POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Plasma Cell Disorder, and Skin Changes) Syndrome as a Sequela of Castleman Disease: A Case Report.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is a rare multisystemic paraneoplastic disorder caused by an underlying plasma cell dyscrasia. Its diagnosis is based on the presence of two mandatory criteria and at least one major and one minor criterion. We report a case of a 52-year-old female patient who presented with complaints of acrocyanosis, night sweats, scaly skin, and swelling on the left side of the neck. She was a known case of hypothyroidism, antiphospholipid syndrome, and cerebral venous thrombosis, and had other comorbidities as well. She also exhibited weakness and paresthesia of the limbs and muscle wasting in the hands. All necessary examinations and investigations were performed and the patient was eventually diagnosed with POEMS syndrome. She underwent chemotherapy along with immunotherapy initially, but as the disease relapsed, she was referred for high-dose therapy (HDT) and autologous stem cell transplantation.

Survival Outcomes and Patterns of Failure in Maxillary Alveolus Squamous Cell Carcinoma.

Introduction Squamous cell carcinoma (SCC) of the maxillary alveolus is a relatively rare disease. There is lack of data on this subsite as compared with other sites. The factors that affect survival in cases of maxillary alveolar SCC are tumor stage, local and cervical metastases, histological grading, and the margin status. Objectives To evaluate the overall survival (OS), the disease free survival (DFS), and the complex interaction and effects of margin status, histological differentiation, habits (such as smoking and the use of smokeless tobacco products), and cervical and distant metastases based on clinicopathological data. Methods We examined the electronic database at our hospital from 2003 to 2017. We included all cases with a histopathological diagnosis of SCC of the maxillary alveolus. Tumors originating primarily from the maxillary alveolus were included, while those originating from adjacent subsites, like the hard palate, the buccal mucosa or the maxillary sinus were excluded. We also excluded all the patients who were not operated on with a curative intent. Results More than half of the patients had stage-IV tumors at the time of presentation, while only one fourth of them had nodal metastasis. The rate of recurrence increased in cases of primary tumors in advanced stages and the degree of histological differentiation. The 2-year and 5-year OS rates were of 54.5% (18 patients) and 30.3% (10 patients) respectively. Conclusion Primary tumors in advanced stages, histological grade, and presence of nodal metastasis are poor prognostic markers in terms of long-term survival.

Evaluation of the herbicide glyphosate, (aminomethyl)phosphonic acid, and glyphosate-based formulations for genotoxic activity using in vitro assays.

Glyphosate, the most heavily used herbicide world-wide, is applied to plants in complex formulations that promote absorption. The National Toxicology Program reported in 1992 that glyphosate, administered to rats and mice at doses up to 50,000 ppm in feed for 13 weeks, showed little evidence of toxicity, and no induction of micronuclei was observed in the mice in this study. Subsequently, mechanistic studies of glyphosate and glyphosate-based formulations (GBFs) that have focused on DNA damage and oxidative stress suggest that glyphosate may have genotoxic potential. However, few of these studies directly compared glyphosate to GBFs, or effects among GBFs. To address these data gaps, we tested glyphosate, glyphosate isopropylamine (IPA), and (aminomethyl)phosphonic acid (AMPA, a microbial metabolite of glyphosate), 9 high-use agricultural GBFs, 4 residential-use GBFs, and additional herbicides (metolachlor, mesotrione, and diquat dibromide) present in some of the GBFs in bacterial mutagenicity tests, and in human TK6 cells using a micronucleus assay and a multiplexed DNA damage assay. Our results showed no genotoxicity or notable cytotoxicity for glyphosate or AMPA at concentrations up to 10 mM, while all GBFs and herbicides other than glyphosate were cytotoxic, and some showed genotoxic activity. An in vitro to in vivo extrapolation of results for glyphosate suggests that it is of low toxicological concern for humans. In conclusion, these results demonstrate a lack of genotoxicity for glyphosate, consistent with observations in the NTP in vivo study, and suggest that toxicity associated with GBFs may be related to other components of these formulations.

