Nerve injury converts Schwann cells in a long-term repair-like state in human neuroma tissue.

Peripheral nerve injury (PNI) induces neuroma formation at the severed nerve stump resulting in impaired nerve regeneration and functional recovery in patients. So far, molecular mechanisms and cell types present in the neuroma impeding on regeneration have only sparsely been analyzed. Herein we compare resected human neuroma tissue with intact donor nerves from the same patient. Neuroma from several post-injury timepoints (1-13 months) were included, thereby allowing for temporal correlation with molecular and cellular processes. We observed reduced axonal area and percentage of myelin producing Schwann cells (SCs) compared to intact nerves. However, total SOX10 positive SC numbers were comparable. Notably, markers for SCs in a repair mode including c-JUN, the low-affinity neurotrophin receptor (NTR) p75, SHH (sonic hedgehog) and SC proliferation (phospho-histone H3) were upregulated in neuroma, suggesting presence of SCs in repair status. In agreement, in neuroma, pro-regenerative markers such as phosphorylated i.e. activated CREB (pCREB), ATF3, GAP43 and SCG10 were upregulated. In addition, neuroma tissue was infiltrated by several types of macrophages. Finally, when taken in culture, neuroma SCs were indistinguishable from controls SCs with regard to proliferation and morphology. However, cultured neuroma SCs retained a different molecular signature from control SCs including increased inflammation and reduced gene expression for differentiation markers such as myelin genes. In summary, human neuroma tissue consists of SCs with a repair status and is infiltrated strongly by several types of macrophages.

Magnetic Resonance Imaging appearance of regenerative peripheral nerve interface.

PURPOSE: To describe the MRI appearance of regenerative peripheral nerve interface (RPNI) and the potential association between the MRI appearance and RPNI revision. MATERIAL AND METHODS: A retrospective assessment was undertaken of the MRI appearance of RPNIs performed at our institution between 1/1/2010 and 7/29/2023 with clinical correlation. RESULTS: Fourteen patients (8 men and 6 women, age range 31-80 years, median age 51 years) with technically adequate MRI of RPNIs were included in this study including 5 patients with below knee amputation with 5 tibial and 4 common peroneal nerves RPNI, 8 patients with above knee amputations (AKA) with sciatic RPNIs, and 1 patient following forequarter amputation with a brachial plexus RPNI. Two patients underwent revision RPNI surgery thrice (AKA-sciatic nerve) for a total of 6 RPNI revisions. On T1 weighted sequences, all RPNIs were isointense to the muscle and blended with the surrounding scar and muscle tissues whereas on T2 weighted sequences, all RPNIs were hyperintense in signal compared to the muscle. All but 1 RPNI underwent post contrast enhancement in variable patterns. No statistically significant difference in MRI appearance was found between RPNIs with or without a following RPNI revision surgery. CONCLUSION: RPNI on MRI typically have a bright and intermediate signal on T2 and T1 weighted sequences, respectively, and typically undergo postcontrast enhancement in variable patterns without a statistically significant difference between the cases with and without follow-up RPNI revision. However, enhancement of RPNI should not be misconstrued as pathological.

Judicious and evidence-based use of radiosurgery - recommendations for low-middle income countries.

Surgical removal remains the primary treatment for most brain tumours. However, radiosurgery presents an effective, less invasive alternative or additional treatment for certain types. Our goal was to explore radiosurgery's roles in treating various brain tumours, focussing on its application in low- and middle-income countries (LMICs). We reviewed all relevant systematic reviews, metaanalyses, and guidelines to determine the most effective radiosurgical approaches. Additionally, we consulted a panel of experts with over ten years of experience in LMICs, such as Pakistan. For brain tumours, stereotactic radiosurgery should generally follow a confirmed histopathological diagnosis. Exceptions include tumours identified through Magnetic Resonance Imaging (MRI), like Vestibular Schwannoma (VS), pre-diagnosed Neurofibromatosis type 2 (NF2), multiple typical meningiomas, and metastases with a known histology from another site. While radiosurgery is gaining traction as a primary and adjunct treatment in some LMICs, the lack of regional guidelines, trained personnel, and collaboration among specialists hinders its wider adoption. Addressing these gaps is crucial for expanding radiosurgical care in these regions.

