Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as a minimally invasive surgical option for the treatment of medium to large vestibular schwannomas

Background

Treatment of vestibular schwannomas presents many controversial aspects, from the indication to the selection of the best treatment option. In the era of stereotactic radiotherapy, microsurgery has to be competitive in terms of providing the best chances of functional preservation and complete tumor removal. The two most commonly used surgical approaches are the retrosigmoid suboccipital and the presigmoid translabyrinthine. We describe the endoscopy-assisted presigmoid retrolabyrinthine approach (EAPRA) aiming at combining the advantages of the retrosigmoid and translabyrinthine techniques.

Methods

For 2 years (from May 2009 to June 2011), the EAPRA was used to remove medium to large sporadic vestibular schwannomas in ten patients.

Results

Complete tumor removal was obtained in eight patients, postoperative transient facial nerve function impairment or worsening was observed in two, and one had hearing deterioration postoperatively. No threatening complications occurred after surgery, and the length of hospitalization was usually less than 10 days.

Conclusions

The EAPRA can provide direct access to the CPA along with labyrinthine complex conservation, allowing hearing function preservation and minimal cerebellar retraction. Endoscopic assistance is a crucial adjunct in the presigmoid retrolabyrinthine approach in order to address the limits imposed by labyrinthine complex preservation. It ensures complete visualization of the intracanalicular portion of the schwannoma, thus improving the rate of a radical tumor resection. The EAPRA could represent a valid surgical option in vestibular schwannoma surgery.     

Surgical treatment of typical peripheral schwannomas: the risk of new postoperative deficits

Background

Although peripheral schwannomas can be resected without postoperative neurological complications, surgeons must anticipate the possibility that new neurological deficits could develop. In order to evaluate the risk of neurological complications in the surgical treatment of these tumours, we performed a retrospective review of cases involving schwannomas in the extremities, as well as an analysis of the related literature.

Method

We reviewed a combined series of 72 schwannomas from the extremities presenting for surgical excision. Meticulous analysis of the files was undertaken, searching for pre-operative findings that could be more frequent in patients with surgical complications. The incidence, severity, and transitory nature of post-operative complications in our series was observed and compared against the literature.

Results

Eleven patients (15.2 %) developed new neurological deficits after surgery: sensory disturbance in seven cases, motor weakness in three, and a single wound hematoma. Most of these complications were temporary. Statistical analysis demonstrated a positive relationship between the presence of complications and both patient age under 50 years (p?=?0.02) and tumours greater than 3 cm in greatest diameter (p?=?0.02).

Conclusions

Although relatively infrequent, the potential for novel post-operative deficits after the surgical treatment of peripheral schwannomas does exist and should be included during pre-operative counseling.     

Surgical consideration of cervical dumbbell tumors

Background

Nineteen patients with cervical dumbbell tumors treated surgically were analyzed retrospectively.

Methods

Surgical strategies for dumbbell tumor were discussed from the perspective of safe, less-invasive surgery.

Results

Patients included 6 men and 13 women, with a mean age at the time of surgery of 48.3 years (range, 25–70 years). Underlying pathologies included 16 schwannomas, 2 neurofibromas, and 1 double tumor (schwannoma and meningioma). According to Eden’s classification, one patient was classified as Type 1, 5 as Type 2, 8 as Type 3, and 5 as Type 4. In 13 cases, tumors were excised through the posterior approach alone, compared to five cases using the anterior approach. One case was excised using combined anterior and posterior approaches. Facetectomy was not performed in 18 cases. In one case, the facet joint on one side had already destroyed and needed instrumentation. Tumors were totally excised in all cases. Postoperatively, the patients did not display any further neurological deficit, with the exception of transient radiculopathy in two patients. Major surgical complications and cerebrospinal fluid leakage were not seen. Tumor recurrence and spinal segmental instability were not found during follow-up period (mean, 41.6 months).

Conclusions

Dumbbell tumor surgery requires sufficient debulking of the epidural and paravertebral mass, using intraoperative nerve stimulation and Doppler ultrasonography to detect the vertebral artery. When using a posterior approach, recapping laminoplasty using an ultrasonic bone curette is very useful to remove tumor without sacrificing facet joints.     

