De-differentiated metastatic adenosquamous carcinoma arising from germ cell tumor in the brain and spine.

Intracranial germ cell tumors have an estimated incidence of 0.4-3.4% in the Western Hemisphere. Patients can present with a variety of differing clinical signs and symptoms including headache, nausea/vomiting, hydrocephalus, obtundation, pyramidal tract signs, ataxia, and hypothalamic/pituitary dysfunction. Rarely germ cell tumors can transform into alternative malignancy. In these cases, treatment options may be difficult. Metastasis to the brain is not uncommon in germ cell tumors and is frequently reported within the pineal region; however, they are less common intraventricularly, within the posterior fossa and have never been reported after malignant transformation. Herein, we present the first reported case of a metastatic adenosquamous carcinoma transformed from a yolk sac tumor with diffuse cerebral metastasis in atypical locations of the brain including intraventricular and posterior fossa. A 53-year-old right-handed Caucasian female was transferred from an outside hospital for a chief complaint of altered mental status with CT head showing right side intraventricular mass and cerebellar hemorrhage. MRI of the brain found multifocal contrast-enhancing lesions of the right lateral ventricle, right cerebellum, right frontal lobe, diffuse lumbar dural enhancement, and an intramedullary lesion at the cervico-medullary junction of the brainstem. The right lateral ventricular lesion and right cerebellar lesions were resected. Pathology findings support a diagnosis of adenosquamous carcinoma, and the morphologic and immunophenotypic features suggest development as a somatic malignancy in a germ cell neoplasm with features of a yolk sac tumor. Germ cell tumors are typically included within the differential of pineal region masses; however, other locations such as intraventricular and posterior fossa are rarely seen. Even rarer are cases with malignant transformation to an alternative lesion for which treatment options are exceptionally scarce. Neurosurgeons and oncologists alike should be aware of this rare possible lesion to add to a broad differential diagnosis.

The effects of radiation therapy on the heart: implications for management.

Chemotherapy, radiotherapy, and surgery constitute the three primary modalities employed in the treatment of patients with cancer. Radiotherapy, in particular, is a mainstay of treatment for patients with cancers of the breast, esophagus, lung, and lymph nodes. Prior studies have shown, however, that radiotherapy can impact the heart. Radiation exposure, in fact, can lead to pathophysiological changes that may result in short- and long-term radiation-induced cardiac toxicities. Such toxicities can cause substantial morbidity and may manifest clinically in the weeks to years after the completion of treatment. As a result, in both modern clinical practice and clinical trials, the heart has been recognized as an organ-at-risk, and radiotherapy treatment plans seek to minimize the dose that it receives. In this review, we focus on the impacts of radiotherapy on underlying cardiac risk factors, the pathophysiology of radiotherapy-induced cardiac changes, and the clinical impacts of radiotherapy on the heart. Due to the location of the heart, we focus primarily on patients who have received radiotherapy for cancers of the breast, esophagus, lung, and lymph nodes, and those who have received cardiac-directed therapy. We then elaborate on the ongoing attempts to further lower the doses delivered to the heart during therapeutic courses of radiation.

Combining Radiotherapy and Immunotherapy in Head and Neck Cancer.

Head and neck squamous cell carcinoma (HNSCC) is a leading cause of morbidity and mortality globally. Despite significant advances in well-established treatment techniques, prognosis for advanced-stage HNSCC remains poor. Recent, accumulating evidence supports a role for immunotherapy in HNSCC treatment. Radiation therapy (RT), a standard treatment option for HNSCC, has immunomodulatory and immunostimulatory effects that may enhance the efficacy of immunotherapy. In several cancer types, combining RT and immunotherapy has been shown to improve tumor response rates, increase survival, and reduce toxicity compared to traditional chemotherapy and radiation therapy. This review provides a timely overview of the current knowledge on the use of RT and immunotherapy for treating HNSCC. It highlights the potential advantages of combining these therapies, such as improved tumor response rates, increased survival, and reduced toxicity. The review also discusses the challenges that need to be addressed when redefining the standard of care in HNSCC, and proposes further research to optimize treatment combinations, minimize radiation-induced toxicity, and identify suitable patient populations for treatment.

