Stereotaxic intracavitary irradiation for cystic craniopharyngiomas

Stereotaxic intracavitary irradiation with instillation of phosphorus-32 (32P) colloidal chromic phosphate was performed in nine patients with cystic craniopharyngiomas. Serial neurological, ophthalmological, neuroendocrinological, and radiological examinations were performed before and after treatment. Dosimetry was determined based on a computerized tomography (CT) estimation of tumor volume, and was calculated to provide a tumoricidal dose (200 to 300 Gy) to the cyst wall. The follow-up period ranged from 14 to 45 months (mean 27 months). After treatment, all nine patients showed improvement of symptoms and radiological evidence of cyst regression. Because of an expanding solid component producing recurrent symptoms, one patient required a craniotomy 14 months after isotope instillation. Three of five patients with impaired visual acuity before surgery had significant improvement in acuity after treatment. Preoperative visual field defects in eight patients improved in four after 32P therapy. Of seven patients with preoperative endocrine abnormalities, one individual showed almost complete normalization and another had improvement in endocrine function. Patients who exhibited residual neuroendocrine function before isotope instillation developed no significant deterioration in endocrine status during the follow-up period. The findings suggest that stereotaxic intracavitary irradiation is a safe and effective treatment which should be considered as the initial surgery for cystic craniopharyngiomas.     

Management of cystic craniopharyngiomas with phosphorus-32 intracavitary irradiation

OBJECTIVE: The efficacy of stereotactic intracavitary irradiation with phosphorus-32 ((32)P) for patients with cystic craniopharyngiomas was assessed on the basis of patient survival, tumor control, and visual and endocrinological function before and after treatment. Limited data are available regarding long-term outcomes. METHODS: Forty-nine patients were treated with stereotactic (32)P intracavitary irradiation. Of these, 25 had had no prior treatment as the primary treatment, and 24 were treated for residual or recurrent tumor cysts. At the time of (32)P intracavitary irradiation, 34 of the patients were adults, and 15 were children younger than 16 years of age. The mean cyst volume was 13 ml. The radiation dose varied from 189 to 250 Gy to the cyst wall during five half-lives of the isotope (mean, 224 Gy). The mean follow-up periods were 7 years after diagnosis and 4 years after (32)P treatment. RESULTS: The actuarial survival rates were 90% at 5 years after the diagnosis and 80% at 10 years. The actuarial tumor cyst control rates were 76% at 5 years and 70% at 10 years after the diagnosis. After treatment, 9 (23%) of 40 patients who underwent preoperative and postoperative visual testing were found to have delayed worsening in visual function, 6 as a result of tumor progression and 3 attributed to irradiation. Nineteen patients (48%) had improved visual function. Of 17 patients who had normal preoperative pituitary function or stalk effect, 12 (71%) had preserved and 5 (29%) had worsened visual function. No complications other than visual or endocrinological deterioration occurred in these patients. CONCLUSION: For patients with cystic craniopharyngiomas, (32)P intracavitary irradiation proved effective, with a low risk of complications, for the control of tumor cysts but not of solid tumor components.     

Internal irradiation for cystic craniopharyngioma

The authors report the results of internal irradiation with labeled chromic phosphate (32P) and gold-198 (198Au) colloid in eight cases of cystic craniopharyngiomas. They used a newly developed dosimetric formula, by which the radiation dose at the cyst wall and at any point far from the radioactive source can be calculated. Ten courses of irradiation in eight patients were carried out by injection of either 32P or 198Au colloid into the cyst through an Ommaya drainage system that had been placed at craniotomy. Follow-up studies ranging from 13 to 156 months revealed that all cysts were effectively treated, with elimination of fluid or collapse of the cyst. This was confirmed by Conray cystography and/or computerized tomography. Not only the dose delivered to the wall but also the thickness of the cyst wall and the location of the cyst are important factors in planning internal irradiation. A safe and adequate dose to the cyst wall could range between 9000 to 30,000 rads for craniopharyngioma. This treatment is suitable for large cysts that are thought to be difficult to remove radically, recurrent cysts resistant to previous treatment, or multiple cysts. Internal irradiation may also be applicable in other cystic intracranial tumors if dosimetry is calculated accurately.     

