Extent Of Tumor Involvement Research Articles

BiZact-Assisted Endoscopic Resection of a Sinonasal Tumor.

The BiZact device, a bipolar electrosurgical scissor designed for tonsillectomy, minimizes thermal tissue damage and seals blood vessels <3 mm in diameter while dividing the soft tissue. This study describes the authors' experience with sinonasal tumor surgery using a BiZact and discusses its clinical utility and advantages. The authors analyzed BiZact-assisted endoscopic sinonasal tumor surgery cases between January 2021 and May 2023. Data were collected on patients' demographics, histopathology, extent of tumor involvement, surgical records, and postoperative medical records. Clinical utility was assessed using the success rate of complete tumor excision, estimated blood loss during surgery, device-related complications, and operation time. A survey of the surgeons' BiZact experience was also conducted. The diagnoses of the 20 patients in this study included squamous cell carcinoma (n = 2), malignant melanoma (n = 1), sarcoma (n = 1), natural killer cell lymphoma (n = 1), inverted papilloma (n = 12), angiofibroma (n = 2), and schwannoma (n = 1). This pilot study demonstrated a shortened operative time, with a median of 0.8 hours and <100 mL of intraoperative blood loss. In addition, no BiZact-related complications were observed. The BiZact device allows efficient sinonasal surgery because it has the unique advantage of one-step sealing and cutting. BiZact-assisted endoscopic sinonasal tumor surgery is a beneficial and safe procedure that reduces blood loss during surgery, shortens the operative time, and minimizes postoperative complications.

Prostate specif c antigen density as a prognostic factor in patients with prostate cancer treated with combined hormonal radiation therapy

Purpose. To evaluate prostate specifc antigen density (PSAD) as a predictor of overall (OS) and cancerspecifc survival (CSS) in patients with prostate cancer (PC) who have undergone combined hormonal-radiation therapy.Material and Methods. In order to assess the prognostic signifcance of PSAD we retrospectively analyzed outcomes of 714 PCa patients who received combined hormonal-radiation therapy at the A.M. Granov Russian Scientifc Center of Radiology and Surgical Technologies, Ministry of Healthcare of Russia, between January 1996 and December 2016. Since the prognosis and management differ according to the extent of tumor involvement, patients were categorized into localized (n=272), locally advanced (n=231) and metastatic (n=211) PC groups. We equentially applied ROC-analysis, Kaplan-Meier product limit estimator and Cox proportional hazards model to assess the prognostic relevance and establish threshold values of PSAD that had a signifcant impact on survival rates.Results. In the localized PC group, PSAD threshold values of 0.34 ng/mL/cc and 0.36 ng/mL/cc were associated with a decrease in OS and CSS, respectively. Patients with “low” PSAD had signifcantly better OS and CSS survival rates in both uni- and multivariate analyses. In locally advanced PC group, PSAD threshold values were 0.28 ng/mL/cc and 0.63 ng/mL/cc for OS and CSS, respectively. However, exceeding the specifed values, in the locally advanced PC group, was not accompanied by a statistically signifcant decrease in survival rates. Finally, in the metastatic PC group, established PSAD threshold values were 2.25 ng/mL/cc and 2.30 ng/mL/ccfor OS and CSS, respectively. According to the results of univariate analysis, patients with “low” PSA tend to demonstrate statistically signifcant better OS and CSS rates. The results of multivariate analysis, however, failed to prove PSAD as an independent prognostic factor within the metastatic PC cohort. Conclusion. PSA density is a reliable tool for assessing survival rates in patients with localized PC who have undergone combined hormonal-radiation therapy.

Contribution of narrow band imaging in delineation of laryngopharyngeal superficial cancer spread: a prospective study.

