Visual field defects after radiosurgery versus temporal lobectomy for mesial temporal lobe epilepsy: Findings of the ROSE trial.

PURPOSE: Stereotactic radiosurgery (SRS) may be an alternative to anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). Visual field defects (VFD) occur in 9-100% of patients following open surgery for MTLE. Postoperative VFD after minimally invasive versus open surgery may differ. METHODS: This prospective trial randomized patients with unilateral hippocampal sclerosis and concordant video-EEG findings to SRS versus ATL. Humphries perimetry was obtained at 24 m after surgery. VFD ratios (VFDR = proportion of missing homonymous hemifield with 0 = no VFD, 0.5 = complete superior quadrantanopsia) quantified VFD. Regressions of VFDR were evaluated against treatment arm and covariates. MRI evaluated effects of volume changes on VFDR. The relationships of VFDR with seizure remission and driving status 3 years after surgery were evaluated. RESULTS: No patients reported visual changes or had abnormal bedside examinations, but 49 of 54 (91%) of patients experienced VFD on formal perimetry. Neither incidence nor severity of VFDR differed significantly by treatment arm. VFDR severity was not associated with seizure remission or driving status. CONCLUSION: The nature of VFD was consistent with lesions of the optic radiations. Effective surgery (defined by seizure remission) of the mesial temporal lobe results in about a 90% incidence of typical VFD regardless of method.

Clinical and imaging spectrum of tuberculosis-associated fibrosing mediastinitis.

PURPOSE: Fibrosing mediastinitis (FM) is a rare disorder characterized by an excessive fibrotic reaction within the mediastinum, which can result in compression of mediastinal structures. To investigate the clinical and imaging characteristics of TB-associated FM, patients with evidence of TB infection were retrospectively evaluated in this study. MATERIALS AND METHODS: A total of 33 patients with clinically diagnosed FM and evidence of TB infection were selected from the database of two institutional medical centers. Medical records were reviewed to evaluate the clinical disease spectrum, responses to therapy and imaging characteristics. RESULTS: TB-associated FM showed distinctive infiltrative pattern on chest CT, such as bilateral involvement and hilar predominance. The majority of patients presented with nonspecific respiratory symptoms due to the compression of mediastinal broncho-vascular structures. Echocardiography discovered pulmonary hypertension to various degrees in 60% of patients. Although only a part of patients responded to medical therapy, they seldom showed deterioration during the follow-up. CONCLUSIONS: TB-associated FM shows some specific imaging characteristics, reflecting immune-mediated fibrotic reaction secondary to TB infection. The insidious progression to mediastinal fibrosis after TB infection poses a challenge to the early diagnosis and results in subsequent respiratory dysfunction and pulmonary hypertension.

Sclerosing cervicitis: homologue of sclerosing retroperitonitis and mediastinitis.

The first known case of an invasive, sclerosing fibrosis of the deep soft tissue of the neck is presented. The morbidity, clinical course, and, most importantly, pathological identity with sclerosing retroperitonitis and sclerosing mediastinitis led us to consider this lesion as the cervical homologue of these lesions, ie, sclerosing cervicitis.

Treatment and clinical management of primary mediastinal large B-cell lymphoma with sclerosis: MACOP-B regimen and mediastinal radiotherapy monitored by (67)Gallium scan in 50 patients.

To evaluate the efficacy of a combined modality treatment (MACOP-B plus mediastinal radiotherapy) and the advantages of Gallium-67-citrate single-photon emission ((67)GaSPECT) over computed tomography (CT) for restaging in patients with primary mediastinal large B-cell lymphoma (PMLBCL) with sclerosis. Between 1989 and 1998, 50 previously untreated patients with PMLBCL with sclerosis (70% with bulky mass) were treated with MACOP-B regimen plus mediastinal radiotherapy. The radiologic clinical stage with evaluation of tumor size included CT and (67)GaSPECT at diagnosis, after chemotherapy, and after radiotherapy. Forty-three patients (86%) achieved a complete response and 7 were nonresponders to treatment. For the imaging evaluation, only 47 patients were evaluable because 3 had disease progression during chemotherapy. After treatment, 3/5 (60%) patients with positive (67)GaSPECT and negative CT scan relapsed, as against 0/21 (0%) with negative (67)GaSPECT and CT scan. Twenty-one patients had a positive CT scan: of these, the 4 with positive (67)GaSPECT all progressed, whereas there were no relapses among the 17 with negative (67)GaSPECT. After radiotherapy, there was a decrease of positive CT (from 33 to 21 cases) and of positive (67)GaSPECT (from 31 to 9 cases). Relapse-free survival rate was 93% at 96 months (median 39 months). In patients with PMLBCL with sclerosis, MACOP-B plus radiation therapy is a very useful first-line treatment and radiation therapy may play an important role. As regards restaging, (67)GaSPECT should be considered the imaging technique of choice at least in patients who show CT positivity.

MACOP-B and involved field radiation therapy is an effective therapy for primary mediastinal large B-cell lymphoma with sclerosis.

PURPOSE: To evaluate the clinical features of presentation and the response to two different third-generation regimens (F-MACHOP and MACOP-B) of primary mediastinal large B-cell lymphoma (MLBCL), a recently defined distinct clinicopathological entity of non-Hodgkin's lymphoma (NHL). PATIENTS AND METHODS: Thirty-seven consecutive patients with MLBCL, eight male and 29 female (F/M ratio 1:3.5) with a median age of 35 years, were enrolled in the present study. Thirty-five (94.5%) patients presented disease confined to thorax, with chest symptoms of a rapidly enlarging mass in the mediastinum in 70% and superior vena cava syndrome (SCVS) in 43% of these patients. The first 10 patients received F-MACHOP and the succeeding 27 patients MACOP-B chemotherapy, associated in 24 (88.8%) with involved field radiation therapy (IFRT). 67Gallium scan was routinely performed pre- and post-IFRT in 18 patients. RESULTS: All 37 patients were assessable for response: 10 of 10 (100%) in the F-MACHOP and 26 of 27 (96.3%) in the MACOP-B group achieved overall responses (CR + PR). Three of 24 (12.5%) patients in PR after chemotherapy obtained CR after IFRT. Persistent Gallium avidity was observed in 16 patients after chemotherapy and in only four patients after IFRT. Thus far, four of the 10 F-MACHOP and two of the 26 MACOP-B responders have presented disease progression. The probability of progression-free survival (PFS) was 91% and 60% (P < 0.02) while overall survival (OS) was 93% and 70% (P = n.s.) at a mean follow-up of 27 and 52 months in the MACOP-B + IFRT and F-MACHOP groups, respectively. CONCLUSION: MACOP-B + IFRT has proved to be a highly effective and less toxic therapeutic approach for primary MLBCL and appears to be superior to other third-generation chemotherapy regimens.