Aggressive surgical treatment with bony pelvic resection for locally recurrent rectal cancer.

BACKGROUND: In the current era of total mesorectal excision, local relapse remains a main cause of recurrence. Although standard treatment for locally recurrent rectal cancer (LRRC) has not been established, R0 resection represents the only potentially curative treatment. However, extended surgery accompanying bony pelvic resection is technically demanding and is still challenging. METHODS: Studied were 35 patients with LRRC who underwent combined resection of bony pelvis between August 2006 and October 2013. Safety and prognostic factors for survival were analyzed. Median follow-up was 33 months. RESULTS: Sacrectomy was performed in 32 patients and 3 patients underwent combined resection of the pubis and ischium. The dominant operative procedure was total pelvic exenteration in 30 (86%) patients. R0 resection was achieved in 27 (77%) patients. No patients died. Pelvic sepsis was the most frequent complication (40%). Recurrence developed in 20 (57%), with the lung the most frequent site (10 patients). Three-year local relapse-free survival (LRFS) and disease-free survival (DFS) were 72.1% and 32.7%, respectively. On multivariate analysis, R1 resection was the only independent risk factor for local recurrence (p = 0.010), and concomitant liver metastasis and initial non sphincter-preserving surgery were independent predictors of worse DFS (p = 0.008 and p = 0.042, respectively). CONCLUSIONS: Aggressive surgical treatment combined with bony resection for carefully selected patients with LRRC was safe with a high rate of R0 resection and favorable LRFS. However, DFS was not satisfactory even after R0 resection and the main cause was lung metastasis. Preventing distant recurrence might be a key to improve survival.

Total spondylectomy following carbon ion radiotherapy to treat chordoma of the mobile spine.

The main form of treatment of a chordoma of the mobile spine is total en bloc spondylectomy (TES), but the clinical results are not satisfactory. Stand-alone carbon ion radiotherapy (CIRT) for bone and soft-tissue sarcomas has recently been reported to have a high rate of local control with a low rate of local recurrence. We report two patients who underwent TES after CIRT for treating a chordoma in the lumbar spine with good medium-term outcomes. At operation, there remained histological evidence of viable tumour cells in both cases. After the combination use of TES following CIRT, neither patient showed signs of recurrence at the follow-up examination. These two cases suggest that CIRT should be combined with total spondylectomy in the treatment of chordoma of the mobile spine.

Does xanthine oxidase contribute to the hydroxyl radical generation in ischemia and reperfusion of the cochlea?

We investigated the effect of a hydroxyl radical scavenger, 1,3-dimethyl-2-thiourea (dimethylthiourea), and two xanthine oxidase inhibitors, oxypurinol and allopurinol, on the threshold shift of the compound action potential (CAP) after transient ischemia of the cochlea. Transient ischemia of 30 min duration was induced in albino guinea pigs via a skull base approach. The animals were treated with perilymphatic perfusion of dimethylthiourea, oxypurinol or allopurinol from 10 min before the onset of ischemia to 4 h after the termination of ischemia. Dimethylthiourea ameliorated the CAP threshold shifts at 4 h after the onset of reperfusion in a dose-dependent manner. However, oxypurinol and allopurinol did not affect the post-ischemic cochlear dysfunction. These results imply that the hydroxyl radical plays an important role in generation of cochlear dysfunction induced by ischemia-reperfusion and that xanthine oxidase may not be the primary source of this radical.

Poly(adenosine diphosphate-ribose) synthetase inhibitor 3-aminobenzamide alleviates cochlear dysfunction induced by transient ischemia.

The present study was undertaken to determine the possible deleterious role played by poly(adenosine diphosphate-ribose) synthetase (PARS) in cochlear ischemia-reperfusion injury. Transient ischemia of the cochlea was induced in albino guinea pigs for 15, 30, or 60 minutes by pressing the labyrinthine artery at the porus acusticus internus. The animals were given intravenous 3-aminobenzamide (a PARS inhibitor) or physiological saline solution I minute before the onset of reperfusion. The compound action potential thresholds were measured before the onset of ischemia and 4 hours after the onset of reperfusion. A statistically significant reduction in the postischemic compound action potential threshold shift was observed in the animals treated with 3-aminobenzamide after 15 or 30 minutes of ischemia, whereas no statistical difference was found after 60 minutes of ischemia. These results suggest that excessive activation of PARS exerts deleterious effects on the cochlear injury induced by transient ischemia.

Effect of A1 adenosine receptor agonist upon cochlear dysfunction induced by transient ischemia.