The aim of this study was to assess the performance of Narrow Band Imaging (NBI) added to White Light (WL) in the delineation of laryngopharyngeal superficial cancer spread during office-based transnasal flexible endoscopy. This bi-centric prospective study was conducted between October 2014 and December 2017. We included consecutive patients with laryngopharyngeal malignant tumors. Transnasal flexible endoscopy was performed by two endoscopists who were blinded to each other's assessments and who examined each patient independently. The first endoscopist only performed a WL examination, while the second endoscopist carried out both WL and NBI. The extent of tumor involvement was reported based on predefined anatomical sub-units. Biopsies in NBI + /WL- sub-units were subsequently performed during panendoscopy. Eighty-four patients were included in the study. A total of 72 NBI + /WL- sub-units were sampled in 38 patients, and 37 of the biopsies were positive (51.4%): 16 for invasive carcinoma, 17 for high-grade dysplasia/carcinoma in situ and 4 for low-grade dysplasia. Ultimately, 26.2% of patients had at least one positive biopsy in an NBI + /WL- sub-unit and, therefore, a better tumor delineation. The clinical T stage was upgraded in 4.8% of cases examined. Adding NBI to WL imaging during transnasal flexible endoscopy in patients presenting with laryngopharyngeal pre-malignant or malignant lesions improves the delineation of superficial cancer spread, thereby leading to better adapted treatments. Clinicaltrials.gov registration number: NCT02035735.

Duodenal GI stromal tumors: Is radical resection necessary?

Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors that pose a surgical challenge, and long-term outcomes after resection have not been detailed outside of small case series. This study uses the National Cancer Database (NCDB) to examine the determinants of radical resection for duodenal GISTs as well as the impact of local vs radical resection on overall survival (OS). The NCDB was queried for nonmetastatic duodenal GISTs from 2004 to 2014. Predictors of radical resection were determined using multivariate logistic regression stratified by extent of tumor involvement. Factors associated with OS were identified with Cox proportional regression analysis. Treatment at an academic center, size >5 cm, and extra-duodenal extension were associated with radical resection. On multivariate analysis, radical resection was associated with decreased OS (HR, 1.93; P < .03). Systemic therapy, extra-duodenal extension, grade, stage, mitoses, and receipt of systemic therapy did not impact OS. Local resection of duodenal GISTs is associated with improved OS compared to radical resection after controlling for tumor factors and systemic treatment. Traditional indicators of tumor aggressiveness were associated with radical resection, but not OS. When feasible, local resection should be considered for resection of duodenal GISTs.

161 - The AJCC 8th edition no longer substages pT2 prostate cancer: Does extent of tumor involvement not matter?

161 - The AJCC 8th edition no longer substages pT2 prostate cancer: Does extent of tumor involvement not matter?

Risk factor analysis of progressive spinal deformity after resection of intramedullary spinal cord tumors in patients who underwent laminoplasty: a report of 105 consecutive cases.

Laminoplasty has been used in recent years as an alternative approach to laminectomy for preventing spinal deformity after resection of intramedullary spinal cord tumors (IMSCTs). However, controversies exist with regard to its real role in maintaining postoperative spinal alignment. The purpose of this study was to examine the incidence of progressive spinal deformity in patients who underwent laminoplasty for resection of IMSCT and identify risk factors for progressive spinal deformity. Data from IMSCT patients who had undergone laminoplasty at Beijing Tsinghua Changgung Hospital between January 2014 and December 2016 were retrospectively reviewed. Univariate tests and multivariate logistic regression analysis were used to assess the statistical relationship between postoperative spinal deformity and radiographic, clinical, and surgical variables. One hundred five patients (mean age 37.0 ± 14.5 years) met the criteria for inclusion in the study. Gross-total resection (> 95%) was obtained in 79 cases (75.2%). Twenty-seven (25.7%) of the 105 patients were found to have spinal deformity preoperatively, and 10 (9.5%) new cases of postoperative progressive deformity were detected. The mean duration of follow-up was 27.6 months (SD 14.5 months, median 26.3 months, range 6.2-40.7 months). At last follow-up, the median functional scores of the patients who did develop progressive spinal deformity were worse than those of the patients who did not (modified McCormick Scale: 3 vs 2, and p = 0.04). In the univariate analysis, age (p = 0.01), preoperative spinal deformity (p < 0.01), extent of tumor involvement (p < 0.01), extent of abnormal tumor signal (p = 0.02), and extent of laminoplasty (p < 0.01) were identified as factors associated with postoperative progressive spinal deformity. However, in subsequent multivariate logistic regression analysis, only age ≤ 25 years and preoperative spinal deformity emerged as independent risk factors (p < 0.05), increasing the odds of postoperative progressive deformity by 4.1- and 12.4-fold, respectively (p < 0.05). Progressive spinal deformity was identified in 25.7% patients who had undergone laminoplasty for IMSCT resection and was related to decreased functional status. Younger age (≤ 25 years) and preoperative spinal deformity increased the risk of postoperative progressive spinal deformity. The risk of postoperative deformity warrants serious reconsideration of providing concurrent fusion during IMSCT resection or close follow-up after laminoplasty.

