Intramedullary Ependymomas: Clinical Presentation, Surgical Treatment Strategies and Prognosis

Intramedullary ependymomas are rare tumors but comprise the majority of intramedullary glial neoplasms in the adult. These tumors are benign, slow-growing lesions which are optimally treated with gross-total surgical resection without adjuvant therapy. This objective can be attained safely in a majority, of patients. Post-operative functional outcome is related to pre-operative functional status. Hence, early diagnosis, prior to symptomatic progression, is critical to the successful treatment of these tumors. Adjuvant therapy is indicated for the rare malignant or disseminated tumor or following sub-total resection.     

Magnetic Resonance Imaging of Intramedullary Spinal Cord Tumors

The advent of MRI has significantly changed the diagnosis of spinal cord tumors. Standard imaging provides excellent localization and characterization of the tumor in a noninvasive fashion. Exact histologic diagnosis of the two most common tumors, ependymoma and astrocytoma, remains elusive but there are some suggestive imaging characteristics. It is hoped that some of the newer MR imaging sequences will improve characterization of the tumor and thereby influence therapy. Several of these pulse sequences are already used routinely in brain imaging. Evaluation of new imaging sequences in the spine has lagged behind brain MR imaging, mainly due to technical factors. Work on animal spine models and extrapolation from brain imaging studies suggest that it is only a matter of time before some of these techniques become clinically relevant.     

股骨髓腔扩大对股骨骨折愈合影响的超微结构研究

用20只兔股骨干中段开放骨折模型，Φ4．0mm钻头扩髓，Φ4．0mm斯氏钉固定；对照组不扩髓，用Φ3．5mm斯氏钉内固定。术后2、4、8周取骨痂电镜观察，结果显示，扩髓组骨折愈合过程延迟。     

The use of elastic intramedullary nailing in the stabilisation of paediatric fractures

The treatment of paediatric long-bone fractures remains controversial. Elastic intramedullary nailing has been proposed as an alternative for the treatment of paediatric long-bone fractures. PATIENTS: We treated 68 children in a time span of 9 years with 32 fractures of the forearm, 27 fractures of the femur and nine fractures of the tibia. The mean age was 8.3 years and the mean admission time 2.6 days. RESULTS: Mean consolidation time was 7.9 weeks for the forearm fractures, 11.9 weeks for the femur fractures and 10.6 weeks for the tibial fractures. Full weight bearing for the latter two fracture types was allowed within the first week. There were no major complications. The complications encountered were three hydrops of the knee, four low-grade infections and one delayed union. Leg length discrepancy was only seen in five patients (18%) and was less than 2 cm. DISCUSSION: In femur fractures, we let the parents decide between skeletal traction and intramedullary rods. When confronted with the possible complications (operation-related complications and infection) compared to the advantages (early weight bearing and short admission time), they almost always choose the operative approach. In our opinion, elastic intramedullary nailing is an excellent treatment option for diaphyseal fractures in children with skeletal immaturity, especially of the femur.     

Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases

We present our experience with elastic stable intramedullary nailing (ESIN) used in the single bone fixation of both bones forearm fractures in children. From May 2002 to July 2004, 20 children (14 boys and 6 girls), median age of 10 years (range 6–15 years) were treated with ESIN for 16 closed and 4 grade I open forearm fractures. All patients were reviewed clinically at a median follow-up of 20 months (range 6–30 months). All fractures were radiologically united at a median of 6.7 weeks (6–9 weeks). The median operating time was 35 min (range 25–60 min). The median hospital stay was 2 days (range 1–3 days). Removal of the nails was undertaken in all 20 children at a median of 19 weeks (range 16–24 weeks) post-operatively. At follow-up, a full range of elbow and wrist movements were found in all cases. There was no clinically significant rotational deformity in any case. ESIN seems to be a safe method in the treatment of single bone fixation of both bones forearm fractures in children between 6 and 15 years of age.     

