Exophytic Component Research Articles

Microsurgical Resection of Cervical Intradural Juxtamedullary Solitary Fibrous Tumor: 2-Dimensional Operative Video

Solitary fibrous tumors (SFTs) are uncommon mesenchymal lesions originally described as pleura-based neoplasms. Intradural juxtamedullary SFTs are rare, hard, and scarcely vascularized and generally present a conspicuous extramedullary exophytic component without dural attachment and nerve root involvement. Gross-total resection is the mainstay of treatment, although the absence of an arachnoidal plane and the firm adherence to the spinal cord make resection challenging. We describe the case of a 74-yr-old female patient presenting with a history of progressive spastic tetraparesis due to a cervical juxtamedullary SFT. The patient was not able to walk and magnetic resonance imaging (MRI) of the cervical spine demonstrated a possible intramedullary lesion at C2-C3 with homogeneous enhancement after gadolinium injection. Given the progressive nature of symptoms, the patient elected to have surgical resection of the tumor. The patient underwent C2-C3 laminoplasty and tumor resection under neurophysiologic monitoring. The tumor presented extremely hard without dural attachment or nerve root involvement and was progressively debulked using microsurgical techniques and ultrasonic aspirator. The identification of a plane between the mass and the spinal cord white matter allowed for a gross total resection. Permanent pathological analysis eventually demonstrated SFT. The patient's neurological condition was unchanged postoperatively. MRI performed 2 mo after the operation demonstrated gross total resection of the lesion. At the 6-mo follow-up visit, the patient was able to walk with assistance. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

Spinal Cord Cavernous Malformations: MRI Commonly Shows Adjacent Intramedullary Hemorrhage

There is a relative paucity of radiology literature on spinal cord cavernous malformations (SCMs). We hypothesized that the classic MRI features of cavernous malformations are not highly prevalent. The purpose was to review MR imaging findings of SCMs with a focus on prevalence of hemorrhagic features, including adjacent intramedullary hemorrhage at initial presentation. In this single-institution study, 78 SCMs in 76 patients diagnosed on imaging/pathology were retrospectively evaluated for size, location, cord expansion, exophytic component, popcorn morphology, signal characteristics, including T1 weighted (T1w) and T2w rims, blood-fluid levels, and adjacent intramedullary hemorrhage. Intramedullary hemorrhage was defined as centrally and/or eccentrically located linear or flame shaped non-edematous signal abnormality extending longitudinally away from SCMs, distinct from lesional rim. Sixty-three percent (49/78) of SCMs measured <1 cm in length, 78% (61/78) extended to the cord surface, 65% (51/78) were expansile, and 32% (25/78) were exophytic. Popcorn morphology was seen in 15% (12/78) on T1w and 22% (17/78) on T2w. Internal blood-fluid levels were evident in 4% (3/78). Sixty-nine percent (54/78) showed T2w hypointense rims; the T2w rim was complete/near-complete in 37% (29/78). A rim on T1w was visible in 49% (38/78); this was hyperintense in 58% (22/38). Adjacent intramedullary hemorrhage was seen in 45/78 (58%), was most commonly bidirectional in 67% (30/45) and eccentric in 68% (30/44). Cord edema was seen in 22% (17/78); 53% (9/17) also demonstrated intramedullary hemorrhage with edema. The classically described popcorn morphology, internal blood-fluid levels, and complete/near-complete T2w hypointense rims are often absent on MRIs in SCMs. Adjacent intramedullary hemorrhage is frequently present, often eccentric and bidirectional.

Parietal skull extramedullary relapse in multiple myeloma

A 59-year-old man was diagnosed with kappa light chain multiple myeloma (MM), CS IIIA (DS), I (ISS), carrying del(17 p), 80% of plasma cell bone marrow infiltration and lytic bone...

Histopathological evaluation of minor salivary gland papillary-cystic tumours: focus on genetic alterations in sialadenoma papilliferum and intraductal papillary mucinous neoplasm.