Endoscopic Endonasal Versus Transorbital Surgery for Middle Cranial Fossa Tumors: Comparison of Clinical Outcomes Based on Surgical Corridors

Based on our experience with the endoscopic endonasal approach (EEA) and transorbital approach (TOA) for middle cranial fossa tumors, we evaluated the efficacy and limitations of visualization and the clinical outcomes associated with the approaches depending on the surgical corridors. In addition, we determined the optimal strategy for each approach. Between September 2015 and May 2018, we retrospectively reviewed clinical outcomes in 21 patients who underwent minimally invasive endoscopic surgery for middle cranial fossa tumors involving the cavernous sinus. We classified the endoscopic approaches into 4 groups: endonasal quadrangular transcavernous (type I), endonasal infratemporal (type II), transclival medial-to-lateral (type III), and transorbital (type IV) routes. Displacement of the internal carotid artery, extent of tumor involvement, and the surgical corridor to the tumor direction were the primary determinants of the approach. The study enrolled 21 patients. Based on the classification of approaches, 6 patients underwent surgery via type I, 5 via type II, 1 via type III, 7 via type IV, and 2 via a combined approach. Among the 21 patients, gross total resection was performed in 12 (57.1%), subtotal resection in 6, and partial resection in 3. Comparison of the type I (EEA) with the type 4 (TOA) route showed that the gross total resection rate with the EEA was 33.3% compared with 71.4% with the TOA (P= 0.286). Endoscopic surgery can be considered an alternative with acceptable sequelae and reduced morbidity for the management of middle cranial fossa tumors. Surgeons should be aware of the strengths and weaknesses of each surgical corridor and select the optimal approach for each patient based on the tumor.

Diffuse Large B-cell Lymphoma Presenting as Upper Gastrointestinal Bleeding

Gastric lymphoma is a rare cause of GI bleeding. We hereby report a case of diffuse large B-cell lymphoma that extensively invaded the stomach, spleen and pancreatic tail and demonstrates the aggressive nature of the disease and our diagnostic and therapeutic approach. A 74-year-old woman with a history of peptic ulcer disease presented with dark output from her nasogastric tube and melena. CT without contrast two months ago showed a large necrotic mass invading the spleen, for which she underwent a non-diagnostic CT-guided para-aortic lymph node biopsy as well as laparoscopic biopsy of greater curvature lymph node and retroperitoneal mass that was suspicious for lymphoma. On presentation, she was febrile, hypotensive and tachycardic. She was intubated and sedated. Labs revealed a Hgb of 7.9 g/dL, WBC 33.8 K/mm, AST 125 IU/L, ALP 186 U/L, alb 1.6 g/dL, T bili 2.4 mg/dL. CT scan on admission showed heterogeneous neoplasm involving the pancreatic tail, gastric body, spleen and metastatic upper abdominal lymphadenopathy (Figure 1). PET demonstrated an intensely FDG-avid confluent mass involving the pancreatic tail, spleen and greater curvature of the stomach with FDG-avid abdominal adenopathy (Figure 2). EGD showed a nonbleeding, large infiltrative non-circumferential mass on the lesser curvature of the stomach (Figure 3). A review of the prior laparoscopic biopsies showed large atypical cells of B-cell origin based on PAX5, CD19 and CD79a expression, diagnosis of a diffuse large B-cell lymphoma was made. Results of EGD with biopsy and laparoscopic biopsy were consistent. Given recurrent active bleeding requiring vasopressors and transfusions, IR was consulted and hemostasis achieved with embolization of left gastric and splenic artery. However, she died soon after discharge due to the diffuse nature of the disease. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma. Since DLBCL can advance quickly, it usually requires immediate chemotherapeutic treatment once the diagnosis is established. Surgery is considered as second-line treatment for severe perforation, bleeding, or a need for palliative treatment. An EGD can help confirm the diagnosis and rule out other sources of bleeding. In this setting, EGD biopsy could have obviated the need for a laparoscopic biopsy. Given the extent of tumor involvement in our case, endoscopic hemostasis is rarely successful and IR is necessary for hemostasis.Figure: A large mass inseparable from the pancreatic tail and gastric antrum inferiorly was seen on CT abdomen/pelvis. This appears to invade the spleen at the splenic hilum and the largest component of the mass measures up to 11 x 7.2 x 12 cm.Figure: Intensely FDG-avid confluent mass with central necrosis is noted involving the pancreatic tail, spleen and greater curvature of the stomach, correlating to hypoenhancing mass noted on CT measuring approximately 11.5 x 7.2 cm.Figure: EGD showed a large, infiltrative mass with oozing and stigmata of recent bleed.

