Cm In Maximum Diameter Research Articles

A protocol for a Canadian prospective observational study of decision-making on active surveillance or surgery for low-risk papillary thyroid cancer

IntroductionLow-risk papillary thyroid cancer (PTC) is increasingly being diagnosed throughout the world; yet the mortality risk is low compared with other malignancies. Traditional management includes thyroid surgery, sometimes followed by...

Clinical Outcomes After Endoscopic Endonasal Resection of Giant Pituitary Adenomas.

Giant pituitary adenomas represent a surgical challenge. We present the results of the endoscopic endonasal approach (EEA) for giant pituitary adenomas. We retrospectively reviewed the medical records of 55 patients with giant pituitary adenomas (>4 cm in maximum diameter) who underwent surgery with an EEA between 2008 and 2016. Factors affecting the extent of resection were evaluated. The mean patient age was 55.5 years. Tumors were nonfunctional in all but 4 patients, including 2 with growth hormone-secreting tumors, 1 with an adrenocorticotropic hormone-secreting tumor, and 1 with prolactinoma. Gross total resection was achieved in 24 patients (44%), and near-total resection (>90%) was achieved in 26 patients (47%). A multilobular configuration (P= 0.002) and cavernous sinus invasion (P= 0.044) negatively affected the extent of resection, whereas tumor size, intraventricular, and anterior or posterior fossa extension did not. Ten patients underwent adjuvant radiotherapy. All patients with hormone-secreting adenomas required adjuvant medical and/or radiotherapy to achieve biochemical remission. Postoperative vision was improved or normalized in 32 patients (66%), stable in 15 patients (31%), and worsened in 1 patient. A new hormonal deficit occurred in 8 patients (17%), whereas recovery of an existing hormonal deficit occurred in 6 patients (20%). The mean duration of follow-up was 41 months. Tumor recurrence/progression occurred in 6 patients (11%). Complications included apoplexy of residual tumor resulting in ischemic stroke in 1 patient, postoperative cerebrospinal fluid leak in 1 patient, and permanent diabetes insipidus in 4 patients (7%). Surgery with the EEA is an excellent option for managing giant pituitary adenomas. It results in superior clinical outcomes to those obtained using traditional microscopic transsphenoidal and transcranial approaches as reported in the literature.

Carbon-ion radiotherapy for inoperable endometrial carcinoma.

This is a pooled analysis to evaluate the toxicity and efficacy of carbon-ion radiotherapy (C-ion RT) for inoperable endometrial carcinoma. Eligible patients had previously untreated Stage I–III endometrial carcinoma without para-aortic lymph node metastasis. Total dose to the tumor was 62.4–74.4 Gy [relative biological effectiveness (RBE)] in 20 fractions, and the dose to the gastrointestinal tract was limited to <60 Gy (RBE). Intracavitary brachytherapy was not combined in the present study. Fourteen patients with endometrial carcinoma were analyzed. Ten of the 14 patients were judged medically inoperable, and the others refused surgery. The numbers of patients with Stage I, II and III disease were 1, 9 and 4, respectively. Tumor size was 3.8–13.8 cm in maximum diameter. Median follow-up periods for all patients and surviving patients were 50 months (range, 12–218 months) and 78 months (range, 23–218 months), respectively. Two of three patients receiving 62.4–64.8 Gy (RBE) had local recurrence whereas none of 11 patients receiving 68.0 Gy (RBE) or more had local recurrence. Three patients developed distant metastases and one of them also had local recurrence. The 5-year local control, progression-free survival, overall survival, and cause-specific survival rates were 86%, 64%, 68% and 73%, respectively. No patient developed Grade 3 or higher acute or late toxicity. The present study showed that C-ion RT alone could be a safe and curative treatment modality for inoperable endometrial carcinoma.

