Accelerated Unilateral Radiographic Huntingtonian Changes Following Neoadjuvant Chemotherapy for a Nongerminomatous Germ Cell Tumor Leading to Identification of Occult Disease in the Dorsal Striatum.

Basal ganglia nongerminomatous germ cell tumors comprise 10% to 15% of germ cell tumor and have substantial morbidity at the time of local failure. In this submitted image we present a case where neoadjuvant chemotherapy unmasked a unilateral caudate head loss consistent with Huntingtonian changes. Careful review of the patient's imaging identified disease within the dorsal striatum that was not previously identified at the time of diagnosis. Review of the diffusion tensor fractional anisotropy imaging identified progressive white matter likely secondary to the occult disease within the dorsal striatum. Although this patient was asymptomatic and had no signs of a movement disorder, similar findings have been noted to be a prelude to such findings several months later. The occult disease was incorporated into the patient's radiotherapy planning target volume as oversight of these changes would have led to a marginal miss and potential early disease relapse.

Management of nerve sheath tumors arising in the sympathetic chain.

BACKGROUND: Extradural schwannomas arising from the sympathetic chain are uncommon benign nerve sheath tumors. We present our experience with three patients having such tumors located in the cervical, thoracic and lumbar regions and we describe clinical presentation, surgical treatment, and outcomes. METHODS: Between 2002 and 2006, the medical records of three patients with pathologically proven sympathetic schwannomas at the Moffitt Cancer Center were reviewed retrospectively. RESULTS: The three patients were female, with a mean age of 44 years. Presentation and symptomatology varied between patients, and radiographic findings were not diagnostic. Complete excision of tumors was performed in all three patients without added morbidity or mortality. Surgical observation, histopathology, and immunohistochemistry confirmed the tumors to be schwannomas arising from the sympathetic chain. The schwannomas had a mean diameter of 3.2 cm and were all benign. At a mean follow-up of 21 months following resection, all patients remained free of disease recurrence. CONCLUSIONS: Sympathetic schwannomas are rare tumors that are difficult to diagnose preoperatively. Diagnosis relies on clinical suspicion, and confirmation is often obtained by means of surgical pathology. Long-term surveillance is not recommended and surgical excision should be considered for this tumor, even though the tumor is considered benign and recurrence is rare.

Impact of systemic targeted agents on the clinical outcomes of patients with brain metastases.

BACKGROUND: To determine the clinical benefits of systemic targeted agents across multiple histologies after stereotactic radiosurgery (SRS) for brain metastases. METHODS: Between 2000 and 2013, 737 patients underwent upfront SRS for brain metastases. Patients were stratified by whether or not they received targeted agents with SRS. 167 (23%) received targeted agents compared to 570 (77%) that received other available treatment options. Time to event data were summarized using Kaplan-Meier plots, and the log rank test was used to determine statistical differences between groups. RESULTS: Patients who received SRS with targeted agents vs those that did not had improved overall survival (65% vs. 30% at 12 months, p < 0.0001), improved freedom from local failure (94% vs 90% at 12 months, p = 0.06), improved distant failure-free survival (32% vs. 18% at 12 months, p = 0.0001) and improved freedom from whole brain radiation (88% vs. 77% at 12 months, p = 0.03). Improvement in freedom from local failure was driven by improvements seen in breast cancer (100% vs 92% at 12 months, p < 0.01), and renal cell cancer (100% vs 88%, p = 0.04). Multivariate analysis revealed that use of targeted agents improved all cause mortality (HR = 0.6, p < 0.0001). CONCLUSIONS: Targeted agent use with SRS appears to improve survival and intracranial outcomes.