Real-world analysis of clinical and economic impact of 21-gene recurrence score (RS) testing in early-stage breast cancer (ESBC) in Ireland.

PURPOSE: Results from TAILOR-X suggest that up to 70% of hormone receptor-positive (HR+) node-negative (N0) ESBC patients (pts) may avoid chemotherapy (CT) with RS ≤ 25. We assess clinical and economic impacts of RS testing on treatment using real-world data. METHODS: From October 2011 to February 2019, a retrospective, cross-sectional observational study was conducted of HR+ N0 ESBC pts who had RS testing in Ireland. Pts were classified low risk (RS ≤ 25) and high risk (RS > 25). Clinical risk was calculated. Data were collected via electronic patient records. Cost data were supplied by the National Healthcare Pricing Regulatory Authority. RESULTS: 963 pts. Mean age is 56 years. Mean tumour size is 1.7 cm. 114 (11.8%), 635 (66%), 211 (22%), 3 (0.2%) pts had G1, G2, G3 and unknown G, respectively. 796 pts (82.8%) low RS, 159 (16.5%) high RS and 8 pts (0.7%) unknown RS. 263 pts (26%) were aged ≤ 50 at diagnosis; 117 (45%) had RS 0-15, 63 (24.5%) 16-20, 39 (15.3%) 21-25 and 40 (15.2%) RS 26-100. 4 pts (1.5%) had unknown RS. Post-RS testing, 602 pts (62.5%) had a change in CT decision; 593 changed to hormone therapy (HT) alone. In total, 262 pts received CT. Of pts receiving CT; 138 (53%) had RS > 25, 124 (47%) had RS ≤ 25. Of pts aged ≤ 50, 153 (58%) had high clinical risk, of whom 28 had RS 16-20. Assay use achieved a 62.5% change in treatment with 73% of pts avoiding CT. This resulted in savings of €4 million in treatment costs. Deducting assay costs, savings of €1.9 million were achieved. CONCLUSION: Over the 8 years of the study, a 62.5% reduction in CT use was achieved with savings of over €1,900,000.

Vestibular compensation in guinea pigs given intravenous lidocaine after unilateral labyrinthectomy.

Intravenous lidocaine has been reported to alleviate vertigo in Meniere's disease and suggested as a possible antivertigo agent after unilateral labyrinthectomy in a study of cats. To further evaluate the effects of intravenous lidocaine on the acute phase of postural compensation, we subjected 13 pigmented guinea pigs to unilateral labyrinthectomy. Seven received intravenous lidocaine (4 mg/kg) immediately after labyrinthectomy. The other six served as controls and received an equivalent-volume injection of normal saline solution. Total body curvature, trunk curvature, yaw head tilt, and roll head tilt were measured at frequent intervals for up to 30 hours after surgery. Both groups had immediate difficulties with posturing that gradually improved. The lidocaine group tended to exhibit delayed postural compensation, but this was only statistically significant for roll head tilt. These results do not show improvement in postural compensation from unilateral labyrinthectomy after the administration of intravenous lidocaine. A species-specific effect on the vestibular pathways is suggested, and we conclude that further evaluation of lidocaine and the vestibular system is warranted.

The effect of intracranial surgical trauma on gadolinium-enhanced magnetic resonance imaging.

Gadolinium-enhanced magnetic resonance imaging (MRI) is currently the gold standard for diagnosis of an acoustic neuroma. Its status is diagnosis of a recurrent or residual neuroma is not nearly as clear. A pilot study of 36 postoperative cases showed enhancement in 100% of the patients at the operative site. To examine the role of surgical trauma and biodegradable packing on enhanced MRI, an animal study was designed. Cats and monkeys that underwent posterior fossa surgical procedures had preoperative and postoperative MRI and histologic correlation of any enhanced area. Areas of postoperative enhancement should not be considered as diagnostic of tumor. Further studies are necessary to develop a criteria for recurrent tumor diagnosis with enhanced MRI.

Surgical management of CSF otorhinorrhea following retrosigmoid removal of cerebellopontine angle tumors.