Clinical outcomes of endoscopic versus microscopic trans-sphenoidal surgery for large pituitary adenoma

Objective: To compare clinical outcomes of large pituitary adenomas (≥3 cm in maximum diameter), operated on by Endoscopic Transsphenoidal Surgery (ETS), versus Microscopic Transsphenoidal Surgery (MTS).Methods: Medical records and MRI Scans of patients with a diagnosis of pituitary adenoma for whom transphenoidal surgery was done were reviewed. Complete pre and post-operative data were available for 121 patients. Thirty five patients had large pituitary adenoma and were enrolled in this study. ETS was done in 16 patients, and 19 underwent MTS. All patients were followed for at least six months. Clinical and imaging characteristics were reported in details. Post-operative clinical outcomes were defined as clinical outcomes persisted 6 months after surgery.Results: The average tumor size was 36.3 ± 4.4 mm in ETS group, and 34.0 ± 4.6 mm in MTS group, (p = .46). Six months after surgery, tumor size was 4.6 ± 6.6 mm in ETS and 17.7 ± 12.2 mm in MTS group, (p = .002). Gross total resection (GTR) was observed in the 81.2% of the patient in the ETS group. In the MTS group, GTR was observed in 15.8%.Post-operative clinical outcomes including new onset hypopituitarism, visual impairment, and permanent diabetes insipidus (DI) were comparable between the two groups.Conclusion: ETS is superior to MTS in treatment of large pituitary adenomas with comparable post-operative complications.

Guideline for therapy of malignant thyroid tumours: pleading for an actualization

Total (or near total) thyroidectomy (TE) followed by radioiodine ((131)I) ablation (RIA) of residual thyroid tissue is considered to be the ideal treatment for differentiated thyroid carcinoma. However, the actual guideline of the DGN (German Society of Nuclear Medicine) recommends for the so-called papillary micro-carcinoma of the thyroid (PMC) no further therapeutic strategy (no complete TE, no (131)I-ablation of the remaining lobe). PMC has been defined as papillary carcinoma measuring 1 cm (T1) in maximal diameter according to the World Health Organization classification system for thyroid tumours (1988). The new WHO-classification (starting in 2003) defines the T1-tumour measuring 2 cm in maximal diameter. The authors demand a new, modern guideline, following the new WHO classification. This includes, that despite the overall excellent prognosis for patients with PMC, the treatment of patients with T1-tumours of the new WHO-classification (including the "old" PMC) should be no different from the treatment of patients with conventional papillary thyroid carcinoma, i.e. complete surgery (TE and central lymph node dissection) followed by RIA of residual thyroid tissue. The authors argue that it is not appropriate to consider the tumour size as the single most important key factor for therapy and prognosis. Even small tumours may have poor prognostic factors, such as lymph node metastasis, multifocality or molecular characteristics (expression of oncogenes).

Gigantic Jejunal Artery Pseudoaneurysm:A Very Rare Case Report, its Management with Endovascular Coiling and Review of the Literature

Pseudoaneurysm is a rare but potentially fatal complication in chronic pancreatitis. The proposed mechanisms for the formation of the pseudoaneurysm suggested the prevalence of pancreatic enzymes at the peripancreatic region or within the pseudocyst that causes erosion of the adjacent arterial wall, leading to vessel rupture into the surrounding cavity or the pseudocyst sac. Mortality rates for pseudoaneurysm rupture can be as high as 70% depending on the condition of the patient, additional comorbidities, the location of the pseudoaneurysm, and the treatment received. The incidence rate for jejunal artery pseudoaneurysm, whether with or without association to chronic pancreatitis, is exceptionally infrequent, with only a handful of cases ever reported. We present a rare case of a 37-yearold patient with a gigantic (10.3 cm in maximum diameter) pseudoaneurysm arising from the 1st jejunal artery with active contrast extravasation into the pseudoaneurysm sac observed under computed tomography angiography. Given the rarity of jejunal pseudoaneurysms, this is the largest size ever reported in current literature. We propose the noteworthy size is linked with continual irritation from surrounding chronic pancreatic inflammatory reactions, resulting in the increased elasticity and pliancy of the pseudoaneurysms/pseudocyst walls. This case report also offers an example of successful endovascular intervention for jejunal pseudoaneurysm in which surgical intervention is technically difficult or even impossible.

