Contralateral trigeminal neuralgia as a false localizing sign in intracranial tumors

Three cases of contralateral trigeminal neuralgia as a false localizing sign in intracranial tumors are reported. In each patient (meningioma, 2 cases; cholesteatoma, 1 case) the tumor was asymptomatic, so that intracranial tumor had not been suspected preoperatively. In all cases, tumors were large and firm. The tumor was supratentorial in two cases. In one case, a cortically mediated mechanism may have caused the neuralgia, whereas in the remaining two cases distortion and displacement of the brain stem and compression of the contralateral Meckel's cave would explain the trigeminal nerve signs.     

The natural history of small renal masses

PURPOSE: Ultrasound, computerized tomography and magnetic resonance imaging are widely available. Incidentally discovered small renal masses are reported more frequently. Most of these masses are low stage renal cell carcinomas. To understand better the natural history of these lesions and offer appropriate management, we followed prospectively a series of patients with this type of lesion. MATERIALS AND METHODS: A total of 13 patients with radiologically detected solitary small renal masses who were unfit for or refused surgery were followed with abdominal imaging for a median of 42 months. Median patient age was 69 years and mean lesion volume at diagnosis was 13.6 cm.3 or 2.95 cm. in diameter. Growth rate was calculated based on tumor volume rather than bi-dimensional diameter. Individual slopes of tumor size in time were calculated. RESULTS: Of the 13 patients 5 underwent surgery following a period of surveillance because of apparent tumor enlargement or new onset of symptoms. Pathological evaluation revealed renal cell carcinoma in all 5. No patient had metastases. Only 2 tumors were fast growing and these were the only 2 cases in which symptoms developed. When these patients were excluded from analysis, average growth rate was 1.32 cm.3 per year (p = 0.5, 95% confidence interval -3.00 to 5.76 cm.3 per year), which was not statistically significantly different from 0 slope or no growth. CONCLUSIONS: These results demonstrate that the growth rate of small renal tumors is variable, tumors that are destined to grow and possibly metastasize do so early and most small tumors grow at a low rate or not at all.     

胸骨肿瘤的临床与影像学分析

目的 :分析胸骨肿瘤的临床及影像学表现。方法 :回顾性分析18例经手术或病理证实的胸骨肿瘤患者的临床及影像学资料,其中男13例,女5例;年龄24~73岁,平均58.3岁;11例保守治疗,7例手术治疗;病程2个月~6年。1例患者无明显症状,1例有胸部外伤史。18例患者经X线片、CT、MRI检查,观察骨质破坏形态、骨皮质改变、MRI信号异常、瘤周骨髓水肿以及增强强化等指标。结果 :18例中恶性骨肿瘤16例,良性肿瘤2例;发生于胸骨柄7例,胸骨体9例,胸骨柄、体部均受累2例。影像学表现上,胸骨肿瘤具有膨胀性骨质破坏的倾向,15例骨质破坏区边界连续性或部分中断,2例骨皮质边缘毛糙、变薄,1例骨皮质增厚。7例行MRI检查均未见瘤周骨髓水肿,2例可见软组织侵犯;与邻近肌肉相比,4例T1WI表现为低信号,3例呈等、高信号,6例T2WI表现为等、高信号,1例混杂信号。MRI增强扫描,大部分病例表现为明显强化。结论 :胸骨肿瘤种类多样,以恶性肿瘤居多;胸骨肿瘤的影像学表现大多缺乏特征性,结合临床表现,综合分析其X线、CT及MRI征象,有助于提高胸骨肿瘤的诊断准确性。     

Meningiomas of Meckel's cave.

