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.

Otosclerosis: comparison of complex-motion tomography and computed tomography.

A prospective computed tomographic and complex-motion tomographic evaluation was performed in 18 suspected or proven cases of otosclerosis. Although there was good agreement between both methods, there was no greater diagnostic accuracy with computed tomography. However, computed tomography demonstrated the changes better than complex-motion tomography.

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.

Functional MR of the primary auditory cortex: an analysis of pure tone activation and tone discrimination.

PURPOSE: To use functional MR imaging to measure the effect of frequency (pitch), intensity (loudness), and complexity of auditory stimuli on activation in the primary and secondary auditory cortexes. METHODS: Multiplanar echo-planar images were acquired in healthy subjects with normal hearing to whom auditory stimuli were presented intermittently. Functional images were processed from the echo-planar images with conventional postprocessing methods. The stimuli included pure tones with a single frequency and intensity, pure tones with the frequency stepped between 1,000, 2,000, 3,000, or 4,000 Hz, and spoken text. The pixels activated by each task in the transverse temporal gyrus (TTG) and the auditory association areas were tabulated. RESULTS: The pure tone task activated the TTG. The 1,000-Hz tone activated significantly more pixels in the TTG than did the 4,000-Hz tone. The 4,000-Hz tone activated pixels primarily in the medial TTG, whereas the 1,000-Hz tone activated more pixels in the lateral TTG. Higher intensity tones activated significantly more pixels than did lower intensity tones at the same frequency. The stepped tones activated more pixels than the pure tones, but the difference was not significant. The text task produced significantly more activation than did the pure tones in the TTG and in the auditory association areas. The more complex tasks (stepped tones and listening to text) tended to activate more pixels in the left hemisphere than in the right, whereas the simpler tasks activated similar numbers of pixels in each hemisphere. CONCLUSION: Auditory stimuli activate the TTG and the association areas. Activation in the primary auditory cortex depends on frequency, intensity, and complexity of the auditory stimulus. Activation of the auditory association areas requires more complex auditory stimuli, such as the stepped tone task or text reading.

Magnetic resonance imaging of the jugular foramen.

The jugular foramen in normal volunteers was studied with 1.5 T magnetic resonance (MR) systems in 3-mm-thick head- and surface-coil images. Anatomic sections through cadaver heads were correlated with the MR images to identify the jugular bulb and the course of cranial nerves IX-XI. Sagittal images were more useful than coronal or axial to show the course of these nerves through the skull base. MR demonstrates the anatomic relations of the jugular foramen (except its osseous margins) such that its primary use in evaluating this region can be anticipated.

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.

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.

Functional magnetic resonance imaging of the central auditory pathway following speech and pure-tone stimuli.

Functional magnetic resonance imaging (FMRI) is a new noninvasive technique for imaging cerebral function. Studies of the human central auditory pathway examined responses in eight normal hearing volunteers following auditory stimuli, including narrative speech and pure-tone audiometry. The activation demonstrated by FMRI is modeled on an increase in regional blood flow with increased neuronal activity. The FMRI signals represent deoxyhemoglobin concentration changes in capillaries within the region of the brain that is activated. Brain activation was imaged in the superior temporal gyrus during text reading and pure tones. Activation in both text and pure-tone presentation did not vary with the intensity of the auditory stimulus and elicited a dominant response in the left temporal lobe. These observations demonstrate the capability of FMRI to correlate anatomic and functional relationships in the human central auditory pathway.

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.

Ventilating tubes in tympanoplasty.

The successful surgical treatment of chronic otitis media or its sequela is frequently related to a ventilated tympanic cavity. Tubes at tympanoplasty have been recommended to assure ventilation until eustachian tube and middle ear mucosal functions have been restored and to prevent the complications of graft loss, atelectasis, cholesteatoma and ossicular destruction. This presentation reviews the literature on the subject and documents our results in 40 patients treated by tympanomastoid surgery with ventilating tubes. The types of tubes used, the surgical technique involved, and the selection of cases suitable for this method are described. Cholesteatoma was the primary disease in 32 patients, 6 had chronic otitis media, 1 cholesterol granuloma, and 1 eosinophilic granuloma. Complete healing of grafts following extrusion or removal of the tubes occurred in 34 patients, 2 tubes remain in place, 3 patients had persistent tube site perforations, and 1 was lost to follow-up. None of the patients had graft breakdown as a result of tube placement, and there has been no recurrence of cholesteatoma. In all cases, the follow-up period is a minimum of 18 months and extends to 92 months.

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.

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.

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.

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.

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.

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.

Absent round window reflex: possible relation to step-wise hearing loss.

The diagnosis of perilymphatic fistula can be confusing and prone to error. The signs and symptoms can be extremely varied, and currently there is no clinical or laboratory test that accurately predicts the presence of this entity. The only reliable method of diagnosis, namely surgical exploration, is often frustrating as, commonly, no evidence of an active fistula is found. Four children initially believed to have a perilymphatic fistula were found on exploration instead to have an absent round window reflex with normal mobility of the ossicular chain. These children presented with a history of abrupt, step-wise decreases in their hearing thresholds that frequently progressed from a mixed to a purely sensorineural loss. No anatomic abnormalities were found on high-resolution computed tomography. The authors theorize that this finding may represent altered fluid dynamics within the inner ear. Whether it signifies a prior fistula that has spontaneously healed remains to be confirmed. A review of the literature along with possible pathophysiologic mechanisms is presented.