Management of facial and periocular dog bites: a review of 104 cases

Background

Dog bites are a frequent cause of facial and periocular injuries in both children and adults. This aim of this study is to review current practice in the management of facial and periorbital dog bite injuries and to examine the current evidence-base for such treatment strategies.

Methods

Five hundred eighty-seven patients with dog bite injuries requiring surgical intervention were identified from operating theatre records in one tertiary centre over a 9-year period. A retrospective case note review of 104 patients with facial and periorbital dog bite injuries was performed. Data on patient demographics, type of injury, treatment, and outcome was collected and analysed.

Results

The majority of patients were children, with a mean age of 11 years (range 1–91 years). Injuries involved the cheek in 57 cases (55 %), eyelids in 17 cases (16 %), lips in 24 cases (23 %) and nose in 8 cases (8 %). No facial fractures, canalicular, or globe injuries were recorded. All patients underwent irrigation, debridement, and primary wound closure. Surgical repair occurred within 24 h in 19 cases (18.2 %), within 48 h in 71 cases (68.3 %) and within 5 days in 14 cases (13.4 %). Three patients (2.9 %) developed a wound infection. Two patients (1.9 %) required scar revision surgery.

Conclusions

Periorbital and facial dog bite injuries may result in considerable morbidity. However, the majority of injuries are superficial and canalicular injury and bony injury is uncommon. Early wound irrigation, debridement and primary closure results in a good cosmetic outcome with a low risk of infection.

Level of Evidence:

Level IV, risk/prognostic study.     

Clinical features and surgical outcomes of intramedullary schwannomas

Object

Intramedullary schwannomas are exceedingly rare. Most previous studies are case reports with an associated literature review. The aim of this study was to discuss the clinical features and the outcomes of microsurgery for these rare lesions.

Methods

The authors retrospectively reviewed the data of twenty patients with intramedullary schwannomas. All patients had performed preoperative and postoperative magnetic resonance imaging (MRI) and underwent microsurgery. The diagnosis of intramedullary schwannomas was based on radiological and pathological criteria. Modified McCormick classification was applied to assess neurological function.

Results

There were 15 males and five females with a mean age of 44.7 years. Ten tumors were located in the cervical cord, five in the thoracic cord, two in the cervicothoracic cord, two in the thoracolumbar cord and one in the conus medullaris. Patients presented with nonspecific symptoms and the mean duration of symptoms was 37.4 months. Intraoperatively, the tumor was connected to the dorsal rootlet in four cases. Gross total resection (GTR) of the tumor with a well-demarcated dissection plane was achieved in 16 cases, and subtotal resection (STR) was achieved in four cases. No patients received postoperative radiotherapy. During a mean follow-up period of 67.9 months, no recurrence or regrowth of the residual tumors was observed on MRI. Ninety percent of patients experienced an improvement in the McCormick grade and 10 % of patients maintained their preoperative status.

Conclusions

Intramedullary schwannomas are benign but clinically progressive lesions. The accurate diagnosis depends on pathology. For symptomatic patients, early surgery should be performed before neurological deficits deteriorate. When GTR cannot be achieved, STR of the tumor for decompression is advised. Postoperative radiotherapy is not recommended for these benign tumors. A good clinical outcome after GTR or STR can be expected.     

Effectiveness of C5 or C6-Cz assembly in predicting immediate post operative facial nerve deficit

Background

Intraoperative neurophysiology monitoring (IOM) is a valuable tool in cerebellopontine angle (CPA) surgeries posing risk to the cranial nerves. Transcranial electrical stimulation (TES) for cranial nerves has been performed in the last 7 years, for obtaining the facial nerve motor evoked potential (MEP), using either C3/C4-Cz or C3-C4 (or inverse) stimulating points, which have been correlated with facial nerve functional outcome.

Method

Intraoperative surgical and electrophysiological findings were documented prospectively. Patient files were reviewed for clinical data. We studied 23 patients undergoing CPA tumor resection using C5 or C6-Cz montage for TES, and were able to determine the correlation between facial nerve functional outcome and the amplitude drop of facial MEP above 50 %. Patients were evaluated for immediate facial nerve outcome and 6 months after the surgery. Follow-up was performed by structured telephone interviews with local physicians.