Cerebrospinal fluid (CSF) otorhinorrhea continues to be one of the most common complications following surgery for cerebellopontine angle (CPA) tumors. For retrosigmoid approaches, this complication has been reported to occur in 12-19 percent of patients. Nearly all prior surgical attempts at control have included middle ear and eustachian tube obliteration along with packing of the mastoid. This article reviews 165 retrosigmoid procedures (January 1982-December 1990) for removal of CPA tumors, with a leak rate of 9.8 percent (16 cases), 7.2 percent (12 cases) requiring surgical control. An operative technique involving only mastoid obliteration is presented. This approach is less invasive as it limits the scope of the surgical field and also maintains the integrity of the middle ear for potential preservation of hearing. This approach has resulted in control in 100 percent of the patients, without reoperation. The routes of the CSF leak, the technique, and the rationale for its use are presented.

Gadolinium-enhanced magnetic resonance imaging in facial nerve lesions.

We present our 2-year experience with a contrast enhancement agent in magnetic resonance imaging (MRI) examining facial nerve pathology. Characteristics of the agent gadolinium diethylenetriamine pentaacetic acid are reviewed. The radiographic capability to differentiate pathologic vs. normal facial nerves based on enhancement and a change in signal intensity generated by the nerve is demonstrated. Experience with facial nerve disorders including Bell's palsy, facial nerve neuromas, a facial nerve graft site, postoperative facial paralysis, and traumatic facial paralysis is presented. The ability to image the facial nerve in Bell's palsy provides an entirely new means of examining this disorder, and its implications are discussed. The ability to enhance the paralyzed facial nerve in the temporal bone after posterior fossa surgery supports a previously held concept as to the pathophysiology of this problem.

MR imaging of facial nerve enhancement in Bell palsy or after temporal bone surgery.

The authors evaluated magnetic resonance (MR) images obtained with intravenously administered gadolinium in ten patients who had facial paralysis and no facial nerve tumor. In patients with either Bell palsy (four patients) or facial paralysis after temporal bone surgery (six patients), intratemporal facial nerve enhancement was seen. Facial nerve enhancement on MR images proved to be a nonspecific finding.

Gadolinium-enhanced magnetic resonance imaging in temporal bone lesions.

A 2-year experience with an enhancement agent in magnetic resonance imaging (MRI) is examined through case presentations. Characteristics of the agent Gadolinium DTPA/Dimeglumin are reviewed. Radiographic capabilities in enhanced versus unenhanced MRI are compared. Temporal bone lesions, including acoustic neuromas and facial nerve neuromas, are presented. Recent experience with facial nerve enhancement in Bell's palsy is also presented. Greater accuracy in defining small temporal bone lesions and increased delineation of facial nerve involvement appear to be significant benefits with enhanced MRI.

Facial nerve enhancement in MR imaging.

The significance of facial nerve enhancement after IV gadolinium administration has not been determined. We evaluated the MR appearance of facial nerves (nonenhanced and enhanced) in patients without and with masses involving the temporal bone, internal auditory canal, or cerebellopontine angle. In patients without such masses, no facial nerve enhancement was seen. In the other group, four of 11 patients showed facial nerve enhancement and geniculate ganglion masses. Three of these four patients had neurofibromatosis; one had surgical verification of a facial nerve neurofibroma. Enhanced MR facilitates identification of abnormal facial nerves.

MR detection of tumor in the internal auditory canal.

The MR appearance of 15 tumors within or near the internal auditory canal was analyzed in detail and compared with the subsequent surgical observations. In most cases, nonenhanced MR showed the precise extent of the intracanalicular and extracanalicular tumor despite minor variations in appearance. In a case of facial nerve neurinoma, the extent to which the tumor invaded the canal was underestimated by MR. Gadolinium-DTPA enhancement is expected to eliminate uncertainties in MR imaging of the internal auditory canal.

Retrosigmoid intracanalicular vestibular nerve section: an alternative surgical approach for Menière's disease.

Selective vestibular nerve section has been shown to be an extremely effective treatment for control of vertigo in Menière's disease. In recent years the retrolabyrinthine approach has popularized this form of treatment. An alternative to the retrolabyrinthine approach is presented. It consists of a retrosigmoid intracanalicular dissection, and approach used for acoustic neuroma surgery. A review of the surgical technique, the rationale for its selection over the retrolabyrinthine approach, and the initial results and operative complications during its first eighteen months of use are presented.

Mixed glioma of the cerebellopontine angle.

A rare case of mixed ependymoma and astrocytoma of the cerebellopontine angle is reported. Its clinical presentation, characteristics on evaluation, and prognosis are compared with those of the acoustic neuroma and glioma. The central form of von Recklinghausen's disease and familial multiple lipomatosis as it applies to the patient is also discussed.

