Utility of susceptibility weighted imaging (SWI) and pseudo-continuous arterial spin labeling (pCASL) in diagnosis of falcine venous thrombosis in a child with transient ischemic attack.

Pediatric stroke and transient ischemic attack (TIA) are uncommon but true emergencies with a wide differential diagnosis. Diagnostic imaging plays a critical role in differentiating the diverse range of etiologies. In this case, we report a 3-year-old female with no medical history who developed acute neurological deficits and demonstrate how adjunct advanced imaging including susceptibility weighted imaging (SWI) and pseudo-continuous arterial spin labeling (pCASL) can play a significant diagnostic role in the emergent setting. Imaging was performed with a Philips Ingenia 3.0T MRI. MRI brain, MR angiography (MRA), and phase contrast angiography MR Venography (PCA-MRV) were obtained. pCASL and SWI sequences were performed using SENSE (sensitivity encoding) parallel imaging techniques. MRI/MRA brain showed no restricted diffusion, abnormal T1/T2/FLAIR signal, arterial occlusion, or irregular angioarchitecture. SWI revealed increased susceptibility along the posterior falx cerebri and right posterior parietal and occipital lobes, and pCASL showed decreased blood flow within these same regions. No falcine sinus was visualized on PCA-MRV, but SWI and pCASL findings led to diagnosis of falcine sinus thrombosis and initiation of appropriate treatment. Repeat MRI one month later showed interval resolution of the abnormal SWI findings and a now patent persistent falcine sinus visualized on PCA-MRV imaging. Routine use of SWI imaging on all brain MRIs and addition of pCASL imaging when there is concern for ischemia or infarction in the emergent setting can limit the risk of missed occult diagnoses like a thrombosed falcine sinus.

Short hospital stay following neck dissection.

OBJECTIVES: To review the clinical characteristics of patients who had a short hospital stay (<24 hours) following neck dissection, and to assess the incidence and type of complications in this patient group. DESIGN: Case series. SETTING: University-based academic medical center. PATIENTS: All patients who underwent neck dissection at our institution from July 2004 through June 2008 and were discharged within 24 hours postoperatively (short stay) were included. MAIN OUTCOME MEASURES: Patient demographics, cancer site and type, and details of the procedures performed were quantified. In addition, medical records were reviewed for complications requiring readmission within 30 days postoperatively. RESULTS: Review of a prospectively maintained surgical database identified 122 consecutive neck dissections performed at our institution from July 1, 2004, to June 30, 2008. Of these 122 procedures, 71 involved a subsequent postoperative stay of less than 24 hours. These 71 procedures were performed in 69 patients; they had a mean age of 59 years and a sex distribution that was 33% female and 67% male. Neck dissection alone was performed in 22 of the 71 short-stay cases (31%). The most commonly performed concurrent procedures included limited oral cavity or oropharyngeal resections (21 patients) and parotidectomy (13 patients). Modified radical neck dissection was performed in 22 of the 71 cases (31%); the remaining procedures were selective neck dissections. Cranial nerve XI, the internal jugular vein, and the sternocleidomastoid muscle were all preserved in 57 cases (80%). Of the 71 short-stay cases, only 2 (3%) required readmission for a surgical complication within 30 days of their procedure. CONCLUSIONS: In carefully selected patients, discharge within 24 hours following neck dissection seems to be safe and appropriate. Given the potential for substantial cost savings, short stay should be studied further in this patient population.

Prevalence, morphology, and prognosis of human papillomavirus in tonsillar cancer.

OBJECTIVES: We sought to identify the prevalence of human papillomavirus (HPV) in tonsillar squamous cell carcinoma, and to examine the relationship of HPV to prognosis and tumor morphology. METHODS: We performed in situ hybridization for HPV and retrospective clinical outcome analysis. RESULTS: Of the 48 patients with tonsillar carcinoma, in situ hybridization identified 35% as HPV-positive tumors. Age-matched controls had no evidence of HPV. There was no significant difference between HPV-positive and HPV-negative patients regarding age (p = 0.34), tobacco consumption (p = 0.59), alcohol consumption (p = 0.91), or treatment method (p = 0.39). Forty-four patients were eligible for outcome analysis. The overall rate of recurrence in this population was 25%, and the disease-specific survival rate was 84%. There was no significant difference between the two groups either in the incidence of recurrence (p = 0.14) or in the disease-specific survival rate (p = 0.19). HPV-associated tumors developed from the tonsillar crypts significantly more frequently than did HPV-negative tumors (p = 0.01). CONCLUSIONS: As previously described, HPV is significantly associated with squamous cell carcinoma of the tonsil; however, HPV status in our series did not correlate with clinical outcome. Morphologically, we found that HPV-positive tumors had their origin in the tonsillar crypts, whereas HPV-negative tumors arose from the surface epithelium.