Detection of recurrent gliomas with quantitative thallium-201/technetium-99m HMPAO single-photon emission computerized tomography.

Deteriorating clinical status after high-dose radiation therapy for high-grade gliomas may be due to radiation changes or may signal recurrent or residual tumor mass. The two conditions cannot be distinguished reliably by computerized tomography (CT) or magnetic resonance (MR) imaging. The authors assessed the ability of sequential thallium-201 chloride (201Tl) and technetium-99m hexamethylpropylene amine oxime (99mTc HMPAO) single-photon emission CT (SPECT) to distinguish tumor recurrence from radiation changes after high-dose (greater than or equal to 600 cGy) radiation therapy for malignant gliomas. Preoperative tumor/nontumor uptake ratios were analyzed in 32 patients and correlated with the presence of gross tumor at the time of reoperation. In 12 of 13 patients with 201Tl tumor/scalp ratios of 3.5 or greater, recurrent tumor was present. The authors found 99mTc HMPAO SPECT to be useful for identifying the absence of solid tumor recurrence in patients with low to moderate 201Tl uptake (ratio 1.1 to 3.4) and low perfusion to that site. In 11 of 12 patients with 99mTc HMPAO tumor/cerebellum ratios of 0.50 or less, no recurrent tumor mass was present. Three of seven patients with 201Tl ratios of 3.4 or less and 99mTc HMPAO ratios of 0.51 or more had recurrent tumor found at surgery; thus the test was not predictive in this group. It is concluded that the use of sequential 201Tl and 99mTc HMPAO SPECT accurately identifies the presence of tumor recurrence versus radiation changes in most patients with high-grade astrocytomas who have undergone tumor resection and high-dose radiation therapy.     

Comparison of 99mTc and 131I scans in thyroid function studies

Thyroid function was studied in 170 patients, using technetium-99m (99Tc) and oral radio-iodine (131I); 110 patients had normal thyroid function, and 60 had hyperthyroidism. The 20-minute 99mTc uptake gave an accurate assessment of thyroid function in 95% of patients, and the 24-hour 131I uptake was accurate in 92%. One hundred 99mTc and 131I scintiscans were compared by 3 observers. Scans obtained with each isotope were of comparable quality, and in only 1 patient were both scans of poor quality. 99mTc is as good as 131I for assessing thyroid function and morphology, but has several advantages over 131I.     

Stereotactic management of cystic gliomas of the brain stem

Although cystic gliomas of the brain stem can be readily aspirated using a stereotactic technique, they will frequently recur, resulting in progressive neurological deficit. Since standard neurosurgical approaches to cystic gliomas of the cerebral hemispheres and cerebellum are difficult to apply to brain stem lesions, modification of these techniques are necessary to provide cyst control with minimal morbidity and mortality. This report, based upon 12 procedures performed on 10 patients with gliomas of the mesencephalon, pons, and medulla, details an approach using aspiration, stereotactically placed cyst catheters, and/or intracavitary irradiation with colloidal chromium phosphorus-32 in addition to external radiation therapy and chemotherapy. Cyst control without mortality or permanent morbidity was obtained in all patients using this multimodality approach.     

Brain and skull metastases of hepatic or pancreatic cancer--report of six cases.

Brain and skull metastases from primary hepatic or pancreatic cancer are very rare. The authors describe six cases of metastatic tumors. These are skull (three cases) and brain (one) metastasis of hepatic cancer and brain metastasis (two) of pancreatic cancer. In three hepatic cancer patients, the metastatic lesions were diagnosed before the diagnosis of primary cancer. In these patients, plain skull x-ray showed osteolytic lesions and vascular enlargement. A postcontrast computed tomographic (CT) scan showed an enhanced high-density epidural mass. Angiograms showed a tumor stain fed by abnormal vessels from the external carotid artery. In one patient with a metastatic brain tumor from hepatic cancer, a CT scan showed a high-density mass with hematoma. In one of the brain metastases from pancreatic cancer, a CT scan revealed a cystic, ring-like enhanced lesion in the thalamus. In the other case, a CT scan showed an isodensity mass in the vermis and hydrocephalus. Metastatic tumors from primary hepatic cancer were soft and hemorrhagic, but they were clearly demarcated from the surrounding tissue. In the case of thalamic metastasis, the cyst content was aspirated and an anticancer agent was administered into the cystic cavity. In the other cases, the tumors were totally removed. The outcome was very poor in all cases.     