The effect of exposure to radiofrequency fields on cancer risk in the general and working population: A systematic review of human observational studies - Part I: Most researched outcomes.

BACKGROUND: The objective of this review was to assess the quality and strength of the evidence provided by human observational studies for a causal association between exposure to radiofrequency electromagnetic fields (RF-EMF) and risk of the most investigated neoplastic diseases. METHODS: Eligibility criteria: We included cohort and case-control studies of neoplasia risks in relation to three types of exposure to RF-EMF: near-field, head-localized, exposure from wireless phone use (SR-A); far-field, whole body, environmental exposure from fixed-site transmitters (SR-B); near/far-field occupational exposures from use of hand-held transceivers or RF-emitting equipment in the workplace (SR-C). While no restrictions on tumour type were applied, in the current paper we focus on incidence-based studies of selected "critical" neoplasms of the central nervous system (brain, meninges, pituitary gland, acoustic nerve) and salivary gland tumours (SR-A); brain tumours and leukaemias (SR-B, SR-C). We focussed on investigations of specific neoplasms in relation to specific exposure sources (i.e. E-O pairs), noting that a single article may address multiple E-O pairs. INFORMATION SOURCES: Eligible studies were identified by literature searches through Medline, Embase, and EMF-Portal. Risk-of-bias (RoB) assessment: We used a tailored version of the Office of Health Assessment and Translation (OHAT) RoB tool to evaluate each study's internal validity. At the summary RoB step, studies were classified into three tiers according to their overall potential for bias (low, moderate and high). DATA SYNTHESIS: We synthesized the study results using random effects restricted maximum likelihood (REML) models (overall and subgroup meta-analyses of dichotomous and categorical exposure variables), and weighted mixed effects models (dose-response meta-analyses of lifetime exposure intensity). Evidence assessment: Confidence in evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: We included 63 aetiological articles, published between 1994 and 2022, with participants from 22 countries, reporting on 119 different E-O pairs. RF-EMF exposure from mobile phones (ever or regular use vs no or non-regular use) was not associated with an increased risk of glioma [meta-estimate of the relative risk (mRR) = 1.01, 95 % CI = 0.89-1.13), meningioma (mRR = 0.92, 95 % CI = 0.82-1.02), acoustic neuroma (mRR = 1.03, 95 % CI = 0.85-1.24), pituitary tumours (mRR = 0.81, 95 % CI = 0.61-1.06), salivary gland tumours (mRR = 0.91, 95 % CI = 0.78-1.06), or paediatric (children, adolescents and young adults) brain tumours (mRR = 1.06, 95 % CI = 0.74-1.51), with variable degree of across-study heterogeneity (I2 = 0 %-62 %). There was no observable increase in mRRs for the most investigated neoplasms (glioma, meningioma, and acoustic neuroma) with increasing time since start (TSS) use of mobile phones, cumulative call time (CCT), or cumulative number of calls (CNC). Cordless phone use was not significantly associated with risks of glioma [mRR = 1.04, 95 % CI = 0.74-1.46; I2 = 74 %) meningioma, (mRR = 0.91, 95 % CI = 0.70-1.18; I2 = 59 %), or acoustic neuroma (mRR = 1.16; 95 % CI = 0.83-1.61; I2 = 63 %). Exposure from fixed-site transmitters (broadcasting antennas or base stations) was not associated with childhood leukaemia or paediatric brain tumour risks, independently of the level of the modelled RF exposure. Glioma risk was not significantly increased following occupational RF exposure (ever vs never), and no differences were detected between increasing categories of modelled cumulative exposure levels. DISCUSSION: In the sensitivity analyses of glioma, meningioma, and acoustic neuroma risks in relation to mobile phone use (ever use, TSS, CCT, and CNC) the presented results were robust and not affected by changes in study aggregation. In a leave-one-out meta-analyses of glioma risk in relation to mobile phone use we identified one influential study. In subsequent meta-analyses performed after excluding this study, we observed a substantial reduction in the mRR and the heterogeneity between studies, for both the contrast Ever vs Never (regular) use (mRR = 0.96, 95 % CI = 0.87-1.07, I2 = 47 %), and in the analysis by increasing categories of TSS ("<5 