A series of 16 patients with meningiomas of Meckel's cave is reported. Trigeminal neuralgia, typical or atypical, was the initial symptom in 10 patients (62.5%). At admission, trigeminal signs and symptoms were present in 15 patients (93.7%); in 7 patients (43.7%), trigeminal dysfunction was combined with the impairment of other cranial nerves. On retrospective analysis, these patients fall into two clinical groups that differ also in prognosis. Group 1 comprises eight patients with trigeminal signs and symptoms only. These patients had small meningiomas strictly affecting Meckel's cave. Total removal of the tumor was achieved in seven of eight patients, without adjunctive postoperative neurological deficits. In this group, there were no tumor recurrences. Group 2 comprises the other eight patients in whom trigeminal dysfunction was combined with impairment of other cranial nerves. These patients had large tumors arising from Meckel's cave and secondarily invading the cavernous sinus (five patients) or extending into the posterior fossa (two patients) or largely growing into the middle fossa (one patient). Total removal was achieved in only one patient, and a worsening of the preoperative neurological status was observed in four patients; there were three cases of tumor progression. A subtemporal intradural approach (used in the past in every case) is still used for the small tumors of Group 1 with good results. Since 1985, for tumors involving the cavernous sinus, we have employed a frontotemporal craniotomy with extradural clinoidectomy and superior and lateral approach to the cavernous sinus. When the tumor extends toward the posterior fossa, we use a combined temporosuboccipital-transpetrosal approach.(ABSTRACT TRUNCATED AT 250 WORDS)     

Congenital disseminated malignant rhabdoid tumor: a distinct clinicopathologic entity demonstrating abnormalities of chromosome 22q11

The clinical, pathologic, and immunohistochemical features of a widely disseminated tumor with rhabdoid phenotype are described in nine infants < or = 3 months of age. Five neonates had tumor evident at birth, two of which had placental metastases. The average survival following diagnosis was < 6 weeks. None of the infants had an apparent primary tumor in either the kidney or brain. In four cases, the dominant mass involved the head and neck region, and in two cases, the primary mass was paraspinal. The histologic features were those of a high-grade, round cell neoplasm with abundant cytoplasm and containing cells with cytoplasmic filamentous inclusions. Immunohistochemical studies revealed polyphenotypic antigen expression. Genetic information was available from eight of nine cases. Karyotype analysis revealed abnormalities of chromosome band 22q11-12 in three of six tumors. Fluorescence in situ hybridization studies or molecular studies demonstrated 22q11.2 deletions in all five cases with available frozen tissue, two of which had translocations involving 22q by karyotype analysis. The similar clinical and pathologic findings in these rapidly fatal tumors in infants and the demonstration of abnormalities of chromosome 22q11 in a majority of the cases supports their histogenetic and nosologic relationship to the family of malignant rhabdoid tumors that typically occur in young children in several anatomic sites, including kidney, soft tissues, liver, and brain. Like neuroblastoma and rhabdomyosarcoma, malignant rhabdoid tumor can appear as disseminated disease at birth or shortly thereafter.     

Postoperative brain metastasis from esophageal carcinomas: report of 4 cases]

Out of 83 cases received resection of primary esophageal lesion, 4 patients were affected by metastatic brain tumor which was reported to rarely occur. All 4 patients had symptoms of central nervous system. Three of them were diagnosed by CT and the other one at autopsy. All of the primary esophageal tumors were advanced and of histological stage III or IV. They located in the middle or lower thoracic esophagus. Brain tumor of one case was removed and this case was of progression free at the last presentation. The other 3 cases were not received resection of metastatic brain tumors and died. All of 3 were autopsied and two of them had no metastasis in the lung. Therefore, it was considered that these hematogenic metastases were not through lung filtrations but through other routes, which Batson O. V. experimentally proved and designated as vertebral vein system in 1940. It is concluded that aggressive surgical intervention to metastatic brain tumors was beneficial with regard to prognosis for cases without other metastatic lesions.     

Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients

OBJECT: This study is a retrospective analysis of 60 surgically treated patients with 64 peripheral nerve sheath tumors (PNSTs) at the second cervical (C-2) nerve root. The anatomical subtleties of these tumors and their implications for surgical strategy when compared with other spinal PNSTs and other tumors in the foramen magnum region are reviewed. METHODS: Sixty patients with C-2 PNSTs treated surgically in the Department of Neurosurgery at King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College between 1992 and 2006 were studied. All patients underwent magnetic resonance imaging. Tumors were divided into 3 groups depending on their anatomical location identified during surgery. Those tumors located within or extending into the spinal dural tube were called Type A, those located within the dural tube of the C-2 ganglion were labeled as Type B, and tumors extending laterally into the paraspinal region were labeled as Type C. Follow-up durations ranged from 6 months to 15 years (mean 64 months). RESULTS: There were 38 male and 22 female patients in the study, who ranged in age from 6 to 62 years (mean 28 years). Nine patients had clinical features indicative of neurofibromatosis (NF). The mean duration of symptoms at the time of presentation was 27 months (range 4 days-5 years). Two patients had no specific symptoms related to the C-2 PNST, 6 patients had only local symptoms such as neck pain or stiffness, and 52 patients had symptoms of varying degrees of myelopathy. There were 5 solely Type A tumors, 7 Type A + B tumors, 31 Type B tumors, and 21 Type B + C tumors. All Type A, A + B, and B tumors were totally resected. Seven of 21 Type B + C tumors were partially resected, and the remainder were completely resected. All patients postoperatively reported varying improvement in their preoperative symptoms. Except for patients with NF who were disabled by other tumors, the rest of the patients resumed their normal life style. There have been no cases of symptomatic tumor recurrence. CONCLUSIONS: The majority of PNSTs located at the C-2 level in these patients probably arose from the large C-2 ganglion and are limited within the dural confines or are interdural in location. In contrast to other spinal PNSTs, the location of C-2 PNSTs is in most cases posterior to the lateral mass of the atlas and axis and the atlantoaxial joint and is exposed to the posterior without any bone cover. Radical tumor resection is safe, resolution of clinical symptoms is rapid, and recurrence rates are extremely low. In a selected number of cases, bone work for tumor exposure and resection can be entirely avoided.     

Brain tumors occurring before 1 year of age: a retrospective reviews of 22 cases in an 11-year period (1977-1987).

Congenital brain tumors have been reported infrequently and their management remains ill defined. An 11-year review (1977-1987) of all children with brain tumors with the onset of symptoms before 1 year of age was completed. Twenty-two children with the following histological diagnoses were treated: astrocytoma (7 patients), primitive neuroectodermal tumor (6 patients), papilloma or carcinoma of the choroid plexus (3 patients), malignant teratoma (2 patients), dermoid tumor (2 patients), embryonal rhabdomyosarcoma (1 patient), and chloroma (1 patient). Fifteen tumors were supratentorial in location, and 7 were infratentorial. Initial symptoms were hydrocephalus (32%), focal neurological deficit (23%), asymptomatic increase in head circumference (18%), failure to thrive (14%), and seizures (4.5%). The goal of treatment was a radical excision when possible, with primary chemotherapy in the last 6 years of the review period. Radiation therapy was the adjunct to surgery in the initial 5-year period. All patients with papillomas of the choroid plexus and dermoid lesions underwent a total resection with no recurrence. All 7 astrocytomas were supratentorial, with 6 occurring in the diencephalon. Five of the seven patients with astrocytomas survived more than 5 years. The 6 primitive neuroectodermal tumors were located equally between the supra- and infratentorial spaces. Four of the 6 infants with these tumors received chemotherapy (2 received chemotherapy alone; 2 received chemotherapy and radiation therapy) and are tumor free 2 to 9 years later. A fifth child received radiation therapy alone early in the series and survived only 4 months. The family of the other child refused adjunctive treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Two cases of the middle fossa tumor following radiotherapy against retinoblastoma

Two cases of brain tumors which developed after radiotherapy against retinoblastomas are reported. A 17-year-old girl was admitted with a chief complaint of swelling in her forehead after head injury in July, 1981. At 7 months old her left eye had been enucleated and she had received radiation therapy of 40 Gy to the right eye because of her bilateral retinoblastoma. On admission a CT scan revealed a high density mass with a partial low density area in her right middle fossa. A right frontotemporal craniotomy was performed and the tumor was removed subtotally, which was diagnosed as a malignant fibrous histiocytoma. The second case was a 14-year-old boy, who had received radiotherapy of 39.6 Gy against retinoblastoma of the right eye after enucleation at 2 months old. He had been well for 14 years after the therapy and was admitted to the hospital with complaints of headache, nausea, vomiting and unsteady gait in January 1985. A CT scan demonstrated a large contrast enhancing mass in the righ middle fossa, which was removed subtotally on January 14, 1985. A histological diagnosis of fibroblastic meningioma was made. Each patient developed a secondary brain tumor after radiotherapy against retinoblastoma. Those tumors appear to be radiation induced, although 10 to 15% of the patients who survived retinoblastoma without radiotherapy had been reported to develop secondary nonocular tumors. The patients with retinoblastoma should be followed up carefully after the initial treatment.     