Survival Outcomes and Patterns of Failure in Maxillary Alveolus Squamous Cell Carcinoma

Abstract Introduction Squamous cell carcinoma (SCC) of the maxillary alveolus is a relatively rare disease. There is lack of data on this subsite as compared with other sites. The factors that affect survival in cases of maxillary alveolar SCC are tumor stage, local and cervical metastases, histological grading, and the margin status. Objectives To evaluate the overall survival (OS), the disease free survival (DFS), and the complex interaction and effects of margin status, histological differentiation, habits (such as smoking and the use of smokeless tobacco products), and cervical and distant metastases based on clinicopathological data. Methods We examined the electronic database at our hospital from 2003 to 2017. We included all cases with a histopathological diagnosis of SCC of the maxillary alveolus. Tumors originating primarily from the maxillary alveolus were included, while those originating from adjacent subsites, like the hard palate, the buccal mucosa or the maxillary sinus were excluded. We also excluded all the patients who were not operated on with a curative intent. Results More than half of the patients had stage-IV tumors at the time of presentation, while only one fourth of them had nodal metastasis. The rate of recurrence increased in cases of primary tumors in advanced stages and the degree of histological differentiation. The 2-year and 5-year OS rates were of 54.5% (18 patients) and 30.3% (10 patients) respectively. Conclusion Primary tumors in advanced stages, histological grade, and presence of nodal metastasis are poor prognostic markers in terms of long-term survival.

Treatment Outcomes of Maxillary Sinus Squamous Cell Carcinoma at a Dedicated Cancer Institute: A Retrospective Study.

Introduction Squamous cell carcinoma arising at the maxillary sinus is a rare neoplasm, characterized by an aggressive growth pattern and glooming prognosis. The proximity of the maxillary sinus with complex anatomical structures such as the eye, skull base, infratemporal fossa, pterygomaxillary fossa, nasal cavities, and ethmoid sinuses makes the surgical treatment of tumors infiltrating into these structures very challenging. The study's objective was to investigate the prognostic factors of survival and maxillary sinus SCC treatment outcomes. Methods We did a retrospective analysis of patients treated for maxillary sinus SCC at our institution between 2004 -2018. The study included all the patients with histologically proven maxillary sinus SCC treated with curative intent. The medical record of 43 patients was reviewed and utilized for the analysis. The Kaplan-Meier curve calculated five-year overall survival. Results A total of 43 patients were analyzed. At the presentation time, the mean age was 54.56 years (SD ± 11.65). Smoking (n=13, 30.2%) was the common risk factor. 36 (83.7%) patients presented with stage IV disease. Surgery was performed in 16 (37.2%) patients, whereas 27 (62.8%) patients received radiation and chemotherapy. Treatment failure was seen in 35 (81.4%) patients with locoregional recurrence in 30 (85.7%) patients and distant metastases in 5 (14.3%) patients. The five years overall survival in our study was 22%. Loco-regional recurrence and distant metastasis were the significant factors impacting survival (p=0.01). Conclusion Maxillary sinus SCC is rare cancer that is more common in males and usually presents at an advanced stage with a poor outcome. These tumors have a higher rate of treatment failure with a poor prognosis. Locoregional recurrence and distant metastasis adversely impact the overall survival.

Phenytoin prophylaxis and functional outcomes following spontaneous intracerebral hemorrhage: A systematic review and meta-analysis.

INTRODUCTION: Seizure activity following spontaneous intracerebral hemorrhage (sICH) can worsen patients' comorbidity. However, data regarding whether seizure prophylaxis for sICH is associated with patients' poor functional outcome is inconclusive. We performed a systematic review and meta-analysis to assess the relationship between phenytoin prophylaxis and poor functional outcome after sICH. METHODS: We conducted our search on PubMed, Scopus, and EMBASE databases as of October 30, 2020 for studies that included information on seizure prophylaxis and functional outcome in patients with sICH. Primary outcome was poor functional outcome at the longest follow-up in patients receiving seizure prophylaxis. The secondary outcome was poor functional outcome at 90 days follow-up. We conducted random effects meta-analysis and moderator analyses to detect sources of heterogeneity for our outcomes. RESULTS: We included eleven studies in the final analysis with a total of 4268 patients. A moderator analysis further showed prospective studies had lower heterogeneity. We did not find an association between seizure prophylaxis and poor functional outcome at time of longest follow-up (OR 1.2, 95%CI 0.9-1.6, p-value = 0.22, I2 = 61%), nor at 90-day follow-up (OR 1.4, 95%CI 0.8-2.4, p-value = 0.24, I2 = 78%). CONCLUSION: Seizure prophylaxis following sICH was not associated with worse functional outcomes at longest follow-up or at 90 days. Neither levetiracetam nor phenytoin was associated with outcome in our exploratory meta-regression, though there is a trend towards better outcomes in populations where there was a higher percentage of patients who received levetiracetam. More randomized trials are needed to confirm this observation.