Cancer of the parotid gland: role of 7th nerve preservation.

Most neoplasms arising in the parotid gland are benign. Patients with cancer of the parotid gland usually present with normal facial nerve function. In these patients, findings at the time of surgery will guide the management of the facial nerve, with most surgeons preserving the nerve unless it is adherent to, or imbedded in, a malignant tumor. In cases where the margins of resection are close to the facial nerve, adjuvant radiotherapy administered postoperatively has significantly improved local control of disease. The minority of patients with parotid cancer who present with facial nerve palsy has a poor prognosis despite extensive surgical resection including the facial nerve.

Expression of vascular endothelial growth factor receptors on tumor cells in head and neck squamous cell carcinoma.

BACKGROUND: Angiogenesis is essential for the growth of solid tumors, including head and neck squamous cell carcinoma (HNSCC). Angiogenesis is regulated by angiogenic factors such as vascular endothelial growth factor (VEGF) and VEGF receptors (VEGFRs) 1, 2, and 3 known to be located on vascular endothelial cells (VECs). We hypothesize that VEGFRs are also expressed on HNSCC tumor cells in vitro and in vivo and likely control tumor function in vivo. DESIGN: Immunohistochemical analysis for VEGFR-1 (n = 13), VEGFR-2 (n = 21), and VEGFR-3 (n = 16) was performed on human HNSCC tumor samples. Specimens were analyzed for receptor expression and staining intensity. A cultured oral SCC cell line (SCC-25) and a pharyngeal SCC cell line (FADU) were also studied for receptor expression. RESULTS: The HNSCC tumor cells expressed VEGFR-1, VEGFR-2, and VEGFR-3 in all specimens evaluated. Staining for all 3 receptors was also found on tumor-associated macrophages and fibroblasts, except that VEGFR-2 was not present on fibroblasts. Staining intensity for VEGFR-1 and VEGFR-2 was significantly higher in tumor cells and macrophages than in VECs stained for the same receptor. Both cultured HNSCC cell lines demonstrated expression of all 3 receptors. CONCLUSIONS: This represents the first report of all 3 VEGFRs being expressed by HNSCC cells. These findings indicate that VEGF may be an autocrine regulator of tumor cell activity in addition to its known angiogenic effects on VECs. The presence of VEGFRs on tumor-associated macrophages and fibroblasts contributes to the complexity of the VEGF/VEGFR system in human cancer.

Association of fibrin and interleukin 8 in human oral squamous cell carcinoma.

OBJECTIVE: We have recently demonstrated that fibrin induces a specific, dose- and time-dependent upregulation of the angiogenic factor interleukin 8 (IL-8) from human oral squamous cell carcinoma (OSCC) cells in vitro. In this study we begin to test the hypothesis that fibrin induces IL-8 expression from tumor cells in vivo by studying their in vivo association in OSCC. STUDY DESIGN: The presence of fibrin(ogen) was initially evaluated in 20 archival human OSCCs by means of immunohistochemistry with a polyclonal antibody. The presence of fibrin and IL-8 was then studied in 19 sections from 8 different patients' head and neck tumors (including 6 OSCCs) by means of immunohistochemistry with a monoclonal antibody against fibrin. These 8 tumors had been treated with inhibitors of new fibrin formation and degradation immediately after surgical removal. RESULTS: Fibrin staining was found in 100% of the tumor sections tested. IL-8 staining was found in the cytoplasm of tumor cells in 100% of the studied tumors, including areas adjacent to fibrin. CONCLUSIONS: These data demonstrate an in vivo association between fibrin and IL-8 in OSCC. These studies support our hypothesis that fibrin induces expression of protumorigenic factors such as IL-8 from tumor cells in vivo.

Using Lasers in Head and Neck Oncologic Surgery.

Few technologic advances in medicine have captured the imagination of the general public, and physicians, to the extent that the laser has. The laser clearly evokes images of space-age technology, and is frequently regarded as a panacea by patients. The reality is, of course, that the laser has no inherent special ability to cure diseases, and is simply another tool available to contemporary surgeons. We will review the current application of lasers in head and neck oncologic surgery. The basic mechanism of lasers will be discussed, with emphasis on the carbon dioxide (C02) laser. This discussion will include analysis of photodynamic therapy for cancer of the upper aerodigestive tract, which is rapidly evolving as a means of incorporating lasers in the treatment of head and neck cancer.