Phyllodes tumor of the prostate: long-term followup study of 23 cases

PURPOSE: Phyllodes tumor of the prostate is a rare neoplasm of uncertain malignant potential. We studied a large series of phyllodes tumors to define the combination of histological features that are most useful for predicting patient outcome. MATERIALS AND METHODS: A total of 23 cases were obtained from our collective files from 1973 to 2002, and numerous clinical and pathological features were evaluated. A review of the reported cases of phyllodes tumor of the prostate was done. RESULTS: Patient age was 25 to 86 years (mean 55) and they usually presented with urinary obstructive symptoms and hematuria. The diagnosis was made in 18 tumors by transurethral resection, in 2 by enucleation, in 1 by tumor resection and in 2 by prostatectomy. We analyzed 5 histological features, including cellularity (scale of 1 to 3), cytologic atypia (scale of 1 to 3), the number of mitotic figures per 10 high power fields, the stroma-to-epithelium ratio (low or high) and necrosis (present or absent). This combination of features revealed that 14 cases were low grade phyllodes tumor, 7 were intermediate grade and 2 were high grade with the high grade cases characterized by increased cellularity, severe cytological atypia, more than 5 mitotic figures per 10 high power fields and a high stroma-to-epithelium ratio, indicating stromal overgrowth. Immunohistochemical studies of 8 tumors revealed consistent, intense cytoplasmic immunoreactivity in stromal cells for vimentin and actin, in luminal epithelial cells for prostate specific antigen, prostatic acid phosphatase and broad-spectrum keratin AE1/AE3, and in basal cells for high molecular weight keratin 34beta-E12. Recurrence was seen in 7 of 14 low grade tumors (50%) and in 1 patient low grade sarcoma emerged with subsequent distant metastases 14 years after initial diagnosis following 5 recurrences. Recurrence was seen in 6 of 7 intermediate grade tumors and low grade sarcoma emerged with subsequent abdominal wall metastases in 1 patient 11 years after initial diagnosis following 3 recurrences. The phyllodes tumor recurred in each patient with high grade tumors with a time to first recurrence of 6 and 0.2 years, respectively. Distant metastases developed in these 2 patients. CONCLUSIONS: Histological grading of prostatic phyllodes tumors is predictive of short-term outcome based on the combination of stromal cellularity, cytological atypia, number of mitotic figures and the stroma-to-epithelium ratio. However, these tumors usually recur after transurethral prostatic resection and they are often locally aggressive with time. The emergence of overt sarcoma and metastatic disease is more frequent than previously recognized. Complete resection at initial diagnosis appears to be indicated.     

Meningiomas involving the clivus: a six-year experience with 41 patients

A series of 41 meningiomas involving the clivus operated on from July 1983 to January 1990 is reported. The presenting symptoms and signs of these patients were similar to those reported previously. All the patients were evaluated by pre- and postoperative thin-section, high-resolution computed tomography using soft tissue and bone algorithms. Most of the patients also underwent magnetic resonance imaging. The regions of the clivus involved by tumor were divided into upper, middle, or lower regions on the basis of anatomical landmarks. The diameter of the tumor was measured in three axes, and a tumor volume and a tumor equivalent diameter were computed to categorize tumors as small, medium, large, or giant types. There were 9 medium, 27 large, and 5 giant tumors in this series. Some simple and some complex operative approaches were employed to effect tumor removal. Large and giant tumors often required more than one operative approach to remove the tumor. Intraoperative technical difficulties included tumor consistency, vascularity, dissection from the brain stem, and vascular and cranial nerve encasement. Postoperative computed tomographic scans documented total excision in 32 patients (78%). Residual tumor remained in the clival or cavernous sinus areas. These patients were either being observed, or were treated with gamma knife radiosurgery. There was one operative death due to pneumonia (2%), and three patients (7%) suffered permanent major neurological changes, presumably due to vascular occlusions in the posterior circulation. In the follow-up period, which ranged from 3 to 76 months, 2 patients (6%) with tumors that had appeared to be totally excised experienced recurrence. These patients were treated by a second operation, alone or in combination with radiation therapy. Two patients who had subtotal excisions (25%) had evidence of regrowth. In 2 patients, tumor growth continued despite gamma knife radiosurgery or external beam radiotherapy.     

