Transglottic carcinoma

The cases of 152 patients with transglottic carcinoma were reviewed. There were 31% T2, 39% T3, and 30% T4 lesions. Twenty-six percent of patients had neck node metastases at initial presentation, and 19% with no neck dissection or radical irradiation to the neck subsequently developed neck metastases. Patients treated with voice conservation surgery +/- neck dissection +/- radiation (VCS +/- ND +/- R) had small transglottic carcinomas, whereas total laryngectomy +/- neck dissection +/- radiation (TL +/- ND +/- R) was used for patients with larger lesions. The reason for radiation alone (RA) was the patient's poor general condition or refusal of surgery. The total failure rate (primary, neck, and distant metastases) was 39%. Patients treated with TL +/- ND +/- R had fewer primary and stomal failures (12%) than those treated by VCS +/- ND +/- R (23%) and RA (33%), but ultimate failure after salvage treatment was the same (12%-13%). Sixty percent of patients treated with VCS and 67% with RA had their voices preserved. The major complication rate (overall, 16%) was highest in the group treated with VCS +/- ND +/- R. Five-year observed and adjusted survival for the entire group was 47% and 55%, respectively. The lower survival in the RA group was attributable to a high death rate from intercurrent disease. The incidence of second tumors was 14%. Unfavorable prognostic factors were older age, pretreatment tracheostomy, advanced stage and the presence of tumor in surgical specimen, and lymph nodes.     

跨声门癌与喉癌的跨声门侵犯

目的 探讨跨声门癌的定义及局部浸润扩展的组织病理学特点,明确跨声门癌与喉癌的跨声门侵犯的区别。方法 ５０例跨声门癌喉全切除标本,火棉胶包埋,制成连续切片,ＨＥＩ杂色,光交易下观察。结果 ５０便中,喉室全部受累,肿瘤主闰于喉呈以喉室为中心,浸润声门旁间隙者占８２％,浸润方式中,粘膜下深层浸润占５２％,粘膜下深层润伴粘膜表面浸润占３８％,沿粘膜表面浸润占１０％。跨声门癌以青草古深层浸润为主要方式占９０     

跨声门癌与喉癌的跨声门侵犯(附50例全喉连续切片观察)

目的探讨跨声门癌的定义及局部浸润扩展的组织病理学特点，明确跨声门癌与喉癌的跨声门侵犯的区别。方法５０例跨声门癌喉全切除标本，火棉胶包埋，制成连续切片，ＨＥ染色，光镜下观察。结果５０例中，喉室全部受累，肿瘤主体位于喉室或以喉室为中心，浸润声门旁间隙者占８２％（４１／５０）。浸润方式中，粘膜下深层浸润占５２％（２６／５０），粘膜下深层浸润伴粘膜表面浸润占３８％（１９／５０），沿粘膜表面浸润占１０％（５／５０）。跨声门癌以粘膜下深层浸润为主要方式占９０％（４５／５０），向声门上区、声门区呈基本均等态势浸润扩展。结论跨声门癌系原发喉室，以此为中心纵向跨区发展的恶性肿瘤。其组织学特点为以粘膜下深层浸润为主要扩展方式。而跨声门侵犯系喉癌的晚期病变，两者有本质区别。     

Spinal astrocytoma with intracranial metastases

Summary We present a 21-year-old man with a spinal intramedullary astrocytoma in the low thoracic segment who died of multiple intracranial metastases more than 3 years after primary surgery.     

Management of intracranial metastases of differentiated carcinoma of thyroid

Summary Brain metastases in differentiated carinoma of the thyroid is a rare occurrence. We treated five documented cases of carcinoma of thyroid with brain metastases out of 400 cases of thyroid cancer treated between 1972 to 1993. 4 were females out of which one was pregnant during the appearance of brain metastases. All cases were treated with thyroidectomy, and radioiodine as primary therapy. Brain metastases developed 6 months to 11 years following treatment of the primary and were treated with radiotherapy and suppressive levothyroxine. We observed the beneficial effect of suppressive thyroxine and the poor prognosis associated with pregnancy and withdrawl of thyroid replacement therapy. 3 of the 5 patients are alive 12–23 months after treatment for brain metastases, while 2 patients died at 4 months and 7 years post brain metastases due to pulmonary and hepatic failure, respectively.     

