Successful treatment of mixed (mainly cancer) pain by tramadol preparations.

The patient, a 70-year-old Japanese woman diagnosed with parotid gland cancer, underwent wide excision and reconstruction (facial nerve ablation, nerve transposition). At 1 month after the surgery, she was brought to our hospital's pain medicine department because her postoperative pain and cancer-related pain were poorly controlled. She had already been prescribed a tramadol (37.5 mg)/acetaminophen (325 mg) combination tablet (5 tablets/day). However, in addition to the continuous pain in her face and lower limbs, she was troubled by a trigeminal neuralgia-like prominence ache. Because this pain could not be controlled by an increase to eight combination tablets per day, we switched her medication to a tramadol capsule. At 11 months post-surgery, we then switched her medication to an orally disintegrating tramadol tablet to improve medication adherence of the drug. From 14 months post-surgery, the patient also used a sustained-release tramadol preparation, and she was then able to sleep well. Her current regimen is an orally disintegrating sustained-release tablet combination (total 300 mg tramadol) per day, and she achieved sufficient pain relief. Because tramadol is not classified as a medical narcotic drug, it widely available and was shown here to be extremely useful for the treatment of our patient's mixed (mainly cancer) pain. J. Med. Invest. 64: 311-312, August, 2017.

Radiological features of cerebellar glioblastoma.

BACKGROUND AND PROPOSE: Glioblastoma (GBM) is the most common type of malignant primary central nervous system tumor in adults; however, the prevalence of GBM arising in the cerebellum is extremely low. This study aimed to demonstrate the radiological features of cerebellar GBMs, including computed tomography (CT), magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), and (18)F-fluorodeoxyglucose (FDG)- and (11)C methionine (MET)-positron emission tomography (PET) findings. MATERIALS AND METHODS: We retrospectively reviewed seven patients with cerebellar GBM (six men and one woman: mean age: 56 years, range: 18-73 years). We reviewed medical records and radiological data, including preoperative CT, MRI and PET. All patients underwent CT and MRI. DWI data were acquired in four patients. Three patients underwent FDG- and MET-PET examinations. All patients underwent total or subtotal tumor resection and received pathological diagnoses. RESULTS: Four patients had imaging findings consistent with GBM and received preoperative cerebellar GBM diagnoses. Two patients exhibited homogeneous patchy and nodular enhancement without necrosis on MRI, which resembled malignant lymphoma and metastasis. One case exhibited Lhermitte-Duclos disease-like parallel linear striations (i.e.,"tiger-striped" appearance). Although the imaging findings of these three patients were inconsistent with GBM, pathological diagnosis confirmed cerebellar GMB. CONCLUSIONS: Some evaluated cases of cerebellar GBM did not exhibit the common CT, MRI, and PET findings of supratentrial GBM, leading to considerable difficulty with preoperative differential diagnosis.

Accuracy of diffusion tensor magnetic resonance imaging-based tractography for surgery of gliomas near the pyramidal tract: a significant correlation between subcortical electrical stimulation and postoperative tractography.

BACKGROUND: Diffusion tensor (DT) imaging-based fiber tracking is a noninvasive magnetic resonance technique that can delineate the course of white matter fibers. OBJECTIVE: To evaluate the accuracy and usefulness of this DT imaging-based fiber tracking for surgery in patients with gliomas near the pyramidal tract (PT). METHODS: Subjects comprised 32 patients with gliomas near the PT. DT imaging-based fiber tracks of the PT were generated before and within 3 days after surgery in all patients. A tractography-integrated navigation system was used during the operation. Cortical and subcortical motor-evoked potentials (MEPs) were also monitored during resection to maximize the preservation of motor function. The threshold intensity for subcortical MEPs was examined by searching the stimulus points and changing the stimulus intensity. Minimum distance between the resection border and the illustrated PT was measured on postoperative tractography. RESULTS: In all subjects, DT imaging-based tractography of the PT was successfully performed, preoperatively demonstrating the relationship between tumors and the PT. With the use of the tractography-integrated navigation system and intraoperative MEPs, motor function was preserved postoperatively in all patients. A significant correlation was seen between threshold intensity for subcortical MEPs and the distance between the resection border and PT on postoperative DT imaging. CONCLUSION: DT imaging-based fiber tracking is a reliable and accurate method for mapping the course of subcortical PTs. Fiber tracking and intraoperative MEPs were useful for preserving motor function in patients with gliomas near the PT.

Evaluation of intraoperative brain shift using an ultrasound-linked navigation system for brain tumor surgery.

