Extracranial temporal bone paragangliomas: Re-defining the role of otologic surgery within the scope of function-preserving multimodal concepts.

INTRODUCTION: The aim of this study was to present our concept in the management of extracranial temporal bone paragangliomas and demonstrate the outcome after primary surgical management of the middle ear component, with an individualized indication for adjuvant radiotherapy. MATERIALS AND METHODS: The records of all patients treated for extracranial jugulotympanic paragangliomas by means of primary surgical management between 2010 and 2021 were studied retrospectively. RESULTS: Twenty-nine patients made up our study sample (mean age 58.8 years). 15 cases were managed solely by means of surgery. Out of the remaining 14 cases with reduction of the middle ear component, adjuvant irradiation was performed in 11 cases, whereas a wait-and-scan strategy was adopted at the patient's request in three cases. No further growth was detected in our study cases. CONCLUSION: Our protocol seems to be associated with an acceptable quality of life and a satisfactory oncologic outcome.

Leptomeningeal Metastases in Renal Cell Carcinoma at Initial Diagnosis: 2 Case Reports and Literature Review.

Leptomeningeal metastasis (LM) in solid tumors are rare, even more in renal cell carcinoma (RCC). To date there is a lack of consensual treatment modalities of leptomeningeal metastasis. Furthermore, with the improvement of outcomes and more effective systemic targeted therapies, the management of leptomeningeal metastasis becomes a real challenge. We here report two cases of RCC with leptomeningeal metastasis at initial diagnosis. Both patients had concurrent adjacent skull bone metastasis. Therapeutic management of both patients consisted in surgical resection, followed by radiotherapy in one case. Systemic treatment was delayed according to current recommendations for the management of metastatic RCC. The aim of this work is to report the therapeutic approach and related outcomes and also provide a review of the currently available literature on leptomeningeal disease in renal cell carcinoma. Indeed, local treatment with curative outcome of meningeal location in RCC should be performed specially in LM at initial diagnosis.

Cryopreserved amniotic membrane and umbilical cord for a radiation-induced wound with exposed dura: a case report.

An 87-year old male received surgical excision of scalp melanoma and subsequent radiotherapy due to metastasis to the skull. A radiation-induced wound developed with osteoradionecrosis that required necrotic bone excision resulting in a 7.5x8.5cm wound over the exposed dura, which remained non-healing despite many attempts by local wound care management. Due to the refractory nature of the wound, strips of cryopreserved umbilical cord (cUC) allograft were applied over the exposed dura resulting in significant vascular granulation tissue formation in the central wound bed within four weeks. Re-epithelialisation around the wound perimeter was further promoted by injection of particulate amniotic membrane umbilical cord matrix (AMUC) at the 16th week, and completed by another application of cUC strips and injection of AMUC proximal to the necrotic bone at the 21st week. Vascularisation of the necrotic bone was further promoted by application of cUC and AMUC injection directly into the bony margins at 29 weeks and 34 weeks, respectively, followed by application with an AMUC-hydrogel paste, applied four times over an eight week interval. By 96 weeks, healthy re-epithelialised tissue had formed under the necrotic bony margins. This report highlights the unique regenerative capabilities of cUC and AMUC in promoting wound healing over exposed dura in a long-standing full-thickness, radiation-induced scalp and skull wound.

Extra-articular tenosynovial giant cell tumor of diffuse type in the temporal area with brain parenchymal invasion: a case report.

Tenosynovial giant cell tumor of diffuse type is a locally aggressive neoplasm that most commonly arises in the lower extremities. Herein, we report for the first time a case of an extra-articular tenosynovial giant cell tumor of diffuse type in the temporal region with brain parenchymal invasion. Imaging studies revealed an intracranial expansile mass in the temporal bone without involvement of the temporomandibular joint. The unusual location of the tumor without involvement of the joint and the presence of brain parenchymal invasion made this case challenging to diagnose.

Comparison of linear and nonlinear programming approaches for "worst case dose" and "minmax" robust optimization of intensity-modulated proton therapy dose distributions.