Primary intracranial germinoma with massive ventriculoperitoneal shunt metastases

Ventriculoperitoneal shunt metastases from primary intracranial germinomas are extremely rare. To date, only three case reports of this phenomenon have appeared in the literature. We present the case of a 25-year-old black male who developed ventriculoperitoneal shunt metastases 10 months following diagnosis of an intracranial germinoma. Radiotherapy destroyed most of the intracranial tumor, but abdominal metastases became progressive and were not treated with radiotherapy. The role of radiotherapy in the treatment of ventriculoperitoneal shunt metastases is examined and previous cases in the literature are reviewed.     

Prediction of intracranial metastases in cancer patients with headache

BACKGROUND: The current study was conducted to investigate the diagnostic value of neurologic evaluation for the prediction of intracranial metastases in cancer patients with new or changed headache. METHODS: Between February 1997 and February 2000, general practitioners and specialists referred cancer patients with new or changed headache to the Department of Neurology at the study institution. All patients underwent a structured history and neurologic examination. Magnetic resonance imaging (MRI) of the brain was used as the gold standard for determining the presence of intracranial metastases. The association between baseline patient characteristics, history variables, and variables from the neurologic examination in patients with intracranial metastases was evaluated by univariate and multivariate logistic regression analyses in combination with receiver operating characteristic (ROC) curve analyses. RESULTS: Sixty-eight consecutive patients were included in the current study (48 females and 20 males). The mean age of the patients was 57 years (range, 24-88 years; standard deviation +/- 13.3 years). Breast carcinoma was the primary tumor in 32 patients (47.1%) and lung carcinoma was the primary tumor in 12 patients (17.6%). Intracranial metastases occurred in 22 patients (32.4%). The occurrence of intracranial metastases was predicted in the multivariate logistic regression analyses by one baseline patient characteristic variable and 2 history variables (i.e., headache duration of < or =10 weeks [odds ratio (OR) of 11.0; 95% confidence interval (95% CI), 1.1-108.2], emesis [OR of 4.0; 95% CI, 1.1-14.3], and pain not of tension- type [OR of 6.7; 95% CI, 1.8-25.1]). No variable from the neurologic examination was found to add information to the prediction model. When at least one of the three predictors was present, all patients with intracranial metastases could be identified with this prediction model. MRI could be omitted in 12 patients (26%) without intracranial metastases. The ROC area under curve of this model was 0.83. CONCLUSIONS: Intracranial metastases were found in 32.4% of the cancer patients with headache as the presenting symptom. Although 3 significant clinical predictors were found (headache duration < or =10 weeks, emesis, and pain not of tension- type), few patients could be excluded from undergoing MRI because of a low specificity. Therefore, MRI of the brain was considered to be warranted in all patients in the current study.     

Spinal extramedullary anaplastic ependymoma with spinal and intracranial metastases

Summary We describe a 29-year-old woman who presented with progressive neck pain, sensory deficit and weakness in both arms. Magnetic resonance imaging (MRI) of the cervical spine revealed an extramedullary tumor with severe spinal cord compression. During surgery an intradural extramedullary tumor was found. Further imaging showed a second lumbar spinal tumor. Microscopy of both tumors showed that both tumors were anaplastic ependymomas, which almost never present as extramedullary tumors. Two years after surgery, an intracranial extracerebral metastasis was found, without evidence of spinal recurrence.     

Initial clinical experience with frameless radiosurgery for patients with intracranial metastases