Neoadjuvant Capecitabine and Oxaliplatin Before Concurrent Capecitabine and Radiation in Locally Advanced Rectal Cancers: Experience of a Cancer Hospital in Pakistan.

PURPOSE: To report the toxicity and pathologic response rates after adding neoadjuvant capecitabine and oxaliplatin (CAPOX) followed by concurrent radiation and capecitabine (CAPRT) and surgery in patients with locally advanced rectal cancer. MATERIALS AND METHODS: We retrospectively analyzed medical records of 301 patients between January 2007 and December 2014. Patients were treated with four cycles of neoadjuvant chemotherapy comprising CAPOX, followed by radiotherapy at doses of 45-54 Gy in 25-30 fractions with concurrent capecitabine. A response assessment scan was performed at 4-6 weeks postradiation followed by surgical evaluation at 6-8 weeks. Pathologic tumor and nodal response rates as well as circumferential resection margin were assessed on surgical specimens. RESULTS: The median age of the patients was 43 years (range, 16-78). Overall, 227 (75.4%) patients were able to complete four cycles of CAPOX. Neoadjuvant chemotherapy was well-tolerated with no serious adverse effects. The most common toxicity was diarrhea (grade 2, n = 108; 35.8%; grade 3, n = 57; 18.9%; grade 4, n = 25; 8.3%) followed by neuropathy (grade 2, n = 132; 43.8%; grade 3, n = 54; 17.9%) and oral mucositis (grade 2, n = 108; 35.8%; grade 3, n = 47; 15.6%; grade 4, n = 9; 2.99%). A total of 229 (76.1%) patients underwent surgery. Pathologic complete response was seen in 52 (22.7%; 95% CI, 13 to 28), whereas 200 (87.3%; 95% CI, 82 to 99) patients had a negative circumferential resection margin on pathology. CONCLUSION: Neoadjuvant chemotherapy with CAPOX before CAPRT and planned total mesorectal excision surgery result in good tumor regression and substantial pathologic complete response rates with acceptable toxicity. With growing interest in organ preservation in rectal cancer, the strategy of completing all chemotherapy and chemoradiotherapy before planned surgery offers a favorable paradigm. However, further randomized clinical trials are needed to support this evidence.

Preventing seizure occurrence following spontaneous intracerebral haemorrhage: A systematic review and meta-analysis of seizure prophylaxis.

INTRODUCTION: Spontaneous intracerebral haemorrhage (ICH) is associated with high mortality and high morbidity, including seizures. Seizure prophylaxis is "not recommended" by the American Stroke Association, but practice variation still exists due to inconclusive data. We performed a meta-analysis to assess the current relevant literature to determine the efficacy of seizure prophylaxis following ICH. METHODS: We performed searches of PubMed, Scopus, and Embase up to September 15, 2020. We included observational and randomized controlled studies reporting seizure prophylaxis and occurrence in adults with ICH. Outcomes were seizures, as defined by the authors, within 14 days of ICH and at the longest point of follow-up. We used random-effects models to estimate the odds ratios (ORs) for seizure prophylaxis and outcomes. The PROSPERO registration was CRD42019140493. RESULTS: We included 8 studies (2852 patients) in our analysis. The mean (± standard deviation) age of the pooled patients was 65 (±4) years; 39 % (± 5%) were female. Seizure prophylaxis did not prevent seizures at the longest follow-up time (OR 0.708, 95 % CI 0.438-1.143, p = 0.158, I2 = 34 %). This result was confirmed in subgroup analyses using categorical variables and in meta-regressions using continuous variables. Additionally, seizure prophylaxis was not associated with preventing early seizures, defined as < 14 days of ICH (OR 0.66, 95 % CI 0.21-2.08, p = 0.48, I2 = 35 %). CONCLUSION: Seizure prophylaxis following ICH was not associated with seizure prevention in adults. Most included studies were observational. Further randomized controlled trials examining the efficacy of seizure prophylaxis in high-risk patients and different types of antiepileptic drugs are needed.

Impact of preoperative surgical anxiety on postoperative surgical recovery among surgical patients: Role of surgical coping.

