le A. Michel

CLINICAL OUTCOMES OF PATIENTS RECEIVING INTEGRATED PET/CT-GUIDED RADIOTHERAPY FOR HEAD AND NECK CARCINOMA

PURPOSE We previously reported the advantages of (18)F-fluorodeoxyglucose-positron emission tomography (PET) fused with CT for radiotherapy planning over CT alone in head and neck carcinoma (HNC). The purpose of this study was to evaluate clinical outcomes and the predictive value of PET for patients receiving PET/CT-guided definitive radiotherapy with or without chemotherapy. METHODS AND MATERIALS From December 2002 to August 2006, 42 patients received PET/CT imaging as part of staging and radiotherapy planning. Clinical outcomes including locoregional recurrence, distant metastasis, death, and treatment-related toxicities were collected retrospectively and analyzed for disease-free and overall survival and cumulative incidence of recurrence. RESULTS Median follow-up from initiation of treatment was 32 months. Overall survival and disease-free survival were 82.8% and 71.0%, respectively, at 2 years, and 74.1% and 66.9% at 3 years. Of the 42 patients, seven recurrences were identified (three LR, one DM, three both LR and DM). Mean time to recurrence was 9.4 months. Cumulative risk of recurrence was 18.7%. The maximum standard uptake volume (SUV) of primary tumor, adenopathy, or both on PET did not correlate with recurrence, with mean values of 12.0 for treatment failures vs. 11.7 for all patients. Toxicities identified in those patients receiving intensity modulated radiation therapy were also evaluated. CONCLUSIONS A high level of disease control combined with favorable toxicity profiles was achieved in a cohort of HNC patients receiving PET/CT fusion guided radiotherapy plus/minus chemotherapy. Maximum SUV of primary tumor and/or adenopathy was not predictive of risk of disease recurrence.

Cranial thickness in superior canal dehiscence syndrome: implications for canal resurfacing surgery.

Objective: To use morphometric analyses of cranial thickness to investigate 2 cases of unanticipated calvarial bone resorption in superior canal dehiscence (SCD) resurfacing surgery. Design: Retrospective morphometric analysis of high-resolution computed tomography (CT) temporal bone scans in normal and control subjects with accompanying case reports. Setting: Tertiary care referral center. Patients: Two patients with SCD and failed resurfacing because of bone resorption. Temporal bone CT scans from 30 sex-matched controls. Intervention: Resurfacing of SCD via a middle fossa approach using a split thickness calvarial graft from the craniotomy site. Main Outcome Measure: Mean cross-sectional area of the middle fossa craniotomy bone flap and mean cranial thicknessat 30 and 45 degrees above the middle fossa floor. Results: Two patients had delayed failure of SCD resurfacing surgery as manifested by return of symptoms. High-resolution CT scans in both, and intraoperative confirmation in one, confirmed resorption of the bone graft. Measurements of cross-sectional area of the middle fossa craniotomy onhigh-resolution CT scans demonstrated significantly reduced values in the two SCD patients as compared with normal controls (Mann-Whitney U test, p < 0.05). Cranial thickness outside the squamous temporal bone was reduced but did notreach statistical significance. Conclusion: Morphometric measurements of the calvarium have demonstrated that the squamous temporal bone is thinner in patients with SCD as compared with controls. Thus, the process leading to defects in the tegmen extends beyond the petrous pyramid. This suggests that there may be extratemporal factors leading to the development of a dehiscence. These findings also have implications for the surgical treatment of this disorder. Resurfacing methods may have a higher failure rate as the bone graft has reduced mass and maybe prone to resorption. Canal plugging methods may provide amore definitive means of addressing the dehiscent labyrinth than resurfacing.

Effect of Magnetic Resonance Imaging on Internal Magnet Strength in Med-El Combi 40 Cochlear Implants

Objective: Magnetic resonance imaging (MRI) has been contraindicated when cochlear implants containing an internal magnet are in place because of concerns regarding torque, force, demagnetization, artifacts, induced voltages, and heating. The objective was to determine the magnetic field strength of Med‐El Combi 40+ cochlear implant internal magnets after MRI studies.

Gamma knife radiosurgery for acoustic neuromas performed by a neurotologist: early experiences and outcomes.