The Impact of Medicaid Expansion on Patients with Cancer in the United States: A Review.

Since 2014, American states have had the option to expand their Medicaid programs as part of the Affordable Care Act (ACA), which was signed into law by former President Barack H. Obama in 2010. Emerging research has found that Medicaid expansion has had a significant impact on patients with cancer, who often face significant financial barriers to receiving the care they need. In this review, we aim to provide a comprehensive examination of the research conducted thus far on the impact of Medicaid expansion on patients with cancer. We begin with a discussion of the history of Medicaid expansion and the key features of the ACA that facilitated it. We then review the literature, analyzing studies that have investigated the impact of Medicaid expansion on cancer patients in terms of access to care, quality of care, and health outcomes. Our findings suggest that Medicaid expansion has had a positive impact on patients with cancer in a number of ways. Patients in expansion states are more likely to receive timely cancer screening and diagnoses, and are more likely to receive appropriate cancer-directed treatment. Additionally, Medicaid expansion has been associated with improvements in cancer-related health outcomes, including improved survival rates. However, limitations and gaps in the current research on the impact of Medicaid expansion on patients with cancer exist, including a lack of long-term data on health outcomes. Additionally, further research is needed to better understand the mechanisms through which Medicaid expansion impacts cancer care.

Radiotherapy and Immunotherapy in Lung Cancer.

The emergence of immune checkpoint inhibitors (ICIs) as a pillar of cancer treatment has emphasized the immune system's integral role in tumor control and progression through cancer immune surveillance. ICIs are being investigated and incorporated into the treatment paradigm for lung cancers across stages and histology. To date, definitive concurrent chemoradiotherapy followed by consolidative durvalumab is the only National Comprehensive Cancer Network's recommended treatment paradigm including radiotherapy with ICI in lung cancers, although there are other recommendations for ICI with chemotherapy and/or surgery. This narrative review provides an overall view of the evolving integration and synergistic role of immunotherapy and radiotherapy and outlines the use of immunotherapy with radiotherapy for the management of small cell lung cancer and non-small cell lung cancer. It also reviews selected, practice-changing clinical trials that led to the current standard of care for lung cancers.

The incorporation of cognitive-sparing techniques into prophylactic cranial irradiation in the management of small cell lung cancer.

The use of prophylactic cranial irradiation (PCI) remains an important component in the management of small cell lung cancer (SCLC). This is due to the high rates of subclinical brain metastases at the time of diagnosis. Following a response to initial treatment, PCI historically has been associated with improvements in overall survival and decreased development of brain metastases in patients with limited stage (LS-SCLC) and extensive stage (ES-SCLC) SCLC. However, PCI is commonly withheld in these settings in favor of observation, largely due to its association with cognitive sequelae following treatment. While randomized data has demonstrated that in patients with ES-SCLC, PCI may be withheld in favor of close MRI surveillance without a detriment in overall survival or cognitive functioning, these patients did not undergo formal neuropsychological assessments. In recent years, cognitive sparing techniques incorporated into whole brain radiation therapy and PCI, such as the addition of memantine and hippocampal avoidance, have demonstrated significant improvements in cognitive outcomes. As the overall survival in patients with SCLC continues to improve due to the incorporation of novel systemic therapies (e.g., immune checkpoint inhibitors), the role of PCI and maximizing quality of life remains a highly relevant topic. This article reviews the role of PCI and cognitive-sparing techniques in the management of SCLC.

Oncologic causes of oculopalatal tremors: neurophysiology and treatment.