years": mRR = 0.97, 95 % CI = 0.83-1.14, I2 = 41 %; "5-9 years ": mRR = 0.96, 95 % CI = 0.83-1.11, I2 = 34 %; "10+ years": mRR = 0.97, 95 % CI = 0.87-1.08, I2 = 10 %). There was limited variation across studies in RoB for the priority domains (selection/attrition, exposure and outcome information), with the number of studies evenly classified as at low and moderate risk of bias (49 % tier-1 and 51 % tier-2), and no studies classified as at high risk of bias (tier-3). The impact of the biases on the study results (amount and direction) proved difficult to predict, and the RoB tool was inherently unable to account for the effect of competing biases. However, the sensitivity meta-analyses stratified on bias-tier, showed that the heterogeneity observed in our main meta-analyses across studies of glioma and acoustic neuroma in the upper TSS stratum (I2 = 77 % and 76 %), was explained by the summary RoB-tier. In the tier-1 study subgroup, the mRRs (95 % CI; I2) in long-term (10+ years) users were 0.95 (0.85-1.05; 5.5 %) for glioma, and 1.00 (0.78-1.29; 35 %) for acoustic neuroma. The time-trend simulation studies, evaluated as complementary evidence in line with a triangulation approach for external validity, were consistent in showing that the increased risks observed in some case-control studies were incompatible with the actual incidence rates of glioma/brain cancer observed in several countries and over long periods. Three of these simulation studies consistently reported that RR estimates > 1.5 with a 10+ years induction period were definitely implausible, and could be used to set a "credibility benchmark". In the sensitivity meta-analyses of glioma risk in the upper category of TSS excluding five studies reporting implausible effect sizes, we observed strong reductions in both the mRR [mRR of 0.95 (95 % CI = 0.86-1.05)], and the degree of heterogeneity across studies (I2 = 3.6 %). CONCLUSIONS: Consistently with the published protocol, our final conclusions were formulated separately for each exposure-outcome combination, and primarily based on the line of evidence with the highest confidence, taking into account the ranking of RF sources by exposure level as inferred from dosimetric studies, and the external coherence with findings from time-trend simulation studies (limited to glioma in relation to mobile phone use). For near field RF-EMF exposure to the head from mobile phone use, there was moderate certainty evidence that it likely does not increase the risk of glioma, meningioma, acoustic neuroma, pituitary tumours, and salivary gland tumours in adults, or of paediatric brain tumours. For near field RF-EMF exposure to the head from cordless phone use, there was low certainty evidence that it may not increase the risk of glioma, meningioma or acoustic neuroma. For whole-body far-field RF-EMF exposure from fixed-site transmitters (broadcasting antennas or base stations), there was moderate certainty evidence that it likely does not increase childhood leukaemia risk and low certainty evidence that it may not increase the risk of paediatric brain tumours. There were no studies eligible for inclusion investigating RF-EMF exposure from fixed-site transmitters and critical tumours in adults. For occupational RF-EMF exposure, there was low certainty evidence that it may not increase the risk of brain cancer/glioma, but there were no included studies of leukemias (the second critical outcome in SR-C). The evidence rating regarding paediatric brain tumours in relation to environmental RF exposure from fixed-site transmitters should be interpreted with caution, due to the small number of studies. Similar interpretative cautions apply to the evidence rating of the relation between glioma/brain cancer and occupational RF exposure, due to differences in exposure sources and metrics across the few included studies. OTHER: This project was commissioned and partially funded by the World Health Organization (WHO). Co-financing was provided by the New Zealand Ministry of Health; the Istituto Superiore di Sanità in its capacity as a WHO Collaborating Centre for Radiation and Health; and ARPANSA as a WHO Collaborating Centre for Radiation Protection. REGISTRATION: PROSPERO CRD42021236798. Published protocol: [(Lagorio et al., 2021) DOI https://doi.org/10.1016/j.envint.2021.106828].

Correlation of Immunomodulatory Cytokines with Tumor Volume and Cerebrospinal Fluid in Vestibular Schwannoma Patients.