Cervical teratomas: an analysis. Literature review and proposed classification

Cervical teratomas are uncommon lesions usually diagnosed at birth but occasionally reported in older children and adults. During a 58-year span, nine cervical teratomas were identified at our institution (four previously reported): three stillborns with giant tumors; five live newborns; and one adult with a malignant tumor. Of the five newborns, two prematures died within one hour of birth. Of the three survivors, 2 had respiratory distress at birth. These infants were treated with early excision and are well at 7, 6, and 2 years of age. The last patient also had cystic fibrosis. The adult died of metastatic disease 8 months after resection. A literature review disclosed 212 cases in addition to the five reported here. Previous attempts at categorizing cervical teratomas have failed to address clinical patterns and have little prognostic value. We propose a classification based on birth status, age at diagnosis, and the presence or absence of respiratory distress. Group I--stillborn and moribund live newborns: number (N), 27; mortality (M), 100%. Group II--newborn with respiratory distress: N, 99; M, 43.4%. Group III--newborn without respiratory distress: N, 37; M, 2.7%. Group IV--children age 1 month to 18 years: N, 31; M, 3.2%. Group V--adults: N, 23; M, 43.5%. Twenty-six patients in group II and one in group III died without excision of the mass. Seventy-three patients in group II, 36 in group III, and 31 in group IV had extirpation of the tumor. Operative mortality was 11%, 0%, and 3.2%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Watchful waiting policy in recurrent Ta G1 bladder tumors

OBJECTIVE: To determine the outcome of a watchful waiting policy in patients suffering from small, recurrent, papillary bladder tumors. METHODS: Watchful waiting has been considered an option when a small (<10 mm) papillary, asymptomatic tumor with negative urinary cytology was found on follow-up cystoscopy in patients who had previous resection(s) of superficial, low-grade (Ta) bladder tumor(s). The watchful waiting protocol included cystoscopy and urinary cytology every 3 months for 2 years (and then every 6 months). Surveillance was stopped if the patient had developed either symptoms related to the tumor or positive cytology, or if there had been a significant alteration in tumor morphology or size. RESULTS: Thirty-eight watchful waiting periods were documented in 28 patients (mean age 67.7 years). Mean period length was 13.5 months (SD 14.4 months; range 3-60 months). Thirty periods were terminated with tumor resection. The main reasons for termination of surveillance were the appearance of additional tumors (19 patients) and excessive tumor growth (9 patients). Hematuria indicated tumor removal in only one patient. All resected tumors were stage Ta (23 were grade 1, and 7, grade 2). The rate of tumor growth during the watchful waiting period depended highly on the tumor's largest diameter at the beginning of surveillance. If the initial tumor diameter was smaller than 5 mm (32 cases), the tumor growth rate was 4+/-5.1 mm3/mo (mean+/-SD); if the initial tumor diameter was > or =5 mm (6 cases), the tumor growth rate was 870+/-1116 mm3/mo (p < 0.05). CONCLUSIONS: Small, recurrent papillary bladder tumors after resection of low-grade Ta tumor(s) pose minimal risk for the patient. A watchful waiting policy- without resection of the tumor-may be considered in these patients.     