Results

The sensibility of the studied parameters was 92.8 % for amplitude drop of facial nerve MEP, with positive predictive value of 81.2 %. The absence of changes during IOM has shown a negative predictive value of 100 %.

Conclusion

In this series, the used montage was effective in predicting new facial deficit.     

Improvement of efficacy in surgical management of facial basal cell carcinoma: an interdisciplinary pilot study in The Netherlands

Background

The increasing incidence of basal cell carcinoma demands for an improvement of current health care management to gain more efficacies in the interdisciplinary treatment of facial basal cell carcinoma. We prospectively evaluated the level of agreement between referring dermatologists and plastic surgeons to assess in which cases routine pre-operative consultation of patients with facial basal cell carcinoma was not required for surgical treatment by plastic surgeons.

Methods

The outcome of a self-designed standardized referral form was prospectively evaluated in 100 patients with clinically suspected facial basal cell carcinoma that were referred from the dermatology outpatient clinic to the surgical outpatient clinic of Plastic Surgery for tumor removal under local anesthetics between 2009 and 2011.

Results

The level of agreement between the dermatologists and plastic surgeons on whether patients could be booked on the surgical outpatient clinic without routine pre-operative consultation was categorized as “moderate agreement” (Kappa?=?0.589). We found that in 12.7 % of the patients with high-risk facial basal cell carcinoma (BCCs), both specialists agreed that pre-operative consultation was not required. In another 12.7 % of the patients, consensus was not achieved. In 74.6 % of the patients, both specialists agreed that pre-operative consultation was recommended.

Conclusions

We found that in selected patients with high-risk facial BCCs, both specialists agreed that pre-operative consultation was not required. Once a standardized referral system has been implemented, its use may improve efficacy in the surgical treatment of high-risk facial BCC. Future research should be directed towards clinical controlled trials. Level of Evidence: Level III, risk/prognostic study.     

Primary spinal cord tumors: review of 678 surgically treated patients in Japan. A multicenter study

Purpose

To clarify the relative frequency of various histopathological primary spinal cord tumors and their features in Japanese people and to compare this data with other reports.

Methods

Primary spinal cord tumor surgical cases from 2000 to 2009, which were registered in our affiliated hospital database were collected. We examined age at surgery, sex, anatomical location, vertebral level of the tumor, and pathological diagnosis in each case.

Results

Of the 678 patients in our study, 377 patients (55.6 %) were males and 301 patients (44.4 %) were females (male/female ratio 1.25). The mean age at surgery was 52.4 years. Of these tumors, 123 cases (18.1 %) were intramedullary, 371 cases (54.7 %) were intradural extramedullary, 28 cases (4.1 %) were epidural, and 155 cases (22.9 %) were dumbbell tumors. The pathological diagnoses included 388 schwannomas (57.2 %), 79 meningiomas (11.6 %), 54 ependymomas (8.0 %), 27 hemangiomas (4.0 %), 23 hemangioblastomas (3.4 %), 23 neurofibromas (3.4 %), and 9 astrocytomas (1.3 %). The male/female ratios for schwannomas, meningiomas, ependymomas, hemangiomas, hemangioblastomas, neurofibromas, malignant lymphomas, and lipomas are 1.4, 0.34, 1.3, 1.5, 2.3, 1.3, 2.7 and 2.3, respectively.

Conclusion

This is the first published research in English on the epidemiology of primary spinal cord tumors in Japanese people. Similar to other reports from Asian countries, our data indicates a higher male/female ratio overall for spinal cord tumors, a higher proportion of nerve sheath cell tumors, and a lower proportion of meningiomas and neuroepithelial tumors compared to reports from non-Asian countries. Data in the current study represent the characteristics of primary spinal cord tumors in Asian countries.     

Vestibular schwannoma surgery via the retrosigmoid transmeatal approach

Background

Aims of modern vestibular schwannoma surgery are complete tumor resection with functional facial nerve and hearing preservation, if possible. Here we present our technique of bimanual dissection for vestibular schwannoma resection through the retrosigmoid approach.