Objective: To assess early outcomes after Gamma knife radiosurgery of acoustic neuromas and other skull base tumors. Background: Gamma knife radiosurgery is one of the available methods to treat acoustic neuromas, in addition to micro-surgical resection. Neurootologists have long been associated with microsurgical resection of these tumors; however, the application of Gamma knife radiosurgery to the treatment of these tumors by neurootologists has not been previously described. Setting: Acoustic Neuroma and Skull Base Surgery Program / Tertiary Referral Center. Study Design/Patients/Intervention: Prospective clinical study of all patients treated by the senior author and our gamma knife team beginning in June 2000. Main Outcome Measures: Preoperative MRI, audiometry, vestibular testing and facial nerve electromyography were completed. At six-month intervals postoperatively, audiometry, caloric testing and MRI were performed to determine thresholds and speech discrimination ability, vestibular function, and the size of the tumor. Results: From June 2000 until March 2004, 38 patients were treated, and these included 33 acoustic neuromas, two meningiomas, one glomus jugulare tumor, and two facial neuromas. Greater than 36 month follow-up was available in 7 patients, > 24 months in 24, > 12 months in 31, and > 6 months in 34 patients. Statistically significant reduction in tumor size was seen over time, and tumor control was achieved in all but two patients. Various patterns of changes in auditory function, both in threshold and speech discrimination were observed in either positive or negative directions. Conclusions: Preliminary experience with Gamma knife radiosurgery indicates that this treatment method represents another option for neurootologists to use in managing patients with skull base tumors.

Gamma Knife Surgery of Vestibular Schwannomas: Volumetric Dosimetry Correlations to Hearing Loss Suggest Stria Vascularis Devascularization as the Mechanism of Early Hearing Loss

Objective: Determine which variables are correlated with early hearing changes after gamma knife surgery of vestibular schwannomas (VSs). Study Design: Prospective clinical study of hearing outcomes, radiation dosimetry, conformity, and tumor size of all sporadic unilateral VS patients treated between June 2000 and July 2009. Setting: Tertiary referral center. Patients: Fifty-nine VS patients with at least 6 months of follow-up data were studied. Interventions: Audiometry and imaging were performed to determine auditory thresholds, speech discrimination, and tumor size. Radiation doses to 5 volumes were measured. Main Outcome Measures: Pretreatment and posttreatment comparisons were performed with regard to change in tumor size; radiation dose to specific volumes including the internal auditory canal, cochlea, basal turn of the cochlea, and modiolus; and conformity of the treatment. Results: The mean follow-up was 63.76 months (standard deviation, ±29.02 mo; range, 9-109 mo). The median follow-up was 65.5 months. A statistically significant association between maximum radiation dose to the cochlea volume and 3-frequency pure-tone average in patients starting with 50 dB or lesser PTA3 was demonstrated using linear regression analysis. Conclusion: Longitudinal changes in hearing occur over time, with the largest changes seen in the first 12 months after treatment. With our study outcomes as basis, limiting the dose of radiation to the cochlea to no more than 4 Gy would likely reduce vascular injury to the stria vascularis and improve hearing outcomes. Shielding the cochlea during the treatment planning process would be one mechanism to accomplish this goal.

Bisphosphonate-related osteonecrosis of the mandible and maxilla: Clinical and imaging features

Objective: Bisphosphonate-related osteonecrosis of the jaws is a rare, but morbid, condition. We present the clinical and imaging features of 19 patients. Methods: A review of 19 bisphosphonate-related osteonecrosis patients was performed. Patient demographics, diagnosis, dental procedures, symptoms and clinical findings, location and pattern of involvement, and presence of fractures, sequestra, and fistulae were documented. Results: Patients included 14 women and 5 men aged 48 to 80 years. Diagnoses included breast carcinoma (n = 11), multiple myeloma (n = 4), osteoporosis (n = 4), prostate carcinoma (n = 2), and lymphoma (n = 1). Seventeen patients received intravenous and 2 received oral bisphosphonates for 2 to 5 years. Bone involvement was noted in the mandible (74%), maxilla (16%), and both (10%). A lytic and sclerotic pattern was most common (58%). Additional findings included fractures (n = 5), sequestra (n = 4), and oroantral fistulae (n = 2). Conclusions: Bisphosphonate-related osteonecrosis is a rare, but morbid, condition, and imaging features can mimic other conditions. It is important for the radiologist to consider this entity in the appropriate clinical setting.