Minor salivary gland tumours showing a predominant papillary-cystic structure are rare, and constitute a mixture of various types of neoplasm; thus, the histopathological assessment of these tumours poses a significant diagnostic challenge. We aimed to delineate the histological characteristics of these tumours and further mutational aspects with a particular focus on sialadenoma papilliferum (SP) and intraductal papillary mucinous neoplasm (IPMN). We retrieved 28 papillary-cystic tumours of the minor salivary glands, and performed histological re-evaluation and mutation analyses of several key oncogenes. The histological classifications were as follows: SP (n=10), SP-like intraductal papillary tumour (SP-IPT) (n=2), IPMN (n=9), intraductal papilloma, cystadenoma, and cystadenocarcinoma (two, three and two respectively). Whereas SP typically consisted of a combination of exophytic squamous epithelium and endophytic intraductal papillary infoldings, SP-IPT lacked the exophytic component. SP and SP-IPT frequently harboured BRAF V600E mutations (75.0%), which were identified in both squamous and ductal components. IPMN was characterised by a well-demarcated cystic lesion filled exclusively with a papillary proliferation of mucinous cells and a high rate of AKT1 E17K mutations (88.9%). Intraductal papillomas were unilocular cystic lesions with intraluminal papillary growth of bland columnar cells. In contrast, both cystadenomas and cystadenocarcinomas showed a multicystic appearance with a papillary configuration. Cystadenocarcinomas invaded the surrounding tissue and were composed of markedly atypical tumour cells. The appropriate interpretation of histological findings and specific genetic alterations (e.g. BRAF V600E and AKT1 E17K in SP and IPMN) would be useful for the correct diagnosis of minor salivary gland papillary-cystic tumours.

Ganglioglioma of Conus Medullaris—A Rare Case

Abstract Gangliogliomas favor the temporal lobe. They are rarely reported in the spinal cord. Ganglioglioma of the conus medullaris is very rare. An 11-year-old boy presented with progressive weakness of bilateral lower limbs. Clinical examination and radiologic investigations revealed a lesion in the conus medullaris with an exophytic component involving the cauda equina roots. The lesion was excised near totally. Its histopathologic examination revealed it to be a ganglioglioma. Gangliogliomas of the conus medullaris are rare lesions. Subtotal or near-total excision with preservation of the function should be the aim of the surgical intervention. Because preoperative function largely dictates the postoperative course, it is advisable to intervene early at the first hint of neurologic compromise.

Novel Surgical and Radiologic Risk Factors for Progression or Recurrence of Pediatric Pilocytic Astrocytoma

Introduction: Pilocytic astrocytomas (PA) are a common, benign childhood tumor known for their slow growth rates and excellent prognosis. The aim of our study was to characterize patient, tumor, and imaging-related risk factors for recurrence and progression of disease. Methods: We identified 116 patients with PA who underwent surgery at our institution between 2000 and 2015. Data were collected retrospectively from the clinical charts. Results: The mean age at resection was 7 ± 5 years (range 0.5–31) and mean follow-up was 6 ± 3 years. Initial resection was complete in 33 patients (29%), subtotal in 78 patients (67%), and biopsy in 5 patients (4%). A total of 45/116 (40%) patients experienced either recurrence or progression after initial resection with a mean time to recurrence or progression of 2.2 years. Bivariate analysis identified subtotal resection, tumor location, age at diagnosis, and imaging features (i.e., T2 invasion, exophytic component, hemorrhage, and solid tumors) as factors significantly associated with recurrence or progression (p < 0.05). Conversely, PAs that were completely resected, predominately cystic, and located in the cerebellum were significantly associated with no recurrence or progression (p < 0.05). Multivariate regression analysis narrowed down 4 robust risk factors: extent of resection, T2 invasion, predominantly solid lesions, and presence of an exophytic component (p < 0.05). Conclusion: Total surgical removal of PA has been the most important prognostic factor for the clinical course of PA. Our study reveals additional risk factors for the recurrence or progression of disease: tumor invasion, solid composition, and tumors with an exophytic component.

Salivary Sialadenoma Papilliferum Consists of Two Morphologically, Immunophenotypically, and Genetically Distinct Subtypes.