Method

A slightly curved surgical incision is planned two fingers behind the ear extending from the level of the tip of the ear to 1 cm below the mastoid tip. The retrosigmoid craniectomy exposes the sinus knee, the inferior border of the transverse sinus, the medial border of the sigmoid sinus and horizontal segment of the occipital squama. The dura is opened under the microscope in semilunar fashion parallel to the course of the sigmoid sinus. We open the IAC with a high-speed diamond drill from lateral to medial, opening the canal for 180° of its circumference. The intrameatal part of the vestibular schwannoma is partially removed and the facial nerve identified Thereafter, we open the capsule and debulk the tumor with an ultrasonic surgical aspirator in the CPA. Once the tumor’s mass is significantly reduced, a bimanual dissection of the cleavage plane between capsule and the surrounding arachnoid is performed. Starting from below, the capsule is elevated with a tumor grasping forceps and the arachnoid membrane is peeled off. Following the cleavage plane, the facial nerve is separated in a medial to lateral direction from the VS’s capsule. Throughout the whole procedure the field is irrigated with warm Ringer’s solution. We seal the drilled posterior lip of the IAC as well as eventually opened mastoid air cells with a free muscle or fat patch.

Conclusion

Vestibular schwannoma surgery through the retrosigmoid approach is a safe procedure that allows gaining good functional results.     

The relationship between nervus intermedius anatomy, ultrastructure, electrophysiology, and clinical function. Usefulness in cerebellopontine microsurgery

Background

Although previous studies have described the clinical features of the nervus intermedius (NI), no attempt has yet been made to describe the relationship between the ultrastructural and electrophysiological characteristics of the nervus intermedius and its motor competence.

Objective

In this study, we analyzed the intraoperative electrophysiological response obtained during vestibular schwannoma surgery. The ultrastructure was studied using electron microscopy.

Materials and Methods

Thirty-six consecutive patients underwent microsurgery for vestibular schwannoma with cerebellopontine angle tumors. The patients were extensively monitored intraoperatively. Selective stimulation of the nervus intermedius was attempted in all cases. The patients were then examined postoperatively and followed for a minimum of 1 year. Forty-three isolated human brainstems were analyzed to collect the ultrastructural NI data.

Results

We found a correlation between the NI motor responses in the perinasal and perioral regions and the ultrastructure characteristics, with few (0.5 %) but large myelinated motor fibers (diameters >12 μm). Both characteristics are consistent with the clinical observation of transient weakness of the levator anguli oris muscle. These observations indicate a relationship between the intraoperative electrophysiological identification of the NI nervus intermedius and its clinical and ultrastructural characteristics.

Conclusions

Identifying the NI in the deformed anatomy of tumors could provide a fixed landmark during cerebellopontine surgery and help prevent damage of the facial nerve.     

Facial nerve preservation with preoperative identification and intraoperative monitoring in large vestibular schwannoma surgery

Background

Microsurgery is an option of choice for large vestibular schwannomas (VSs). Anatomical and functional preservation of facial nerve (FN) is still a challenge in these surgeries. FNs are often displaced and morphologically changed by large VSs. Preoperative identification of FN with magnetic resonance (MR) diffusion tensor tracking (DTT) and intraoperative identification with facial electromyography (EMG) may be desirable for improving functional results of FN.

Method

In this retrospective study, eight consecutive cases with large VS (≥30 mm in maximal extrameatal diameter) were retrospectively studied. FN DTT was performed in each case preoperatively. All the cases underwent microsurgical resection of the tumor with intraoperative FN EMG monitoring. Correctness of prediction for FN location by DTT was verified by the surgeon’s inspection. Postoperative FN function of each patient was followed up.

Results

Preoperative identification of FN was possible in 7 of 8 (87.5 %) cases. FN location predicted by preoperative DTT agreed to surgical finding in all the 7 cases. FN EMG was helpful to locate and protect the FN. Total resection was achieved in 7 of 8 (87.5 %). All FNs were anatomically preserved. All cases had excellent facial nerve function (House–Brackmann Grade I–II).

Conclusions

FN DTT is a powerful technique in preoperatively identification of FN in large VS cases. Continuous intraoperative FN EMG monitoring is contributive to locating and protecting FNs. Radical resection of large VSs as well as favorable postoperative FN outcome is available with application of these techniques.     