Oculopalatal tremor (OPT) is an acquired pathology characterized by continuous and rhythmical soft palatal movements combined with pendular nystagmus. Aside from vascular lesions, oncological masses affecting the dentatorubro-olivary pathway can impair brainstem and/or cerebellar pathways, manifesting as dyssynchronous movement. In this review, we delve into the neurophysiology of OPT along with oncological causes and treatment options based on the most recent clinical trial data. This literature review includes medication treatment data from clinical trials enrolling individuals with features of OPT, including acquired pendular nystagmus (APN). Trials were deemed eligible for inclusion in this review if one or more participants had symptoms determined by the trial authors to be caused by OPT. Trials investigating the treatment of APN secondary to a separate cause, such as multiple sclerosis, were excluded from this review. Several early treatments failed to demonstrate a benefit for patients with APN due to OPT. Trials of anticholinergic agents were largely ineffective and poorly tolerated. Botulinum toxin A demonstrated improvement in APN symptoms. Most recently, trials including memantine and gabapentin have demonstrated success with attenuation of APN. Surgical modalities such as DBS have yet to show improvement, though with only a single case report as evidence. Oculopalatal tremor is a unique manifestation of posterior fossa tumors disrupting the Guillain-Mollaret triangle. Symptom control through medication management has had limited success attributed to poor response and medication intolerance. Surgical modalities like DBS may have an emerging role in OPT treatment by targeting dyssynchronous activity in the dentatorubro-olivary pathway.

Spontaneous cervical epidural hematoma: Insight into this occurrence with case examples.

BACKGROUND: First characterized in the 19th century, spontaneous spinal epidural hematoma (SSEH) is known as the idiopathic accumulation of blood within the spinal canal's epidural space, causing symptoms varying from general back pain to complete paraplegia. With varying etiologies, a broad spectrum of severity and symptoms, a time-dependent resolution period, and no documented diagnosis or treatment algorithm, SSEH is a commonly misunderstood condition associated with increasing morbidity. While SSEH can occur at any vertebrae level, 16% of all SSEH cases occur in the cervical spine, making it a region of interest to clinicians. CASE DESCRIPTION: Herein, the authors present two case examples describing the clinical presentation of SSEH, while also reviewing the literature to provide a comprehensive overview of its presentation, pathology, and treatment. The first case is a patient with nontraumatic sudden onset neck pain with rapidly progressing weakness. The second case is a patient with painless weakness that developed while taking 325 mg of aspirin daily. CONCLUSION: Clinicians should keep SSEH in their differential diagnosis when seeing patients with nontraumatic sources of weakness in their extremities. The appropriate steps should be followed to diagnose and treat this condition with magnetic resonance imaging and surgical decompression if there are progressive neurological deficits. There is a continued need for more extensive database-driven studies to understand better SSEHs clinical presentation, etiology, and ultimate treatment.

Pulsed Electromagnetic Field Stimulators Efficacy for Noninvasive Bone Growth in Spine Surgery.

The growth of pulsed electromagnetic field (PEMF) therapy and its progress over the years for use in post-operative bone growth has been revolutionary in its effect on bone tissue proliferation and vascular flow. However, further progress in PEMF therapy has been difficult due to lack of more evidence-based understanding of its mechanism of action. Our objective was to review the current understanding of bone growth physiology, the mechanism of PEMF therapy action along with its application in spinal surgery and associated outcomes. The authors of this review examined multiple controlled, comparative, and cohort studies to compare fusion rates of patients undergoing PEMF stimulation. Examining spinal fusion rates, a rounded comparison of post-fusion outcomes with and without bone stimulator was performed. Results showed that postoperative spinal surgery PEMF stimulation had higher rates of fusion than control groups. Though PEMF therapy was proven more effective, multiple factors contributed to difficulty in patient compliance for use. Extended timeframe of treatment and cost of treatment were the main obstacles to full compliance. This review showed that PEMF therapy presented an increased rate of recovery in patients, supporting the use of these devices as an effective post-surgical aid. Given the recent advances in the development of PEMF devices, affordability and access will be much easier suited to the patient population, allowing for more readily available treatment options.

Paracoccygeal Transsacral Approach: A Rare Approach for Axial Lumbosacral Interbody Fusion.

