Post-traumatic cutaneous meningioma

Cutaneous meningiomas are extremely rare tumours and their diagnosis is difficult. We describe the case of a patient who developed a paranasal swelling after head trauma and associated fractures in the same region years before. Histopathological examination of an incisional biopsy revealed the diagnosis of cutaneous meningioma. After one and a half years' follow up, surgical excision was performed because of progressive growth of the tumour and associated aesthetic problems. Extracranial meningiomas can develop probably secondary to trapping of meningeal tissue after trauma. If there is no intracranial connection surgical removal can be considered.     

Radical radiotherapy compared with surgery for advanced squamous cell carcinoma of the base of tongue

PURPOSE: This study reports on T3/T4 base of tongue (BOT) tumors treated at the Erasmus MC (Rotterdam) with external beam radiotherapy (EBRT) and brachytherapy (BT). Local control, survival, and functional outcome are compared to results obtained in similar patients treated at the Vrije University Medical Center (VUMC, Amsterdam) by surgery and postoperative RT (PORT). METHODS AND MATERIALS: At Rotterdam 46/2 Gy was given to the primary and bilateral neck, followed by an implant using low-dose-rate (LDR 24-35 Gy; median 27 Gy), or fractionated high-dose-rate (fr. HDR 20-28 Gy; median 24 Gy). A neck dissection (ND) was performed in case of N+ disease. 67% of BOT tumors had a T4 cancer. At Amsterdam surgery (S) followed by PORT 40-70 Gy (median 60 Gy) was performed; 26% BOT tumors were T4. Sex, age and nodal distribution were similar. Actuarial local control and survival were computed. Performance Status Scale (PSS) scores were established. Xerostomis was determined on visual analog scales (VAS). RESULTS: Local failure at 5-years was 37% (Rotterdam) vs. 9% (Amsterdam) (p < 0.01). The overall survival was not significantly different (median 2.5 years vs. 2.9 years, respectively [p = 0.47]). The PSS favored brachytherapy. Both groups were equally affected by xerostomia. CONCLUSIONS: The 5-year local control was 65% with EBRT and BT. This result is strongly affected by 4 patients with residual disease after implantation. The Rotterdam patients had more advanced BOT tumors (67% vs. 26% T4), explaining the higher local failure rate. Given the organ preservation properties of radiotherapy-only and the better PSS scores, the jury is still out on the optimal treatment for BOT tumors.     

More differences between HNPCC-related and sporadic carcinomas from the endometrium as compared to the colon

PURPOSE: Recognition of hereditary nonpolyposis colorectal cancer (HNPCC)-related endometrial carcinoma from sporadic carcinoma by histologic features as compared with colonic cases. STUDY DESIGN: Case-control study. METHODS AND MATERIALS: From the files of the Nijmegen Hereditary Cancer Clinic, HNPCC-related (n = 6) endometrial and colorectal (n = 18) carcinomas were selected. For every HNPCC-related tumor, 2 sporadic control cases were included. The tumors were evaluated for the following 7 pathologic features: tumor differentiation, T-stage, growth pattern, presence of Crohn-like lymphoid reaction, mucinous differentiation, presence of lymphangioinvasive growth, and the amount of tumor-infiltrating lymphocytes. RESULTS: HNPCC-related endometrial carcinomas were significantly more often poorly differentiated (83% versus 27%), more often showed the presence of a Crohn-like lymphoid reaction (100% versus 13%) and lymphangioinvasive growth (67% versus 0%), and high number of tumor-infiltrating lymphocytes were more often present (100% versus 36%) compared with sporadic endometrial carcinomas. The differences between HNPCC and sporadic colorectal cancer specimens were less discriminating. CONCLUSIONS: HNPCC-related endometrial carcinomas are characterized by poor differentiation, more frequent Crohn-like lymphoid reaction, lymphangioinvasive growth and more tumor-infiltrating lymphocytes. These features therefore might form the basis for selecting patients for counseling in a hereditary cancer clinic or testing for microsatellite instability or mutation analysis of mismatch repair genes, especially when they are of relatively young age.     

Evaluation of donor site function and morbidity of the fasciocutaneous radial forearm flap

OBJECTIVE: To assess the results of the use of the free radial forearm flap in terms of objective morbidity and subjective patient response. STUDY DESIGN: The donor sites were examined from 37 patients who underwent reconstruction with a free fasciocutaneous radial forearm flap in the head and neck after ablative tumor surgery. METHODS: Patients were asked to fill in a written questionnaire. The following additional tests were performed: resting skin temperature of digits I and V, temperature after submersion in iced water, grip and pinch tests, and goniometry. RESULTS: Resting skin temperature was slightly decreased for donor hands 0.69 degrees C (P < .001) and 0.31 degrees C (P = .048) for digits I and V, respectively, but recovery after submersion in iced water showed no differences. The strength tests and goniometry revealed no statistically significant findings between donor and control sides. On the questionnaire, 9 patients (24%) reported slightly impaired function, 14 (38%) could not wear their watch or bracelet, 17 (46%) reported numbness, 5 (14%) reported soreness, 5 (14%) reported itching, 6 (16%) reported cold intolerance, 5 (14%) reported bad cosmetic appearance, and 9 (24%) expressed the opinion that they were insufficiently counseled. CONCLUSION: There is a negligible objective morbidity of a free radial forearm flap harvest procedure, but a number of patients have subjective complaints when asked. Elaborate presurgical counseling can probably reduce these complaints.     