The present study was undertaken to determine whether 2-chloro-N6-cyclopentyladenosine (CCPA), a highly selective A1 adenosine receptor agonist, attenuated cochlear dysfunction induced by transient ischemia or not. Ischemia of different durations (15, 30 or 60 min) was induced in 46 albino guinea pigs by transiently pressing the labyrinthine artery. CCPA or physiological saline solution was intraperitoneally administered to the animals 15 min prior to ischemia. The post-ischemic CAP threshold shift from the pre-administration value was measured 4 h after the onset of reperfusion to assess post-ischemic cochlear dysfunction. A statistically significant reduction in the CAP threshold shift was seen in CCPA-given animals after 15- and 30-min ischemia, whereas there was no statistical difference after 60-min ischemia. These results suggest that A1 adenosine receptor agonist exerts a protective effect on the cochlear injury induced by transient ischemia of intermediate duration.

Distortion-product otoacoustic emissions in experimentally induced hydropic ears.

The postoperative changes of distortion-product otoacoustic emissions (DPOAEs) and cochlear potentials were examined using 15 albino guinea pigs in which endolymphatic hydrops was induced by obliterating the endolymphatic sac. DPOAEs (geometric mean: 4,6 and 8 kHz) were measured once before and every week after surgery. At the 2nd (n = 5), 4th (n = 5) and 12th (n = 5) postoperative weeks, endocochlear potential (EP) and compound action potential (CAP) were measured. Although the reduction in DPOAEs at 8 kHz was first detected at the 12th week, the amplitude of DPOAEs at 4 and 6 kHz was already reduced at the first week and decreased gradually thereafter. In contrast to these results, the CAP threshold was not elevated at the 2nd week and a slight increase was first detected at the 4th week. The results obtained in the present study suggest that DPOAEs are more sensitive than CAP in detecting the presence of hydrops.

Aicardi syndrome accompanied by auditory disturbance and multiple brain tumors.

We described a 5-month-old girl with Aicardi syndrome accompanied by auditory disturbance and multiple brain tumors. She was admitted to our hospital because she suffered from intractable flexor spasms. Physical examination revealed craniofacial asymmetry, left auricular deformity, scoliosis, and remarkable hypotonia with psychomotor retardation. Abnormal ophthalmological findings included chorioretinopathy with pale and round-shaped peripapillary lacunae, and there was modified hypsarrhythmia in her EEG. MRI revealed multiple brain tumors in the 3rd and the lateral ventricles which are considered to be choroid plexus papilloma with agenesis of the corpus callosum. ACTH therapy was administered because of the intractable seizures. After ACTH therapy, the thresholds of waves I and V were much improved. The interpeak latency of waves I-V of the left ear and the peak latency of wave I of the right ear had been lengthened. Acoustic reflex with contralateral stimulation showed no response in the left ear. These findings indicate that the auditory system is also involved in the Aicardi syndrome and that ACTH is effective for its dysfunction.

The effect of furosemide on the endocochlear potential in ears with experimentally induced endolymphatic hydrops.

The endocochlear potential (EP) was measured in 38 guinea pigs with experimentally induced endolymphatic hydrops at the 3rd, 6th, 12th and 24th postoperative weeks, and the effects of furosemide (FUR, 50 or 80 mg/kg) on the EP were examined. A time-related reduction of the EP from the normal value and increased susceptibility to FUR were disclosed in the hydropic animals. Furthermore, 24-week animals given 80 mg/kg FUR showed a significantly slower recovery rate of the EP than the other groups, indicating impairment of the strial function progressive with post-operative time. The negative component of the EP was considered to be unimpaired until at least 12 weeks after the surgery.

[Incidental meningioma].

Intracranial tumors are accidentally discovered during operations for neurosurgical diseases, such as head trauma or cerebral aneurysm. Furthermore, in the autopsy specimen, intracranial tumors which had not been recognized before the patient's life are sometimes found incidentally. Those tumors are; meningioma, glioma, pituitary adenoma, and so forth. Among these instances, meningioma seems to be the most frequent. In this paper, the authors discussed five cases of asymptomatic meningiomas found unexpectedly, referred as "Incidental Meningioma." Incidental meningioma listed up here are five out of 38 clinical cases with intracranial meningioma which authors experienced during recent twelve years in our hospital. In 480 autopsy cases in our hospital in the same period, there was only one case with which incidental intracranial tumor was detected. This incidental tumor was index-finger tip sized parasagittal meningioma. This was not included in this series. These 5 clinical cases were composed of all women ranging in age from 48 to 72 years. Three of them were discovered during aneurysm surgery, the other one was found during the evacuation of acute subdural hematoma. The remaining one case (Case 5) was demonstrated intracranial meningioma unexpectedly by CT scanning. The size of those tumors were ranged from 7 to 20 mm in diameter except Case 5. In Case 5, tumor size was about 30x40 mm in diameter. The localization of those tumors were; three convexity, one pterion, and one falx meningiomas. Positive findings referable to those tumors at ancillary neuroradiological examinations, were shown only in one case (Case 2) with the exception of Case 5 retrospectively. That was abnormal calcified shadow in frontal bone at the right side in Case 2. The histological nature of them was various, but psammomatous type belonging to transitional meningioma was worthy to note, because such a type was relatively rare in our total cases. Incidental tumors seemed to be relatively rare in cases with cerebral aneurysm. In our series comprising 747 operated cases for cerebral aneurysm, there were 5 cases with incidental tumor (0.67%). Three of these 5 cases were incidental meningioma which were listed up in the paper. In all cases with incidental meningioma, except for Case 5, there were no definite feeding arteries, and they could be easily extirpated, with uneventful recovery.