PURPOSE: To review the initial clinical experience with frameless stereotactic radiosurgery (SRS) for treating intracranial metastatic disease. METHODS AND MATERIALS: Sixty-four patients received frameless SRS for intracranial metastatic disease. Minimum follow-up was 6 months with none lost to follow-up. Patients had a median of 2 metastases and a maximum of 4. The median number of isocenters was 2 with median arcs of 10 and median dose of 17.5 Gy. Thirteen patients were treated for progressive/recurrent disease after surgical resection or whole brain radiotherapy (WBRT). Fifty-one patients were treated with frameless SRS as an an adjunct to initial treatment. Of the total treated, 17 were treated with SRS alone, 20 were treated with WBRT plus SRS, 16 were treated with surgical resection plus SRS, and the remaining 11 were treated with surgical resection plus WBRT plus SRS. RESULTS: With a median actuarial follow-up period of 8.2 months, ultimate local control was 88%. The median time to progression was 8.1 months. The median overall survival was 8.7 months. Of the 17 patients treated with SRS alone, 86% had ultimate local control with mean overall survival of 7.1 months. Of the 13 patients who received surgical resection plus SRS without WBRT as primary treatment, there was 85% ultimate local control with an overall survival of 10.3 months. Three patients treated with initial surgery alone had recurrence treated with SRS 2-3 months after resection. All these patients obtained local control and median survival was >10 months. Of the 13 patients who received WBRT followed by SRS as boost treatment, 92% had local control and mean overall survival was 7.3 months. Of 7 patients who received SRS after recurrence after WBRT, 100% had local control with median survival of 8.2 months. For 8 patients who received surgery followed by WBRT and SRS, local control was 50%; however, ultimate intracranial control was achieved in 7 of 8 patients with repeat SRS and surgical resection. The overall survival in this group of patients was 14.7 months. No patient had a serious (Grade 3 or higher) complication requiring intervention. CONCLUSIONS: Frameless optically guided radiosurgery is less invasive, can be performed as a standard radiotherapy-based simulation procedure, and maintains submillimetric accuracy. Our initial results with frameless SRS for metastatic disease suggest survival times and local control (88%) eqiuvalent to frame-based methodologies. Practical noninvasive delivery makes treatment and potential retreatment to avoid WBRT more feasible.     

Sweat gland carcinoma with lung metastases

Sweat gland carcinoma is a rare skin tumor. The tumor has propensity to spread to lymph nodes and distant metastases has been reported. Their exact incidence in the Indian setting is not known. Aspects related to treatment are also not clearly defined. Though surgery forms the initial treatment approach, adjuvant treatment has not been properly explored. We report here a case of sweat gland carcinoma with bilateral lung metastases.     

Prolactin-producing pituitary carcinoma with pulmonary metastases

Pituitary adenomas rarely are metastatic. Extracranial visceral metastases of prolactinomas were not previously reported. The authors report a case of a 34-year-old man with a prolactin-producing pituitary carcinoma and histologically proven lung metastases. Pathologic examination of the pulmonary spread included electron microscopy and immunohistochemistry; these confirmed prolactin production by the tumor. The patient's presentation at initial diagnosis, disease recurrence, clinical course, management, and response to therapy (with its theoretic basis) are detailed. Despite the use of dopamine analogues (to tolerance and in combination), there was documented intracranial and extracranial disease progression. Possible future therapeutic maneuvers are discussed.     

Risk of intracranial hemorrhage with anticoagulation therapy in melanoma patients with brain metastases

Venous thromboembolism (VTE) is a frequent complication in melanoma patients with brain metastases (BM). The management of these patients is challenging because of the high risk of intracranial hemorrhage (ICH) and the limited data available on the safety of anticoagulation in this scenario. We reviewed the treatments and outcomes among melanoma patients with BM and VTE at our institution to determine the safety of anticoagulation in these patients. A retrospective chart review was performed to identify melanoma patients with BM who were diagnosed with VTE. The clinical characteristics of the BM and the VTE, the treatments given for VTE, subsequent ICH, and overall survival (OS) were determined. The characteristics and outcomes were compared between patients who received systemic anticoagulation and those who did not. A total of 74 evaluable melanoma patients with BM and VTE were identified. Fifty-seven (77%) patients received systemic anticoagulation. There was no significant difference in the number (P=0.40) or the maximum diameter (P=0.55) of brain metastasis between the patients who received anticoagulation and those who did not. Two (4%) patients who received anticoagulation developed ICH, which was not statistically different from the patients who did not receive anticoagulation (0%, P=1.00). There was a trend toward longer OS from VTE among patients who received systemic anticoagulation (median OS: 4.2 vs. 1.2 months, P=0.06). Anticoagulation for VTE did not significantly increase the risk of ICH or decrease OS in patients with melanoma BM. These data support the safety of systemic anticoagulation for VTE in these patients.     