Primary gastric low-grade fibromyxoid sarcoma with FUS-CREB3L1 fusion – A hitherto undescribed origin of Evans tumor

Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft tissue neoplasm with a deceptively benign histological appearance. Only several LGFMS cases originating from the gastrointestinal tract have been reported, but all of them are from the small intestine or colon. Here, we describe a case of gastric LGFMS that was proven to have a characteristic FUS-CREB3L1 fusion gene. A 54-year-old Japanese female complained of epigastralgia. Abdominal computed tomography revealed a solid mass probably originating from the lessercurvature of the gastric body and protruding outside the gastric wall. Under the clinical diagnosis of suspicious gastrointestinal stromal tumor of the stomach, gastric wedge resection including the tumor was done. The macroscopic finding showed a mass approximately 8.0cm in maximal diameter with white-tan cut surface, arising from the gastric wall. Histological examination revealed a mesenchymal tumor consisting of blunt spindle cells with occasional collagen rosettes and inflammatory cells. Tumor was immunohistochemically positive for MUC4 and the molecular analysis using formalin-fixed paraffin embedded tissue detected FUS-CREB3L1 fusion which is a minor fusion gene type in LGFMS. Thus, the pathological diagnosis of gastric LGFMS was confirmed. To the best of our knowledge, the present case is the first one of LGFMS arising from the stomach in the English literature.

Modified method for distinguishing the intersegmental border for lung segmentectomy.

This paper analyzed the results of a modified and simpler technique for distinguishing the intersegmental border during lung segmentectomy surgery. From January 2013 to December 2015, 539 patients with screening‐detected lung nodules <2 cm in maximum diameter underwent anatomic segmentectomy. With the guidance of preoperative three‐dimensional computed tomography bronchography and angiography, the bronchus, artery, and intrasegmental vein of the targeted segment could be precisely dissected under unilateral differential ventilation, and then intersegmental demarcation was confirmed by the modified inflation‐deflation method. The demarcation presented by this method was highly coincident with the real intersegmental border. Dissection along the border between the collapsed and inflated segments using either electrocautery or staples was safe, with almost no air leak or bleeding. This technique is a simple and effective alternative to previously described intersegmental border marking methods.

Clinical Outcomes for Frameless Image-Guided Stereotactic Radiation Therapy to Intact Brain Metastases in Five Daily Hypofractionated Treatments

Image-guided multi-lead collimator (MLC) linac-based hypofractionated stereotactic radiation (FSRT) is increasingly practiced for brain metastases. We report our outcomes for 5-fraction FSRT including the rate of radiation necrosis. 113 patients with 184 brain metastases who were treated with FSRT from Oct 2009-Dec 2014 were retrospectively reviewed. Overall Survival (OS) and progression free survival (PFS) rates were calculated using the Kaplan-Meier method. Local control rates were determined with Fine and Gray’s competing risk method with death as the competing risk. Predictive factors were identified using Cox regression multivariable analysis. All patients were treated in a thermoplastic mask using a cone-beam CT image-guided linac equipped with a MLC and six-degrees-of-freedom treatment couch. All patients were treated with a 5 daily fraction dose scheme to the gross tumor volume (GTV) with a 2 mm planning target volume (PTV). 30 Gy in 5 fractions was the most common prescription. The median follow-up was 11 months. Non-small cell lung cancer the most frequently treated histology (46%) followed by breast cancer (21%) and melanoma (9%). FSRT was given for a single brain metastasis in 67 (59%) patients and for multiple metastases in 46 patients (41%). 77 patients (68%) were treated as upfront and 36 (32%) as salvage following whole brain radiation. 50 patients (44%) had treated lesions >2 cm in maximum diameter. 43 targets (23%) received 25-27.5Gy, 111 (60%) received 30 Gy, and 30 (16%) received >30 Gy in 5 fractions. The PFS rates at 6 months, 12 months and 24 months were 65%, 38%, and 15%, respectively (median, 9.0 months). The OS rates at 6 months, 12 months and 24 months were 69% 47% and 20%, respectively (median OS, 11.8 months). The local failure rates at 6 months, 12 months and 24 months were 8.2%, 22% and 35%, respectively (median, 11.43 months). With regards to other patterns of failure, cumulative incidence rates of leptomeningeal disease at 6 months, 12 months and 24 months were 9.8%, 14% and 17% respectively (median, 4.4 months). 28 targets in 25 patients (15%) developed radiation necrosis, of which 17 were symptomatic (9%). Post-treatment necrosis was a positive prognostic factor (HR 2.1, p=0.003) for OS. Upfront therapy as opposed to salvage (HR 0.54, p=0.02) and those treated with doses > 30Gy (HR 0.55, p=0.03) were predictive for local control. Frameless image-guided MLC-based linac FSRT for intact brain metastasis results in long-term local control with an acceptable rate of RN.