Image-guided neurosurgery using navigation systems is an essential tool to increase accuracy in brain tumor surgery. However, brain shift during surgery has remained problematic. The present study evaluated the utility of a new ultrasound (US)-linked navigation system for brain tumor surgery in 64 patients with intracranial tumors. The navigation system consisted of a StealthStation navigation system, a SonoNav system, and a standard US scanner. This system determines the orientation of the US images and reformats the images from preoperative computed tomography (CT) or magnetic resonance (MR) imaging to match the US images. The system was used intraoperatively to measure brain shift several times, using the results to guide tumor resection. US-linked navigation provided information regarding brain shift, and extent of tumor resection during surgery. Evaluation of brain shift was easily achieved in all patients, without using intraoperative CT or MR imaging. Accurate information regarding the true anatomical configuration of the patient could be obtained in all phases of the operation. Magnitude of brain shift increased progressively from pre- to post-resection and depended on the type of cranial structure. Integration of the US scanner with the navigation system allowed comparisons between the intraoperative US and preoperative images, thus improving interpretation of US images. The system also improved the rate of tumor resection by facilitating the detection of remnant tumor tissue. This US-linked navigation system provides information on brain shift, and improves the accuracy and utility of image-guided surgery.

Visualization of treatment response in tumors by use of dynamic contrast-enhanced magnetic resonance imaging.

Our goal in this study was to present a method for generating functional parametric maps of hemodynamic parameters in tumors and a visualization method for assessing treatment response by use of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). A total of 13 patients with musculoskeletal tumors were included in this study. First, tumor blood flow (F(T)) maps were generated from DCE-MRI data by use of deconvolution analysis, and K(1), k(2), and f were obtained from a two-compartment model, where K(1) and k(2) denote the rate constant for the transfer of contrast agent from blood to tissue and from tissue to blood, respectively, and f is the fraction of the blood volume. Images were generated by application of the linear least squares method pixel by pixel. Furthermore, the images of the distribution volume (V(d)) and permeability-surface area product (PS) were obtained from the relations V(d) = K(1)/k(2) and PS = -F(T) x ln(1 - K(1)/(F(T)), respectively. Second, two-dimensional (2D) plots were generated with V(d) and K(1) placed on the x- and y-axes, and three-dimensional (3D) plots were generated by the addition of PS on the z-axis. In the case of good responders whose biopsied specimens revealed tumor necrosis greater than 90%, both 2D and 3D plots gradually approached the origin after an increasing number of treatments. On the other hand, in the case of non-responders whose biopsied specimens showed little chemotherapeutic effect, large changes were not observed in either plot. In conclusion, our method will be promising for evaluating the treatment response in tumors visually.

Measurement of tumor blood flow using dynamic contrast-enhanced magnetic resonance imaging and deconvolution analysis: a preliminary study in musculoskeletal tumors.

OBJECTIVE: To measure tumor blood flow (TBF) using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). METHODS: A DCE-MRI was performed using inversion recovery-preparation fast-field echo sequences. Dynamic data were obtained every 3.2 seconds for 2 minutes, immediately after gadolinium injection. In 14 patients with malignant musculoskeletal tumors, TBF maps were generated pixel-by-pixel by deconvolution analysis. For preclinical studies, muscle blood flow in 5 volunteers and signal intensities of different gadolinium concentrations were measured. RESULTS: There was a good linear relationship between signal intensities and gadolinium concentrations (r = 0.989, P < 0.001, at gadolinium concentrations

Subcutaneous fibrolipoma in the back.

A 65-year-old man presented with a subcutaneous giant mass in his upper back. The tumor had a massive fatty and non-adipose component that enhanced heterogeneously on contrast-enhanced computed tomography and magnetic resonance imaging. Therefore, the lesion was initially thought to be a liposarcoma or spindle cell lipoma. After surgery, the tumor was histologically diagnosed as a fibrolipoma. Subcutaneous fibrolipoma is a rare neoplasm that is defined as a subtype of lipoma.

Tl-201 and Tc-99m HMDP scintigraphic findings in extraskeletal osteosarcoma.

Extraskeletal osteosarcoma is an extremely rare high-grade malignant soft tissue tumor, which accounts for approximately 4% of osteosarcomas and less than 1% of all soft tissue sarcomas. There have been reports describing the scintigraphic findings of this tumor, especially with Tl-201. We report a biopsy-proven case of extraskeletal osteosarcoma in which the bone and thallium scans were found to be useful in monitoring chemotherapy response. The Tc-99m HMDP bone scan revealed increased extraskeletal uptake in the tumor.

Measurement of radiation dose in cerebral CT perfusion study.