A Ten-Year Study of Prostate Cancer: A Southern Iranian Experience

Prostate cancer is the most common malignancy among the male population in the United States and the 3rd most common non-skin cancer among men in Iran. Its prevalence has shown a rising trend in recent decades. The aim of this study was to report the epidemiological features of prostate cancer in patients referred for prostate biopsy in the south of Iran and to evaluate the accuracy of the levels of the prostate-specific antigen (PSA) and the PSA-density (PSAD) as well as the extension of the disease in the prediction of the biological behavior of prostate cancer. This is a retrospective study on the medical records of 1982 consecutive patients who underwent transrectal ultrasound-guided biopsy due to an abnormal digital rectal examination and/or an elevated PSA level following referral from the Urology Ward to the Radiology Department of Shahid Faghihi Hospital in Shiraz, southern Iran, between December 2003 and July 2014. The overall cancer detection rate was 33.1%. Although the cancer was more prevalent among the elderly patients, a significant fraction (7%) of the patients were aged < 55 years. The sensitivity and specificity of the PSA were 97.4% and 8.7% and those of the PSAD were 82.9% and 52%, respectively. Of the 637 patients with prostate cancer, 250 (39.2%) had unilateral disease, 378 (59.4%) had bilateral disease, and 9 (1.4%) had inner-gland involvement. Most of the patients with bilateral involvement had high-grade Gleason scores. Our study underlines the relationship between age and the frequency of cancer; the levels of the PSA and the PSAD and the Gleason score; and the extent of tumor involvement and the grade of prostate cancer and also highlights the significance of screening, especially in younger patients.

Accuracy of Various MRI Sequences in Determining the Tumour Margin in Musculoskeletal Tumours.

SummaryBackgroundIt is imperative that bone tumour margin and extent of tumour involvement are accurately assessed pre-operatively in order for the surgeon to attain a safe surgical margin. In this study, we comprehensively assessed each of the findings that influence surgical planning, on various MRI sequences and compared them with the gold standard – pathology.Material/MethodsIn this prospective study including 21 patients with extremity bone tumours, margins as seen on various MRI sequences (T1, T2, STIR, DWI, post-gadolinium T1 FS) were measured and biopsies were obtained from each of these sites during the surgical resection. The resected tumour specimen and individual biopsy samples were studied to assess the true tumour margin. Margins on each of the MRI sequences were then compared with the gold standard – pathology. In addition to the intramedullary tumour margin, we also assessed the extent of soft tissue component, neurovascular bundle involvement, epiphyseal and joint involvement, and the presence or absence of skip lesions.ResultsT1-weighted imaging was the best sequence to measure tumour margin without resulting in clinically significant underestimation or overestimation of the tumour extent (mean difference of 0.8 mm; 95% confidence interval between −0.9 mm to 2.5 mm; inter-class correlation coefficient of 0.998). STIR and T1 FS post-gadolinium imaging grossly overestimated tumour extent by an average of 16.7 mm and 16.8 mm, respectively (P values <0.05). Post-gadolinium imaging was better to assess joint involvement while T1 and STIR were the best to assess epiphyseal involvement.ConclusionsT1-weighted imaging was the best sequence to assess longitudinal intramedullary tumour extent. We suggest that osteotomy plane 1.5 cm beyond the T1 tumour margin is safe and also limits unwarranted surgical bone loss. However, this needs to be prospectively proven with a larger sample size.

Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases.