Robust optimization of intensity-modulated proton therapy (IMPT) takes uncertainties into account during spot weight optimization and leads to dose distributions that are resilient to uncertainties. Previous studies demonstrated benefits of linear programming (LP) for IMPT in terms of delivery efficiency by considerably reducing the number of spots required for the same quality of plans. However, a reduction in the number of spots may lead to loss of robustness. The purpose of this study was to evaluate and compare the performance in terms of plan quality and robustness of two robust optimization approaches using LP and nonlinear programming (NLP) models. The so-called "worst case dose" and "minmax" robust optimization approaches and conventional planning target volume (PTV)-based optimization approach were applied to designing IMPT plans for five patients: two with prostate cancer, one with skull-based cancer, and two with head and neck cancer. For each approach, both LP and NLP models were used. Thus, for each case, six sets of IMPT plans were generated and assessed: LP-PTV-based, NLP-PTV-based, LP-worst case dose, NLP-worst case dose, LP-minmax, and NLP-minmax. The four robust optimization methods behaved differently from patient to patient, and no method emerged as superior to the others in terms of nominal plan quality and robustness against uncertainties. The plans generated using LP-based robust optimization were more robust regarding patient setup and range uncertainties than were those generated using NLP-based robust optimization for the prostate cancer patients. However, the robustness of plans generated using NLP-based methods was superior for the skull-based and head and neck cancer patients. Overall, LP-based methods were suitable for the less challenging cancer cases in which all uncertainty scenarios were able to satisfy tight dose constraints, while NLP performed better in more difficult cases in which most uncertainty scenarios were hard to meet tight dose limits. For robust optimization, the worst case dose approach was less sensitive to uncertainties than was the minmax approach for the prostate and skull-based cancer patients, whereas the minmax approach was superior for the head and neck cancer patients. The robustness of the IMPT plans was remarkably better after robust optimization than after PTV-based optimization, and the NLP-PTV-based optimization outperformed the LP-PTV-based optimization regarding robustness of clinical target volume coverage. In addition, plans generated using LP-based methods had notably fewer scanning spots than did those generated using NLP-based methods.

Spot scanning proton therapy minimizes neutron dose in the setting of radiation therapy administered during pregnancy.

This is a real case study to minimize the neutron dose equivalent (H) to a fetus using spot scanning proton beams with favorable beam energies and angles. Minimum neutron dose exposure to the fetus was achieved with iterative planning under the guidance of neutron H measurement. Two highly conformal treatment plans, each with three spot scanning beams, were planned to treat a 25-year-old pregnant female with aggressive recurrent chordoma of the base of skull who elected not to proceed with termination. Each plan was scheduled for delivery every other day for robust target coverage. Neutron H to the fetus was measured using a REM500 neutron survey meter placed at the fetus position of a patient simulating phantom. 4.1 and 44.1 µSv/fraction were measured for the two initial plans. A vertex beam with higher energy and the fetal position closer to its central axis was the cause for the plan that produced an order higher neutron H. Replacing the vertex beam with a lateral beam reduced neutron H to be comparable with the other plan. For a prescription of 70 Gy in 35 fractions, the total neutron H to the fetus was estimated to be 0.35 mSv based on final measurement in single fraction. In comparison, the passive scattering proton plan and photon plan had an estimation of 26 and 70 mSv, respectively, for this case. While radiation therapy in pregnant patients should be avoided if at all possible, our work demonstrated spot scanning beam limited the total neutron H to the fetus an order lower than the suggested 5 mSv regulation threshold. It is far superior than passive scattering beam and careful beam selection with lower energy and keeping fetus further away from beam axis are essential in minimizing the fetus neutron exposure.

Radionecrosis of the frontal lobe as a consequence of malignant ethmoid tumor management: incidence, diagnosis, risk factors, prevention and management.