PURPOSE: To evaluate radiation dose in cerebral perfusion studies with a multi-detector row CT (MDCT) scanner on various voltage and current settings by using a human head phantom. MATERIALS AND METHODS: Following the CT perfusion study protocol, continuous cine scans (1 sec/rotation x60 sec) consisting of four 5-mm-thick contiguous slices were performed three times at variable tube voltages of 80 kV, 100 kV, 120 kV, and 140 kV with the same tube current setting of 200 mA and on variable current settings of 50 mA, 100 mA, 150 mA, and 200 mA with the same tube voltage of 80 kV. Radiation doses were measured using a total of 41 theroluminescent dosimeters (TLDs) placed in the human head phantom. Thirty-six TLDs were inside and three were on the surface of the slice of the X-ray beam center, and two were placed on the surface 3 cm caudal assuming the lens position. RESULTS: Average radiation doses of surface, inside, and lens increased in proportion to the increases of tube voltage and tube current. The lowest inside dose was 87.6+/-15.3 mGy, and the lowest surface dose was 162.5+/-6.7 mGy at settings of 80 kV and 50 mA. The highest inside dose was 1,591.5+/-179.7 mGy, and the highest surface dose was 2,264.6+/-123.7 mGy at 140 kV-200 mA. At 80 kV-50 mA, the average radiation dose of lens was the lowest at 5.5+/-0.0 mGy. At 140 kV-200 mA the radiation dose of lens was the highest at 127.2+/-0.6 mGy. CONCLUSION: In cerebral CT perfusion study, radiation dose can vary considerably. Awareness of the patient's radiation dose is recommended.

Extraskeletal osteosarcoma in the thigh: a case report.

Extraskeletal osteosarcoma is a rare malignant soft-tissue tumor. There are few reports describing the radiological findings of this tumor, especially concerning its MRI and scintigraphic appearance. We report a 58-year-old man with extraskeletal osteosarcoma in the thigh. Radiographs showed small foci of mineralization in the mass. The tumor showed low intensity on T1-weighted images and predominantly high intensity on T2-weighted images, and the tumor was heterogeneously well enhanced on Gd-DTPA-enhanced T1-weighted images. Bone scintigraphy showed extraskeletal uptake in the tumor, and thallium-201 scintigraphy revealed marked inhomogeneous accumulation.

Usefulness of turbo-fluid-attenuated inversion-reovery (tFLAIR) sequence in diagnosing meningioma.

PURPOSE: We evaluated qualitatively and quantitatively the usefulness of turbo-FLAIR (tFLAIR) in diagnosing meningioma in comparison with the T2-weighted turbo spin echo (T2W-TSE) sequence. MATERIALS AND METHODS: Forty-eight patients diagnosed with meningioma were studied. In the qualitative study, we evaluated tumor delineation, contrast (Co) of tumor-to-CSF (cerebrospinal fluid), Co of tumor-to-brain parenchyma, Co of peripheral edema-to-brain parenchyma, and detectability of tumor margin. In quantitative study-1, using signal intensity (SI), we measured SI and calculated Co-SI of tumor-to-gray matter, Co-SI of tumor-to-white matter, Co-SI of peripheral edema-to-white matter, and Co-SI of tumor-to-CSF. In quantitative study-2, using film density, we measured density (De) on hard-copy film images and calculated Co-De for the same items as in quantitative study-1. RESULTS: In the qualitative study, tFLAIR was superior to T2W-TSE in tumor delineation, Co of tumor-to-CSF, Co of tumor-to-brain parenchyma, and Co of peripheral edema-to-brain parenchyma. In quantitative study-1, tFLAIR was superior to T2W-TSE in Co-SI of tumor-to-CSF, however, T2W-TSE was superior to tFLAIR in Co-SI of tumor-to-white matter. In quantitative study-2, tFLAIR was superior to T2W-TSE in all Co-De. CONCLUSION: tFLAIR was superior to T2W-TSE in the depiction of meningioma.

Spindle epithelial tumor with thymus-like differentiation of the thyroid: a case report with pathological and molecular genetics study.

We report an unusual case of spindle epithelial tumor with thymus-like differentiation (SETTLE) of the thyroid present in a 6-year-old boy. The tumor, located at both the left lobe and isthmus, was a circumscribed mass with slightly gritty whorled appearance. Microscopically, the lobulated, highly cellular, spindle cell neoplasm was arranged in intersecting bundles and fascicles separated by fibrous bands. Benign-appearing glands entrapped within fibrous bands and foci of squamous differentiation within spindle cells were observed. Immunohistochemically, the spindle cells were diffusely positive for cytokeratins, vimentin, and alpha-smooth muscle actin and patchily reactive for muscle-specific actin and epithelial membrane antigen, exhibiting myoepithelial differentiation. The spindle cells were also patchily immunopositive for p53 protein. Molecular genetic analysis revealed Ki-ras gene mutations at codons 13 (GGC(gly) to AGC(ser)) and 15 (GGC(gly) to AGC(ser)) on the same allele. Mutation of the p53 gene was not detected. This is the first report on Ki-ras oncogene mutations in a case of SETTLE.