7 fractionated cyberknife radiotherapy for giant skull metastasis: a case report

This is a report on the experience of using stereotactic radiotherapy for a large symptomatic metastatic skull tumor. The stereotactic radiotherapy was delivered in 7 fractions using the Cyberknife and produced excellent therapeutic results. This case concerns a 75-year-old female. Nineteen months after uterine cancer surgery, the patient demonstrated metastasis to the mediastinum lymph node and a tumor at the parietal bone tumor but was still undergoing observation. An increase of the parietal bone tumor became evident and the appearance of right hemiplegia, aphasia, and cognitive dysfunction caused her to consult this hospital. We observed a large 236 cm3 tumor spread over the subcutaneous tissue of the superior sagittal sinus, pressing the brain out of the dura mater and causing bone destruction. As a result of our findings, we began stereotactic Cyberknife radiotherapy delivered in 7 fractions. At the follow up visit one month after the treatment, the image of the tumor had already decreased, and after three months it was confirmed that the image of the tumor had disappeared. The patient's symptoms ameliorated rapidly. As a result, the patient has returned to an independent home-lifestyle, with amelioration of her quality-of-life defects. Six months after irradiation, there is no evidence of tumor regrowth or complications such as dermatopathy, cerebral edema, or necrosis. Cyberknife radiotherapy could shorten the treatment period and result in a reduction of the amount of irradiation to unaffected parts of the brain. In this case, though the tumor had spread widely in the subcutaneous tissue, the exposure doses were delivered at 2Gy/time and could be limited to under 70Gy. It is thought that Cyberknife radiotherapy will become one of the key treatments to help improve quality of life when treating symptomatic metastatic tumors.     

Undifferentiated large cell carcinoma of the thymus associated with Castleman disease-like reaction: a distinctive type of thymic neoplasm characterized by an indolent behavior

Five cases of a distinctive type of undifferentiated large cell thymic carcinoma accompanied by an inflammatory reaction having morphologic features closely resembling those of Castleman disease (CD) of the hyaline vascular type (HVCD) are reported. The tumors occurred in 3 men and 2 women with a median age of 53 years. Three patients were asymptomatic and the tumors were found incidentally; 1 patient presented with fatigue, weight loss, dyspnea, and chest pain, and another with acanthosis nigricans. The tumors were characterized by the admixture of two components: a neoplasm of cytokeratin (+)/CD5(-) undifferentiated large tumor cells and an inflammatory reaction resembling the late stage of HVCD. Some of the cases were associated with a remarkably indolent clinical course, especially when considering their high-grade morphology. Three patients were alive without disease at 1, 10, and 22 years. One patient was alive with persistent disease at 1 year. One patient's clinical course was unique in that the primary thymic tumor was found 16 years after a metastasis had been detected in two distant lymph nodes. The two possible explanations for the coexistence here described are as follows: 1) a CD-like reaction to the tumor as the morphologic manifestation of a host immune response; and 2) a malignancy engrafted upon preexisting HVCD of the thymus, in a manner analogous to that operating in the reported cases of tumors of dendritic/reticulum cells complicating HVCD at other sites. The first hypothesis is favored, with the added suggestion that the CD-like reaction may bear a relationship to the peculiarly indolent behavior that these tumors exhibit.     

73例巨指(趾)畸形患者临床疗效分析

目的 分析73例巨指(趾)畸形患者的临床特点.方法 回顾性分析1965年至2006年收治的73例巨指(趾)畸形患者的资料,统计分析其发病情况、受累指(趾)的分布及特征、治疗方法、X线片及病理检查结果,对获得随访的28例患者的疗效进行分析.结果 巨指中,示指受累最多,其次为拇、中指;巨趾中,第2趾受累最多.静止型巨指(趾)12例,均为出生后即有;进展型巨指(趾)61例,发病时间不一:出生即有39例,2岁以内17例,2岁以上5例.巨指(趾)偏斜共37例;并指3例;巨拇合并大鱼际饱满16例;多指粗大合并手掌及前臂增粗8例.结论 巨指多发生在正中神经支配区,主要累及示、拇及中指,并伴有正中神经脂肪浸润;巨趾多发生在足底内侧神经支配区,以第2趾多见.进展型巨指(趾)多于静止型,且指(趾)粗大可出生即有,并可合并并指、指(趾)偏斜、大鱼际饱满、手掌及前臂增粗.     