Malignant ethmoid tumors are treated by surgery followed by radiotherapy. This study aimed to evaluate the incidence, risk factors and outcome of radionecrosis of frontal lobe and determine preventive measures. Retrospective study of ethmoid malignancies treated from 2000 to 2011. All patients underwent surgery with/without anterior skull base resection using endoscopic or external approaches followed by irradiation (mean dose 64 Gy). Median follow-up was 50 months. Eight of 50 patients (16 %) presented with fronto-basal radionecrosis, connected to duraplasty, with a latent interval of 18.5 months. Although asymptomatic in six, radionecrosis triggered seizures and required surgery in two cases. Survival was not impacted. Risk factors included dyslipidemia, occurrence of epilepsy and dural resection. Radionecrosis may result from the combination of anterior skull base resection and radiotherapy for the treatment of ethmoid malignancies. Preventive measures rely on improving the duraplasty and optimization of the Gy-dose delivery.

Decellularized porcine derived membrane (Tarsys®) for correction of lower eyelid retraction.

Retraction of the lower eyelid can be consequence of medical and surgical conditions. Various kinds of allotransplants and biomaterial have been used to correct it; we report on the surgical correction of lower lid retraction with a decellularized porcine derived membrane (Tarsys(®)). A 49-year-old patient with a history of adenoid cystic carcinoma in the pterygo-palatine fossa, requiring extensive surgery and repeated radiotherapy, presented with 6 mm lagophthalmus and exposure keratopathy secondary to facial nerve palsy. The lower lid malposition was corrected with a Tarsys(®) implant. Three months after surgery no lagophthalmos was present and substantial relief of signs and symptoms of ocular surface disease and good symmetry between right and left eye was achieved. If general condition or morbidity in potential donor sites hamper harvesting autologous graft material to support the lower lid, bioengineered xenografts can be used successfully to correct eyelid malpositions such as lower lid retraction.

Metastatic adenocarcinomas of the temporal bone: a report of three cases.

We reported three cases with adenocarcinomas of the lung, prostate and stomach, which metastasized to the temporal bone. Two of them had proven adenocarcinoma of the lung and stomach, respectively at the time of the diagnosis of the temporal bone tumor. But the other patient had no known primary malignancy when the tumor in the petrous apex was demonstrated radiologically. First he underwent biopsy of the petrous apex lesion and the pathology was reported as malignant; then a probable distant malignancy spreading to the temporal bone was suspected and searched for. Subsequently, his prostate adenocarcinoma was proved with prostate biopsy.

[Proposal for the delineation of postoperative primary clinical target volumes in ethmoid cancers]. / Proposition de délinéation des volumes cibles anatomocliniques postopératoires de la tumeur primitive des cancers de l'ethmoïde.

It is proposed to delineate the anatomo-clinical target volumes of primary tumor (CTV-P) in ethmoid cancers treated with post-operative radiotherapy. This concept is based on the use of radioanatomy and the natural history of cancer. It is supported by the repositioning of the planning scanner with preoperative imaging for the replacement of the initial GTV and the creation of margins around it extended to the microscopic risk zones according to the anatomical concept. This article does not discuss the indications of external radiotherapy but specifies the volumes to be delineated if radiotherapy is considered.

Cranial nerve deficit caused by skull metastasis of prostate cancer: three Japanese castration-resistant prostate cancer cases.

We report 3 Japanese patients with cranial nerve deficit caused by skull metastasis of prostate cancer (PCa). Case 1 was a 75-year-old patient with a chief complaint of diplopia. The cause of diplopia was right oculomotor nerve palsy from the skull metastasis. External beam radiation therapy (EBRT) to the whole brain, 40 Gy in 20 fractions, was performed and the diplopia improved. Case 2 was a 72-year-old patient with a chief complaint of facioplegia. Bone scintigraphy and computed tomography (CT) of the head revealed right occipital bone metastasis of PCa resulting in right facial nerve palsy. EBRT to the right occipital bone, 50 Gy in 25 fractions, with daily oral dexamethasone (DEX) was performed and facioplegia showed complete recovery. At 12 months after onset, the patient was followed-up with no symptoms. Case 3 was a 74-year-old patient with a chief complaint of diplopia. Diffusion-weighted magnetic resonance imaging (MRI) and positron emission tomography (PET) showed right petrous bone metastasis resulting in right abducent nerve palsy. EBRT to the right petrous bone, 44 Gy in 22 fractions, with oral DEX was performed and diplopia showed complete recovery. At 13 months after onset, the patient was followed-up with no symptoms. MRI and PET may detect PCa metastasis in the skull base more clearly than other imaging modalities. EBRT with 40-50 Gy in 20-25 fractions in association with corticosteroid administration may be reasonable treatment of patients with metastatic PCa who develop cranial nerve dysfunction.