Papillary salivary gland neoplasms are rare tumors usually arising in the minor salivary glands of the oral cavity. Their classification has been historically confusing due to overlapping histologic features, but molecular analysis may clarify these entities. Sialadenoma papilliferum (SP) is a peculiar member of this group that demonstrates both an endophytic ductal and an exophytic squamous component. SP closely resembles syringocystadenoma papilliferum of the skin, a tumor which has recently been shown to harbor BRAF V600E or HRAS mutations. We sought to perform histologic and immunophenotypic analysis of a group of SP, along with BRAF and HRAS mutational analysis. We collected 13 SP cases from 7 females and 6 males ranging from 2 to 91years (mean 62.8). Five exophytic ductal papillomas were also analyzed as controls. Histological analysis was performed along with immunohistochemistry for CK7, p63, and SOX10. BRAF VE1 immunohistochemistry was done in all tumors, and BRAF V600E and HRAS Sanger sequencing was successfully performed in all but two cases. Histologic analysis revealed that SP consisted not only of classic SP (9 of 13 cases) but also an oncocytic variant (4 of 13 cases) characterized by a glandular component that uniformly exhibited abundant granular cytoplasm and prominent nucleoli. By immunohistochemistry, all SP demonstrated luminal CK7 and basal p63 expression, but SOX10 was expressed only in conventional SP (9 of 9 cases). BRAF VE1 immunohistochemistry was positive in 9 of 9 conventional SP but 0 of 4 oncocytic SP; staining was present in both the exophytic and endophytic components. BRAF V600E mutational status was confirmed by Sanger sequencing in 11 cases (7 conventional and 4 oncocytic). The exophytic ductal papillomas were negative for BRAF mutations, and all tumors tested were negative for HRAS mutations. In summary, we demonstrated that SP consists of two variants: (1) conventional SP which is SOX10-positive and harbors BRAF V600E mutations similar to syringocystadenoma papilliferum of the skin; and (2) an oncocytic variant which is SOX10-negative and negative for BRAF mutations. We also demonstrated that both the endophytic glandular component and exophytic squamous components of conventional SP harbor BRAF V600E mutations and are therefore neoplastic.

Pediatric primary spinal atypical teratoid rhabdoid tumor: a case series and review of the literature.

Atypical teratoid rhabdoid tumors (ATRTs) are rare malignant central nervous system tumors, commonly occurring before 3 years of age. Median overall survival (OS) of patients with these tumors is about 1 year, despite aggressive multimodal therapy. Pediatric primary spinal ATRTs are even more rare, with fewer than 50 cases reported. The authors present a series of four patients who were treated at Ann and Robert H. Lurie Children's Hospital of Chicago in the period from 1996 to 2017.These patients, with ages 2-11 years, presented with pain and a decline in motor functions. They were found to have lesions in the lumbar, thoracic, and/or cervical spine. One patient's tumor was intramedullary with exophytic components, while another patient's tumor had both intra- and extradural components. All patients underwent resection followed by chemotherapy (systemic and intrathecal). Two patients had fractionated radiation therapy and one had an autologous stem cell transplant. Three patients are known to be deceased (OS 8.5-45 months). The fourth patient was in remission 19 years after her initial diagnosis. To the authors' knowledge, this is the largest series of pediatric primary spinal ATRTs documented at a single institution. These cases illustrate a variety of presentations of spinal ATRT and add to the body of literature on this aggressive pathology.A systematic MEDLINE search was also conducted using the keywords "atypical teratoid rhabdoid tumor," "pediatric spinal rhabdoid tumor," and "malignant rhabdoid tumor spine." Reports were included for patients younger than 21 years, without evidence of intracranial or systemic disease at the time of diagnosis. Clinical characteristics and outcomes of the four institutional cases were compared to those in the literature. This review yielded an additional 48 cases of primary pediatric spinal ATRTs reported in the English-language literature. Patients (ages 2 months to 19 years) presented with symptoms of pain, regression of motor function, and spinal cord compression. The majority of tumors were intradural (14 extramedullary, 8 intramedullary, 1 both). Eleven cases in the literature described tumors limited to extradural structures, while 10 tumors involved the intra- and extradural spine. Four reports did not specify tumor location. Although rare, spinal ATRT should be considered in the differential diagnosis of pediatric patients presenting with a new spinal mass.

Chondrosarcoma of trachea: case report of successful surgical treatment of local recurrence