Stereotactic Body Radiation Therapy for Large Hepatocellular Carcinomas

To evaluate efficacy and safety of Stereotactic Body Radiation Therapy (SBRT) for hepatocellular carcinoma (HCC) patients with primary lesion at least 5 cm in diameter. Through an IRB-approved retrospective review of departmental records, we identified 194 patients treated with SBRT for HCC at our institution from 2004-2015. After reviewing all available radiographic and clinical records, 36 patients were found to have a primary lesion greater than or equal to 5 cm in maximum diameter. We recorded radiographic response and treatment toxicities (using CTCAE 3.0). Gender distribution was 32 (89%) male and 4 (11%) female with median age 71 (range 53-93) years at the time of diagnosis and SBRT. Median Zubrod performance score was 1 (range 0-2). Among 35 patients with calculable Child Pugh classification, 23 (66%), 10 (28%), and 2 (6%) of patients were class A, B, and C respectively. Median lesion size was 6 (range 5-14) cm. Radiotherapy was delivered using stereotactic technique and prescribed to isocenter with a median dose of 42.5 (range 30 to 62.5) Gy. All patients were treated in either 5 or 10 total fractions. Assuming an alpha/beta ratio of 10, median biologically equivalent dose (BED) for all patients was 72 (range 39-141) Gy. SBRT was the initial treatment modality for 29 (81%) patients, while 19% of patients had undergone prior treatment [transarterial chemoembolization (TACE) in 4 (11%) patients and radiofrequency ablation (RFA) in 3 (8%) patients]. The 3 month local radiographic response was complete in 6%, partial in 47%, stable in 38%, and progressive disease in 9% of patients (2 were unknown). 58% of patients experienced no treatment toxicity, 19% experienced grade 1 toxicity, and 14% experienced grade 2 toxicity (unknown for 3 patients). No acute or late grade 3 radiation toxicities were reported. SBRT is a safe and effective treatment modality for patients with large HCC lesions, especially if they are not amendable to other therapeutic interventions.

Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm

OBJECTIVE Stereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%-62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy. METHODS Fifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board-approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient. RESULTS Among 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23-83 years), 23 patients (43%) had non-small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12-18 Gy) and 15 Gy (range 12-15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm3 (range 2.4-31.3 cm3) and 7.0 cm3 (range 1.0-29.7 cm3). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm3 (range 0.1-23.1 cm3). The median change in volume compared with baseline was a decrease of 54.9% (range -98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3-7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively. CONCLUSIONS 2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) and 6-month (88%) LC rates and an overall AE rate of 11%. Prospective studies with larger cohorts and longer follow-up are necessary to assess the durability and toxicities of 2-SSRS.