Neoadjuvant targeted molecular therapies in patients undergoing nephrectomy and inferior vena cava thrombectomy: is it useful?

Objective

To assess the effect of neoadjuvant targeted molecular therapies (TMTs) on size and level of inferior vena cava tumor thrombi and to evaluate their impact on surgical management.

Methods

We retrospectively analyzed the data of 14 patients treated for a clear cell renal cell carcinoma with inferior vena cava thrombi by neoadjuvant TMT before nephrectomy. Clinical, pathological and perioperative data were gathered retrospectively at each institution. The primitive tumor size and the thrombus size were defined by computed tomography before TMT. The tumor thrombus level was defined according to the Novick’s classification.

Results

Before TMT, thrombus level was staged I for 1 (7 %), II for 10 (72 %) and III (21 %) for 3 patients. First-line therapy was sunitinib in 11 cases and sorafenib in 3 cases. Median therapy duration was two cycles (1–5). Three patients experienced major adverse effects (grade III) during TMT. Following TMT, 6 (43 %) patients had a measurable decrease, 6 (43 %) had no change, and 2 (14 %) had an increase in the thrombus. One patient (7 %) had a downstage of thrombus level, 12 (85 %) had stable thrombi, and 1 (7 %) had an upstage. Regarding primary tumor, 7 (50 %), 5 (36 %) and 2 (14 %) patients had a decrease, stabilization and an increase in tumor size, respectively.

Conclusion

Neoadjuvant TMT appears to have limited effects on renal tumor thrombi. This retrospective study failed to demonstrate a significant impact of neoadjuvant TMT on surgical management of clear cell renal cell carcinoma with inferior vena cava tumor thrombi.     

Laparoscopic approach for retrorectal tumors

Background

Retrorectal tumors are uncommon and may represent a surgical challenge. Laparoscopic excision has been reported in very few papers. We present our experience of nine cases operated by a transabdominal laparoscopic approach, between 2005 and 2011.

Methods

There were two males and seven females with a mean age of 35 years (range 19–48). The tumors were discovered incidentally in four cases or because of nonspecific clinical signs. All patients have had an MRI preoperatively.

Results

Only one patient required open conversion due to a huge tumor >7 cm of diameter. Postoperative mortality was nil. One patient developed a hematoma in the pelvic area. The median hospital stay was 4.7 days (range 4–8). Final diagnostic were as follows: four schwannomas, one ganglioneuroma, two tailgut cysts, one anterior meningocele, and one paragangliomas. During the follow-up showed no recurrences, but four of nine patients developed neurologic complications as parenthesis and sciatic pain and one patient developed retrograde ejaculation.

Conclusions

Our case series shows that the laparoscopic approach is a feasible and safe option. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space to minimize the vascular and neurological injuries.     

Removal of thoracic dumbbell tumors through a single-stage posterior approach: its usefulness and limitations

Background

The purpose of this study was to evaluate the surgical results of the single-stage surgery only from posterior approach for the management of thoracic dumbbell tumor and to discuss its usefulness and limitations.

Methods

Sixteen cases of large thoracic dumbbell tumor (11 men and 5 woman, mean age, 44 years) were analyzed retrospectively. Pathologic findings included schwannoma in 10 patients, neurofibroma in 2 patients (Recklinghausen in 1 patient), meningioma in 2 patients, myxolipoma in 1 and ganglioneuroma in 1. They underwent single-stage removal of dumbbell tumor using the posterior approach followed by laminectomy and often costotransversectomy combined with instrumentation. Clinical and radiologic outcomes are reviewed.

Results

The mean follow-up period for clinical and radiographic outcome variables was 66 months (range, 24–120 months). Operative time ranged from 185 to 420 min (mean, 320 min), with estimated blood loss ranging from 71 to 1830 ml (mean, 540 ml). Postoperative complications were pleural injury during the enucleation of paravertebral tumors, which could be repaired, and the chest tube was detained to prevent postoperative pneumothorax. Postoperative complications included atelectasis in one case. All patients had tumors successfully removed with no neurological deterioration. One patient underwent both posterior and anterior surgery because of attachment to and compression of an artery. We were not able to diagnose this case preoperatively, although a biopsy had been performed.