Prevention of symptomatic vasospasm by topically applied nimodipine.

A 2.4 x 10(-5) M solution of the Calcium-antagonist Nimodipine was administered to the exposed cerebral vessels in 17 patients intraoperatively clipping of a ruptured aneurysm. The interval between subarachnoid haemorrhage and operation was 48 to 72 hours. The CT investigation had revealed blood accumulation in the basal cisterns in all cases. Vasodilatation was observed in all instances; the percentage being greater in small vessels as compared to large vessels. Postoperatively, a neurological deficit combined with angiographically verified vasospasm occurred in two patients, but was reversible in both. Fifteen patients remained free from symptomatic vasospasm and were discharged without neurological deficit. In 13 of these patients and 3 additional cases, a plastic cannula was placed intraoperatively so that postoperative topical administration of Nimodipine was possible. Postoperative control-angiograms after a mean interval of 7 days from SAH did not show severe spasm in any of the patients; localised moderate asymptomatic spasm was found in 8 cases and was reserved in 5. Moderate postoperative symptomatic spasm was observed in 2 patients, treated and reversed in one patient. In 5 of 7 cases without evidence of spasm in the angiogram postoperative topical administration of Nimodipine caused vasodilatation. It is concluded, that topical intracisternal administration of Nimodipine reverses intraoperative vascular spasm and decreases the probability of postoperative symptomatic vasospasm after early surgery.

The microsurgical anterior interhemispheric approach suitably applied to ruptured aneurysms of the anterior communicating artery in the acute stage.

From 1973 to 1980, 177 cases with ruptured aneurysms of the anterior communicating artery (Aco) have been operated on using various microsurgical procedures. Since 1974, 136 cases were directly operated on using the microsurgical anterior interhemispheric (AIH) approach: a modification of Lougheed's approach. The overall mortality was 5%. The early operations, within 1 week of onset of subarachnoid haemorrhage had a 3% mortality in grade 1 and 2 patients; a 16% mortality in grade 3 and 4 and a 25% mortality in grade 5 patients. The rate of cases in which the patient was independent following surgery was 92% in grade 1 and 2 patients, 47% in grade 3 and 4, and 25% in grade 5 in the same group. The AIH approach for severe cases in the acute stage has the following benefits: 1. The retraction pressure on the brain in the AIH approach is half as much as that in Yasargil's approach. The aneurysms can be operated on with less retraction of the brain and thus without damaging the brain, olfactory nerves, bridging veins, hypothalamic arteries and other perforating arteries. 2. Various types of aneurysms, whatever their position, especially those located high and in a posterior direction, can be easily clipped. 3. Adequate removal of clots can be achieved from the interhemispheric fissure, the chiasmatic and the prepontine cisterns and the frontal lobe. 4. Interarterial anastomosis between both anterior cerebral arteries can be applied if necessary to allow easy clipping on unusual aneurysms. 5. Temporary occlusion of A1's and A2's and external decompression can be easily done if necessary.

[Intracranial extradural liposarcoma in the posterior fossa--a case report (author's transl)].

A case of liposarcoma, which originated primarily in the left infraauricular area and infiltrated to the posterior fossa, was reported. The patient was a 25-year-old housewife, who was admitted because of symptoms of intracranial hypertension. She showed left facial palsy and deviation of the tongue to the left without any cerebellar signs. Neurological examinations suggested a mass lesion in the posterior fossa. Suboccipital craniectomy was performed and the tumor sized 4 X 4 X 3 cm in the extradural space was partially removed. Microscopically, the tumor consisted of lipoblasts and diagnosed as liposarcoma. Intracranial liposarcoma, whether primary or secondary, is very rare and only several cases have been reported.