囊性颅咽管瘤立体定向囊腔内放疗的临床研究

目的　探讨囊性颅咽管瘤囊腔内放疗的有效性和安全性。方法　对 5 6例囊性颅咽管瘤行CT引导立体定向囊腔内放疗 ,根据个体化剂量设计分别置入 1～ 3次、2 .4～ 14 .8MBq不等胶体磷酸铬 (Cr3 2 Po4) ,并进行临床随访观察。结果　 5 6例患者术后神经功能均很快出现不同程度的改善。随访 6个月至 9年 ,49例视力、视野障碍中 ,45例获得逐渐改善 ,4例恶化 ,偏瘫 3例恢复正常 ,所有内分泌功能障碍者均获得稳定或不同程度好转 ,复查CT或MR示 :5例瘤实质增大 (9% ) ,2例新的囊腔形成 ,1例导管在脑室内囊腔略缩小 ,囊腔完全消失 2 4例 (4 3 % ) ,囊腔明显缩小 (>80 % )2 4例 (86% )。无手术死亡及严重并发症。结论　立体定向囊腔内放疗是一种治疗囊性颅咽管瘤的安全而有效方法 ,放射剂量设计的个体化是提高治疗有效率的关键。     

儿童颅咽管瘤质子和光子治疗的剂量学比较

目的：对3例儿童颅咽管瘤进行剂量学比较，以探讨质子在儿童颅咽管瘤放疗中的潜在优越性。方法：靶区肿瘤照射剂量为55Cy。每例患者分别作单纯光子、光子和质子混合射线以及单纯质子的治疗计划，治疗方法均为三维适形治疗；应用适形指数以量化地比较3种治疗计划对靶区的剂量覆盖和正常组织的照射容积和剂量。结果：3种治疗计划均达到满意的靶区剂量覆盖，92％～100％的PTV在处方剂量95％的范围内。质子治疗的运用使得正常脑组织、脑干、大脑颞叶和内耳的剂量显著下降。当肿瘤与视交叉有少许间隙时，质子治疗可以降低视交叉的平均剂量和最低剂量。单纯质子体现出较混合射线更强的优越性。单纯光子、混合射线和单纯质子的适形指数分别为O．631、O．784和O．848，即质子治疗提供的高剂量区曲线分布更符合PTV的形状。结论：在保证靶区剂量的基础上，质子的应用普遍减少了颅内正常组织的照射，并在部分患者中提供了剂量提升的可能性。     

Evaluation of children with craniopharyngioma using carbon-11 methionine PET prior to proton therapy

Background

Fluorine-18 (¹⁸F) fluorodeoxyglucose (FDG) positron emission tomography (PET) is limited in its evaluation of brain tumors due to the high basal activity of the cerebral cortex and white matter. Carbon-11 methionine (¹¹C MET) has little uptake under normal conditions. We prospectively investigated the uptake of ¹⁸F FDG and ¹¹C MET PET in patients with craniopharyngioma prior to proton therapy.

Methods

Ten patients newly diagnosed with craniopharyngioma underwent PET imaging using ¹⁸F FDG and ¹¹C MET. PET and MRI studies were registered to help identify tumor volume. Measurements of maximum standardized uptake value (SUV_max) were taken of the tumor and compared with noninvolved left frontal background white matter using a paired t-test. Uptake was graded using a 4-point scale.

Results

Median patient age was 9 years (range 5–19). Seven patients were diagnosed by pathology, 1 by cyst fluid aspiration, and 2 by neuroimaging. Median FDG SUV_max for tumor and background were 2.65 and 3.2, respectively. Median MET SUV_max for tumor and background were 2.2 and 1, respectively. There was a significant difference between MET tumor SUV_max and MET background SUV_max (P = .0001). The difference between FDG tumor SUV_max and FDG background SUV_max was not significant (P = .3672).

Conclusion

¹¹C MET PET uptake is significantly greater within the tumor compared with noninvolved background white matter, making it more useful than FDG PET in identifying active tumor in patients with craniopharyngioma. Future work will focus on using ¹¹C MET PET to discriminate between active and inactive tumor after irradiation.     