Complete resection of a huge pancreatic undifferentiated carcinoma with osteoclast-like giant cells

Pancreatic undifferentiated carcinoma with osteoclast-like giant cells (PUC-OGC) is a rare neoplasm. We report a case of rapidly advancing PUC-OGC. A 54-year-old man had elevated tumor marker levels. Abdominal computed tomography showed a cystic mass in the body and tail of the pancreas, which infiltrated adjacent organs. The tumor exhibited rapid growth (doubling time: 39days) but no metastases. We diagnosed PUC-OGC clinically and excised the pancreatic body and tail along with the spleen, left kidney, adrenal gland, and transverse colon. Pathological diagnosis showed histology consistent with PUC-OGC and a negative margin without nodal involvement despite the tumor being 28cm in maximum diameter and having invaded the left kidney. The patient survived a year with a recurrence of liver metastasis after the initial surgery due to the partial hepatectomy and chemotherapy. Complete resection might be a good strategy to cure PUC-OGC in this case.

Abdominal aortic aneurysm: pictorial review of common appearances and complications.

Abdominal aortic aneurysms (AAAs) are defined as focal dilatations of the abdominal aorta that are 50% greater than the proximal normal segment or when it is more than 3 cm in maximum diameter. The early diagnosis and treatment is very important to prevent catastrophic complications. Due to its ability to assess the peri-aortic soft tissue and the exact extension of aneurysm, as well as its excellent vascular opacification and multiplanar reconstruction capabilities, computed tomography angiography (CTA) has become an integral part of the evaluation of AAA and has virtually replaced conventional angiography for the evaluation of AAA. Knowledge of the characteristic imaging features of AAA is essential for the prompt diagnosis of life-threatening complications. In this pictorial essay, we will discuss the CTA findings in AAA and its complications including rupture, infection, aorto-enteric fistula and aorto-caval fistula.

Endometrial Carcinoma: MR Imaging-based Texture Model for Preoperative Risk Stratification-A Preliminary Analysis.

Purpose To evaluate the associations among mathematical modeling with the use of magnetic resonance (MR) imaging-based texture features and deep myometrial invasion (DMI), lymphovascular space invasion (LVSI), and histologic high-grade endometrial carcinoma. Materials and Methods Institutional review board approval was obtained for this retrospective study. This study included 137 women with endometrial carcinomas measuring greater than 1 cm in maximal diameter who underwent 1.5-T MR imaging before hysterectomy between January 2011 and December 2015. Texture analysis was performed with commercial research software with manual delineation of a region of interest around the tumor on MR images (T2-weighted, diffusion-weighted, and dynamic contrast material-enhanced images and apparent diffusion coefficient maps). Areas under the receiver operating characteristic curve and diagnostic performance of random forest models determined by using a subset of the most relevant texture features were estimated and compared with those of independent and blinded visual assessments by three subspecialty radiologists. Results A total of 180 texture features were extracted and ultimately limited to 11 features for DMI, 12 for LVSI, and 16 for high-grade tumor for random forest modeling. With random forest models, areas under the receiver operating characteristic curve, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were estimated at 0.84, 79.3%, 82.3%, 81.0%, 76.7%, and 84.4% for DMI; 0.80, 80.9%, 72.5%, 76.6%, 74.3%, and 79.4% for LVSI; and 0.83, 81.0%, 76.8%, 78.1%, 60.7%, and 90.1% for high-grade tumor, respectively. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of visual assessment for DMI were 84.5%, 82.3%, 83.2%, 77.7%, and 87.8% (reader 3). Conclusion The mathematical models that incorporated MR imaging-based texture features were associated with the presence of DMI, LVSI, and high-grade tumor and achieved equivalent accuracy to that of subspecialty radiologists for assessment of DMI in endometrial cancers larger than 1 cm. However, these preliminary results must be interpreted with caution until they are validated with an independent data set, because the small sample size relative to the number of features extracted may have resulted in overfitting of the models. © RSNA, 2017 Online supplemental material is available for this article.