To explore the outcomes of surgical treatment of sacral neurogenic tumors Between 1 January 2003 and 31 December 2012, data on 64 patients with sacral neurogenic tumors treated with surgery were retrospectively analyzed. The mean age of the 64 cases (35 males and 29 females) was 37.2 years (range, 21-69 years); 38 had neurilemmomas and 26 neurofibromas. Thirty-four of the tumors involved S 1 and S 2 , 11 S 3 or lower, and 19 were single presacral soft tissue masses. Tumors were removed via anterior, posterior or combined anteroposterior approaches. Patients with unstable sacroiliac joints underwent iliolumbar fixation. Depending on the extent of tumor involvement, one of three surgical approaches was used: a single anterior approach (19 patients), single posterior approach (25 patients), or a combined anteroposterior approach (20 patients). The mean operation time was 3 h (range, 2-6 h) and the mean blood loss 878 mL (range, 400-3120 mL). The mean duration of follow-up was 58.2 months (range, 24-93 months). These surgeries had the following complications. Three patients had massive intraoperative hemorrhage and posterior back pain and discomfort postoperatively. One patient had intraoperative ureteral injuries requiring intraoperative ureteral catheterization. In two patients, the tumor involved the S 1 nerve roots bilaterally, necessitating their removal, which resulted in obvious lower limb motion and sphincteric dysfunction. In 13 patients with unilateral tumor involvement of the nerve roots of S 1 and lower spinal levels, only the contralateral nerve roots of the S1 and lower levels were preserved; eight of these patients had impaired bladder and bowel function. Posterior incisions failed to heal in 10 patients, secondary wound healing occurred in nine of them and one required a gluteus maximus myocutaneous flap. Three patients developed postoperative cerebrospinal fluid leaks that were and alleviated by waist belt compression bandaging and placing them in the Trendelenburg position. Eight patients developed tumor recurrences postoperatively; pathological examination of the tissue excised in the second surgeries revealed malignant changes in the three patients with neurilemmomas. There were no intraoperative deaths. Rod fractures occurred in three of the 18 patients requiring iliolumbar reconstruction. The clinical characteristics of sacral neurogenic tumors make them easy to diagnose. The approach to resection should be determined by the location and size of the tumor. Patients with huge tumors may lose considerable blood intraoperatively and a have higher risk rate of postoperative complications.

Radioembolization with yttrium-90 resin microspheres for neuroendocrine tumor liver metastases.

We aimed to evaluate the effectiveness and safety of radioembolization with yttrium-90 (90Y) microspheres in cases with unresectable neuroendocrine tumor liver metastases (NETLMs). Thirty patients (mean age, 55 years) underwent resin-based 90Y radioembolization for unresectable NETLM at a single institution between April 2008 and June 2013. Post-treatment tumor response was assessed by cross-sectional imaging using the Response Evaluation Criteria in Solid Tumors (RECIST). Prognostic variables that affected survival were determined. The mean follow-up was 23.0±19.4 months and the median overall survival was 39 months (95% CI, 12.6-65.4 months), with one- and two-year survival rates of 71% and 45%, respectively. Imaging follow-up using RECIST at three-month intervals demonstrated partial response in 43%, complete remission in 3%, stable disease in 37%, and progressive disease in 17% of patients. Extent of tumor involvement was found to have a statistically significant influence on overall survival (P = 0.03). The existence of extrahepatic disease at the time of radioembolization, radiographic response, age, and primary neuroendocrine tumor site were not significant prognostic factors. The current study demonstrates the effectiveness and safety of radioembolization for the treatment of unresectable NETLMs. We identified that the extent of tumor involvement has a significant effect on overall survival. The use of imaging methods reflecting metabolic activity or cellularity such as scintigraphy or diffusion-weighted MRI would be more appropriate, for the response evaluation of liver metastases after radioembolization.

Patterns of relapse after concurrent temozolomide and dose-escalated intensity-modulated radiation therapy (IMRT) in newly diagnosed glioblastoma (GBM).