The Utility of External Beam Radiation and Intracystic 32 P Radiation in the Treatment of Craniopharyngiomas

Background. The management of craniopharyngiomas has historically been controversial in terms of the extent of initial surgical resection and the use of additional treatments. Various options include radical excision versus a more conservative surgical approach followed by external beam radiation; most recently, intracystic ³² P radiation has been used in selected patients. Methods. We reviewed our experience with 25 patients with craniopharyngiomas treated between 1984 and 1999 to assess the effectiveness of external beam radiation and intracystic ³² P radiation therapy in preventing progression and recurrence of local disease. Results. All patients underwent surgery as a component of initial therapy for their histologically-proven craniopharyngiomas. Fifteen patients additionally received external beam radiation. Forty-five percent of patients who underwent incomplete resections followed by external beam radiation required additional therapy. In contrast, 80% of patients who had incomplete resections without post-operative external beam radiation required further treatment. Seven patients had intracystic ³² P colloid injections. Neither of the two patients receiving ³² P intracystic radiation as part of their initial therapy needed further treatment. Only one of the five patients receiving ³² P intracavitary radiation for disease progression following initial therapy required further intervention. Of the remaining four patients, three enjoyed responses to treatment and one had stable disease. Conclusions. Our observations support the use of external beam radiation for prevention of tumor progression in adults unable to receive a complete surgical resection. Our results additionally suggest that intracystic ³² P radiation results in control of cystic components of craniopharyngiomas in the majority of cases.     

经翼点入路显微手术切除小儿颅咽管瘤20例

目的　探讨提高手术根治颅咽管瘤的方法。方法　对 2 0例颅咽管瘤 ,均在全麻下行翼点入路 ,采用显微外科技术 ,根据肿瘤的位置 ,采用视交叉前间隙、颈内动脉和视神经间隙及颈内动脉外侧等间隙切除肿瘤。结果　全切除 16例、近全切除 3例、大部切除 1例。近期明显好转 14例、改善 4例、无变化及死亡各 1例。半年以上随访 18例 ,能正常生活者 16例 ,生活需人照顾 2例。结论　翼点入路手术能满足鞍区多种类型颅咽管瘤的显露 ,能提高肿瘤全切率及治愈率。     

Vinorelbine, bleomycin and methotrexate as a salvage therapy for patients with head and neck squamous carcinoma in relapse after cisplatin/fluorouracil

Background: Cisplatin (CDDP) and 5-fluorouracil (5-FU) represent the standard chemotherapy for advanced/recurrent head and neck squamous carcinoma (HNSC); however, the duration of response is often short, with a median survival of only five to six months.Patients and methods: Patients with HNSC were treated with vinorelbine 20 mg/m² and methotrexate 50 mg/m² every week and bleomycin 15 mg/m² every two weeks. All patients were previously treated with a CDDP/5-FU regimen.Results: Forty-eight patients were evaluable for response and toxicity. After a median follow-up of 15 months, 16 patients are still alive and 32 have died. We had one complete response (2%), 12 partial responses (25%) (overall response rate 27%; 95% CI: 14%–39%), 11 stabilizations (23%) and 24 progressions (50%) of disease. Neutropenia grade 3–4 was seen in 12 patients; peripheral neurotoxicity in two patients. There were no toxic deaths.Conclusions: This regimen, administered in an outpatient setting, revealed some activity as a second-line treatment in patients with HNSC, with acceptable toxicity.     

Intracavitary bleomycin for the control of malignant effusions

The results of treatment with intracavitary bleomycin are reported in twenty patients with a malignant pleural effusion and five patients with malignant ascites. The control rate was 17/20 (85%) patients with malignant pleural effusions and 3/5 (60%) patients with malignant ascites. Toxicities were minimal with fever being the most common side effect in four patients (16%. Bleomycin is an effective and nontoxic sclerosing agent.     