Sporadic vestibular schwannomas (VSs) often exhibit slow or negligible growth. Nevertheless, some VSs increase significantly in volume within a few months or grow continuously. Recent evidence indicates a role of inflammation in promoting VS growth. Therefore, our study aimed to identify cytokines, which are associated with larger VSs. The expression of different cytokines in VS tumor samples and VS primary cultures was investigated. Additionally, the concentration of cytokines in cell culture supernatants of VS primary cultures and cerebrospinal fluid (CSF) of VS patients and healthy controls were determined. Correlation analysis of cytokine levels with tumor volume, growth rate, Koos grade, age, and hearing was examined with Spearman's-rank test. The mRNA expression of CC-chemokine ligand (CCL) 18, growth differentiation factor (GDF) 15, and interferon regulatory factor 4 correlated positively with tumor volume. Moreover, the amount of GDF15 in the cell culture supernatant of primary cells correlated positively with tumor volume. The concentrations of the cytokines CCL2, CCL5, and CCL18 and transforming growth factor beta (TGFB) 1 in the CSF of the patients were significantly different from those in the CSF controls. Inhibition of immune cell infiltration could be a putative approach to prevent and control VS growth.

Postoperative dysgeusia following microsurgical resection for acoustic neuroma: a systematic review and meta-analysis.

OBJECTIVE: To determine the collated rate of postoperative dysgeusia after microsurgical intervention in acoustic neuroma patients. METHODS: The systematic review with meta-analysis was undertaken following PRISMA guidelines. A thorough search of PubMed/Medline, the Cochrane Database of Systematic Reviews, and Epistemonikos was undertaken for studies published up until May 16, 2024 reporting postoperative taste disturbance rates after microsurgical intervention for acoustic neuroma. The methodological quality of the included studies was assessed via the Methodological Index for Non-Randomized research (MINORS) tool. Using MedCalc (v. 20.215) software, the random-effects model was developed for proportional meta-analysis. RESULTS: Eight studies, encompassing 2,402 patients (mean age = 49.06 years; 48.54% female population), were included in the analysis. The overall pooled rate of postoperative dysgeusia following microsurgical management of acoustic neuroma was 23.7% (95% CI: 9.266-42.359, p < 0.0001). When stratified by surgical approach, the rate of postoperative dysgeusia for the retrosigmoid approach was 18.8% (95% CI: 2.821-44.461, p < 0.0001). Postoperative dysgeusia data stratified for other major microsurgical approaches (subtemporal and translabirynthine approaches) was not reported by any of the included studies. CONCLUSION: Our systematic review and meta-analysis calculated a collated rate of almost 25% and recognized postoperative dysgeusia as a common complication following microsurgical management of acoustic neuromas. These results highlight the significance of preoperative counselling and the development of strategies that minimize the likelihood of harm to the chorda tympani nerve during microsurgical intervention for acoustic neuroma.

Hearing preservation and quality of life in small to medium sized vestibular schwannomas after a wait and scan approach or stereotactic radiosurgery: a systematic review and meta-analysis.

BACKGROUND: The management of vestibular schwannomas (VS) encompasses a choice between conservative "wait-and-scan" (WAS) approach, stereotactic radiosurgery (SRS) or open microsurgical resection. Currently, there is no consensus on the optimal management approach for small to medium sized VS. This study aims to compared outcomes related to hearing in patients with small and medium sized VS who underwent initial treatment with WAS versus SRS. METHODS: A systematic review of the available literature was conducted using PubMed/MEDLINE, Embase, and Cochrane up December 08, 2023. Meta-analysis was performed using a random-effect model to calculate mean difference (MD) and relative risk (RR). A leave-one-out analysis was conducted. The risk of bias was assessed via the Risk of Bias in Non-randomized Studies-Interventions (ROBINS-I) and Cochrane Risk of Bias assessment tool (RoB-2). Ultimately, the certainty of evidence was evaluated using the GRADE assessment. The primary outcomes were serviceable hearing, and pure-tone average (PTA). The secondary outcome was the Penn Acoustic Neuroma Quality of Life Scale (PANQOL) total score. RESULTS: Nine studies were eligible for inclusion, comprising a total of 1,275 patients. Among these, 674 (52.86%) underwent WAS, while 601 patients (47.14%) received SRS. Follow-up duration ranged from two to eight years. The meta-analysis indicated that WAS had a better outcome for serviceable hearing (0.47; 95% CI: 0.32 - 0.68; p < 0.001), as well as for postoperative functional measures including PTA score (MD 13.48; 95% CI 3.83 - 23.13; p < 0.01), and PANQOL total score (MD 3.83; 95% CI 0.42 - 7.25; p = 0.03). The overall certainty of evidence ranged from "very low" to "moderate". CONCLUSIONS: Treating small to medium sized VS with WAS increases the likelihood of preserving serviceable hearing and optimized PANQOL overall postoperative score compared to SRS. Nevertheless, the limited availability of literature and the methodological weakness observed in existing studies outline the need for higher-quality studies.