Desmoplastic fibroblastoma: a clinicopathologic analysis of 7 cases

Objective: To investigate the clinical features, immunohistochemical and differential diagnosis of desmoplastic fibroblastoma. Methods: The clinical data and pathology features of 7 cases of desmoplastic fibroblastoma were collected and immunohistochemical study were carried out in all cases with a review of the literatures. Results: There were 2 males and 5 females, with age ranging from 31 to 71 years (average and mean age were 59 and 61 years, respectively). The tumors were located in extremities and abdomen (left toe and right toe, right foot back, left leg and right thigh, right forearm and left hepatic lobe). Clinically, the tumors presented as slow growing painless masses of long standing duration. Grossly, the tumors were well-circumscribed with firm, white to gray cut-off surface. Tumor size ranged from 1.2 to 4.0 cm in maximum diameter (average 3.0 cm). Microscopically, 2 cases were located in dermis, 4 cases were located in subcutaneous and 1 case was located in liver parenchyma. It was composed of spindle-shaped or stellate cells with a fibroblastic or myofibroblastic appearance, and sparsely scattered in densely fibrous or fibromyxoid background. There was small vascular component in tumor background. At high magnification, the tumor cells were medium size with abundant cytoplasm, and the nucleus were small and always with small nucleoli. In some cases, the tumor cells were slightly larger with enlarged nuclei, but without cellular atypical and mitosis. Immunohistochemical study showed that the tumor cells were strongly positive for vimentin, desmin, S-100 protein and CD34, but CKpan was negative. α-SMA showed focal positive in one case. Ki-67 index ranged from 1% to 2%. Four cases were followed-up (ranged from 11 to 21 months, average 16.5 months) and the patients had no recurrence after surgery. Conclusions: Desmoplastic firoblastoma is a rare soft benign tumor. The differential diagnosis includes other benign or low-grade fibroblastic/myofibroblastic lesions.

Contour variations of the body and tail of the pancreas: evaluation with MDCT

To analyze morphology/contour variations of the pancreatic body and tail in subjects free of pancreatic disease. We retrospectively reviewed triple-phase, contrast-enhanced multi-detector row computed tomography (3P-CE-MDCT) examinations of 449 patients who had no clinical or CT evidence of pancreatic diseases. These patients were evaluated for morphologic/contour variations of the pancreatic body and tail, which were classified into two types. In Type I, a portion of normal pancreatic parenchyma protrudes >1cm in maximum diameter from the body or tail (Ia-anteriorly; Ib-posteriorly). Type II was defined as a morphologic anomaly of the pancreatic tail (IIa-globular; IIb-lobulated; IIc-tapered; IId-bifid). Thirty-eight (8.5%) out of 449 patients had body or tail variations. Of those, 23 patients showed Type I variant: Ia in 21 and Ib in two. Type II variant was identified in 15 patients: IIa in eight, IIb in two, IIc in two and IId in three. Protrusion of the anterior surface of the normal pancreas, especially in the tail, was the most frequently occurring variant. Recognizing the types and subtypes of morphology/contour variations of the pancreatic body and tail could help prevent misinterpretation of normal variants as pancreatic tumors on unenhanced MDCT.

Modified Video-Assisted Thyroidectomy in a Benign Unilateral Thyroid Swelling

Background and aim: Conventional thyroidectomy may cause a long neck scar and a variety of potential complications. The concept of minimally invasive surgery has recently found many supporters in the management of thyroid disorders. The aim of this study was to evaluate the suprasternal approach of modified minimal invasive video-assisted endoscopic thyroidectomy (MIVAET) in treatment of unilateral simple nodular goiter in term of: feasibility of the operation, the identification of recurrent laryngeal nerves (RLN) and parathyroid glands, operative time, postoperative pain and cosmetic result. Patients and methods: This study was conducted on 20 patients with a simple solitary thyroid nodule in Surgical Oncology Unit at General Surgery Department, Tanta University Hospital from March 2015 to June 2016. Patients included in the study had small nodule less than 5 cm in maximum diameter, unilateral lesion, no previous neck surgery, benign lesion and euthyroid state. Every patient was subjected to MIVAET through a Suprasternal 2-cm neck incision. Results: The present study comprised 18 females (90%) and 2 males (10%) patients with a mean age of 32 years, The mean operative time was 63 minutes, simple nodular goiter was the commonest pathological finding, 90% of the patients stayed in the hospital one day and 70% were satisfied from cosmetic appearance of their scar 6 months after the operation. Conclusion: Modified minimal invasive video-assisted endoscopic thyroidectomy was feasible, can be done safely and effectively with a better aesthetic outcome and pathological control without increasing the risk of complications.