ESIN in Forearm Fractures

Abstract Background and Purpose: Elastic stable intramedullary nailing (ESIN) is well established for stabilizing pediatric forearm fractures. To prevent uncritical use, it is necessary to evaluate the problems and complications of this common technique. Patients and Methods: Four pediatric surgical departments participated in a retrospective study analyzing the last 400 fractures treated with ESIN. Continuous documentation of treatment, postoperative course and follow-up formed the basis of evaluation. In this article forearm fractures (n = 163, 40.7%) are discussed, and epidemiology, indication, fracture types, intraoperative technique, postoperative management and problems, as well as complications and results are compared to those described in the literature. Results: Complete, transverse fractures of the midshaft (73%) were mainly seen. Indication for intervention was an intolerable axial deviation (85.9%). Intraoperative technique (operating and transillumination time, site of approach, material choice) and postoperative management (hospital stay, number of X-ray controls, and follow-up) differed highly depending on the hospitals circumstances. Postoperatively, 3.0% of patients showed soft-tissue irritation due to sharp nail ends or wound infections. Complications (10.4%) included secondary rupture of a tendon in 3.7%, refracture with nails in situ in 2.5%, axial deviations > 10° or instability of osteosynthesis in 1.8%, delayed healing in 1.2%, migration of nails in 0.6%, and technical failure in 0.6%. Overall, a significant functional restriction (limitation of movement > 10°) was found in three cases only (1.8%) following radial neck fracture. Conclusion: ESIN in pediatric forearm fractures is an often used technique with clear indications and excellent results to be expected. Numerically, complications have not altered considerably, but they rather show a shifting of problems with optimization and refinement of technique and improvement of equipment. Thus, continuous evaluation of technical principles and procedural recommendations constitutes the mainstay in the prevention of problems and complications.     

Histology in mixed germ cell tumors. Is there a favorite pairing?

PURPOSE: Mixed germ cell tumors account for approximately 30% to 50% of testicular tumors. To our knowledge a systematic review with statistical analysis of the associations of histological subtypes in mixed germ cell tumors has not been done previously. It was our impression that such associations exist. Delineating concordant histological types may provide insight into the ontogeny of testicular tumors and also have important clinical implications. MATERIALS AND METHODS: We retrospectively reviewed the testis cancer data base at our institution. The primary tumor of orchiectomy specimens was examined in 2589 patients. Of these patients mixed histology was noted in 1765 (68.2%). ORs were calculated for all possible combinations of teratoma, embryonal carcinoma, yolk sac tumor, choriocarcinoma and seminoma. In addition, we evaluated the association of various histological types with teratoma at post-chemotherapy retroperitoneal lymph node dissection. RESULTS: Of 10 possible combinations of histological types in the primary tumor, positive correlations were noted in 4. The strongest correlation was found between teratoma and yolk sac tumor (OR 2.58, p <0.001). Teratoma or yolk sac tumor in the testis was associated with teratoma in the pathology specimen at post-chemotherapy retroperitoneal lymph node dissection. CONCLUSIONS: The strongest associations of histological subtypes in mixed germ cell tumors were seen between yolk sac tumor and teratoma. Similar associations are seen in late relapse and in some cases of prepubertal tumors. Further study of these associations may prove valuable in understanding the biology and clinical behavior of germ cell tumors.     

Impact of unnecessary exploratory laparotomy on the treatment of patients with metastatic germ cell tumor