Hydrodissection Facilitates Open Resection of Morton's Neuroma Through a Plantar Approach: Technique Tip.

Visual AbstractThis is a visual representation of the abstract.

Neuroma morphology: A macroscopic classification system.

INTRODUCTION/AIMS: Neuromas come in different shapes and sizes; yet the correlation between neuroma morphology and symptomatology is unknown. Therefore, we aim to investigate macroscopic traits of excised human neuromas and assess the validity of a morphological classification system and its potential clinical implications. METHODS: End-neuroma specimens were collected from prospectively enrolled patients undergoing symptomatic neuroma surgery. Protocolized images of the specimens were obtained intraoperatively. Pain data (Numeric rating scale, 0-10) were prospectively collected during preoperative interview, patient demographic and comorbidity factors were collected from chart review. A morphological classification is proposed, and the inter-rater reliability (IRR) was assessed. Distribution of neuroma morphology with patient factors, was described. RESULTS: Forty-five terminal neuroma specimens from 27 patients were included. Residual limb patients comprised 93% of the population, of which 2 were upper (8.0%) and 23 (92.0%) were lower extremity residual limb patients. The proposed morphological classification, consisting of three groups (bulbous, fusiform, atypical), demonstrated a strong IRR (Cohen's kappa = 0.8). Atypical neuromas demonstrated higher preoperative pain, compared with bulbous and fusiform. Atypical morphology was more prevalent in patients with diabetes and peripheral vascular disease. DISCUSSION: A validated morphological classification of neuroma is introduced. These findings may assist surgeons and researchers with better understanding of symptomatic neuroma development and their clinical implications. The potential relationship of neuroma morphology with the vascular and metabolic microenvironment requires further investigation.

Consensus guidelines for the management of vestibular schwannoma for lowand middle-income countries.

Vestibular Schwannoma (VS), previously known as acoustic neuroma, constitutes the majority of tumours found in the cerebellopontine angle (CPA). Most guidelines for managing CPA tumours have been developed by high-income countries (HICs). However, these guidelines often fall short in addressing the unique challenges encountered in low- and middle-income countries (LMICs), such as Pakistan. In LMICs, issues related to a limited healthcare workforce, inadequate infrastructure, and constrained financial resources hinder the effective implementation of these HIC-derived guidelines. Additionally, it has been observed that VS tends to present at a larger size in LMICs compared to HICs. Given that VS is the predominant type of CPA tumour and other types are covered under separate guidelines, this article aims to provide practical, contextspecific recommendations for the screening, diagnosis, and management of Vestibular Schwannoma in LMIC settings. Our focus is to bridge the gap in care strategies and adapt them to the resource constraints and clinical realities of LMICs.

Evaluation of MRI features of neuromas in oncological amputees, and the relation to pain.