Lumbosacral interbody fusion is a mainstay of surgical treatment for degenerative spinal pathologies causing chronic pain and functional impairment. However, the optimal technique for this procedure remains controversial. Well-established open approaches, including anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF), have historically been the standard of practice. A recent paradigm shift in spinal surgery has led to the investigation of minimally invasive approaches to mitigate tissue damage without compromising outcomes. This extensive review aims to examine current clinical and biomechanical evidence on the paracoccygeal transsacral approach to an axial lumbosacral interbody fusion. Since this technique was first described in 2004, accumulating evidence suggests it results in high fusion rates, consistent improvements in pain and function, reduced perioperative morbidity, and low rates of complication. Although early clinical outcomes have been promising, there is a paucity of comparative data investigating outcomes of the paracoccygeal transsacral approach to traditional alternatives and other minimally invasive techniques. Here, we summarize current evidence and discuss pertinent topics for the spinal surgeon considering this novel approach, including indications, advantages, relevant anatomy, contraindications, and technical considerations.

BIIB093 (intravenous glibenclamide) for the prevention of severe cerebral edema.

BACKGROUND: Vasogenic edema in the setting of acute ischemic stroke can be attributed to the opening of transient receptor potential 4 channels, which are expressed in the setting of injury and regulated by sulfonylurea receptor 1 (SUR1) proteins. Glibenclamide, also known as glyburide, RP-1127, Cirara, and BIIB093, is a second-generation sulfonylurea that binds SUR1 at potassium channels and may significantly reduce cerebral edema following stroke, as evidenced by recent clinical trials. This review provides a comprehensive analysis of clinical considerations of glibenclamide use and current patient outcomes when administered in the setting of acute ischemic stroke to reduce severe edema. METHODS: National databases (MEDLINE, EMBASE, Cochrane, and Google scholar databases) were searched to identify studies that reported on the clinical outcomes of glibenclamide administered immediately following acute ischemic stroke. RESULTS: The pharmacological mechanism of glibenclamide was reviewed in depth as well as the known indications and contraindications to receiving treatment. Eight studies were identified as having meaningful clinical outcome data, finding statistically significant differences in glibenclamide treatment groups ranging from matrix metalloproteinase-9 serum levels, midline shift, modified Rankin Scores, National Institute of Health Stroke Score, and mortality endpoints. CONCLUSION: Studies analyzing the GAMES-Pilot and GAMES-PR trials suggest that glibenclamide has a moderate, however, measurable effect on intermediate biomarkers and clinical endpoints. Meaningful conclusions are limited by the small sample size of patients studied.

Venous sinus stenting for intractable pulsatile tinnitus: A review of indications and outcomes.

BACKGROUND: Pulsatile tinnitus presents as a unique variation of tinnitus in which a conscious perception of the heartbeat is localized to the ears in either unilateral or bilateral fashion. The sensation is typically caused by an increase in turbulent blood flow in the affected ear, in most cases, due to a structural abnormality of the venous sinuses - the most common of which being stenosis. Herein, we discuss the etiology of pulsatile tinnitus followed by indications for treatment of various pathologies which have been successfully treated with venous sinus stenting and have led to resolution of auditory symptoms. METHODS: The authors queried PubMed database using combinations of the keywords "venous sinus stenting," "endovascular treatment," and "pulsatile tinnitus" to identify relevant studies published in English after 2001 and before December 1, 2020 and verified selected. RESULTS: Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting. CONCLUSION: The success of venous sinus stenting is clinically relevant as an effective treatment option for patients suffering from pulsatile tinnitus. Future applications and studies are needed and are currently being developed to further demonstrate the effectiveness of stents in the treatment of pulsatile tinnitus.

Clinical manifestations, classification, and surgical management of sacral tumors and the need for personalized approach to sacrectomy.