The study objective is to report a case of tracheal chondrosarcoma, which is a very rare malignant tumor. Only 18 cases have been described so far in English medical literature. Materials and methods. A 74-year-old male patient visited an otorhinolaryngologist in August 2011 with complaints of hoarseness of voice, which have been gradually increasing during the last 3 years. The patient was diagnosed with myxoid chondrosarcoma. Results. In September 2011, the patient underwent thyroidectomy and circular resection of the trachea at the level of its second ring with the creation of a tracheal anastomosis. This volume of surgery was determined by the presence a thyroid nodule in the right thyroid lobe, which invaded the cricoid cartilage and the first ring of the trachea. In November-December 2011, the patient underwent a course of adjuvant external beam radiotherapy with a total dose of 50 Gy delivered in 2.0 Gy fractions, 5 days per week. No cancer recurrence had been observed during 3 years and 9 months of follow up. In September 2015, the patients was found to have a 24-mm thyroid nodule with an exophytic component in the right thyroid cartilage plate. This finding was considered as recurrent chondrosarcoma. In May 2016, the patient had laryngectomy. We performed margin-negative (R0) resection. The patient has now been in remission for 2 years and 9 months. Conclusion. We demonstrate successful treatment of a patient with tracheal chondrosarcoma with a long-term remission after surgery for recurrent tumor.

Combined petrosal approach for resection of recurrent brainstem cavernous malformation: operative video and technical nuances.

Brainstem cavernous malformations are formidable lesions because of their eloquent location and propensity for bleeding resulting in neurological impairment. The surgical management can be challenging due to their deep location around critical neurovascular structures. In this operative video manuscript, the authors demonstrate resection of a large recurrent pontine cavernous malformation with an exophytic component in the cerebellopontine angle via a combined petrosal approach. Both anterior and posterior (retrolabyrinthine) petrosectomies were performed to allow multi-corridor access to the lesion. Due to excessive scar formation from prior surgeries, sharp dissection was paramount to create dissection planes around the lesion. This video atlas demonstrates the operative technique and surgical nuances of the skull base approach, safe resection of the malformation through the operative corridor, gentle handling of the neurovascular structures and a multi-layered reconstruction technique to prevent cerebrospinal fluid leakage. The use of endoscopic-assisted microsurgery of the brainstem is also demonstrated. A gross total resection was achieved, and the patient improved neurologically. In summary, the combined petrosal approach with endoscopic assistance is an important strategy in the armamentarium for the surgical management of brainstem cavernous malformations.The video can be found here: https://youtu.be/oAETW6tVc_Y.

Intramedullary teratoma.

Intramedullary teratoma.

Endoscopic Endonasal Transclival Approach for Resection of a Pontine Glioma: Surgical Planning, Surgical Anatomy, and Technique.

The endoscopic endonasal approach (EEA) has been proposed as a potential alternative for ventral brainstem lesions. The surgical anatomy, feasibility, and limitations of the EEA for intrinsic brainstem lesions are still poorly understood. To describe the surgical planning, anatomy, and technique of an intrinsic pontine glioma operated via EEA. Six-human brainstems were prepared for white matter microdissection. Ten healthy subjects were studied with high-definition fiber tractography (HDFT). A 56-yr-old female with right-hemiparesis underwent EEA for an exophytic pontine glioma. Pre- and postoperative HDFTs were implemented. The corticospinal tracts (CSTs) are the most eloquent fibers in the ventral brainstem. At the pons, CSTs run between the pontine nuclei and the middle cerebellar peduncle (MCP). At the lower medulla, the pyramidal decussation leaves no room for safe ventral access. In our illustrative case, preoperative HDFT showed left-CST displaced posteromedially and partially disrupted, right-CST posteriorly displaced, and MCP severely disrupted. A transclival exposure was performed achieving a complete resection of the exophytic component with residual intra-axial tumor. Immediately postop, patient developed new left-side abducens nerve palsy and worse right-hemiparesis. Ten days postop, her strength returned to baseline. HDFT showed preservation and trajectory restoration of the CSTs. The EEA provides direct access to the ventral brainstem, overcoming the limitations of lateral approaches. For intrinsic pathology, HDFT helps choosing the most appropriate surgical route/boundaries for safer resection. Further experience is needed to determine the indications and limitations of this approach that should be performed by neurosurgeons with high-level expertise in EEA.

PHOTODYNAMIC THERAPY FOR HEAD AND NECK BASAL CELL SKIN CANCER WITH ADDITIONAL INTERSTITIAL LASER IRRADIATION

The article is devoted to the development and evaluation of the effi ciency of photodynamic therapy (PDT) with photosensitizer photolon with additional interstitial laser irradiation in patients with head and neck basal cell skin cancer (BCSC). Treatment was performed in 55 patients. On the fi rst stage, all patients underwent photodynamic therapy with interstitial irradiation using fl exible optical fi bers with cylindrical diffuser, on the second stage PDT with distant delivery of laser at a dose of 50-300 J/cm2 was carried out. During the follow- up period of 6 months to 4 years in 13 (23.6%) of the 55 patients a recurrence of the disease was diagnosed. A higher rate of recurrence was in the group of patients who underwent PDT for recurrent neoplasms compared with patients with primary disease (37.5% and 4.3%, respectively), in patients with endophytic growth of the tumor compared to patients with exophytic component (30.0% and 16.0%, respectively) and in patients with large tumors (up to 2.0 cm – 14.3%, from 2.0 to 5.0 cm – 16.7% and more than 5.0 cm – 54.4%).