2052 Background: We hypothesized that IMRT would permit us to safely escalate the dose of radiation with concurrent temozolomide substantially above the current standard of 60 Gy and that this increased dose would more adequately control local disease leading to an alteration in the patterns of relapse in patients with GBM. Methods: Between 2003 and 2012 a total of 69 patients were treated with dose-escalated IMRT with concurrent temozolomide. 39 patients were initially treated in a combined phase I/II trial with IMRT doses of 66 to 81 Gy over 6 weeks with concurrent daily temozolomide (75 mg/m2) followed by adjuvant cyclic temozolomide (200 mg/m2 d1-5 q28d for 6 or more cycles). Subsequently, 30 additional patients were treated to 66-72 Gy based on the reported efficacy and safety of the initial phase I/II study. Results: All 69 patients were assessed to evaluate the effect of dose escalation on late toxicity and patterns of progression. Median RT dose was 72 Gy and median overall survival was 19.0 months. Late CNS grade III toxicity was observed at 78 (2 of 7 patients) and 81 Gy (1 of 9 patients). 0 of 53 patients receiving 75 or less Gy developed necrosis. 64% (44/69) of patients had progression of their disease after dose-escalated chemoradiotherapy. The patterns of progression differ, however, from previous studies which identify in-field relapse of 72-80% with standard dose radiation (Brandes AA, Tosoni A, Franceschi E, et al: J Clin Oncol. 27:1275-9, 2009). In this cohort, 41% (18/44) of patients developed marginal or distant relapse compared to 59% (26/44) who developed local, in-field relapse. Conclusions: Patients with GBM can safely receive standard temozolomide with up to 75 Gy in 30 fractions, delivered using IMRT. Dose-escalated chemoradiotherapy improves local control and leads to an increased percentage of patients progressing distally, highlighting the need for improved tumor targeting with newer imaging modalities to identify the initial extent of tumor involvement as well as the need for more effective systemic treatment. I/II study.

CT and MR imaging findings of acinic cell carcinoma in salivary gland

Objective To explore the CT and MR imaging findings of acinic cell carcinoma (ACC) in salivary gland and enhance the diagnosis of this rare disease. Methods The CT and MR imaging characteristics of 20 patients (7 males and 13 females,median age 44 years old) with pathologically proved ACC were retrospectively reviewed.CT and MR images were evaluated in relation to the following: location,size,morphology,margin,CT density/MR signal intensity and enhancement pattern. Results Twelve lesions were located in parotid gland,two lesions in maxillary Sinus,and one lesion in submandibular,parapharyngeal,infratemporal fossa,buccal,nasal cavity,and hard palate respectively.The size of lesions were 0.7~ 5.8 cm.Sixteen lesions less than 3 cm in size demonstrated round or oval round masses with well defined margin.Four lesions more than 3 cm in size demonstrated irregular masses with unclear margin.Among them,bony destruction of the wall of the maxillary sinus was noted in 3 cases,and the preauricular skin was invaded in 1 case.The densities (signal intensity) were homogeneous in 6 cases and heterogeneous in 14 cases.Lesions were slightly low density in 11 case and isodensity in 3 cases on CT plain scan.Lesions were homogeneous isointense in 2 cases and heterogeneous isointense in 4 cases on T 1WI,heterogeneous hyperintense in all cases on T 2WI.On post contrast images,lesions demonstrated remarkable enhancement in 14 cases,moderate enhancement in 2 cases and mild enhancement in 3 cases. Conclusions The imaging characteristic of ACC were nonspecific.CT and MR could accurately detect the extent of tumor involvement and was helpful to provide more comprehensive information for the strategy of clinic therapy. Key words: Carcinoma,aciniar cell; Tomography,X-ray computed; Magnetic resonance imaging

Evaluation of microscopic tumor extension in early-stage cervical cancer: quantifying subclinical uncertainties by pathological and magnetic resonance imaging findings

We performed a detailed analysis of hysterectomy specimens of uterine cervical cancer to determine the appropriate length of uterine body to include within the clinical target volume. Between 2008 and 2011, 54 patients with uterine cervical carcinoma underwent hysterectomy. Those with quality pre-operative magnetic resonance imaging (MRI) data were included for analysis. Tumor sizes measured by MRI and microscopy were compared with regard to brachytherapy-oriented parameters. Detailed descriptive analysis focusing on the extent of tumor involvement was also performed. A total of 31 specimens were analyzed. The median maximal tumor length measured by MRI was slightly shorter than microscopic length (19 vs. 24 mm, respectively), while the maximal radius was almost identical. No tumors with a maximal size <2 cm by MRI (n = 6) extended to the uterine body ≥ 1/3. The majority of maximal tumor length underestimation on MRI was within 1 cm. Precise tumor delineation can be made by MRI. For patients with tumors <2 cm on MRI, treating the entire uterine body length may not be necessary. A 1-cm margin around an MRI-based gross tumor seems to be adequate to cover the actual tumor involvement.