OBJECTIVE: The impact of time on neuroma growth and morphology on pain intensity is unknown. This study aims to assess magnetic resonance imaging (MRI) differences between symptomatic and non-symptomatic neuromas in oncological amputees, and whether time influences MRI-detected neuroma dimensions and their association with pain. MATERIAL AND METHODS: Oncological patients who underwent traditional extremity amputation were included. Post-amputation MRIs were assessed before decision for neuroma surgery. Chart review was performed for residual limb pain (numeric rating scale, 0-10) and the presence of neuropathic symptoms. Neuromas were classified as symptomatic or non-symptomatic, with neuroma size expressed as radiological neuroma-to-nerve-ratio (NNR). RESULTS: Among 78 neuromas in 60 patients, the median NNR was 2.0, and 56 neuromas (71.8%) were symptomatic with a median pain score of 3.5. NNR showed no association with symptomatology or pain intensity but correlated with a longer time-to-neuroma-excision interval and a smaller nerve caliber. Symptomatic neuromas were associated with lower extremity amputation, T2 heterogeneity, and the presence of heterotopic ossification. Lower extremity amputation, T2 heterogeneity, perineural edema, and presence of heterotopic ossification were associated with more painful neuromas. CONCLUSION: MRI features associated with symptomatic neuromas and pain intensity were identified. Awareness of the potential clinical significance of these imaging features may help in the interpretation of MRI exams and may aid clinicians in patient selection for neuroma surgery in oncological amputees.

Single-Dose Calcium Channel Blocker Toxicity in a Patient With Severe Liver Disease.

Calcium channel blockers (CCBs) are commonly used in the management of multiple diseases, including hypertension, arrhythmia, and vasospastic disorder. Nimodipine, a dihydropyridine CCB, has demonstrated utility in preserving hearing following vestibular schwannoma resection surgery. Due to its widespread use, CCB overdose is common. This case report presents a unique case of CCB toxicity in a 56-year-old female with end-stage liver dysfunction. The patient developed vasodilatory shock after receiving a single dose of prophylactic nimodipine following vestibular schwannoma surgery. The primary objective of this report is to highlight the unique risk for CCB toxicity that exists for patients with advanced liver disease who receive nimodipine in the perioperative setting.

Managing Major Peripheral Nerves in Forearm-Level Amputations With TMR and RPNI: What's the Best Recipe?

BACKGROUND: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) prevent symptomatic neuroma formation in amputees. Forearm-level amputations present multiple muscular targets, making it challenging to determine the ideal treatment. The purpose of this study was to evaluate the best TMR targets, role of RPNI, and appropriate patient-selection criteria in forearm-level amputations. We hypothesized that deep and distal TMR targets would best prevent symptomatic neuromas, RPNI would prove a success adjunct, and patients with poorly controlled diabetes would not develop symptomatic neuromas regardless of nerve management. METHODS: We retrospectively identified forearm-level amputations performed between 2017 and 2022. Patients with TMR by outside providers, follow-up <6 months, or insufficient documentation were excluded. Demographics, surgical nerve management, and postoperative complications were collected. The primary outcome was development of a painful neuroma determined by the Eberlin criteria. Patients undergoing TMR were divided a priori into two groups, superficial and proximal versus deep and distal TMR targets, and were compared. RESULTS: Thirty-nine patients met inclusion criteria, and 16 developed a symptomatic neuroma. No patients with a deep or distal TMR target developed a symptomatic neuroma. One nerve out of 12 treated with RPNI developed a symptomatic neuroma. No patient with poorly controlled diabetes developed a symptomatic neuroma, despite no advanced nerve management. CONCLUSIONS: In a case series of forearm amputations, deep and distal TMR targets prevented symptomatic neuroma formation more than superficial and proximal targets. Regenerative peripheral nerve interface is a useful adjunct for neuroma control, especially for the radial sensory nerve. Patients with poorly controlled diabetes may not require advanced nerve management. LEVEL OF EVIDENCE: Level IV retrospective case series.

Current and Future Directions for Upper Extremity Amputations: Comparisons Between Regenerative Peripheral Nerve Interface and Targeted Muscle Reinnervation Surgeries.

Upper extremity amputation can lead to significant functional morbidity. The main goals after amputation are to minimize pain and maintain or improve functional status while optimizing the quality of life. Postamputation pain is common and can be addressed with regenerative peripheral nerve interface surgery or targeted muscle reinnervation surgery. Both modalities are effective in treating residual limb pain and phantom limb pain, as well as improving prosthetic use. Differences in surgical technique between the 2 approaches need to be weighed when deciding what strategy may be most appropriate for the patient.