Role of Imaging in Diagnosis, Predicting Biological Activity and in Treatment Plan of Hydatid Disease

Cystic Echinococcosis (CE) is a zoonotic parasitic disease caused by the larval stage of the cestode Echinococcus granulosus. Hydatid cyst is a significant universal medical problem. In human cestode involves any organ and develops to hydatid cyst. Liver is the first and most frequently involved organ as the liver is the primary filter station of portal circulation. Though hydatid disease is benign disease, traditionally surgery is the treatment of choice for complete elimination of infective focus, which is associated with considerable mortality, morbidity. Systemic chemotherapy and percutaneous drainage have evolved in the recent past as an alternative to conventional surgery. The safety and success rate of these methods is influenced by the size, stage, location of the cysts and associated complications. Benzimidazoles can be considered in multiple, small hydatid cysts, but large cysts (cysts > 6 cm), bone marrow depression, pregnancy are contraindications of pharmacotherapy. Percutaneous drainage combined with ALB is a safe and effective treatment in liver hydatid patients with a surgical contraindication and younger cysts, but the presence of certain radiological signs (pericystic ducts and exophytic components) is a contraindication to non-surgical management because of the danger of biliary obstruction. However, the surgical treatment technique also cannot be standardized, should be tailored according to the cyst relation to the Broncho, biliary, vascular structures and associated complications if any. This review will focus on role of imaging in establishing the diagnosis, in determining cyst location, size, stage of the cyst and in identifying any associated complications, so that enable the clinician to perform recommended therapeutic procedures for the different cyst types and tailor the procedure performed based on cyst relation to broncho, biliary, vascular structures and associated complications.

Spontaneous regression of a mandibular arteriovenous malformation in a 9-year-old boy: Case report with twelve month follow up

Introduction Arteriovenous malformations (AVMs) of the jaws are considered as an unusual disease. Depending on the blood flow, size, and affected site of the AVMs, they may lead to life-threatening complications with significant morbidity. Mandibular AVMs may produce a wide variety of clinical signs and symptoms, which can lead clinicians to misdiagnosis and potential hemorrhages during inadvertent dental extractions in nearby areas of undiagnosed lesions. Although the spontaneous regression of an AVM had already been recognized in other human organs, the complete disappearance of a AVM is still considered a rare phenomenon. We aimed to report a clinical case of a spontaneously regressing AVM. Case description Nine-year-old boy was referred for Oral Medicine Clinic (Orocentro/Piracicaba Dental School - University of Campinas, Brazil) for the evaluation of a mandibular lesion, with an hemorrhagic event history after the inadvertent extraction of a deciduous molar (tooth number 75) associated with the lesion. Intraoral examination revealed an exophytic component with erythematous lesion in the left alveolar ridge, bleeding to light touch, flaccid, pulsatile, with absence of symptoms, and presented mobility grade II in tooth number 36. Both, intraosseous and gingival involvement were observed. Panoramic radiograph showed diffuse bone thinning in the left body involving tooth 36. Tomographic exam showed the presence of hypodense lesion in the left body of considerable dimensions. Considering the clinical characteristics, we formulated the diagnostic hypothesis of AVM. An arteriography without any embolization procedure was performed and confirmed the AVM diagnosis. A spontaneous regression of the AVM clinically and on imaging tests was observed after the arteriography. Twelve month follow up keeps the complete spontaneous regression of the intraoral exophytic component, complete clinical remission of the lesion and number 36 mobility grade I. Results and conclusions Although, oral AVM is a rare event, it may mimic benign inflammatory processes and reactive lesions. Thus, dental extractions associated with atypical lesions should be avoided until a vascular component is ruled out. Spontaneous regression of an AVM is an extremely rare event, not yet described in a lesion. In conclusion, we speculate that this rare case of a spontaneous regression of AVM could be due to the hemodynamic changes in the circulation and pressure of the lesion induced by the arteriographic exam.