Abducens nerve schwannoma: a case report and review of the literature

BACKGROUND: Schwannomas of the abducens nerve are extremely rare tumors; only 10 cases have been reported so far. The tumor may be located within the cavernous sinus (CS) or more commonly at the prepontine region. Patients usually present with VIth cranial nerve paresis. CASE DESCRIPTION: We report a case of a 42-year-old male patient who presented with headache, vertigo, and hearing deficit, but no symptoms or signs related to a VIth cranial nerve impairment. Computed tomography and magnetic resonance imaging showed a large mass with a ring-like contrast enhancement in the prepontine area. Surgical treatment, via a simple retrosigmoid suboccipital approach, revealed a schwannoma originating from the VIth cranial nerve at its prepontine portion. Postoperative histological examination confirmed the diagnosis of schwannoma, and the patient had only a VIth cranial nerve palsy, which resolved during long-term follow-up. CONCLUSIONS: Abducens schwannomas are rare tumors, representing less than 1% of all intracranial schwannomas in our clinic and about 13% of oculomotor nerve schwannomas reported in the literature. These lesions can be mainly divided into tumors originating from the intracavernous portion of the VIth cranial nerve or more commonly from the cisternal part of the nerve, leading to a lesion in the prepontine region. In such cases, with no invasion of the cavernous sinus, radical tumor resection with preservation of the abducens nerve can be performed via a simple suboccipital retrosigmoid approach.     

Anesthetic management of patients undergoing resection of carcinoid metastasis to the brain

BackgroundCarcinoid tumors are derived from enterochromaffin cells and may release physiologically active compounds into the systemic circulation, leading to the development of carcinoid syndrome. Occasionally, these tumors metastasize to the brain, warranting biopsy or resection. In these surgical patients, the perioperative implications for anesthetic management are not heretofore defined in the indexed literature.MethodsPatients who had craniotomy for biopsy or resection of intracranial carcinoid tumors were retrospectively identified at a single medical center. Patient demographics, perioperative anesthetic management, adverse events, and outcome were summarized in this case series.ResultsEleven patients were identified; median age was 60 years (range = 42-78 years), and 45% were male. Immediately before surgery, 4 patients (36%) were receiving a somatostatin analog drug, and no patient had unchecked carcinoid syndrome. All patients received general anesthesia that included inhaled isoflurane and nitrous oxide, and all had invasive arterial blood pressure monitoring. One patient developed sustained hypotension after induction of anesthesia, likely related to hypovolemia and anesthetic drugs, but the possibility of carcinoid mediator release cannot be excluded. There were no other signs or symptoms of carcinoid syndrome in this or any other patient. Of all 11 patients, 10 (91%) experienced either significant disease progression (n = 2; 18%) or death (n = 8; 73%) from carcinoid disease, its sequelae, or an undetermined cause within 3 years after surgery. Of note, 3 of the deaths occurred shortly after surgery, on postoperative days 3, 7, and 8.ConclusionsIn our experience, carcinoid tumor metastasis to the brain—whether because of tumor makeup or prior treatment—is unlikely to produce symptoms of new-onset carcinoid syndrome intraoperatively; however, the risk cannot be completely excluded. Postsurgical prognosis was poor, both within the hospital and after hospital discharge.     

Childhood carcinoid tumors: the St Jude Children's Research Hospital experience

BACKGROUND/PURPOSE: To better characterize childhood carcinoid tumors, the authors reviewed the clinical presentation, treatment, and outcomes of pediatric patients with these rare tumors. METHODS: A retrospective review was conducted of medical records and pathologic materials of all children with carcinoid tumors treated at St Jude Children's Research Hospital between December 1977 and March 1999. RESULTS: Eight patients (median age, 12.7 years) were identified; 2 were boys, and 7 were white. Primary tumor sites were the appendix (n = 5), small intestine (n = 1), bronchus (n = 1), and 1 unknown site. In 7 cases, carcinoid tumor was not suspected at the time the tumor was identified. Seven patients had localized disease; 5 remain disease-free after complete resection, and 2, whose carcinoid tumors were identified incidentally, died of metastatic mucinous adenocarcinoma of the colon. One patient who presented with symptoms of carcinoid syndrome had metastatic disease that responded poorly to cytotoxic chemotherapy and remains alive with active disease. CONCLUSIONS: Although most pediatric carcinoid tumors arise in the appendix, these tumors also occur in other primary sites. Clinical awareness and early diagnosis are important factors in preventing morbidity and mortality. Outcomes are excellent for patients with localized disease that is completely resected, but those with metastatic disease fare poorly. New therapeutic strategies are needed for these patients.