PURPOSE: Patients with testicular germ cell tumors (GCTs) may undergo unnecessary diagnostic or surgical procedures when this diagnosis is not considered. In a cohort of patients who underwent exploratory laparotomy for unsuspected metastatic GCT we determined the impact of this surgery on morbidity, therapeutic delay and cancer therapy. MATERIALS AND METHODS: Between 1980 and 2001, 40 patients who underwent exploratory laparotomy for unsuspected metastatic GCT were later referred to our department for management. Patient records were reviewed retrospectively. RESULTS: Mean patient age at exploratory laparotomy was 34 years. All patients had a midline retroperitoneal mass and 14 had disease at other sites. At the time of evaluation at our institution abnormalities on physical examination and testicular sonogram were identified in 8 (20%) and 22 (55%) patients, respectively. Elevated serum alpha-fetoprotein and/or beta-human chorionic gonadotropin were identified in 26 patients (65%). Eight patients (22%) experienced complications from exploratory surgery. The median interval from laparotomy to chemotherapy was 29 days and in 48% of patients the delay in therapy was 30 days or greater. Of patients with a delay of 30 days or greater 60% required intensive chemotherapy (multiple regimens, or high dose or salvage chemotherapy) compared to 26% with a delay of less than 30 days (p = 0.01). CONCLUSIONS: Exploratory laparotomy contributes to therapeutic delay in a substantial number of patients and it complicates cancer therapy. At presentation evidence to suggest GCT was present in all patients, which highlights the importance of physician awareness in making a prompt diagnosis.     

Prediction of necrosis after chemotherapy of advanced germ cell tumors: results of a prospective multicenter trial of the German Testicular Cancer Study Group

PURPOSE: We evaluated the prognostic parameters of necrotic residual tumors after chemotherapy of advanced germ cell tumors to improve on the current indications for surgery. MATERIALS AND METHODS: Between January 1996 and January 2000, in 8 centers of the German Testicular Cancer Study Group, preoperative parameters were assessed to predict necrosis in the residual tumors of 261 patients with retroperitoneal residual tumor resection after first (92%) and second line (8%) chemotherapy. RESULTS: Of 232 evaluable patients 39 had pure seminoma and 5 had viable cancer (1 with seminoma) in the residual tumor. Of the remaining 193 patients with nonseminoma 35% had necrosis, 34% teratoma and 31% had viable carcinoma in the residual tumor. After multivariate analysis and exclusion of patients with seminoma, the 3 parameters independently predictive of necrosis were alpha-fetoprotein before chemotherapy less than 20 ng/ml, and tumor volume before and after chemotherapy. A mathematical model to predict necrosis yielded a test accuracy of 75%, a sensitivity to predict necrosis of 52% and a specificity of 87%. CONCLUSIONS: Patients with pure seminoma should not undergo residual tumor resection because 97% of patients who received adequate chemotherapy were found to have no residual seminoma. In cases of nonseminoma alpha-fetoprotein values before chemotherapy less than 20 ng/ml and a high percentage of shrinkage during chemotherapy reliably predicted only 19% of cases of necrosis. Therefore, this model is clinically irrelevant and patients with minimal residual disease should undergo surgery. New methods are necessary to improve the preoperative selection of patients after chemotherapy.     

Incidence of contralateral germ cell testicular tumors in South Europe: report of the experience at 2 Spanish university hospitals and review of the literature

PURPOSE: The crude and cumulative incidence of contralateral germ cell testicular tumors (GCTTs) is between 1% to 5% and 3% to 6% at 10 to 15 years in previously reported studies. To evaluate the real incidence of a second GCTT in a southern European population the medical records of 623 patients with GCTT successfully treated between 1976 and 1993 at 2 university hospitals were reviewed. MATERIALS AND METHODS: All patients had been treated with standard treatment strategies according to disease stage and diagnosis year. Contralateral biopsy at GCTT diagnosis was not performed in any patient. Only those with a survival of 1 year or greater were included. In addition to the imaging and biochemical (tumor markers) procedures used to diagnose disease relapse, physical examination of the contralateral testis and/or testicular ultrasound was done yearly. RESULTS: At a median followup of 8.6 years (range 2 to 19.7) 6 patients (1%) had a contralateral GCTT, which was synchronous in 1 and metachronous in 5. The cumulative risk of a contralateral GCTT was 1.2% (95% CI 0.1% to 2.3%) at 15 years and it did not depend on the treatment for the first GCTT. CONCLUSIONS: The incidence of contralateral GCTT in our series was lower than expected compared with other published series. This finding mirrors the lower incidence of GCTT in the general population in our country than in other areas with a higher incidence of contralateral GCTT. Therefore, contralateral testicular biopsy at initial diagnosis is not mandatory in our experience.