Traumatic Neuroma of the Hard Palate Mimicking a Small Salivary Gland Tumor-A Case Report.

In the case of any pathologies arising in the hard palate, it is always important to exclude their possible odontogenic origins. Cone-beam computed tomography is mandatory. In cases where a possible non-teeth-related pathology is confirmed, each clinician should remember possible differential diagnostics. Many small salivary glands between the mucosa and bone are present in this palatal area. Both benign and malignant tumors arising from the small glands, and mucosa of the hard palate, might occur. The case presented here mimics a solid tumor because of the nodule consistency. Because of a healthy palatal mucosa without any erosions or irritations with firm attachment to the submucosal nodule, a possible malignant tumor of small salivary gland origins was suspected in this case. When the tumor diameter is small, an excisional biopsy is required to collect good and representative material for further histopathological evaluation. In most cases, bulky nodules present on the palate are hard on palpation, non-movable, and covered with healthy mucosa. Possible bone infiltrations with mucous membrane ulcerations could manifest a more expansive character of the lesion. In the presented case, an unusual occurrence of a traumatic neuroma without any past traumatic etiology of the palate was first differentiated from the occurrence of adenoid-cystic carcinoma (ACC), pleomorphic adenoma, other benign/malignant small gland tumors, or atypical, fibroma/schwannoma of the palate. This paper presents treatment options for this rare oral neural tumor occurrence in the palate and differential diagnosis between hard palate tumors in a 42-year-old male patient, furthermore highlighting the role of an excisional biopsy as a good source for a tissue sample.

Extent of resection and progression-free survival in vestibular schwannoma: a volumetric analysis.

OBJECTIVE: To preserve facial nerve function in vestibular schwannoma (VS) microsurgery, some have advocated subtotal resection (STR) if the tumor is densely adherent to a thinned facial nerve. The objective of this study was to determine if residual volume is associated with progression and whether there is a threshold residual volume that should be pursued during STR to prevent recurrence. A secondary objective of this study was to determine whether facial nerve function at last follow-up was associated with extent of resection (EOR). METHODS: Clinical and radiographic data were retrospectively collected from the records of 164 patients with VS who underwent resection. Tumor volumes were measured using Visage, and standard statistical methods were used. The House-Brackmann scale was used to assess changes in facial nerve function before surgery and at last follow-up. RESULTS: Sixty-one patients (37%) received gross-total resection (GTR) and 103 (63%) received STR. The median clinical and radiographic follow-ups were 49 and 48 months, respectively. The median residual volume was 0.5 cm3 after STR. Kaplan-Meier actuarial survival analysis revealed a 96.3% 5-year progression-free survival (PFS) rate after GTR, which was greater than that after STR (84.5%, p = 0.03). Recursive partitioning analysis of patients receiving STR revealed a residual volume of 0.60 cm3 as the optimal threshold for recurrence. Patients with residual volume ≥ 0.60 cm3 had a 76.0% 5-year PFS, regardless of adjuvant SRS, which was lower than that for patients undergoing GTR (96.3%) or STR (95.6%) with residual volumes < 0.60 cm3 (p < 0.01). On Cox regression analysis, residual volume ≥ 0.60 cm3 (HR 14.4, p = 0.01) was independently associated with progression, even when accounting for patient age, adjuvant radiosurgery, and preoperative tumor size. In 112 patients with at least 24 months of follow-up after their last treatment, tumor control was achieved in 111 (99.1%) patients at a median last follow-up of 71 months. Worse facial nerve function at the last follow-up was independently associated with prior treatment for VS (adjusted OR 3.7, p = 0.04), but not residual volume cohort or preoperative tumor volume. CONCLUSIONS: Residual volume > 0.60 cm3 after VS resection was independently associated with tumor progression, even accounting for adjuvant SRS. These data support maximizing the EOR during VS surgery, even if GTR cannot be safely achieved.

Polish cross-cultural adaptation of a disease-specific quality-of-life instrument: The Penn Acoustic Neuroma Quality-of-Life Scale.