Treatment of Recurrent or Persistent Cervical Node Metastases in Differentiated Thyroid Cancer: Deceptively Simple Options

Occasionally in medicine a clinical situation that appears simple on the surface is, in reality, much more difficult and complex. Such is the case with the common occurrence (estimated to be as frequent as 30%) of recurrent or persistent papillary thyroid cancer identified in cervical lymph nodes (1, 2). Given the frequency of this circumstance, it would be expected that there would be a large number of prospective, randomized trials assessing the effectiveness of various treatment modalities. In fact, no such trials exist, and the literature represents retrospective studies with a relatively small number of patients. There are several potential (not mutually exclusive) approaches to such patients, including observation, surgery, radioactive iodine therapy, and ethanol injection. The clinical issue is how to approach these patients when there is apparent recurrence or persistence of cervical lymph nodes after initial therapy, which would usually include a thyroidectomy with radioactive iodine therapy. The American Thyroid Association guidelines (3) note that development of a recurrence is associated with a higher mortality, but the clinical benefit of diagnosing and treating small-volume recurrent disease that was detected by sensitive techniques is unclear. In the absence of distant metastases, surgery is favored for cervical lymph node recurrence (3). For patients with recurrent or persistent cervical nodal disease, comprehensive compartment and/or central neck dissection should be performed (3). Limited lateral and/or central compartment dissection is considered a reasonable alternative to more comprehensive neck dissection (3). Several basic questions arise before the issue of appropriate treatment can be considered. How often do cervical lymph nodes grow and cause significant local disease (e.g. tracheal or esophageal invasion or vascular invasion with bleeding)? These circumstances are thought to be extremely rare, especially in patients already preselected for relatively nonaggressive disease. Do local cervical metastases cause distant metastases? Recent studies have led to theories that cancer metastases from the original site involve multiple events including epithelial to mesenchymal transition, and local and distant invasion, each involving a complex series and interactions of genes and proteins, and a receptive distant host site (4). Cancer cells have been found to circulate. Furthermore, there is evidence that local and distant metastases can return to the site of the original tumor and reseed the primary tumor (4, 5). Therefore, it is conceivable that papillary thyroid cancer residing in cervical lymph nodes could relate to progressive primary and distant tumor growth. A corollary question is whether removal of a portion of the cervical node mass would relate to improvement in clinical parameters such as disease-free survival, morbidity, and mortality. It is unknown whether the number or localization of involved cervical nodes or the extent of tumor involvement in an involved cervical lymph node is associated with a worse clinical course. There are no controlled studies comparing different therapeutic approaches to these issues. Given that definitive answers to these important questions are not known, we have to rely on clinical studies to provide guidance on how to approach these patients. In this issue of the JCEM, Robenshtok et al. (6) report that monitoring selected low-risk individuals with recurrent or persistent cervical papillary thyroid cancer in lateral lymph nodes is a reasonable option in many patients. Excluding from analyses patients with aggressive histology or clinical features and using sonographic criteria, they

Transorbital Approach to the Anterior Cranial Skull Base

Based on our experience with the endoscopic endonasal approach (EEA) and transorbital approach (TOA) for middle cranial fossa tumors, we evaluated the efficacy and limitations of visualization and the clinical outcomes associated with the approaches depending on the surgical corridors. In addition, we determined the optimal strategy for each approach.Between September 2015 and May 2018, we retrospectively reviewed clinical outcomes in 21 patients who underwent minimally invasive endoscopic surgery for middle cranial fossa tumors involving the cavernous sinus. We classified the endoscopic approaches into 4 groups: endonasal quadrangular transcavernous (type I), endonasal infratemporal (type II), transclival medial-to-lateral (type III), and transorbital (type IV) routes. Displacement of the internal carotid artery, extent of tumor involvement, and the surgical corridor to the tumor direction were the primary determinants of the approach.The study enrolled 21 patients. Based on the classification of approaches, 6 patients underwent surgery via type I, 5 via type II, 1 via type III, 7 via type IV, and 2 via a combined approach. Among the 21 patients, gross total resection was performed in 12 (57.1%), subtotal resection in 6, and partial resection in 3. Comparison of the type I (EEA) with the type 4 (TOA) route showed that the gross total resection rate with the EEA was 33.3% compared with 71.4% with the TOA (P = 0.286).Endoscopic surgery can be considered an alternative with acceptable sequelae and reduced morbidity for the management of middle cranial fossa tumors. Surgeons should be aware of the strengths and weaknesses of each surgical corridor and select the optimal approach for each patient based on the tumor.