Surface-coil magnetic resonance imaging of the internal auditory canal.

Computed tomography is effective for detecting acoustic neuromas, but not for resolving individual nerves in the internal auditory canal. Surface-coil magnetic resonance (MR) images of the internal auditory canal were obtained using a 1.5 T superconducting magnet, a 13.5-cm-diameter surface coil, 3- and 5-mm-thick slices, and partial-saturation pulse sequences. Cranial nerves VII and VIII (three branches) were identified on MR images in volunteers and on corresponding cryomicrotomic sections. The nerves were obscured in one patient with an acoustic neuroma. Because high-resolution surface-coil images can demonstrate specific nerves in the internal auditory canal, MR should be a sensitive study to evaluate cranial nerves VII and VIII in patients with facial paralysis and neurosensory hearing loss that is congenital or caused by small acoustic neuromas.

Magnetic resonance imaging of the internal auditory canal.

Three patients with exclusively or predominantly intracanalicular neuromas and 5 with presumably normal internal auditory canals were examined with prototype 1.4- or 1.5-tesla magnetic resonance (MR) scanners. MR images showed the 7th and 8th cranial nerves in the internal auditory canal. The intracanalicular neuromas had larger diameter and slightly greater signal strength than the nerves. Early results suggest that minimal enlargement of the nerves can be detected even in the internal auditory canal.

Congenital hypoplasia of the depressor anguli oris muscle in the differential diagnosis of facial paralysis.

Facial paralysis presents an interesting diagnostic challenge. Etiologies ranging from facial nerve neuromas and CPA tumors to inflammatory disease and traumatic injuries need be considered and evaluated. However, an asymmetric facial appearance may result from abnormalities of facial musculature as well as facial innervation. Two cases of congenital hypoplasia of the depressor anguli oris muscle, a child and an adult, are reviewed to examine its presentation and diagnostic differentiation from other forms of facial paralysis. Photographs presenting the facial deformity and electrodiagnostic studies will be reviewed.

Fahr's disease. An otolaryngologic perspective.

An idiopathic basal ganglion calcification occurring in a 35-year-old man was first observed as a speech deficit. The literature is reviewed, the condition of patients with this disease is evaluated, and a prognosis is given. To our knowledge, the prolongation of visual-evoked potentials by this abnormality is reported herein for the first time.

Sudden sensorineural hearing loss: operative complication in non-otologic surgery.

Sudden sensorineural hearing loss is a well recognized phenomenon in otologic practice with both viral and vascular etiologies being supported. However, sudden hearing loss as a complication of non-otologic surgical procedure is a seldom reported and rare phenomenon. Five cases of unilateral sudden sensorineural hearing loss which are time related and probably causally related to non-otologic surgery are presented. Two cases underwent open heart surgery and support previous reports of hearing loss secondary to cardiopulmonary bypass procedures. Three noncardiac cases are also reviewed. None of these patients had prior otologic disease which would predispose to a sudden hearing loss, and no intraoperative or postoperative complication was specifically noted as a cause of the hearing loss. The literature is reviewed and attention is drawn to the problem. We wish to encourage further reports and to recommend early identification and treatment in those cases related to cardiopulmonary bypass.

A case of cysticercosis cerebri. Neurotologic implications.

Cysticercosis is an unusual disease entity in the United States. A case is reviewed in which a young Mexican-American female presented to an otologist's office with a headache and vertigo. Her symptoms were a manifestation of a single larval cysticercus cyst which had become lodged in the fourth ventricle resulting in an obstructive hydrocephalus and a fatal course. The epidemiology of this disease traces the life cycle of the pork tapeworm from man, normally the definitive host, to the pig, the intermediate host. It is noteworthy that the disease cysticercosis in humans is a deviation from the parasite's normal life cycle in which man serves as the intermediate host. The literature is reviewed. The broad clinical spectrum of this disease's presentation can extend from a single headache to multiple nerve palsies and convulsions. The importance of radiographic evaluation complement fixation testing and CSF evaluation in making a diagnosis is stressed. There is no known medical treatment for this disease. Surgical procedures such as primary excision and shunts to relieve intracranial pressure have had mixed results. The prognosis depends on the location and the number of infesting larva. Special note is made of this disease's endemic status in Mexico and other Latin American countries and the role that this may play in medicine practiced in the southwest United States considering the ever-increasing immigration from this area.