BACKGROUND: Although comprising 7% of all spinal tumors, sacral tumors present with a litany of issues due to their slow growth and difficulty in detection. As a result, sacral tumors can grow unperturbed for years until a patient presents for an incidental workup of an unassociated minor trauma or an offending primary tumor source that has metastasized to the sacrum; in most cases, this includes primary tumors of the breast, prostate, and lung. The goal of this review is to outline the pathophysiology underlying sacral tumors including the various tissues and structures that can be targeted for treatment, along with a discussion of the surgical approach to sacrectomy. METHODS: An extensive review of the published literature was conducted through PubMed database with articles simultaneously containing both search terms "sacral tumors" and "sacrectomy." No date restrictions were used. RESULTS: The search yielded 245 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. CONCLUSION: Once a sacral tumor has reached the point of diagnostic detection, invasive sacrectomy is typically utilized (through an anterior, posterior, or combination approach) to locally isolate and resect the tumor and minimize risk of future tumor growth and additional bone loss. While institutions have varying criteria for surgical approaches, a combination of anterior and posterior approach has traditionally been used in total and high sacrectomies due to the control it provides surgeons toward the rectum and vasculature anterior to the sacrum. A posterior-only approach can be performed for tumors that failed to invade pelvic organs or extend past the lumbosacral junction. Early detection with screenings can help avoid invasive sacrectomy by identifying the onset of tumor formation in the sacrum, particularly for highly metastatic cancers.

Prevalence of sports-related spinal injury stratified by competition level and return to play guidelines.

Spinal injury is among the most severe and feared injuries an athlete may face. We present an up-to-date review of the recent literature, stratifying recommendations based on injury location (cervical, thoracic, and lumbar spine) and type, as well as, the level of competitive play (high school, collegiate, professional). A literature search was completed to identify all publications reporting return to play guidelines for athletic injuries or injury-related surgery irrespective of the study design. Publication dates were not restricted by year. Search terms used included "return to play" and "spinal injury" on National Library of Medicine (PubMed) and Google Scholar. Selection criteria for literature included axial spine injury guidelines for athletic participation post-injury or post-surgery. Literature found from the search criteria was sorted based on level of competition and location of axial spine injury involved. It was found that professional athletes are more likely to suffer severe spinal injuries, require surgery, and necessitate a longer return to play (RTP), with high school and college athletes usually returning to play within days or weeks. Injuries occur mainly within contact sports and concordance exists between initial and subsequent spinal injuries. Adequate rest, rehabilitation, and protective equipment alongside the education of athletes and coaches are recommended. In conclusion, a multidisciplinary approach to patient management is required with consideration for the emotional, social, and perhaps financial impact that spinal injury may have upon the athlete. Consensus from the literature states that in order for an athlete to safely return to play, that athlete should not be actively suffering from pain, should have a full range of motion, and complete return of their strength in the absence of neurological deficit.

Cellular transplantation and platelet-rich plasma injections for discogenic pain: a contemporary review.

Degenerative disc disease (DDD) is the leading cause of chronic back pain. It is a pathologic condition associated with aging and is believed to result from catabolic excess in the intervertebral discs' (IVD) extracellular matrix. Two new treatment options are intradiscal cellular transplantation and growth factor therapy. Recent investigations on the use of these therapies are discussed and compared with emerging evidence supporting novel cellular injections. At present, human and animal studies provide a compelling rationale for the use of cellular injections in the treatment of discogenic pain. Since DDD results from the IVD extracellular matrix's unmitigated catabolism, cellular injections are used to induce regeneration and homeostasis in the IVD. Here, we review intervertebral disc anatomy, DDD pathophysiology and clinical considerations, as well as the current and emerging literature investigating outcomes associated with cellular transplantation and platelet-rich plasma for discogenic pain. Further high-quality trials are certainly warranted.

Repetitive Traumatic Discopathy in the Modern-Era Tennis Player.

Degenerative disc disease is more prevalent among athletes than the general population. Repetitive traumatic discopathy is a pattern of injury that has been described in athletes participating in sports that impart repetitive mechanical forces on the lumbar spine. Hence, tennis players may be particularly susceptible to repetitive traumatic discopathy due to the fast-paced nature of the modern tennis match. Recent biomechanical studies have identified the lumbar spine as the focal point of motion during tennis strokes, and the lumbar spine is notably the most frequent location of injury observed in tennis players. In this comprehensive review, we examine current evidence and discuss the epidemiology, pathophysiology, biomechanics, diagnosis, and treatment of repetitive traumatic discopathy in tennis players. Additionally, we outline considerations for rehabilitation and return to the tennis court after operative management.