Ectopic recurrence of craniopharyngioma: a case report and review of the literature

Summary The ectopic recurrence of craniopharyngioma is a rare postoperative complication, for which there are fifteen reported cases that have been surgically verified. The authors present a rare case of ectopic recurrence along the tract of the surgical route. A 12-year-old girl, who had undergone total removal of a suprasellar craniopharyngioma 4 years previously, presented with a generalized tonic-clonic seizure. Magnetic resonance imaging revealed a strongly enhancing cystic tumor in the right frontal lobe, under the bone flap used for the previous craniotomy. Gross total resection was achieved by revision of previous craniotomy. The intraoperative findings revealed that the recurrent tumor was anatomically related to the previous surgical tract, suggesting dissemination along the operative tract. The histopathological features of the mass were the same as those of the previous suprasellar craniopharyngioma. The case presented here and a review of the reports on the previous instances of ectopic recurrence of craniopharyngioma suggest that meticulous protection of the surgical field and careful handling of the tumor during the operation are required. It should be emphasized that long-term follow-up is mandatory, even in patients who underwent a gross total removal.     

Intracavitary bleomycin and tetracycline in the management of malignant pleural effusions: a randomized study

Both bleomycin and tetracycline have been suggested as the sclerosing agent of choice in the management of malignant pleural effusions. To determine if one drug is superior to the other in this role, patients with malignant pleural effusions were randomly assigned to receive either bleomycin or tetracycline in the previously evacuated pleural space through a thoracostomy tube. Following instillation of the assigned agent, the tube was clamped for 8 hours and then reattached to suction. When the chest tube drainage had slowed to less than 40 ml in a 24-hour period or if 7 days had passed, the tube was removed. Pleural sclerosis was attempted 42 times in 34 patients. No statistically significant differences were found between the two treatment groups when prevention of effusion reaccumulation and time to removal of the chest tube (efficiency) were compared. Side effects including pleural pain and fever, occurred with both agents, but were manageable. Since one drug was not clearly superior to the other, and bleomycin is more costly, we suggest that tetracycline rather than bleomycin be used when pleural sclerosis is needed to manage malignant pleural effusions.     

Radiation therapy for pancreatic cancer: eleven year experience at the JCRT

Radiation therapy (XRT) for 41 patients with unresectable pancreatic cancer resulted in a median survival of 7.0 months. There was no difference in median survival for patients receiving external beam alone (3500 to 5600 cGy) (n = 28), intraoperative (IORT) boost plus external beam (5040 to 6750 cGy) (n = 9), or a gold-198 implant +/- external beam radiation (n = 4). A pilot study using orthovoltage IORT boost indicates no acute toxicity with doses of 1250 to 1750 cGy. Serious late damage has not been observed in any patients followed to 2 years. Local recurrence in patients treated post-operatively after "radical" surgery occurred in one of 10 (10%). This adjuvant treatment is safe and appears to improve local control rates compared to historical data, but survival is still poor. The median survival for the post-operative group is 10 months; three patients are alive without disease 8 months to 8.3 years after treatment.     

Radiotherapy for craniopharyngioma in children: a national audit

A survey of current radiotherapy practices in the United Kingdom for treatment of craniopharyngioma in children was undertaken in view of the need to optimize control and minimize side effects in a patient group who can expect to survive for prolonged periods after treatment. Useable replies were received from 16 practitioners. A high level of conformity was reported in some areas but practice varied considerably in others. Thus whereas 15 employed magnetic resonance imaging (MRI) alone or with computed tomography (CT) to establish the gross tumour volume (GTV), six exclusively used pre-operative and seven exclusively used post-operative studies. Twelve added a margin of 1 cm to establish the planning target volume (PTV). Nine used CT planning. Fourteen gave radiation doses of between 50 and 55 Gy, but eight different dose/fractionation combinations were used. The most favoured regime (used by six) was 50 Gy in 30 fractions. Two centres provided written information on possible side effects of treatment. We suggest that it might prove helpful if a national treatment protocol was developed.     