Evaluation of the tumor-brain interface of intracranial meningiomas on MR imaging including FLAIR images.

PURPOSE: The usefulness of fluid-attenuated inversion recovery (FLAIR) imaging for the evaluation of brain diseases has been reported. The purpose of this study was to evaluate the brain-meningioma interface with MRI including FLAIR imaging. MATERIALS AND METHODS: This study involved 48 patients with 50 intracranial meningiomas. We retrospectively evaluated the brain-meningioma interface by various imaging method including FLAIR. If a thin layer with a signal intensity different from that of the tumor and brain was observed in the areas of the tumor-brain interface in T(1)-weighted IR (T(1)WIR) and T(2)-weighted turbo SE (T(2)WTSE) images, we defined this structure as the rim. The presence or absence of the rim and the signal intensity were evaluated, and the length and the signal intensity of the rim observed with FLAIR and contrast-enhanced T(1)WIR (CE-T(1)WIR) images were evaluated. RESULTS: In 35 of the 50 lesions (70.0%), the rim was observed in the tumor-brain interface as a layer of low signal intensity in T(1)WIR images and high signal intensity in T(2)WTSE images. In 13 lesions (26.0%), no rim was detected. Flow voids were observed at the tumor-brain interface in 20 of the 50 lesions (40.0%). No rim showed a low signal intensity of the tumor-brain interface in both T(1)WIR and T(2)WTSE images. The rim exhibited an iso-to-high signal intensity compared to the tumor parenchyma in FLAIR images and an enhanced signal intensity in CE-T(1)WIR images. In contrast to T(1)WIR images, the rim in FLAIR images tended to be identified across the entire circumference. CONCLUSION: The rim at the brain-meningioma interface revealed as low signal intensity in T(1)WIR images and high signal intensity in T(2)WTSE images, which was conventionally considered to be the CSF cleft, was often revealed in FLAIR images as high signal intensity compared to the tumor parenchyma, and an enhanced signal intensity in CE-T(1)WIR images. Therefore, the presence of CSF in such rims is unlikely, and the rims might reflect the capsule structure of the tumor surface.

Prediction of tumor-brain adhesion in intracranial meningiomas by MR imaging and DSA.

OBJECTIVES: The purpose of this study was to evaluate the usefulness of MRI (magnetic resonance imaging) and DSA (digital subtraction angiography) by using preoperative MRI and DSA findings in the examination of meningiomas before excision. In particular, we focused on their usefulness in predicting tumor-brain adhesion during surgery. MATERIALS AND METHODS: The subjects were 36 patients with intracranial meningioma who underwent tumor excision at which time neurosurgeons examined the tumor-brain adhesion. Two neurosurgeons evaluated the degree of tumor-brain adhesion from operation records and videotapes recorded during surgery. Two neuroradiologists retrospectively evaluated the preoperative MRI findings including tumor diameter, signal intensity of the tumor parenchyma obtained with T(2)-weighted imaging (T(2)WI), characteristics of the tumor-brain interface, and degree of peritumoral brain edema. The vascular supply was also evaluated from the preoperative DSA findings. The relationship between these MRI and DSA findings and the degree of tumor-brain adhesion during surgery as classified by the neurosurgeons was statistically analyzed. RESULTS: The degree of peritumoral brain edema and the shapes and characteristics of the tumor-brain interface, including the findings of FLAIR (fluid-attenuated inversion recovery) imaging and vascular supply observed by DSA, were significantly correlated with tumor-brain adhesion. In particular, the shapes and characteristics of the tumor-brain interface as observed by T(1)-weighted imaging (T(1)WI), T(2)WI, and FLAIR, respectively, as well as the vascular supply observed by DSA, were closely correlated with the degree of tumor-brain adhesion encountered during surgery. According to these results, we developed a method of predicting tumor-brain adhesion that considers the shape of the tumor-brain interface revealed by MRI and the vascular supply revealed by DSA. CONCLUSIONS: We retrospectively examined the findings of MRI and DSA performed before excision of meningioma and clarified the relationship between the findings and tumor-brain adhesion. We speculated that tumor-brain adhesion can be accurately and simply predicted before surgery with a new method that considers the shape of the tumor-brain interface observed by MRI and vascular supply observed by DSA.