Chemotherapie ermöglicht neben der Applikation einer extrem hohen Medikamentenkonzentration in der Tumorregion eine gleichzeitige Minimierung der Nebenwirkung durch systemische Antagonisierung.Patienten und MethodenIm Rahmen eines multimodalen Therapiekonzepts erhielten 289xa0Patienten mit histologisch gesicherten Karzinomen der Mundhöhle und des Oropharynx eine neoadjuvante i.a. Chemotherapie mit hochdosiertem Cisplatin. Nach TNM-Kriterien waren über 70% der Patienten den Stadienxa0T3 und T4 zuzuordnen. Das Alter zum Zeitpunkt der Intervention lag bei 60xa0Jahren, 71% der Patienten waren Männer.ErgebnisseDer Anteil vollständiger Remissionen (Gradxa0I) nach dem 1. Behandlungszyklus betrug 19,3%, partielle Remissionen konnten bei 35,4% (Gradxa0II) und 41,5% (Gradxa0III) erzielt werden. Der durchschnittliche Beobachtungszeitraum nach Behandlungsende betrug etwa 28xa0Monate (Median 24,2xa0Monate). Von 137xa0Patienten, die einen multimodalen Behandlungszyklus absolvierten, lebten zum Zeitpunkt der Auswertung noch 72,5%; 11% entwickelten ein Lokalrezidiv und 12,4% Lymphknoten- oder Fernmetastasen.SchlussfolgerungDie i.a. Chemotherapie ist ein sicheres Verfahren mit hoher Effektivität und stellt im Rahmen multimodaler Therapiekonzepte zur Behandlung oraler und oropharyngealer Karzinome eine wichtige Option dar.AbstractBackgroundModern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time.Patients and methodsA total of 289xa0patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60xa0years, and 71% of the patients were male.ResultsAfter the first cycle 19.3% of the patients presented with complete remission (gradexa0I); 35.4% and 41.5% showed partial remissions (gradexa0II) or stable disease (gradexa0III), respectively. The mean observation time after treatment was 28xa0months (median: 24.2xa0months). Of the 137xa0patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72,5% of these patients were still alive.ConclusionIntra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.