神经内镜扩大经鼻蝶切除术与开颅术切除颅咽管瘤的疗效对比

目的:研究颅咽管瘤患者采用神经内镜扩大经鼻蝶切除术与开颅术切除的临床效果。方法:临床纳入我院2015年6月至2018年1月期间收治的76例颅咽管瘤患者作为研究对象,按手术情况分为两组各38例。其中38例患者采用传统开颅切除术治疗作为开颅组,另38例患者采用神经内镜扩大经鼻蝶切除术治疗作为内镜组。观察两组患者手术情况、临床缓解率、肿瘤切除率以及并发症情况。结果:两组患者手术时间、出血量均无差异,P＞0.05;内镜组住院时间明显短于开颅组,P＜0.05。内镜组肿瘤全切率、临床缓解率分别为65.79%、86.84%,均高于开颅组的47.37%、55.26%,P＜0.05。两组患者并发症包括颅内感染、偏瘫、颅神经损伤、腺垂体功能减退以及癫痫。内镜组发生率仅为15.79%,明显低于开颅组的44.74%,P＜0.05。结论:神经内镜扩大经鼻蝶切除术治疗颅咽管瘤效果较好,患者预后较好,缩短住院时间,提高肿瘤全切率及临床缓解率,减少术后并发症,安全可靠,值得临床应用及推广。     

儿童颅咽管瘤的手术治疗27例体会

背景与目的：儿童颅咽管瘤是好发于鞍区的良性肿瘤,目前主要的治疗方法是手术切除肿瘤,选择适当的入路既可将肿瘤完整切除又能避免肿瘤周围重要的神经结构损伤,是减少肿瘤复发及术后并发症的关键。我们选择27例手术治疗儿童颅咽管瘤的临床资料以探讨治疗儿童颅咽管瘤的手术入路选择、手术技巧。方法：回顾分析27例儿童颅咽管瘤患者手术治疗的临床资料,总结治疗过程中的体会。结果：27例中肿瘤镜下全切22例,次全切3例,部分切除2例。手术经额硬膜下入路18例,经翼点入路4例,经蝶入路切除3例,经半球间-纵裂入路2例。24例获随访2个月至5年,效果良好者21例,生活需照顾者2例,死亡1例,最常见的术后并发症为垂体功能低下及尿崩。结论：显微外科手术全切颅咽管瘤,效果良好,额下入路能提供鞍上大颅咽管瘤手术切除良好的暴露。     

Incidence, treatment and survival of patients with craniopharyngioma in the surveillance, epidemiology and end results program

Craniopharyngioma is a rare primary central nervous system neoplasm. Our objective was to determine factors associated with incidence, treatment, and survival of craniopharyngiomas in the United States. We used the surveillance, epidemiology and end results program (SEER) database to identify patients who received a diagnosis of craniopharyngioma during 2004-2008. We analyzed clinical and demographic information, including age, race, sex, tumor histology, and treatment. Age-adjusted incidence rates and age, sex, and race-adjusted expected survival rates were calculated. We used Cox proportional hazards models to determine the association between covariates and overall survival. We identified 644 patients with a diagnosis of craniopharyngioma. Black race was associated with an age-adjusted relative risk for craniopharyngioma of 1.26 (95% confidence interval [CI], 0.98-1.59), compared with white race. One- and 3-year survival rates of 91.5% (95% CI, 88.9%-93.5%), and 86.2% (95% CI, 82.7%-89.0%) were observed for the cohort; relative survival rates were 92.1% (95% CI, 89.5%-94.0%) and 87.6% (95% CI, 84.1%-90.4%) for 1- and 3-years, respectively. In the multivariable model, factors associated with prolonged survival included younger age, smaller tumor size, subtotal resection, and radiation therapy. Black race, on the other hand, was associated with worse overall survival in the final model. We demonstrated that >85% of patients survived 3 years after diagnosis and that subtotal resection and radiation therapy were associated with prolonged survival. We also noted a higher incidence rate and worse 1- and 3-year survival rates in the black population. Future investigations should examine these racial disparities and focus on evaluating the efficacy of emerging treatment paradigms.     

Predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours.