Multiple intracranial melanoma metastases treated with surgery and radiosurgery with long term control

Summary A case of malignant melanoma with multiplex brain metastases is described, where both surgical and radiosurgical treatment was applied. Due to CNS manifestations the patient was operated on in two sessions. First the symptomatic large tumor was removed, and the other, small lesion which could not be reached from the same approach was operated later. The primary skin lesion was discovered and removed between the two operations. A CT scan three months after the second operation revealed recurrence at the site of the first operation, and the appearance of two new tumors. The intracranial neoplasms were treated in one session by stereotactic radiosurgery using a linear accelerator. Six months after this treatment a new skin lesion was removed and the patient received DTIC therapy. Successive CT scans after the irradiation showed a steady regression of the radiosurgically treated tumors, and more than one year after the irradiation no tumor could be detected on the CT scans.     

Choriocarcinoma with brain metastases. Successful management of increased intracranial pressure with barbiturates

Choriocarcinoma is a potentially curable neoplasm. Although the presence of intracranial metastases worsens the ultimate prognosis, several reports have shown successful response to therapy. This clinical report outlines a method by which the appropriate therapy may be initiated in a patient with intracranial metastases, who otherwise may not have survived the interval necessary for the induction of successful therapy.     

Stereotactic radiosurgery for four or more intracranial metastases

PURPOSE: To evaluate the outcomes after a single stereotactic radiosurgery procedure for the care of patients with 4 or more intracranial metastases. METHODS AND MATERIALS: Two hundred five patients with primary malignancies, including non-small-cell lung carcinoma (42%), breast carcinoma (23%), melanoma (17%), renal cell carcinoma (6%), colon cancer (3%), and others (10%) underwent gamma knife radiosurgery for 4 or more intracranial metastases at one time. The median number of brain metastases was 5 (range, 4-18) with a median total treatment volume of 6.8 cc (range, 0.6-51.0 cc). Radiosurgery was used as sole management (17% of patients), or in combination with whole brain radiotherapy (46%) or after failure of whole brain radiotherapy (38%). The median marginal radiosurgery dose was 16 Gy (range, 12-20 Gy). The mean follow-up was 8 months. RESULTS: The median overall survival after radiosurgery for all patients was 8 months. The 1-year local control rate was 71%, and the median time to progressive/new brain metastases was 9 months. Using the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) classification system, the median overall survivals for RPA classes I, II, and III were 18, 9, and 3 months, respectively (p < 0.00001). Multivariate analysis revealed total treatment volume, age, RPA classification, and marginal dose as significant prognostic factors. The number of metastases was not statistically significant (p = 0.333). CONCLUSION: Radiosurgery seems to provide survival benefit for patients with 4 or more intracranial metastases. Because total treatment volume was the most significant predictor of survival, the total volume of brain metastases, rather than the number of metastases, should be considered in identifying appropriate radiosurgery candidates.     

Breast carcinoma with neuroendocrine differentiation and myocardial metastases

A 63-year-old Japanese woman was diagnosed with metastatic well-differentiated neuroendocrine carcinoma presenting as a perianal mass without an obvious primary site. Two years later, she presented with a breast mass determined on histologic examination to be the primary neuroendocrine carcinoma. The tumor was weakly positive for estrogen receptor and clearly originated in multifocal ductal carcinoma in situ. At the same time, she was found to have multiple metastases in bone and liver and, later, heart. Most studies report a relatively poor prognosis and limited treatment responsiveness for neuroendocrine breast carcinoma. Better understanding of the cellular origin and molecular pathogenesis of this relatively enigmatic rare disease is required.     

Lung adenosquamous carcinoma with lingual and cardiac metastases

Metastatic lingual tumors are very rare, and hematogenous myocardial metastasis is also relatively uncommon. We report a case of lung adenosquamous carcinoma with metastases to the tongue and the myocardium. A 65-year-old man underwent a partial upper lobectomy for a primary lung cancer in June 1997. He developed a local recurrence and received two courses of radiotherapy, in March and September 1998. A follow-up computed tomography (CT) scan showed a myocardial tumor, suggestive of cardiac metastasis. In October 1998, he began to complain of angina-like chest oppression and showed ischemic changes on electrocardiogram (ECG), and he also developed lingual, subcutaneous, and brain metastases. He died of respiratory failure in December 1998, 20 months after the initial diagnosis of primary lung cancer; metastases to the tongue and myocardium were confirmed by autopsy. Received: April 30, 1999 / Accepted: December 8, 1999