Polypoid urothelial tumor with inverted growth pattern in the renal pelvis: morphologic and molecular characteristics of a unique diagnostic entity

We report 13 cases of unique polypoid urothelial tumors with inverted growth pattern (PUTIPs) occurring in the proximal ureter and renal pelvis. We describe their morphologic features and further characterize them in regard to TERT promoter mutation status and microsatellite instability. Thirteen cases were identified in our consult archives from 1994 to present. Patients ranged in age from 52 to 83 years at the time of diagnosis (mean, 68.4 years). Grossly, lesions were described variously as pink-tan to white exophytic and friable lesions that were polypoid or pedunculated, located in the renal pelvis or proximal ureter. The masses ranged in size from 0.5 to 3.2 cm (mean, 1.6 cm). PUTIP is a polypoid, plaque-like lesion with features of the following: (1) inverted papillary urothelial neoplasm of low malignant potential, lacking an exophytic papillary component; (2) florid von Brunn nest proliferation within and radiating outward from the polypoid lesion; and (3) in some cases, an inverted papilloma with densely hyalinized collagenous stroma. All 4 PUTIPs with formalin-fixed, paraffin-embedded material available were positive for the TERT promoter mutation 228G>A by polymerase chain reaction and were microsatellite stable. Given that PUTIP clinically forms a tumor and is typically treated by nephroureterectomy, it is best regarded as a unique benign urothelial neoplasm that exclusively occurs in the renal pelvis/proximal ureter.

A rare case of primary hepatic solitary fibrous tumor associated with pregnancy

Purpose: To describe a case of histologically and immunohistochemically confirmed primary hepatic solitary fibrous tumor (SFT) associated with pregnancy. Case Report: A 40-year-old Caucasian woman G3P1021 with history of oral contraceptive use and no other known significant past medical history delivered via C-section in November of 2012. Two months post delivery, she noted that her abdomen did not decrease in size and sought medical attention. As part of the work-up, an abdominal MRI revealed a 15.9 cm mass centered in segment 4b of the liver with extension into segments 5 and 8 within the right lobe. In addition, an exophytic component extending inferiorly from the liver into the right mid abdomen was noted. The patient underwent an uncomplicated hepatic segmentectomy with cholecystectomy. Grossly, the tumor consisted of a firm tan-white well-circumscribed and partially encapsulated mass. Histologically, the tumor was composed of cytologically bland spindle cells with a patternless architecture with hypocellular and hypercellular areas embedded within a collagenous fibrous stroma with occasional dilated branching thin-walled blood vessels. The tumor showed no infiltrative margins or necrosis and a mitotic count of 1/10HPF. Tumor cells were strongly and diffusely positive for CD34, BCL-2, and vimentin; weakly positive for STAT6 (nuclear distribution); and focally positive for CD99 and β-Catenin. In addition, estrogen and progesterone receptors (ER and PR) were also performed and showed positive staining. The diagnosis of SFT was confirmed. To date, 36 months post-resection, our patient has been followed with imaging, showing no evidence of residual or recurrent disease. Conclusions: Primary hepatic SFT is exceedingly rare and even more so in association with pregnancy. Positive immunohistochemical staining of tumor cells for progesterone and estrogen receptors may indicate hormonal stimulation as a driver of neoplastic cell proliferation.