Conclusions

Single-stage surgery may be a useful method for removing thoracic dumbbell tumors without the combined anterior approach, unless they are attached to and compressing the artery and the diagnosis cannot be made preoperatively.     

Evaluation of the necessity of primary tumor resection for synchronous metastatic colorectal cancer

Purpose

We evaluated the need for primary tumor resection in patients with colorectal cancer (CRC) and synchronous unresectable metastases who underwent chemotherapy, and identified the associations between the primary tumor characteristics and risk of intestinal obstruction or perforation.

Methods

We retrospectively analyzed the survival and complication rates of patients with synchronous metastatic CRC treated between April 2005 and December 2011.

Results

Of 131 patients, 68 underwent primary tumor resection before chemotherapy, and 63 were treated without resection before chemotherapy. The overall survival (OS) did not significantly differ between the two groups (log-rank P = 0.53). In the resection group, 12 patients (17.6 %) developed postoperative complications. In the non-resection group, 16 patients (25.4 %) required surgical intervention owing to obstruction or perforation during their treatment. Surgical intervention did not affect the OS. A circumferential tumor was a risk factor for obstruction or perforation of the colorectum in non-resected patients (odds ratio = 11.163; P = 0.006).

Conclusion

Resection of primary tumors before chemotherapy is unnecessary in selected patients with synchronous metastatic colorectal cancer. A circumferential tumor is a risk factor for obstruction or perforation during chemotherapy in cases without primary tumor resection.     

Microvascular decompression for neurovascular conflicts in the cerebello-pontine angle: which role for endoscopy?

Background

Microvascular decompression (MVD) is the surgical intervention designed to resolve neurovascular conflicts (NCs) in the cerebellopontine angle (CPA). Today, endoscopy is commonly used in many neurosurgical procedures. This study aims to retrospectively assess the usefulness of endoscopy during MVD, focusing on microscopic endoscopic-assisted (MEA) MVD.

Methods

Between January 2010 and December 2012, 141 patients underwent MVD procedures: 119 (84.5 %) were affected by idiopathic trigeminal neuralgia (TN), 20 (14 %) by hemifacial spasm (HFS), 1 by glossopharyngeal neuralgia (GN) and 1 by TN and GN simultaneously; 128 (91 %) MVD were first time procedures, while 13 (9 %) were recurrences (10 TN, 3 HFS). Visualization techniques used were: pure microscopic in 89 (63 %) cases, fully endoscopic in 12 (8.5 %) and MEA in 40 (28.5 %). The MEA technique was used when the conflict was not clearly identified under microscopic view or it was not certainly resolved.

Results

Overall, a NC was found in 130 (92 %) cases, while 11 patients had no intraoperative evidence of NC. Considering specifically the 40 MEA cases, 12 (8.5 % overall) conflicts not clearly visible with the microscope were revealed and solved, a complete conflict resolution was confirmed in 13 (9 % overall) cases, while an incomplete conflict resolution was shown in four cases (3 % overall).

Conclusion

Pure microscopic MVD remains the technique of choice. The endoscope is a useful adjunctive imaging tool in confirming NCs identified by the microscope, revealing conflicts missed by the microscopic survey alone and verifying adequate nerve decompression.     

The long-term outcome of nerve combing for trigeminal neuralgia

Background

The purpose of our study was to describe and evaluate the long-term clinical outcome of nerve combing for idiopathic trigeminal neuralgia (TN) with and without vascular compression.

Methods

The study included 60 trigeminal neuralgia patients, 28 of which (Group A) had no visible vascular compression intraoperatively and 32 of which (Group B) had trigeminal nerve root entry zone (REZ) compressed by vascular structure. All patients were considered medical failures prior to the surgeries. All of them underwent trigeminal nerve combing. The following outcome measures were assessed: pain relief, recurrence, complication and time to pain relief.