OBJECTIVE: To examine the moderating impact of surgical coping in the relationship between pre-operative surgical anxiety and post-operative surgical recovery. METHODS: The descriptive cross-sectional study was conducted at the surgical department of various hospitals across Punjab, including the Allied Hospital, Faisalabad, District Headquarters Teaching Hospital, Sargodha, Jinnah Hospital, Lahore, and Margalla Institute of Health Sciences, Rawalpindi, Pakistan, from May 1, 2018, to May 1, 2019. It comprised surgical patients of either gender aged 18-60 years. Data was collected using the Amsterdam Pre-operative Anxiety and Information Scale, the Surgical Recovery Scale, and the Coping with Surgical Stress Scale. Moderation analysis was applied using PROCESS Macro 3.2. RESULTS: Of the 200 patients, 85(42.5%) were males and 115(57.5%) were females. The overall mean age was 36.34±12.64 years. Threat avoidance (p<0.001) and information-seeking (p<0.001) coping strategies moderated the relationship between surgical anxiety and surgical recovery of the patients. CONCLUSIONS: The use of appropriate coping strategy for prompt recovery post-surgery is critical.

Calcium Alkali Thiazide Syndrome: What We Need to Know.

Depending on each institution's laboratory test, mean serum calcium levels range between 8.8 and 10.8 mg/dL and hypercalcemia is defined as two standard deviations above the mean. According to recent epidemiological studies, 90% of cases of hypercalcemia are due to hyperparathyroidism or malignancy. Milk Alkali syndrome (MAS) also known as Calcium Alkali syndrome (CAS) is the third biggest cause of hypercalcemia, but its incidence seems to be higher than previously thought. Here we present a case of Calcium Alkali Thiazide syndrome (CATS) in a 57-year-old female who was on calcium and vitamin D supplements (after parathyroidectomy) while also taking thiazide diuretic for hypertension. She was brought to the ED with nausea, vomiting, confusion, difficulty walking along with numbness in extremities. She had parathyroidectomy three weeks ago. During history taking, patient reported intake of calcium carbonate 1 g three times daily, calcitriol 0.5 mcg twice daily, cholecalciferol (vitamin D3) 10,000 units once daily, chlorthalidone 25 mg once daily and irbesartan 300 mg once daily. At admission, her calcium level was 23 mg/dL, ionized calcium 12.03 mg/dL, pH was 7.59 and HCO3 was 33. She was in renal failure with creatinine of 1.9 mg/dL (baseline 0.8 mg/dL). Her parathyroid hormone (PTH) level was 0. A diagnosis of CATS was made. She was treated with intravenous fluids and furosemide and discharged home on hospital day 5 after her calcium and creatinine levels normalized. A triad of hypercalcemia, acute kidney injury and metabolic alkalosis comprises MAS. Traditional MAS was caused by "Sippy diet" (containing milk and alkali) used for the treatment of peptic ulcer disease. Over the decades, the same triad of symptoms occurred in patients using excess calcium and vitamin D, hence changing the name to CAS. A subset of patients at risk for CAS also use thiazide diuretics for hypertension, making them more vulnerable to hypercalcemia and acute kidney injury. In such subset of patients, it is preferable to use the term CATS rather than MAS or CAS.

Toxicity Profile of Procarbazine Lomustine and Vincristine Chemotherapy in Low-Grade Glioma - Retrospective Review.

Background The role of Procarbazine Lomustine and Vincristine (PCV) chemotherapy is already established in terms of improving survival in low-grade glioma (LGG). This improved survival has led to the increasing administration of PCV to LGG patients over the past years. However, like other chemotherapies, serious hematological and non-hematological toxicities may occur. The purpose of this study was to evaluate the toxicity profile of PCV and its clinical relevance in our practice.  Materials and Methods We reviewed 63 patients of LGG retrospectively who received chemotherapy PCV between January 2015 and January 2018 at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore. Results Significant hematological toxicity as grade 3 anemia, thrombocytopenia, and neutropenia occurred in 19%, 27%, and 46% respectively with PCV. Other toxicities such as neurotoxicity, vomiting and derangement of liver enzymes occurred in 3.2%, 19%, and 19% respectively. Patients who were on concurrent anticonvulsants had no increase in PCV toxicity. Survival was not impacted by hematological toxicities up to grade 3. Conclusion PCV chemotherapy is associated with major hematological, hepatic, and clinical toxicities (vomiting, constipation, and neuropathy). Hematological toxicities influenced the course of treatment in terms of delays and interruptions.

Long-Term Toxicity and Efficacy of Intensity-Modulated Radiation Therapy in Cervical Cancers: Experience of a Cancer Hospital in Pakistan.