Skull metastasis from carcinoma of the cervix: a rare case and review of the literature.

Skeletal metastasis from carcinoma of the cervix occurs in 0.8-23% of cases. The majority of bone metastases occur either in the long bones or in the vertebrae. Metastasis to distal bones like the skull is rare. Metastasis to bone is commonly associated with advanced stage and poor control of primary disease. We present a rare case of scalp metastasis in a patient with stage IIIB carcinoma of the cervix. The patient had completed radiation therapy treatment resulting in controlled primary disease until she was diagnosed with skull bone metastasis. We present this case because of its rarity and for documentation and discussion.

[7 fractionated cyberknife radiotherapy for giant skull metastasis: a case report].

This is a report on the experience of using stereotactic radiotherapy for a large symptomatic metastatic skull tumor. The stereotactic radiotherapy was delivered in 7 fractions using the Cyberknife and produced excellent therapeutic results. This case concerns a 75-year-old female. Nineteen months after uterine cancer surgery, the patient demonstrated metastasis to the mediastinum lymph node and a tumor at the parietal bone tumor but was still undergoing observation. An increase of the parietal bone tumor became evident and the appearance of right hemiplegia, aphasia, and cognitive dysfunction caused her to consult this hospital. We observed a large 236 cm3 tumor spread over the subcutaneous tissue of the superior sagittal sinus, pressing the brain out of the dura mater and causing bone destruction. As a result of our findings, we began stereotactic Cyberknife radiotherapy delivered in 7 fractions. At the follow up visit one month after the treatment, the image of the tumor had already decreased, and after three months it was confirmed that the image of the tumor had disappeared. The patient's symptoms ameliorated rapidly. As a result, the patient has returned to an independent home-lifestyle, with amelioration of her quality-of-life defects. Six months after irradiation, there is no evidence of tumor regrowth or complications such as dermatopathy, cerebral edema, or necrosis. Cyberknife radiotherapy could shorten the treatment period and result in a reduction of the amount of irradiation to unaffected parts of the brain. In this case, though the tumor had spread widely in the subcutaneous tissue, the exposure doses were delivered at 2Gy/time and could be limited to under 70Gy. It is thought that Cyberknife radiotherapy will become one of the key treatments to help improve quality of life when treating symptomatic metastatic tumors.

Algorithm for correcting optimization convergence errors in Eclipse.

IMRT plans generated in Eclipse use a fast algorithm to evaluate dose for optimization and a more accurate algorithm for a final dose calculation, the Analytical Anisotropic Algorithm. The use of a fast optimization algorithm introduces optimization convergence errors into an IMRT plan. Eclipse has a feature where optimization may be performed on top of an existing base plan. This feature allows for the possibility of arriving at a recursive solution to optimization that relies on the accuracy of the final dose calculation algorithm and not the optimizer algorithm. When an IMRT plan is used as a base plan for a second optimization, the second optimization can compensate for heterogeneity and modulator errors in the original base plan. Plans with the same field arrangement as the initial base plan may be added together by adding the initial plan optimal fluence to the dose correcting plan optimal fluence.A simple procedure to correct for optimization errors is presented that may be implemented in the Eclipse treatment planning system, along with an Excel spreadsheet to add optimized fluence maps together.

Treatment and outcome of advanced external auditory canal and middle ear squamous cell carcinoma.

