Daniela Alexandru

Evaluation and Management of Vertebral Compression Fractures

Compression fractures affect many individuals worldwide. An estimated 1.5 million vertebral compression fractures occur every year in the US. They are common in elderly populations, and 25% of postmenopausal women are affected by a compression fracture during their lifetime. Although these fractures rarely require hospital admission, they have the potential to cause significant disability and morbidity, often causing incapacitating back pain for many months. This review provides information on the pathogenesis and pathophysiology of compression fractures, as well as clinical manifestations and treatment options. Among the available treatment options, kyphoplasty and percutaneous vertebroplasty are two minimally invasive techniques to alleviate pain and correct the sagittal imbalance of the spine.

Epidemiology of Central Nervous System Metastases

Brain metastases are overwhelmingly the most common type of brain tumor, out numbering primary brain tumors in incidence by more than four-to-one. They are associated with poor prognosis both from a length-of-life as well as a quality-of-life standpoint. Once the brain metastasis is detected, without treatment, most patients die within months, either from widespread systemic disease, or due to the brain metastasis itself. The complications of brain metastases are also devastating. Patients can suffer from seizures, weakness or paralysis, language and communication deficits, as well as cognitive decline. These complications negatively impact on quality of life through effects on functional independence, impairment of capacity to participate in activities and relationships, as well as distortion of individual personality and identity. At the same time, there are great financial burdens associated with both the care and treatment of patients with brain metastases. Early detection of brain metastases in cancer patients is critical for limiting these complications, minimizing these burdens and improving the outlook regarding both survival and quality of life. Understanding the epidemiology of brain metastases can lead to the development of new strategies for the early identification and successful treatment of these patients.

Pulmonary metastases in patients with recurrent, treatment‐resistant meningioma

Meningioma is the most common extra‐axial primary intracranial tumor in adults that rarely metastasizes outside of the central nervous system (CNS). Among recognized sites of metastases, the lung is the most common, but the importance of lung metastases relative to prognosis is unknown. 111Indium (111In)‐octreotide scintigraphy (octreotide scanning) is a valuable imaging modality with which to evaluate intracranial meningiomas and their response to treatment with somatostatin analogues and has the potential to identify extracranial metastatic disease.

The Use of Patient Navigators to Improve Cancer Care for Hispanic Patients

Background Although the United States is one of the countries at the leading edge of medical breakthroughs and treatments, there are great disparities in the access to care among different socioeconomic strata. One of the most striking discrepancies regarding access to care is found among the ranks of the Hispanic population, which is the fastest growing minority in the United States, but for which cancer is the third leading cause of death. It is clear that better and timely treatment for cancer patients belonging to this minority is needed. Patient navigators can be an important tool to improve access to care of patients belonging to this minority group. Methods Through a systemic search, we identified seven articles that employed patient navigators for Hispanic cancer patients. The identified studies addressed very limited pathology, three studying breast and four colon cancer patients. Conclusions The presence of patient navigation can be an effective to remove impediments that limit the access to care in minority populations and can improve outcomes in Hispanic patients suffering from cancer. Further research to evaluate the cost of patient navigation in relationship to the added benefit early diagnosis, continued follow up and treatment is needed.

The Treatment of Angiocentric Glioma: Case Report and Literature Review

Angiocentric glioma is a recently described tumor recognized since 2007 by the World Health Organization Classification of Tumours of the Central Nervous System. We present the only case of angiocentric glioma at our institution in the last 15 years and review the literature in an attempt to establish prognostic parameters. Our search revealed only 27 cases of angiocentric glioma in the literature. The most common presenting symptom of angiocentric glioma was seizures. Gross total resection of the lesion was curative, without need for radiation or chemotherapy.

Odontoid pseudotumor and serial postfusion radiographic evaluation in a patient with a C1-2 mass.

Odontoid pseudotumor is a mass occurring around the odontoid process in the cervical spine and can cause significant neurological symptoms at the craniocervical junction due to compression of the spinal cord and cervicomedullary junction at this level. A literature review was performed to provide input on options for treatment and prognosis for this lesion. The literature search found 12 papers in which pseudotumor was treated with posterior decompression and fixation. Posterior decompression and fixation with serial imaging to monitor the size of the pseudotumor postsurgery is a safe and effective treatment option for odontoid pseudotumors.