Pseudotumor of kidney.

Hypertrophy of the renal columns of Bertin may present as a mass, at times difficult to distinguish from neoplasia or cyst. Herein, we present a case characterized by the inability of this lesion to absorb 99mTc DTPA (99mTechnetium diethylenetriaminepentaacetic acid) isotope on two separate renal studies.     

Infusion cholecystography in the early diagnosis of acute gallbladder disease

The value of infusion cholecystography 99mTc HIDA cholescintigraphy and ultrasonography was compared in 51 patients presenting with a clinical diagnosis of acute cholecystitis. Of the 35 patients with proven gallbladder disease, the presence of gallstones was correctly predicted in 31 (88 per cent) by infusion cholecystography, 32 (90 per cent) by 99mTc HIDA cholescintigraphy and 27 (77 per cent) by ultrasonography. There were no false positive investigations. Infusion cholecystography may be of particular interest to surgeons with no ready access to isotope scanning techniques.     

Stereotactic intracavitary irradiation of huge cystic craniopharyngiomas]

From Jan. 1988 to June 1990, 32 patients with huge cystic craniopharyngiomas were treated by CT-guided stereotactic injection of phosphorus-32. Among them, 14 were male and 18 female. Their ranged 3 to 56 years (average 20 years). The history of illness varied from 1 to 8 years (average 2.8 years). All patients were confirmed pathologically, eleven of them had recurrent tumor after craniotomy. The volume of cystic tumor varied from 14 to 126ml (average 32ml). 1.2-5.6mCi (average 2.3mCi) of 32P were injected in each time. 65 injections were successfully performed. There were neither deaths nor serious complications. Follow-up time ranged from 12 to 24 months. The clinical symptoms of these patients were improved in 27 patients and volumes of the tumors were reduced on CT scans. The effective rate was 84.4%. We conclude that this technique is simple, efficient and safe for the treatment of huge cystic craniopharyngiomas.     

Intracavitary brachytherapy of cystic craniopharyngiomas.

Visual function, endocrinological status, and radiological outcome are reported in 31 patients harboring a cystic craniopharyngioma, who underwent 35 intracavitary brachytherapy procedures with yttrium-90. In 26 of these patients intracavitary brachytherapy was the primary treatment. The follow-up period ranged from 2 to 80 months (41 +/- 22 months, mean +/- standard deviation). Five patients died from tumor-related causes. Endocrine recovery was modest. Prior to brachytherapy, visual acuity was diminished in 38 eyes and field defects were present in 46. Funduscopy before treatment revealed optic atrophy in 47% of the eyes. Visual acuity improved in 29% of the eyes studied, remained stable in 13%, and deteriorated in 58%. Visual field defects improved in 28% of the eyes studied, remained stable in 20%, and deteriorated in 52%. The possible causes for deterioration in visual function are discussed. Complete resolution of 10 cysts was noted. In 12 patients the size of the cyst decreased; however, in three of these patients new cyst formation took place. The cyst size stabilized in six cases and increased in three. Although there is still a substantial degree of visual function deterioration following intracavitary brachytherapy, morbidity is otherwise low, making this treatment modality a reasonable alternative to craniotomy.     

Cystic meningiomas--an update

Eighteen unusual cases of intracranial meningioma associated with a cyst are considered. Three patients were operated upon before the introduction of computed tomography scanning, and the discovery of a peritumoral cyst was unexpected. Among 15 patients studied with computed tomography, 8 had a peritumoral cyst, 6 had an intratumoral cyst, and 1 had a totally cystic meningioma (hypodense on computed tomography). Computed tomography permitted a correct preoperative diagnosis only in four cases. In six additional cases diagnosis was reached by selective angiographic studies. In the remaining cases diagnosis was impossible or incorrect. Different pathogenetic mechanisms underlie different radiologic patterns. The authors comment on the complex processes that lead to cyst formation in meningiomas and stress the necessity of an accurate preoperative study to avoid misdiagnosis.     

