Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years

Abstract

Purpose

Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging.

Methods

In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded.

Results

Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof—especially in the cribriform plate—and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary.

Conclusions

Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary.

https://ift.tt/2B9mDOj

Achilles insertion bone pathology not related to pain in a triathlete with cystic fibrosis

Abstract

This report concerns the unusual case of a 48-year old, world-class triathlete who has won 11 ironman competitions. She has reached the top level of international endurance sport in spite of being diagnosed with cystic fibrosis. This patient presented with Achilles pain and severe bony pathology at her left Achilles insertion. Traditionally this condition is treated via tendon detachment and re-attachment or intra-tendinous surgery, followed by a protracted rehabilitation. These procedures were considered risky due to this patient's chronic disease with vulnerability to immobilization. Instead, she was treated by surgical removal of the superficial bursa alone, under local anaesthetic. This allowed the patient to become active and load her Achilles tendon immediately, and resulted in a significant symptomatic improvement. This case illustrates that despite the presence of severe tendon and bone pathology at the Achilles insertion, pain may originate in the superficial bursa; a structure ignored by traditional operations.

https://ift.tt/2BbuRWg

Merkel-cell carcinoma of the upper limb

Abstract

Merkel-cell carcinoma is a rare form of aggressive cutaneous cancer that is associated with a poor prognosis. Despite significant advances, its pathogenesis is still poorly understood, and treatment remains controversial. Timely diagnosis and early management is essential in improving survival rate. We present a case of a 63-year-old patient with a rapidly growing upper limb Merkel-cell carcinoma. It was treated with wide-local excision and adjuvant radiotherapy.

https://ift.tt/2P85KGT

Unusual lymph node metastasis from cancer of the thoracic esophagus

Abstract

A 76-year-old male received concurrent chemoradiotherapy, at a dose of 60 Gy with low-dose 5-fluorouracil, for cT1bN0M0 squamous cell carcinoma of the mid-thoracic esophagus. Because his primary tumor relapsed with mediastinal and right supraclavicular node metastasis 4 months after completion of chemoradiotherapy, right transthoracic esophagectomy with mediastinal and right cervical lymphadenectomy was performed. However, metastatic tumors developed deep beneath the anterior border of the trapezius muscle 2 months after esophagectomy. En bloc dissection of the adipose tissue including the tumor and the transverse cervical artery was performed, followed by adjuvant radiotherapy of 50.4 Gy to the area of dissection. The patient died of pneumonia 11 months after metastasectomy, with locally recurrent disease. We have had three cases of this unusual lymph nodes metastasis from cancer of the thoracic esophagus to date and here present the characteristic imaging findings and the possible mechanism of this unusual lymph node metastasis.

https://ift.tt/2KQaYn8

Age and adenoma size are independent risk factors for the development of carcinoma ex pleomorphic adenoma

Publication date: September 2018

Source: Oral Oncology, Volume 84

Author(s): E.S. Egal, F.V. Mariano, A.M. Altemani, K. Metze

https://ift.tt/2MnbjCO

ERK-TSC2 signalling in constitutively-active HRAS mutant HNSCC cells promotes resistance to PI3K inhibition

Publication date: September 2018

Source: Oral Oncology, Volume 84

Author(s): Kara M. Ruicci, Nicole Pinto, Mohammed I. Khan, John Yoo, Kevin Fung, Danielle MacNeil, Joe S. Mymryk, John W. Barrett, Anthony C. Nichols

Abstract

Objectives

The PI3K/AKT/mTOR pathway is frequently altered in head and neck squamous cell cancer (HNSCC), making this pathway a logical therapeutic target. However, PI3K targeting is not universally effective. Biomarkers of response are needed to stratify patients likely to derive benefit and exclude those unlikely to respond.

Materials and methods

We examined the sensitivity of cell lines with constitutively-active (G12V mutant) HRAS and wild-type HRAS to PI3K inhibition using flow cytometry and cell viability assays. We then overexpressed and silenced HRAS and measured sensitivity to the PI3K inhibitor BYL719. Immunoblotting was used to determine activation of the PI3K pathway. MEK and mTOR inhibitors were then tested in HRAS mutant cells to determine their efficacy.

Results

HRAS mutant cell lines were non-responsive to PI3K inhibition. Overexpression of HRAS led to reduced susceptibility to PI3K inhibition, while knockdown improved sensitivity. Immunoblotting revealed suppressed AKT phosphorylation upon PI3K inhibition in both wild-type and HRAS mutant cell lines, however mutant lines maintained phosphorylation of S6, downstream of mTOR. Targeting mTOR effectively reduced viability of HRAS mutant cells and we subsequently examined the ERK-TSC2-mTOR cascade as a mediator of resistance to PI3K inhibition.

Conclusions

HRAS mutant cells are resistant to PI3K inhibition and our findings suggest the involvement of a signalling intersection of the MAPK and PI3K pathways at the level of ERK-TSC2, leading to persistent mTOR activity. mTOR inhibition alone or in combination with MAPK pathway inhibition may be a promising therapeutic strategy for this subset of HNSCC tumors.

https://ift.tt/2MJBd0p

Self-reported oral morbidities in long-term oropharyngeal cancer survivors: A cross-sectional survey of 906 survivors

Publication date: September 2018

Source: Oral Oncology, Volume 84

Author(s): Richard C. Cardoso, Ahmad Qazali, Jhankruti Zaveri, Mark S. Chambers, Gary Brandon Gunn, Clifton D. Fuller, Stephen Y. Lai, Frank E. Mott, Katherine A. Hutcheson

Abstract

Objective

The purpose of this study is to estimate the prevalence and severity of late oral morbidities in disease-free oropharyngeal cancer (OPC) survivors using patient reported outcomes.

Materials and methods

Cross-sectional survivorship survey of patients who completed definitive treatment for oropharyngeal carcinoma  > 12-months previously without evidence of recurrence, second primary malignancy, or distant metastasis after index cancer. Using MD Anderson Symptom Inventory- Head and Neck Module (MDASI-HN), scores for 4 self-reported oral morbidities: dry mouth, mucus secretions, mouth and throat sores, and teeth and gum issues were evaluated.

Results

Among 906 survey respondents (57% response rate), (median survival time: 7 years), "dry mouth" and "problems with my mucus" were reported moderate/severe (MDASI-HN item score ≥5) in 39% and 22% of respondents, while 14% reported moderate/severe "problems with teeth and gums". Smoking at the time of survey was significantly associated with the severity of oral symptoms including "mucus" (p = 0.03), "dry mouth" (p = 0.02), "problems with my teeth and gums" (p = 0.001). All the oral morbidities symptom items significantly, positively correlated with the mean interference scores reflecting adverse impact to quality of life (QOL): "mucus" (r = 0.445, p < 0.001), "problems with teeth" (r = 0.446, p < 0.001), "mouth sores" (r = 0.321, p < 0.001) and "dry mouth" (r = 0.459, p < 0.001).

Conclusion

This study showed that 45.5% reported at least one late oral morbidity at moderate/severe level which negatively correlated overall function, even years after treatment.

https://ift.tt/2Mnbdeq