BACKGROUND: The medical community has shown a growing interest in developing methods for measuring and comparing objective patient outcomes coupled with subjective patient assessments. Questionnaires enable healthcare professionals to obtain the patient's perspective about their experienced vestibular schwannomas (VS) symptoms quickly. To date, in Poland, a cross-cultural adapted version of a disease-specific questionnaire for the measurement of quality of life (QoL) in patients with VS has not been produced. OBJECTIVES: This study aimed to adapt the questionnaire evaluating disease-specific QoL in patients with VS (Penn Acoustic Neuroma Quality-of-Life Scale; PANQOL) to Polish and evaluate its psychometric properties. MATERIAL AND METHODS: One-hundred twenty-four patients aged between 24 and 85 years (mean (M) = 60.17 ±standard deviation (SD) = 13.27) diagnosed with VS and treated with Gamma Knife were included in the study. We used a questionnaire translated from English into Polish by a bilingual professional, verified through a back-translation. The final version consisted of 26 items. The internal consistency of the Polish version of the PANQOL scale domains was measured using the Cronbach's alpha (α). To verify the validity of PANQOL subscales, a correlation analysis was conducted between the domains of PANQOL and other questionnaires, including the Assessment of Quality of Life (AQoL-8D), the Glasgow Benefit Inventory (GBI), the 5 Well-Being Index (WHO-5), the Skarzynski Tinnitus Scale (STS) for the presence of dizziness, and the Gardner-Robertson classes. RESULTS: The majority of PANQOL domains showed excellent or good internal consistency (for a PANQOL total of 0.934; for subscales in the range of 0.916-0.424). Our analysis showed strong correlations between the total PANQOL score and AQoL-8D utility score, as well as between the subscales. We observed weak to moderately significant relationships between GBI and PANQOL domains (r = 0.18-0.43), the WHO-5 (r = 0.18-0.56) and the STS scale (r = -0.40- -0.19). CONCLUSIONS: The results demonstrated that the POL-PANQOL is a reliable and valid questionnaire for measuring QoL.

German translation and cross-cultural adaptation of the Vestibular Schwannoma Quality of Life Index (VSQOL).

BACKGROUND: Vestibular schwannomas (VSs) are benign tumors of the vestibulocochlear nerve that often cause significant neurological and functional impairment. Patient-reported outcomes, including quality of life (QoL), are essential for understanding the overall impact of VS and its treatment. This study aimed to translate and culturally adapt the Vestibular Schwannoma Quality of Life (VSQOL) Index into German to expand its relevance to German-speaking populations. METHODS: We used a qualitative approach including translation and cognitive interviews with 10 patients who underwent VS surgery. The translation process followed the TRAPD protocol to ensure linguistic and conceptual accuracy. Cognitive interviews assessed the comprehensibility and relevance of the translated questionnaire. RESULTS: The translation showed remarkable consistency between translators, with minor discrepancies resolved by consensus. Cognitive interviews provided valuable insights that led to refinements in item wording. Participants emphasized the importance of an additional item on physician referrals, reflecting differences in health care systems between the United States and Germany. CONCLUSIONS: The German VSQOL provides a comprehensive tool for assessing QoL in patients with VS that integrates patient-centered dimensions. A Validation study is underway to establish its reliability and validity.

Outcome measures used in peripheral nerve surgery for symptomatic neuroma in upper extremity amputations: A scoping review.

Novel surgical treatments for painful neuromas are increasingly used, but determining which provides the greatest benefit has been difficult due to the inconsistent use of outcome measures. We mapped the current literature of outcome measures used to evaluate peripheral nerve surgery for the management of symptomatic neuromas in patients who underwent an adult-acquired upper extremity amputation (UEA). Medline, Embase, Cochrane, and CINAHL were searched for primary research written in the English language from inception to February 2023. The search yielded 1137 articles, of which 35 were included for final analysis. Studies varied in their assessment of pain, health-related quality of life (HRQOL), neurotrophic measures, psychological and sensorimotor function, highlighting a consensus on crucial domains but also revealing significant heterogeneity in the use and application of outcome measures among primary studies. Our findings highlight the need to establish common standards that reflect the best evidence and unique needs of the UEA population. This includes developing a core outcome set, utilizing multi-center trials, and maintaining flexibility to adapt to ongoing advancements in patient-reported outcome measures (PROMs) research.