肾上腺囊性占位病变的诊断与治疗

为了提高肾上腺囊性占位病变的诊治效果，报告单纯性肾上腺囊肿７例和肿瘤囊性变６例的处理结果。前者大多数无症状，Ｂ超、ＣＴ表现为囊壁菲薄，均匀一致的液性暗区，ＣＴ增强无强化，内分泌检查正常；而后者多数有激素活性症状，Ｂ超、ＣＴ呈不规则的厚壁囊性肿块，ＣＴ增强可强化，内分泌检查多数有相应激素水平升高。单纯性囊肿原则上可以定期复查，只对有明显症状的巨大囊肿才考虑手术治疗。肿瘤囊性变以手术治疗为主，尤其具有激素活性或怀疑恶性者，应积极手术。     

胰腺囊性肿瘤的诊断与治疗

自１９６５～１９９４年，作者收治了１６例胰腺囊性肿瘤病人。男性４例，女性１２例，平均年龄５０９岁。１６例中浆液性囊腺瘤２例，良性的粘液性囊腺瘤７例，粘液性囊腺癌４例，乳头状囊腺癌１例，低分化腺癌１例，未分化癌１例。Ｂ超和ＣＴ检查对于肿物的检出、浆液性囊腺瘤内多发小囊的分辨，以及肿物周边钙化的显示具有一定价值。囊肿壁不完全的活组织检查可导致冰冻甚至石腊切片的误诊。除了个别已被确诊的无症状的浆液性囊腺瘤可进行观察，其余各种类型的病变均要行手术切除。本文对各种类型囊性肿瘤的特征、囊性肿瘤与假性囊肿的鉴别诊断以及各类手术方式进行了讨论。     

Stereotaxic surgery with a magnetic resonance- and computerized tomography-compatible system

Modern stereotaxic surgery is dependent upon compatible advanced imaging tools, including computerized tomography (CT) scanning and magnetic resonance (MR) imaging. The authors describe three cases in which the patients underwent stereotaxic surgery for mass lesions identified by both MR imaging and CT scans. Identical target coordinates were defined by both techniques, and accuracy was confirmed by intraoperative CT. In comparison to stereotaxic CT, MR provided superior contrast resolution, allowed direct multiplanar imaging and target determination, and permitted accurate correlation of the image with histological features. The operative set-up and technique are described. Stereotaxic surgery with MR imaging may permit more accurate histopathological definition of tumor margins and ultimately lead to better dosimetry for therapeutic procedures such as interstitial brachytherapy.     

Cyst fluid analysis in the differential diagnosis of pancreatic cysts. A comparison of pseudocysts,serous cystadenomas,mucinous cystic neoplasms,and mucinous cystadenocarcinoma.

Pancreatic cystic lesions include inflammatory pseudocysts, benign serous tumors, and mucinous neoplasms, some of which are malignant. Clinical and radiologic indices are often inadequate to discriminate reliably among these possibilities. In an attempt to develop new preoperative diagnostic criteria to assist in decisions regarding therapy, the authors have performed cyst fluid analysis for tumor markers (carcinoembryonic antigen: CEA, CA 125, and CA 19.9), amylase content, amylase isoenzymes, relative viscosity, and cytology on 26 pancreatic cysts. The cases included nine pseudocysts, five serous cystadenomas, 4 mucinous cystic neoplasms, 7 mucinous cystadenocarcinomas, and one mucinous ductal adenocarcinoma with cystic degeneration. Carcinoembryonic antigen levels were high (> 367) in all benign and malignant mucinous cysts, but were low (< 23) in the pseudocysts and benign serous cystadenomas, an indication that CEA discriminates between mucinous and nonmucinous cysts (p < 0.0001). Values for CA 125 were high in all malignant cysts, low in pseudocysts, and variable in mucinous cystic neoplasms and serous cystadenomas. Levels of Ca 19.9 were nondiscriminatory. Cyst fluid amylase and lipase content were variable but were generally high in pseudocysts and low in cystic tumors. Amylase isoenzyme analysis was useful to differentiate pseudocysts from cystic tumors. Measurement of the relative viscosity in cyst fluid showed high (> serum viscosity) values in 89% of mucinous tumors and low values (< serum) in all pseudocysts and serous cystadenomas (p < 0.01). Cytologic analysis of cyst fluids was of limited value in differentiating pseudocysts from serous cystadenoma, but in seven of eight mucinous tumors provided useful diagnostic information and correctly classified three of five malignant tumors. The authors conclude that cyst fluid analysis can provide a preoperative classification of these diagnostically difficult lesions. The combination of viscosity, CEA, CA 125, and cytology can reliably distinguish malignant cystic tumors and potentially premalignant mucinous cystic neoplasms from pseudocysts and serous cystadenomas. Amylase content with isoenzyme analysis is useful to identify pseudocysts.     