Detecting recurrent laryngeal carcinoma after radiotherapy: room for improvement

Detecting recurrent laryngeal carcinoma after radiotherapy for a primary tumour can be difficult. Early detection however, is an important prognostic factor. Although a biopsy should be performed in case of clinical suspicion, repeated negative biopsies do not exclude the presence of viable tumour. The trauma caused by biopsies in irradiated tissue may initiate infection, further oedema and failure to heal. We investigated these problems and evaluated the current care and its usefulness. A survey of the current practice concerning diagnostic procedures for detecting recurrent laryngeal carcinoma after radiotherapy in the major institutions treating head and neck cancer in The Netherlands was performed by means of a questionnaire. Furthermore, we performed a comprehensive analysis of the extent and yield of diagnostic work-up in a cohort of patients clinically suspected of a recurrence, who had undergone direct laryngoscopy between 1986 and 1998 in our institution, with a follow-up of at least 6 months. In case of suspected recurrence, 94% of the departments use direct laryngoscopy under general anaesthesia with the taking of biopsies as a diagnostic technique. Imaging does not play an important role. In our department 207 laryngoscopies were evaluated in 131 patients. In 70 patients the first laryngoscopy was negative. Of these initial negative laryngoscopies, 22 (31%) turned out to be false negative within 6 months. Thirty-seven patients remained disease free. They underwent 65 unnecessary laryngoscopies to come to this conclusion. In the decision to perform direct laryngoscopy, the conventional work up leaves room for improvement. Too many unnecessary laryngoscopies are performed. New imaging techniques such as FDG-PET or new applications of CT or MRI may improve the yield of direct laryngoscopy.     

Rationale for superficial injection techniques in lymphatic mapping in breast cancer patients

One of the most avidly debated issues in lymphatic mapping is where the tracers are best deposited in patients with breast cancer. The four superficial approaches are easy to perform and have several other distinct advantages. They are based on the hypothesis that the entire breast parenchyma and the overlying skin drain to a common node in the axilla because of their common embryological origin. Evidence is presented that casts doubt upon the correctness of this assumption. Tracer administration close to the tumor site appears to be the safest approach for the time being. Excellent results can be obtained with this latter approach, despite the fact that it is technically more demanding.     

Motor unit characteristics in healthy subjects and those with postpoliomyelitis syndrome: a high-density surface EMG study

The purpose of this study was to identify optimal ways to detect neurogenic changes with high-density surface electromyography (HD-sEMG). For this purpose, we searched for the variables that most clearly discriminated between postpoliomyelitis and healthy subjects. We obtained HD-sEMG from the quadriceps muscle at different force levels in nine subjects with postpoliomyelitis syndrome and in matched healthy controls. Single motor unit action potentials (MUAPs), extracted from the HD-sEMG signal and the raw signal itself, were analyzed. Areas under the curve of the extracted MUAP waveform, indicating motor unit size, perfectly separated both groups. Raw signal analysis showed significant differences between groups for the monopolarly recorded amplitude up to 60% of maximal force and for the level of interference at higher force levels (40-100% force). We conclude that with HD-sEMG it is possible to detect neurogenic motor unit changes noninvasively, both by analysis of the raw signal itself and by analysis of extracted single MUAPs. The diagnostic yield of the single MUAP analysis is clearly higher. These findings point toward applications for clinical practice and invite further studies exploring the diagnostic value of HD-sEMG.     

Supraglottic carcinoma treated with curative radiation therapy: identification of prognostic groups with MR imaging

PURPOSE: To retrospectively assess the prognostic meaning of tumor characteristics depicted on pretreatment magnetic resonance (MR) images for local outcome in supraglottic squamous cell carcinoma treated with definitive radiation therapy. MATERIALS AND METHODS: Pretreatment MR images acquired in 84 patients with supraglottic carcinoma treated with curative radiation therapy were reviewed for tumor involvement of laryngeal sites including glottis, subglottis, pre-epiglottic space, laryngeal cartilages, and hypopharynx, and for extralaryngeal extension. The volume of each tumor was estimated, and mean tumor volume was calculated for the group of tumors in each T staging category. RESULTS: Results of univariate analysis showed MR imaging-determined primary tumor volume (P =.03), involvement of pre-epiglottic space (P =.008), abnormal signal intensity in thyroid cartilage (P =.04), and extralaryngeal extension beyond thyroid and/or cricoid cartilage (P =.02) to be significant predictors of local control rate. Results of multivariate analysis with the Cox regression model confirmed statistical significance for invasion of pre-epiglottic space (P =.004) and for abnormal signal intensities in thyroid cartilage adjacent to the anterior commissure (P =.04) and in cricoid cartilage (P =.01). Five-year local control rates were calculated from the regression coefficients of three independent MR imaging prognostic factors, and three prognostic groups were identified on the basis of these control rates. The 5-year local control rate in the high-risk group was 35%, significantly lower than the rates in the intermediate- and low-risk groups (60% and 89%, respectively; P =.002). CONCLUSION: MR imaging-determined pre-epiglottic space involvement and abnormal signal intensities in the thyroid cartilage adjacent to the anterior commissure and/or the cricoid cartilage are strong predictors of local outcome in supraglottic carcinoma treated with definitive radiation therapy.     

Risks of ancient practices in modern times

Swaddling, ie, wrapping the child to restrict movement, is an ancient practice. In the Netherlands, it is becoming increasingly popular as an intervention for excessive crying in infants. However, one must be well aware of the potential risks. We present the case reports of a twin boy and girl who had been swaddled and kept in a heated room for several days. On admission to the hospital, both infants suffered from severe hypovolemic shock, hyperthermia, and secondary respiratory insufficiency. The girl developed multiple organ dysfunction syndrome and died, whereas the boy had an uneventful recovery. When swaddling is being considered as an intervention for excessive crying in infants, parents have to be well-informed about the possible side effects and about additional measures that they may have to take to make it a safe intervention.