PURPOSE: To report the chronic toxicity and disease outcomes attributable to intensity-modulated radiation therapy (IMRT) in patients with cervical cancer. METHODS AND MATERIALS: Between January 2014 and December 2018, a retrospective review of medical records of patients with cervical cancer who received radiation therapy with IMRT was performed. Disease and treatment-related details were documented. Follow-up notes were reviewed, and severity of late toxicities was recorded. Overall survival (OS) and disease-free survival (DFS) at 3 years were estimated. RESULTS: A total of 222 patients' records were reviewed. Mean age was 50.7 years. Median follow-up duration was 33 months (range, 2-70 months). The most common toxicity was vaginal stricture (grade 2, n = 59, 26.6%; grade 3, n = 4, 1.80%), followed by proctitis (grade 2, n = 24; 10.8%; grade 3, n = 7; 3.20%). Seven patients (grade 2, n = 5, 2.3%; grade 3, n = 2; 0.90%) developed cystitis, and only 5 (grade 2; 2.3%) were found to have colitis. None of the patients had grade 4 or grade 5 toxicities. There was a significant difference in late complications in patients with nodal disease or those who underwent prior surgery (P < .05). Three-year OS and DFS rates were 79.7% and 81.9%, respectively. Patients with tumor size > 5 cm and those with pelvic lymph node metastasis had poor survival rates (P < .05). CONCLUSION: IMRT is an effective and well-tolerated technique that should be considered in patients with lymph node disease and in postoperative patients. There is an inverse relationship between tumor size and nodal involvement with respect to OS and DFS.

Congenital microgastria-limb reduction association: A case report and review of the literature.

We report a patient with phenotypic semblance to the congenital microgastria-limb reduction association (MLRD). Our patient presented with microgastria, bilateral upper limb anomalies, asplenia, solitary kidney, and mild micrognathia. In addition to the anomalies seen in our patient, MLRD has been associated with respiratory, cardiovascular, and central nervous system anomalies. MLRD is thought to arise from a developmental field defect during embryonic weeks five and six; however, no genetic cause has been elucidated. Along with our patient presentation, we review the literature to further our understanding of the MLRD phenotype spectrum.

An Overview of Laryngeal Cancer Treatment at a Tertiary Care Oncological Center in a Developing Country.

Introduction Development of laryngeal cancer is multifactorial, and management is surrounded with controversies. Recent reports suggest a decline in the survival of these patients. We conducted a study to analyze the clinicopathological parameters and compute the outcomes in terms of survival in patients with laryngeal cancer treated at our institution. Methods Electronic charts of 515 patients with Laryngeal cancer treated at our Hospital and Research Center from 2004 to 2014 were retrospectively reviewed. Results Median age was 62 years. Male: female ratio 91%: 9%. Sixty-two percent were smokers. Histologically, all were squamous cell carcinoma. Most common subsite was glottis (88%). Treatment was non-surgical in 92% and surgical in 8%. The five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional control (LRC) were 67%, 74%, 59% and 70%, respectively. OS, DSS, DFS and LRC for early stage (I-II) and advance stage (III-IV) were 81 and 54%, 86 and 63%, 75 and 45%, and 83 and 57%, respectively. Twenty-two percent recurred locally. Of these failures, 19% were inoperable, 36% were surgically salvaged and 34% refused laryngectomy. Conclusions Our survival rates are comparable with published data. The high refusal rate for salvage total laryngectomy is concerning and needs further study to evaluate the reasons.

The Submental Island Flap in Head and Neck Cancer.

OBJECTIVES: The submental flap provides an alternative technique in orofacial reconstruction, especially in situations where free flap services are not available. The objective of this study is to demonstrate the oncological safety and benefits of this flap in oral cavity reconstruction in a tertiary care cancer hospital. MATERIALS AND METHODS: A total of 27 patients with oral cavity cancers, which underwent submental flap reconstruction from 2015 to 2017 at Shaukat Khanum Cancer Memorial Hospital, were included in the study. We have retrospectively reviewed records of these patients. RESULTS: There were 25 male and 2 female patients with age ranging from 21 to 73 years. Most common primary tumor sites were buccal mucosa (13), tongue (7), and lower alveolus (7). All patients underwent ipsilateral selective neck dissection after flap was harvested. Complete flap loss was observed in three, whereas one patient had flap dehiscence that subsequently healed. Mean follow-up was 11 months. There were four regional recurrences but no local recurrence. On the last follow-up (minimum 6 months), 15 patients were alive without any disease, 4 were alive with disease, and 3 had died. CONCLUSION: Submental flap is a satisfactory option for oral cavity reconstruction. However, preoperative selection of clinically neck node-negative patient is extremely important as it has potential risk of occult metastasis.