Value of susceptibility-weighted imaging in acute hemorrhagic leukoencephalitis

Acute hemorrhagic leukoencephalitis (AHL) is a rapidly progressive disease in the spectrum of acute disseminated encephalomyelitis. Timely accurate diagnosis is crucial but challenging clinically and radiologically. However, imaging findings of AHL are quite specific when susceptibility-weighted imaging is utilized. The purpose of this report is to present the imaging findings of autopsy-proven AHL and thus to facilitate rapid recognition and treatment.

Dorsal Scapular Artery Variations and Relationship to the Brachial Plexus, and a Related Thoracic Outlet Syndrome Case

Rationale Knowledge of the relationship of the dorsal scapular artery (DSA) with the brachial plexus is limited. Objective We report a case of a variant DSA path, and revisit DSA origins and under-investigated relationship with the plexus in cadavers. Methods The DSA was examined in a male patient and 106 cadavers. Results In the case, we observed an unusual DSA compressing the lower plexus trunk, that resulted in intermittent radiating pain and paresthesia. In the cadavers, the DSA originated most commonly from the subclavian artery (71%), with 35% from the thyrocervical trunk. Nine sides of eight cadavers (seven females) had two DSA branches per side, with one branch from each origin. The most typical DSA path was a subclavian artery origin before passing between upper and middle brachial plexus trunks (40% of DSAs), versus between middle and lower trunks (23%), or inferior (4%) or superior to the plexus (1%). Following a thyrocervical trunk origin, the DSA passed most frequently superior to the plexus (23%), versus between middle and lower trunks (6%) or upper and middle trunks (4%). Bilateral symmetry in origin and path through the brachial plexus was observed in 13 of 35 females (37%) and 6 of 17 males (35%), with the most common bilateral finding of a subclavian artery origin and a path between upper and middle trunks (17%). Conclusion Variability in the relationship between DSA and trunks of the brachial plexus has surgical and clinical implications, such as diagnosis of thoracic outlet syndrome.

The evaluation and treatment of primary intraocular lymphoma

Primary intraocular lymphoma (PIOL) is a relatively rare form of Non-Hodgkins Lymphoma arising in the lymphoid tissues of the eye. It is highly correlated with primary CNS lymphoma (PCNSL) and it is estimated that up to 80% of patients presenting with PIOL will eventually manifest intracranial malignancy, which is the largest contributor to mortality. Most patients present with nonspecific visual symptoms, including floaters and blurry vision, and are often initially diagnosed with uveitis or retinitis. Definitive diagnosis requires biopsy of malignant tissues with demonstration of malignant lymphoid cells. Optimal therapy is to this point undefined, and the available literature is limited to case reports and retrospective series. Currently employed therapies include the use of localized external beam radiation therapy (EBRT), whole brain radiation therapy (WBRT), systemic chemotherapy, intrathecal chemotherapy, and, most recently, direct intravitreal (IVT) chemotherapy. While radiation therapy and chemotherapy can produce a high response rate, they have not been shown to effectively prevent relapse or the incidence of CNS spread. Methotrexate has been the most popular therapy used for the treatment of intraocular lymphoma. It has been administered systemically, intrathecally or intravitreally. However due to multiple mechanisms of resistance developed by lymphoma cells against methotrexate, this drug has been unable to prevent disease recurrence. The newest, and perhaps most promising, reported therapy includes the use of rituximab anti-CD20 monoclonal antibody either alone or in combination chemotherapy via intrathecal or IVT administration. Most cases in the literature employ combinations of available therapies, and there are no comparative studies of significant power to date. Multicenter collaboration will be required to determine the true relative efficacy and adversity of the therapeutic options available.

Antivascular Endothelial Growth Factor Antibody for Treatment of Glioblastoma Multiforme

Despite aggressive investigation, glioblastoma multiforme (GBM) remains one of the deadliest cancers, with low progression-free survival and high one-year mortality. Current first-line therapy includes surgery with adjuvant radiation therapy and cytotoxic chemotherapy, but virtually all tumors recur. Given the highly vascular nature of GBM and its high expression of vascular endothelial growth factor and other angiogenic factors, recent investigation has turned to bevacizumab, an antivascular endothelial growth factor monoclonal antibody, for treatment of recurrent GBM. Phase 2 studies demonstrated the efficacy and safety of bevacizumab therapy for recurrent GBM, which led to its approval by the US Food and Drug Administration in 2009 for use in recurrent GBM. Since then, several new Phase 2 studies and retrospective series have demonstrated that bevacizumab significantly increased six-month progression-free survival in patients with recurrent GBM and may do so in new-onset GBM. The objective of this review is to provide a collective resource for these materials, highlighting the efficacy and safety of bevacizumab and calling for increased investigation toward its optimal application in the management of high-grade glioma.