Transfrontal-Sinus-Subcranial Approach to Olfactory Groove Meningiomas: Surgical Results and Clinical and Functional Outcome in a Consecutive Series of 21 Patients

The transfrontal-sinus-subcranial approach (TFSSA) allows for direct exposure and removal of olfactory groove meningiomas (OGMs), without any brain retraction. Compared with other skull base approaches (e.g., fronto-orbitobasal, transbasal, subcranial, fronto-orbitozygomatic, and one-and-half approach), it could offer the same advantages but is less invasive. We report the results in a series of 21 consecutive patients with OGMs and operated on through TFSSA, to propose a viable alternative approach. Mean maximum tumor diameter was 45.9 ± 3.4 mm (range, 25-70 mm). The aim of surgery was Simpson grade I removal. Surgical, clinical, and functional outcomes were reported. Mean follow-up was 87 ± 7 months (range, 36-176 months). In all patients, magnetic resonance imaging after surgery confirmed complete tumor removal. The recurrence-free survival rate was 100% and 85.7% at 5 and 10 years, respectively. Surgery-related mortality and major morbidity were 0% and 4.8%, respectively. Risk of anosmia significantly correlates with meningioma size (P < 0.001) and smell sense was preserved only in patients with tumors less than 4 cm in maximum diameter (4/7; 57.1%). A significant improvement of Mini Mental Standard Examination score was recorded at follow-up (P < 0.001) and no patients worsened their cognitive profile. Visual function improved in 7/8 (87.5%). Karnofsky Performance Scale score after surgery significantly increased (P < 0.001). According to the Glasgow Outcome Score, good outcome was achieved in 20 patients (95.2%). Based on reported results, TFSSA allows complete tumor removal with good outcome and low complication rate. It may be proposed as a safe and effective approach to treat large and giant OGMs.

Slip interface imaging based on MR-elastography preoperatively predicts meningioma-brain adhesion.

PurposeTo investigate the ability of slip interface imaging (SII), a recently developed magnetic resonance elastography (MRE)‐based technique, to predict the degree of meningioma–brain adhesion, using findings at surgery as the reference standard.Materials and MethodsWith Institutional Review Board approval and written informed consent, 25 patients with meningiomas >2.5 cm in maximal diameter underwent preoperative SII assessment. Intracranial shear motions were introduced using a soft, pillow‐like head driver and the resulting displacement field was acquired with an MRE pulse sequence on 3T MR scanners. The displacement data were analyzed to determine tumor–brain adhesion by assessing intensities on shear line images and raw as well as normalized octahedral shear strain (OSS) values along the interface. The SII findings of shear line images, OSS, and normalized OSS were independently and blindly correlated with surgical findings of tumor adhesion by using the Cohen's κ coefficient and chi‐squared test.ResultsNeurosurgeons categorized the surgical plane as extrapial (no adhesion) in 15 patients, mixed in four, and subpial (adhesion) in six. Both shear line images and OSS agreed with the surgical findings in 18 (72%) cases (fair agreement, κ = 0.37, 95% confidence interval [CI]: 0.05–0.69), while normalized OSS was concordant with the surgical findings in 23 (92%) cases (good agreement, κ = 0.86, 95% CI: 0.67–1). The correlation between SII predictions (shear line images, OSS, and normalized OSS) and the surgical findings were statistically significant (chi‐squared test, P = 0.02, P = 0.02, and P < 0.0001, respectively).ConclusionSII preoperatively evaluates the degree of meningioma–brain adhesion noninvasively, allowing for improved prediction of surgical risk and tumor resectability. Level of Evidence: 1 Technical Efficacy: Stage 1J. Magn. Reson. Imaging 2017;46:1007–1016.