Arteriovenous shunts associated with peripheral obliterative arterial disease. Haemodynamic, arteriographic and isotope studies

From among 210 patients with severe peripheral obliterative arterial disease, the presence of an arteriovenous shunt was demonstrated in 17 cases. Arteriovenous communications were visualized by serial angiographic records and 99mTc macroaggregate isotope testing. The regulation of the limb circulation was investigated using the venous isotope dilution method. Characteristic haemodynamic changes were revealed in arteriovenous shunts associated with peripheral arterial obliterative disease: total limb blood was comparatively high, arteriovenous difference was low and limb O2 consumption was decreased. The clinical significance of the haemodynamic changes in arteriovenous shunting associated with obliterative arterial disease is discussed.     

Localization of technetium-99m methylene diphosphonate in bone using microautoradiography

Technetium-99m methylene diphosphonate ([99mTc]MDP) is the most widely used bone-scanning agent today. In order to determine the precise bone locus of 99mTc corresponding to the delayed bone scan image, and to test the potential clinical use of this agent in enhancing the information obtained by bone scan, we employed [99mTc]MDP in this microautoradiographic study of normal bone and bone reparative tissue. Four white rabbits underwent operations in which two 1.5-mm drill holes were created in the subtrochanteric regions of both of their femora. An additional four white rabbits underwent sham operations of their femora, in which neither drilling nor periosteal injury occurred. Two rabbits were controls and did not undergo operation. After 7 days, the first two groups of rabbits were injected with [99mTc]MDP and bone scanned 2 h later. After the scans were completed, all three groups of animals were killed and their femora histologically processed for microautoradiography and routine histopathology. In the two groups that were injected with [99mTc]MDP, all bones showed the isotope to be clearly localized along mineralization fronts. The isotope was occasionally found in the substance of the osteoid, but was absent from the cytoplasm and nuclei of osteoblasts and osteocytes. Osteocytic lacunae showed the presence of isotope at their borders, but no identifiable pattern of isotope uptake was noted. Neither osteoclasts nor Howships lacunae showed isotope uptake.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cystic tumors of the pancreas: preoperative imaging,diagnosis, and treatment

The objective of this retrospective study was to explore the accuracy of preoperative diagnostic methods and the efficacy of treatment for cystic pancreatic tumors. From 1989 to 1999, 18 patients underwent surgery for cystic tumor of the pancreas, classified as follows: one serous cystadenoma, eight mucinous cystadenomas, six mucinous cystadenocarcinomas, and three nonfunctioning islet cell tumors. Computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and fine needle aspiration were performed and subsequently reviewed retrospectively by two radiologists. Three patients underwent the Whipple procedure and 14 and 1 patients underwent distal and central pancreatectomy, respectively. CT showed cystic pancreatic tumors in all cases. One case was misdiagnosed as a pseudocyst. The diagnosis was accurate in 82%, 53%, 37%, and 60% of cases on CT, ERCP, and angiography, and in the cytologic analysis of the aspirated fluid, respectively. All operative procedures were performed without significant morbidity and there were no postoperative deaths. Preoperative diagnosis of cystic pancreatic tumours is imprecise. CT is the most reliable preoperative imaging method. Resection should be the treatment of choice for these lesions, except in cases of serous cystadenoma.     

Preliminary results of thallium 201 and technetium 99m subtraction scanning of parathyroid glands

An evaluation of double isotope subtraction scanning with 201Tl and 99mTc was performed in 14 patients with primary hyperparathyroidism. Twelve of 13 adenomas and seven of seven hyperplastic glands were localized correctly by preoperative scanning. The technique appears useful for the identification of abnormal parathyroid glands before operation.