Results

The median duration of follow-up was 52 months (range 48–96 months) in group A and 56 months (range 48–96 months) in group B. Excellent relief and good relief were noted in 23 patients (82.1 %) and two patients (7.1 %) from group A, respectively, and in 20 (62.5 %) and eight patients (25 %) from group B. The major complication of both groups was facial numbness. And the total complication rate was 15.8 % in group A and 18.8 % in group B. Recurrence was found in one patient in group A and in two in group B by the end of follow-up.

Conclusion

Trigeminal nerve combing is effective in treating TN, but has a much higher pain relief rate in patients without vascular compression than those with vascular compression.     

Long-term surgical outcomes of cervical dumbbell neurinomas

Study design

Retrospective case series.

Objective

To evaluate our treatment strategy for cervical dumbbell neurinoma.

Summary of background data

In treating cervical dumbbell neurinoma, possible difficulties include reoperation due to recurrent tumor, denervation due to nerve root resection, and postoperative spinal deformity due to extensive bony removal.

Methods

We reviewed 75 cases of cervical dumbbell neurinoma that were treated surgically between 1985 and 2006. Postoperative neurological deficits, effects of surgical margins on tumor recurrence, and surgical complications were investigated retrospectively.

Results

Sensory and motor deficits due to resection of specific nerve roots appeared temporarily in 33 and 23 % of all cases, and persisted in 8 and 8 % at final evaluation, respectively. Total, subtotal, and partial resection was performed in 57, 13, and 5 cases, respectively. The total resection rate was low in the tumors that had large extraforaminal components. Of the subtotally resected 13 cases, only two cases of high tumor-growth rate required re-operation or showed tumor growth. Among the five partially resected cases, re-operation was necessary in two cases 13 and 15 years later because of aggravated neurological symptoms due to tumor growth. Two patients who underwent C2 laminectomy developed kyphosis, and three patients who underwent facet joint resection and curettage of vertebral body lesions developed scoliosis.

Conclusion

Total resection should be attempted for cervical dumbbell tumors. In cases where total resection was potentially of high risk, however, subtotal resection (within the capsule) was found to be a practical choice yielding favorable long-term outcome when the tumor growth rate (MIB-1 index) was low.     

Acinar Cell Cystadenoma of the Pancreas: Report of Three Cases and Literature Review

Introduction

Acinar cell cystadenoma (ACC) of the pancreas was first described as a distinct pancreatic cystic neoplasm in 2002.

Methods

We have encountered three cases of ACC at our institution in addition to the 15 cases reported to date in the world literature. The gender distribution in the total cohort of patients with ACC slightly favored females (61 % female), and the median age was 49.5 years.

Results

Almost half (53 %) of the cases were identified incidentally, while the remainder presented with abdominal pain. The median tumor diameter was 5 cm in size, and no patients have had documented disease recurrence or progression, even in the setting of an incomplete resection.

Conclusion

These findings suggest a relatively indolent biology, and that complete resections are curative. As we will show, surgical resection is warranted to treat symptoms and prevent local extension or malignant transformation.     

Endoscopic Ultrasound Staging of Stenotic Esophageal Cancers May Be Unnecessary to Determine the Need for Neoadjuvant Therapy

Introduction

Endoscopic ultrasound (EUS) is an essential component of preoperative staging for esophageal cancer and is used to determine which patients should proceed to primary surgical resection or receive neoadjuvant therapy prior to surgery. However, when the EUS scope cannot traverse a tumor, the role of pre-dilatation is controversial due to the risk of perforation.

Methods

A retrospective review was conducted of all patients with esophageal tumor stenosis that could not accommodate the EUS scope who then proceeded with primary esophagectomy. The pathology results were classified based on the revised seventh edition American Joint Committee on Cancer staging system.

Results

A total of 27 patients met inclusion criteria. The majority of tumors were T3 (24/27, 89 %). There were no stage I tumors, 15 % (4/27) were stage II, 81 % (22/27) were stage III, and 4 % (1/27) were stage IV due to a resected solitary lung metastasis.

Conclusion

Tumors that cannot be assessed with an EUS scope due to tumor stenosis will have locally advanced disease in the majority of cases. In these situations, pre-dilatation of the tumor with EUS staging should be omitted when considering the risk of potential esophageal perforation and the patients should be referred for neoadjuvant therapy.