Can Multistate Modeling of Local Recurrence, Distant Metastasis, and Death Improve the Prediction of Outcome in Patients With Soft Tissue Sarcomas?

Exploration of the complex relationship between prognostic indicators such as tumor grade and size and clinical outcomes such as local recurrence and distant metastasis in patients with cancer is crucial to guide treatment decisions. However, in patients with soft tissue sarcoma, there are many gaps in our understanding of this relationship. Multistate analysis may help us in gaining a comprehensive understanding of risk factor-outcome relationships in soft tissue sarcoma, because this methodology can integrate multiple risk factors and clinical endpoints into a single statistical model. To our knowledge, no study of this kind has been performed before in patients with soft tissue sarcoma. We implemented a multistate model of localized soft tissue sarcoma to statistically evaluate the relationship among baseline risk factors, recurrence, and death in patients with localized soft tissue sarcoma undergoing curative surgery. Between 1998 and 2015, our center treated 539 patients for localized soft tissue sarcoma with surgery as curative intent. Of those, 96 patients (18%) were not included in this single-center retrospective study owing to missing baseline histopathology data (n = 3), not yet observed followup (n = 80), or because a neoadjuvant treatment approach in the presence of synchronous distant metastasis was used (n = 13), leaving 443 patients (82%) for the current analysis, of which 40 were lost to followup during the first year after surgery. All patients had tumors of the stages I to III according to the American Joint Committee on Cancer Stages. The median age of the patients was 62 years (range, 16-96 years), and 217 patients (49%) were female. Three hundred-forty-six patients (78%) had tumors of high grade (Grades 2 and 3), and 310 (70%) tumors were greater than 5 cm in maximum diameter. Patients who had died during the first year of followup were included in this analysis. Median followup for the 443 study patients was 6 years, with 84%, 52%, and 23% of patients being followed for more than 1, 5, and 10 years, respectively. The 15-year cumulative incidences of local recurrence, distant metastasis, and death from any cause, using a competing risk analysis, were 16% (95% CI, 11%-22%), 21% (95% CI, 17%-26%), and 55% (95% CI, 44%-67%), respectively. Wide resection with a margin of 1 mm was the preferred treatment for all patients, except for those with Grade 1 liposarcoma where a marginal resection was considered adequate. Multistate models were implemented with the mstate library in R. In multistate analysis, patients who experienced a local recurrence were more likely to have distant metastasis develop (hazard ratio [HR] = 8.4; 95% CI, 4.3-16.5; p < 0.001), and to die (HR = 3.4; 95% CI, 2.1-5.6; p < 0.001). The occurrence of distant metastasis was associated with a strong increase in the risk of death (HR = 12.6; 95% CI, 8.7-18.3; p < 0.001). Distant metastasis occurring after a long tumor-free interval was not associated with a more-favorable prognosis with respect to mortality than distant metastasis occurring early after surgery (estimated relative decrease in the adverse effect of distant metastasis on mortality for 1-year delay in the occurrence of distant metastasis = 0.9; 95% CI, 0.7-1.1; p = 0.28). High-grade histology (Grades 2 and 3) was associated with a higher risk of overall recurrence (defined as a composite of local recurrence and distant metastasis, HR = 3.8; 95% CI, 1.8-7.8; p = 0.0003) and a higher risk of death after recurrence developed (HR = 4.4; 95% CI, 1.1-18.2; p = 0.04). Finally, the multistate model predicted distinct outcome patterns depending on baseline covariates and how long a patient has remained free from recurrence after surgery. In patients with localized soft tissue sarcoma undergoing resection, the occurrence of local recurrence and distant metastasis contributes to a dramatically impaired long-term survival outcome. Local recurrences are a substantial risk factor for distant metastasis. Multistate modeling is a very powerful approach for analysis of sarcoma cohorts, and may be used in the future to obtain highly personalized, dynamic predictions of outcomes in patients with localized soft tissue sarcoma. Level III, therapeutic study.