Recurrent contralateral abducens nerve palsy in acute unilateral sphenoiditis

OBJECTIVE We describe a patient who presented with recurrent, contralateral abducens nerve palsy resulting from acute sphenoiditis. METHODS Patient medical record and imaging studies were reviewed. A literature review of complications of sphenoiditis was performed. RESULTS Our patient presented with symptoms consistent with an upper respiratory tract infection, as well as severe headache, disequilibrium, and diplopia. Physical examination demonstrated left-sided sixth cranial nerve palsy. Imaging studies were consistent with right sphenoid sinus inflammatory disease. Her medical history was significant for a similar episode 9 years previously, which was managed medically. The current episode was treated acutely with antibiotics and prednisone. Upon resolution of her symptoms, she underwent an endoscopic sphenoidotomy. CONCLUSIONS Although cranial nerve palsies associated with isolated sphenoiditis have been reported, we describe a unique case of recurrent isolated sphenoiditis causing contralateral abducens nerve palsy. Acute management can be medical, with surgical therapy reserved for refractory cases or to prevent future episodes.

Intracranial blastomycosis mimicking high-grade neoplasm on magnetic resonance imaging and spectroscopy

We describe a case of posterior fossa blastomycosis in an immunocompetent patient that mimicked high-grade neoplasm on neuroimaging. Histological analysis confirmed blastomycosis. Because the neuroimaging characteristics of intracerebral blastomycosis can be confused for neoplasm, these lesions must be confirmed histologically before initiating aggressive treatment for presumptive high-grade neoplasm. To our knowledge, it is the first description of a neoplasm mimic on MRS in the setting of intracranial blastomycosis.

Recurrent petrous apex cholesteatoma in a patient with basal cell nevus syndrome

Cholesteatoma is a collection of desquamated epithelium, keratin, and cellular debris with a tendency for expansion and bony destruction. These lesions share histologic features with odontogenic keratocysts and epidermal cysts, two entities common in basal cell nevus syndrome (BCNS). We report an individual with BCNS and simultaneous petrous apex cholesteatomas and discuss the possible association. A 59-year-old Caucasian female with a history of approximately 30 treated basal cell carcinomas (BCCs) and recurrent cholesteatomas presented with three periorbital BCCs. In addition to treatment for BCC beginning in early childhood, the patient had previously undergone numerous excisions of odontogenic keratocysts of the jaw. Physical exam was remarkable for frontal bossing, pectus deformity of the chest, palmar and plantar pitting, and marfanoid habitus. Despite numerous hallmark signs, diagnosis of BCNS had not been made until the age of 58 years. The patient had no family history of malignancy early in life. In addition to cutaneous lesions, the patient had a history of recurrent petrous apex cholesteatoma, first diagnosed at 36 years of age after presenting with facial muscle weakness and progressive ipsilateral hearing loss. There was no prior history of ear disease. Computed tomography revealed marked ipsilateral petrous apex tip erosion. Temporal craniotomy with microsurgical excision of a large cholesteatoma was performed. Postoperatively, facial nerve function returned to baseline, but complete sensorineural deafness persisted. Three additional recurrences with surgical removal occurred, most recently one year prior to current presentation. At that time, magnetic resonance imaging (MRI) without gadolinium disclosed a 4.2 3.2 3.1-cm lesion located in the right petrous apex extending inferiorly into the region of the hypoglossal canal and superiorly into the right temporal lobe (Figure 1). The extirpated mass was found to be consistent with cholesteatoma. Follow-up MRI six months later showed no evidence of further recurrence. As the preceding represented routine clinical practice, prior institutional review board review and approval was not required per institution policy.

R163: MRI of the Airway with Controlled Ventilation in OSA

cellular H2O2 Assay and Immunoblotting were perfomed to measure the oxidative stress and secreted proteins, respectively. RESULTS: H2O2 induced only MUC5AC production and secretion via transcriptional regulation and the MAP kinase signal pathway, through ERK MAP kinase in particular. In addition, ECG markedly inhibited H2O2-induced MUC5AC gene expression and secretion. ECG also suppressed the phosphorylation of ERK MAP kinase. CONCLUSION: These results show that ECG inhibits the H2O2-induced MUC5AC gene and MUC5AC protein expression in human airway epithelium through suppressing the ERK MAP kinase. SIGNIFICANCE: Therefore, it is proposed that a nasal topical application would be more useful than oral uptake to reach the effective experimental dosage in using ECG as a therapeutic agent against the nasal mucus hypersecretory diseases.