THE WAYS TO OPTIMIZE CLINICAL OUTCOMES OF PHOTODYNAMIC THERAPY BY OPTICAL IMAGING TECHNIQUES

Background: Photodynamic therapy (PDT) is a modern minimally invasive technique for treatment of a wide range of diseases, including malignancies. One of directions for PDT development is the individualization of exposure modes that can be achieved with effective treatment monitoring. There are a number of approaches employing imaging techniques, the most promising of them being optical ones. Aim: To analyze factors affecting clinical outcomes of PDT in non-melanoma skin tumors, and to evaluate the prospects of optical imaging techniques for PDT planning and monitoring. Materials and methods: We retrospectively analyzed various aspects of the results PDT obtained in 855 patients with non-melanoma skin tumors. PDT was performed with systemic chlorine photosensitizers. As a source of irradiation, the laser at a wavelength of 662 nm was used following exposure modes: mean power density 0.3 W/cm², the laser irradiation dose of 200 J/cm² for basal cancer and 300 J/cm² for squamous cell carcinoma. Clinical evaluation was performed based on tumor response according to RECIST criteria, by the presence or absence of recurrence during long term follow up and by the presence or absence of cosmetic defects. Fluorescence imaging and optical coherence tomography were used as non-invasive imaging techniques. Results: It was found that clinical predictors of treatment failure included tumor recurrence, squamous type of tumor, and advanced exophytic or infiltrative component. Fluorescence imaging showed an association between clinical outcomes of PDT and fluorescence characteristics of the photosensitizer. The best clinical outcomes were achieved in 147 patients with a combination of high contrast fluorescence (FC>1.2) and a high degree of photobleaching of the agent (ΔIt/IN >25%): the number of complete tumor responses was 94% (138 of 147), with recurrence seen in 3 (2%) patients only with the follow up from 6 to 53 month duration. Clinical predictors of PDT cosmetic failures are tumor recurrence and tumor stage above T2. The most vulnerable zones are the outer ear and nose wings; this fact is related to an involvement of the cartilage located directly beneath the thin skin in the photodynamic reaction. This was demonstrated by optical coherence tomography. Conclusion: Presence of clinical predictors of PDT failure justifies correction of light exposure modes that can be optimally implemented with techniques for objective evaluation of the tumor borders, photosensitizer accumulation and photobleaching. Dynamic non-invasive monitoring of PDT procedure with fluorescence imaging and optical coherence tomography seems promising for implementation of an individual approach resulting in optimal oncological and functional outcomes.

Assessment of metastatic risk of gastric GIST based on treatment-naïve CT features

ObjectiveTo study whether the CT features of treatment-naïve gastric GIST may be used to assess metastatic risk. MethodsIn this IRB approved retrospective study, with informed consent waived, contrast enhanced CT images of 143 patients with pathologically confirmed treatment-naïve gastric GIST (74 men, 69 women; mean age 61 years, SD ± 14) were reviewed in consensus by two oncoradiologists blinded to clinicopathologic features and clinical outcome and morphologic features were recorded. The metastatic spread was recorded using available imaging studies and electronic medical records (median follow up 40 months, interquartile range, IQR, 21–61). The association of maximum size in any plane (≤10 cm or >10 cm), outline (smooth or irregular/lobulated), cystic areas (≤50% or >50%), exophytic component (≤50% or >50%), and enhancing solid component (present or absent) with metastatic disease were analyzed using univariate (Fisher's exact test) and multivariate (logistic regression) analysis. ResultsMetastatic disease developed in 42 (29%) patients (28 at presentation, 14 during follow-up); 23 (16%) patients died. On multivariate analysis, tumor size >10 cm (p = 0.0001, OR 9.9), irregular/lobulated outline (p = 0.001, OR 5.6) and presence of a enhancing solid component (p < 0.0001, OR 9.1) were independent predictors of metastatic disease. On subgroup analysis, an irregular/lobulated outline and an enhancing solid component were more frequently associated with metastases in tumors ≤5 cm and >5–≤10 cm (p < 0.05). ConclusionCT morphologic features can be used to assess the metastatic risk of treatment-naïve gastric GIST. Risk assessment based on pretreatment CT is especially useful for patients receiving neoadjuvant tyrosine kinase inhibitors and those with tumors <5 cm in size.

An unusual thoracic spinal pathology presenting as a dorsally exophytic intramedullary lesion

A 45-year-old woman presented with progressive spastic weakness of her lower limbs of 5 years' duration. She had previously undergone laminectomy and decompression of a thoracic lesion elsewhere. Magnetic resonance imaging of her spine (Fig. 1) demonstrated a well-defined intramedullary lesion from the T3 to T6 levels that was hyperintense on T1- and T2-weighted sequences. It had a broad, dorsally located exophytic component. Patchy areas of heterogeneously enhancing T2 isointense soft tissue components were seen in the superior aspect of the lesion (Fig. 2). There was no infiltration of the lesion into surrounding structures. The diagnosis was consistent with that of a recurrent intramedullary lipoma with a dorsally exophytic component. She underwent re-exploratory surgery and decompression of the lesion. Histopathology confirmed the lesion to be a lipoma. Fig. 2Gadolinium-enhanced T1 magnetic resonance imaging (MRI): (Left) midsagittal section showing patchy enhancement in the superior aspect of the lesion; (Right) axial section demonstrating the enhancing area extending into the exophytic component. View Large Image Figure Viewer Download Hi-res image