Role of Imaging in Rectal Cancer

THIS ARTICLE HAS NO ABSTRACT (FIRST 100 WORDS OF THE ARTICLE ARE DISPLAYED): &#x0D; Staging of rectal cancer is necessary to provide the optimal treatment strategy although proctoscopy or sigmoidoscopy with biopsy are diagnostic. This is achieved by locoregional assessment of the disease by various available radiological investigations. Staging information includes extent of tumor involvement of the rectal wall and adjacent structures, presence or absence of adjacent lymphadenopathy, and determination of distant metastasis. Several modalities exist for the preoperative staging of rectal cancer, like computed tomography (CT); magnetic resonance imaging (MRI) with traditional body, endorectal, or phasedarray coils; endorectal ultrasonography (ERUS) with rigid or flexible probes; and positron emission tomography (PET) with and without. JMS 2012;15(1):4-6.

Differentitation between Primary Central Nervous System Lymphoma and Glioblastoma: Added Value of Quantitative Analysis of CT Attenuation and Apparent Diffusion Coefficient

Purpose : Purpose of this study was to determine if quantitative measures of CT attenuation and ADC values in combination with conventional imaging features can differentiate primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM). Materials and Methods: Twenty-six patients with histologically-proven GBM (14 men and 12 women; median age, 50 years; age range, 22 73 years) and 14 patients with PCNSL (11 men and 3 women; median age, 61 years; age range, 41 74 years) were enrolled. Maximum CT attenuation, minimum ADC, and lesion to normal parenchyma minimum ADC ratios were measured in solid tumor regions. Conventional imaging features were evaluated for the following: ill-defined margin, homogeneous enhancement pattern, degree of necrosis, extent of tumor involvement and multiplicity. The Mann-Whitney test was used to compare maximum CT attenuation and minimum ADC values for PCNSL and GBM. Fisher’s exact test was used to evaluate relationships between pathologic diagnoses and imaging features. Results: The CT attenuations were similar for PCNSL and GBM (37.84 ± 6.90 HU versus 37.00 ± 5.54 HU, p = 0.68), but minimum ADC and minimum ADC ratio were significant lower in PCNSL than in GBM (595.01 ± 228.28 10 mm/s versus 736.52 ± 162.05 10 mm/s; p = 0.028, 0.87 ± 0.26 versus 1.14 ± 0.29; p = 0.007). PCNSL showed greater homogeneous enhancement and smaller necrotic areas than GBM (p = 0.003 and p < 0.001, respectively) and was more likely to have multiple tumors than GBM (p = 0.039). When necrotic PCNSL (n = 4) and necrotic GBM (n = 24) were compared, minimum ADC and minimum ADC ratios were also significantly lower in PCNSL, but CT attenuation were not. Conclusion: Although CT attenuation does not provide valuable information, minimum ADC and minimum ADC ratio and some imaging features can aid the differentiation of PCNSL and GBM. Index words : Central Nervous System∙Lymphoma∙Glioblastoma∙Computed tomography (CT) Diffusion weighted imaging (DWI)

Proteasome activity in tumors of the female reproductive system

Proteasomes (multiproteinase protein complexes) are known to play an important role in cancer pathogenesis, however, few information about their activity in human tumor tissues is available so far. We studied chymotrypsin-like activity of proteasomes in tissues of breast cancer (BC) and endometrial cancer (EC). The chymotrypsin-like total proteasome activity and the 20S and 26S proteasome activity in malignant tissues were shown to be significantly higher in malignant tumors than in normal tissues. No increase in proteasome activity was registered with larger tumor size in both BC and EC, whereas proteasome activity was changed with respect to the extent of tumor involvement. In breast cancer tissues, significant reductions in the total and the 26S proteaome activities were observed in tumors with regional lymph node metastases as compared to tumors without metastases. In endometrial cancer tissues, the total proteasome activity and the 20S and 26S proteasome activities were increased as the depth of myometrial invasion. The data obtained indicate that the proteasome acyivity is significantly changed in the process of cancerogenesis and further study is needed to develop new additional prognostic criteria and effective anti-tumor agents in molecular-directed therapy.