BACKGROUND: Bleomycin pulmonary toxicity (BPT) has been known since the early clinical trials of bleomycin in the 1960s. Postulated risk factors include cumulative bleomycin dose, reduced glomerular filtration rate (GFR), raised creatinine, older age and supplemental oxygen exposure. PATIENTS AND METHODS: From our prospectively collected testicular cancer research database, we reviewed 835 patients treated at the Royal Marsden NHS Trust (Sutton, UK) with bleomycin-containing regimens for germ-cell tumours between January 1982 and December 1999, to identify those with BPT. RESULTS: Fifty-seven (6.8%) patients had BPT, ranging from X-ray/CT (computed tomography) changes to dyspnoea. There were eight deaths (1% of patients treated) directly attributed to BPT. The median time from the start of bleomycin administration to documented lung toxicity was 4.2 months (range 1.2-8.2). On multivariate analysis, the factors independently predicting for increased risk of BPT were GFR <80 ml/min [hazard ratio (HR) 3.3], age >40 years (HR 2.3), stage IV disease at presentation (HR 2.6) and cumulative dose of bleomycin >300,000 IU (HR 3.5). CONCLUSIONS: Patients with poor renal function are at high risk of BPT, especially if they are aged >40 years, have stage IV disease at presentation or receive >300,000 IU of bleomycin. In such cases alternative drug regimens or dose restriction should be considered.     

Primary radiation therapy for early breast cancer: The experience at the joint center for radiation therapy

The results of primary radiation therapy in 176 consecutive patients with clinical Stage I and II carcinoma of the breast were reviewed. Median follow-up time was 47 months. The overall breast relapse rate was 7%. Patients undergoing interstitial implantation had a significantly lower breast relapse rate (1%) than patients not undergoing implantation (11 %). Breast relapse was more common in patients undergoing incisional or needle biopsy (17 %), compared to patients treated after excisional biopsy (5 %). In patients undergoing excisional biopsy, but not interstitial implantation, breast relapse was related to external beam dose. Twelve percent of the patients who received less than 1600 ret dose relapsed in the breast, compared to none of the 19 patients who received more than 1700 ret dose. These results imply that supplemental irradiation to the primary tumor area is required following excisional biopsy of a primary breast cancer when 4500–5000 rad is delivered to the entire breast.     

Radiation therapy in adenoid-cystic carcinoma

Between 1949 and 1977, 74 patients with adenoid-cystic carcinoma of various head and neck sites were treated by radiation therapy at Memorial Sloan-Kettering Cancer Center. Radiation therapy alone was employed in 49 patients for recurrent, unresectable disease, and in 25 patients it was given as an adjunct to surgical resection. Among the 49 patients treated with radiation therapy alone, tumor regression was seen in 47 (96%). However, 44 of the 47 (93.5%) subsequently relapsed locally. Relapse occurred within 18 months in one-half of the patients and within 5 years in all of them. Of the 25 patients who received adjunctive radiation therapy about one-half relapsed locally within five years. There were 9 patients in this group, however, whose field size exceeded 8 X 8 cm and the dose of radiation also exceeded 4500 rad: 88% of these patients remained relapse-free at 5 years, compared with only 22% of the other 16 whose dose, or field size, or both, were inadequate by comparison. These data suggest that when irradiation is employed for advanced, inoperable adenoid-cystic carcinoma, it offers useful palliation but is rarely, if ever, curative. Postoperative irradiation, on the other hand, might improve the local control and the survival in patients with operable adenoid-cystic carcinoma who are at high risk for relapse, but only if the field size and the dose are adequate.     

Cefpodoxime proxetil as a therapeutic option in switching therapy for infective endocarditis in children: case reports and literature review

Infective endocarditis (IE) is uncommon in children, affecting predominantly subjects with congenital heart disease (CHD) and patients with indwelling central lines. The principles of antibiotic treatment in paediatric population are similar to those in adults. Prolonged intravenous administration of bactericidal rather than bacteriostatic agents is preferred. Outpatient intravenous therapy after initial treatment in the hospital may be considered only in selected patients. Partial oral treatment has been described in cases of left-sided, uncomplicated IE caused by common pathogens in adult patients. There are no guidelines or trials in paediatric population regarding switching therapy from intravenous to oral route. We present two cases of IE in children caused by uncommon pathogenic bacteria (Abiotrophia defectiva and Haemophilus parainfluenzae) successfully treated with oral third-generation cephalosporin – cefpodoxime proxetil after initial intravenous therapy. This paper provides observations on different therapeutic approach for IE in children as well as another potential use of cefpodoxime proxetil.