This is a retrospective study to evaluate the outcomes and complications of combined treatment, surgery with or without adjunctive intraoperative radiotherapy, of locally advanced temporal bone squamous cell carcinoma. A series of 17 patients with locally advanced squamous cell carcinoma of the temporal bone were treated between September 2002 and February 2007. Eleven patients had primary tumors, and 6 patients had recurrences. According to the University of Pittsburgh staging system, 5 patients were stage II (T2 N0), 6 patients were stage III (5, T3 N0 and 1, T1 N1), and 6 patients were stage IV (5, T3 N2b and 1, T4 N0). All patients underwent lateral temporal bone resection and pedicle flap reconstruction. Eight patients received intraoperative and postoperative radiotherapies, 4 patients underwent postoperative radiation alone, whereas 5 patients did not receive any adjunctive treatment. Median follow-up was 29.5 months. No major complications were observed. No patients were found to have residual gross tumor. Disease-free survival was 73.3%, and overall survival was 75.6%. Radical external auditory canal and/or middle ear canal resection is of utmost importance to obtain a good surgical outcome. Postoperative radiotherapy is necessary to obtain good local control; no major adverse effects were observed in the intraoperative radiotherapy patients. The incidence of major complication is minimal after pedicle flap reconstruction.

[Therapeutic options in sinunasal adenoid cystic carcinomas--a case report and review]. / Behandlungsstrategie bei sinunasalen adenoidzystischen Karzinomen--Ein Fall mit Literaturübersicht.

BACKGROUND: Adenoid cystic carcinomas (ACC) in sinunasal compartments are often not completely resectable. We discuss both, surgical margins and functional results preoperatively and postoperative options for adjuvant therapy. The former opinion of a resistance of ACC towards chemotherapy or irradiation seems to be outdated, even though consensus about therapeutic strategies is still missing. MATERIAL AND METHODS: We discuss therapeutic options and compare data from literature regarding the best adjuvant therapy with the case of a 25-year-old patient with an advanced ACC of the left fossa pterygopalatina. Further we discuss alternative therapeutic options like neutron irradiation, chemotherapy or targeted therapy. Following the advice from literature, we performed an eye saving tumor resection by a left transmaxilloethmoidale sphenoidectomy via combined trans- und extranasal approach. We accepted close surgical margins for the benefit of the abandonment of dismembering measures and performed an adjuvant radiochemotherapy with taxol and carboplatin. RESULTS: With the described therapeutic strategy we reached an optimal local tumor control with unlimited visus and without functional and cosmetic restrictions up to now. Periodic staging did not show any local tumor progress or metastatic spread hitherto. CONCLUSION: Organ preserving surgery and adjuvant radiochemotherapy even in combination with taxol and carboplatin seems to be a sufficient therapeutic option in treating advanced sinunasal ACC, and might not have any prognostic disadvantages to radical surgery.

The Role of Radiotherapy in Skull Metastasis of Thyroid Follicular Carcinoma.

INTRODUCTION: Bone metastasis is seen in 2.3-12.7% of thyroid follicular carcinomas. Bone metastasis most commonly occurs in the vertebrae, costas and hip bones. In this report we discuss the diagnosis and treatment of a patient followed up due to skull metastasis of thyroid follicular carcinoma in light of literature. CASE REPORT: A 51-year-old female patient underwent surgery due a mass in the scalp. The histopathological examination was reported as metastasis of follicular thyroid carcinoma. No radiotherapy was indicated because of the total excision of the mass and the benign surgical margins. The patient, in whom fine needle aspiration biopsy showed the result of follicular carcinoma underwent a total bilateral thyroidectomy. Whole-body I-131 scintigraphy revealed diffuse activity involvement in the thyroid gland, and lung and bone (skull, sacrum, right acetabulum) metastasis. The patient was scheduled for radioactive iodine therapy. CONCLUSION: Total/near total thyroidectomy and metastasectomy should be the treatment of choice in skull metastasis. Postoperative radioactive iodine and radiotherapy should be offered. Radiotherapy should be reserved for inoperable and residual tumour cases.