Role of phytoestrogen in suppressing bone turnover in a group of postmenopausal women.

BACKGROUND: Osteoporosis has emerged a major health hazard in postmenopausal women. The process of osteoporosis accelerates two year prior to menopause, reaching the peak level during first 3 years of menopause when women loss 3 (see symbol) 5% of their bone mass per year. This study tried to find out the role of phytoestrogne in improving the bone mineral density and bone related biochemical parameters in group of postmenopausal women. METHODS: Fifty postmenopausal women with age range 50 (see symbol) 60 years were included in the study. Phytoestrogen with mineral supplement were given twice daily for 3 months. Biochemical parameters like serum calcium, magnesium, alkaline phosphatase, uric acid, total protein and oestrogen were determined before and after phytoestrogen therapy by autoanalyser and ELIZA (oestrogen assay). T-score before and after phytoestrogen were find out by densitometer DEXA. RESULTS: The level of serum calcium, magnesium, uric acid and oestrogen was increased in women after taking phytoestrogen but significant difference (p < 0.01) was only observed in case of serum calcium. Level of serum alkaline phosphatase and total serum protein were slightly increased with no significant different before and after phytoestrogen therapy. Value of T-score was although markedly decreased after phytoestrogen therapy but it showed no significant difference. CONCLUSION: It is concluded that as the early years of menopause are a period of rapid bone loss, and the risk for osteoporosis increases substantially, the habitual intake of soy protein and isoflavones may play a role in the retardation of bone loss.

Modeling the mutational effects on calmodulin structure: prediction of alteration in the amino acid interactions.

Calmodulin (CaM) is a highly conserved 17kDa eukaryotic protein that can bind specifically to over 100 protein targets in response to a Ca2+ signal. Present study was planned to mutate the crucial residues of N-terminal lobe, central helix, and C-terminal lobe that play important roles in activating and binding of enzymes. In all, 10 mutations were carried out in the predicted 3D structure of calmodulin using the computer program MODELLER 6v2. Mutations at specific residues in both the N-terminal and C-terminal regions resulted in the change in the interaction pattern of these amino acids. No significant change was however predicted by mutating amino acid residues in the central helix. The predicted alteration in the interaction of specific amino acids may either alter the binding affinity with calcium ions or decrease the ability of calmodulin to activate the specific enzymes.

Nasopharynx: clinical, pathologic, and radiologic assessment.

NPC represents 0.2% of malignant disease in the white population but is more common in southern China, among Chinese in East Asia and the United [figure: see text] States, and in North Africa, including Saudi Arabia. NPC in these ethnic groups tends to manifest at a younger age. Undifferentiated carcinoma is the most common histopathologic type and is associated with EBV. The tumor is optimally assessed with CT and MR imaging for staging; PET scanning provides optimal assessment of recurrent tumor or small lymph node metastases. The primary tumor in the nasopharynx may be small and infiltrating, causing no or only a small mass effect in the nasopharynx. In these cases, obliteration of fat planes and loss of muscle boundaries are important diagnostic findings, which are best evaluated with MR imaging including, Gd-DTPA with fat suppression. The size of the NPC varies from 1 to 2 cm to large tumors that extend to the oropharynx, PPS, nasal cavities, paranasal sinuses, and orbits. Skull base erosion is independent of the size of the nasopharyngeal tumor and ranges from slight erosion to extensive destruction. A concomitant finding is intracranial invasion, predominantly to the basal cisterns and cavernous sinuses associated with cranial nerve palsies. Intracranial invasion should be assessed with contrast MR imaging. Lymph node metastases in the neck are present in 90% of cases and are bilateral in 50% of cases. In a small percentage of cases, extension of lymph node metastases to the mediastinum and hilar areas are encountered. Distant metastases involve the lungs, skeleton, and liver, and occasionally the choroid. They are usually present at the initial presentation [figure: see text] and increase in frequency in advanced disease and in recurrent tumors. In addition, the metastatic lymph nodes in the neck reveal no specific imaging features that would allow differentiation from other lymph node metastases. They may be discrete, often multiple, and large and bulky displaying a variable degree of necrosis and enhancement following introduction of contrast material. Local recurrence manifests commonly within the first 2 to 3 years posttherapy and is optimally evaluated by MR imaging and PET scanning.