Involvement of matrix metalloproteinase-13 in stromal-cell-derived factor 1 alpha-directed invasion of human basal cell carcinoma cells.

Basal cell carcinoma (BCC) is one of the most common skin neoplasms in humans and is usually characterized by local aggressiveness with little metastatic potential, although deep invasion, recurrence, and regional and distant metastases may occur. Here, we studied the mechanism of BCC invasion. We found that human BCC tissues and a BCC cell line had significant expression of CXCR4, which was higher in invasive than non-invasive BCC types. Further, of 19 recurrent tumors among 390 BCCs diagnosed during the past 12 years, 17/19 (89.5%) had high CXCR4 expression. We found that the CXCR4 ligand, stromal-cell-derived factor 1alpha (SDF-1alpha), directed BCC invasion and that this was mediated by time-dependent upregulation of mRNA expression and gelatinase activity of matrix metalloproteinase-13 (MMP-13). The transcriptional regulation of MMP-13 by SDF-1alpha was mediated by phosphorylation of extracellular signal-related kinase 1/2 and activation of the AP-1 component c-Jun. Finally, CXCR4-transfected BCC cells injected into nude mice induced aggressive BCCs that co-expressed CXCR4 and MMP-13. The identification of SDF-1alpha/CXCR4 as an important factor in BCC invasiveness may contribute insight into mechanisms involved in the aggressive potential of human BCC and may improve therapy for invasive BCCs.

Cerebellopontine angle metastasis from papillary carcinoma of the thyroid: case report and literature review.

BACKGROUND: Papillary thyroid carcinoma is the most common type of well-differentiated thyroid malignancy and typically has an excellent prognosis and a low incidence of distant metastasis. However, once metastasis has developed in a distant site, prognosis is markedly diminished. Brain metastases from papillary thyroid carcinoma are extremely rare. Currently, there are no established therapeutic guidelines for treating brain metastases from thyroid carcinoma. CASE DESCRIPTION: We report on the case of a patient who presented with worsening neurological symptoms 3 years after resection of a thyroid papillary carcinoma. Magnetic resonance imaging identified a lesion of the cerebellopontine angle that encased the lower cranial nerves. The patient underwent a left retrosigmoid craniotomy with a 98% resection of the mass and received postoperative adjuvant radioiodine therapy, external beam radiation, and Gamma Knife radiosurgery. The patient tolerated the procedure well and demonstrated significant progressive improvement in her neurological symptoms postoperatively. After the multimodal approach to therapy, she remains symptom-free at 3-year follow-up. Radiographic monitoring of the small tumor remnant reveals a decrease in size from the postoperative period. CONCLUSION: This article is the first formal case report of cerebellopontine angle metastasis from papillary thyroid carcinoma. Therapeutic protocols for brain metastases of papillary thyroid carcinoma are not firmly established. This case illustrates the unique event of a cerebellopontine angle metastasis from papillary thyroid carcinoma, which was successfully treated with a combination of surgical, chemical, and radiological modalities. This aggressive course of therapy has resulted in an excellent outcome in this instance.

Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy.

BACKGROUND: The trigeminocardiac reflex is the sudden-onset of dysrhythmia and hypotension during manipulation of any of the branches of the trigeminal nerve. The trigeminal nerve and cardioinhibitory vagus nerve constitute the afferent and efferent pathways in the reflex arc. The trigeminocardiac reflex has been reported to occur during craniofacial surgery, balloon-compression rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle. PATIENT & METHOD: A 2-year-old male patient with haemangioma near the sella turcica underwent rhizotomies of both sides of the dorsal sensory roots, of the trigeminal nerves for palliation of intractable trigeminal pain. RESULTS: In this report, we experienced two unexpected episodes of asystole after transection of the sensory roots of the trigeminal nerves. CONCLUSION: Sectioning of the intracranial dorsal sensory root of the trigeminal nerve provides clear evidence of the central role of the trigeminal nerve as the afferent pathway of the trigeminocardiac reflex arc.

Fully endoscopic vascular decompression of the facial nerve for hemifacial spasm.

Hemifacial spasm is an uncommon disorder manifesting as a unilateral, involuntary, sporadic contraction of the musculature innervated by the seventh cranial nerve. Although debated, the etiology of hemifacial spasm is generally accepted as compression of the facial nerve by vessels of the posterior circulation. Early surgical techniques were ineffective and fraught with morbidity. Over the past 25 years microvascular decompression surgery has allowed the safe and effective treatment of hemifacial spasm. Recent reports combining microsurgical and endoscopic techniques have documented the advantages of the endoscope in exposing the anatomy of this region. Enhanced visualization allows a less traumatic dissection and increases the surgeon's ability to locate nerve-vessel conflicts often difficult to identify through the limited view of the microscope. This article reviews the history of hemifacial spasm and describes the first three cases of fully endoscopic vascular decompression for hemifacial spasm, emphasizing the advantages of this novel surgical approach.

Retained foreign body in the orbit and cavernous sinus with delayed presentation of superior orbital fissure syndrome: case report.

Reports of delayed onset of neurological symptoms after penetrating intracranial trauma are rare. We present the case of a patient who presented with superior orbital fissure syndrome 72 hours after reported trauma to the right eye. Subsequent workup revealed a foreign body located within the orbit, passing through the superior orbital fissure and into cavernous sinus, impinging on the right cavernous carotid artery. Evidence of an intraorbital abscess was also present. Surgical management consisted of a combination of frontopterional and orbital approaches to fully expose both the cavernous sinus and the orbital contents. The foreign body was removed and the abscess was drained. The carotid artery was found to be intact. At 10-month follow-up examination, a slight ptosis and medial gaze of the right eye persist. All other symptoms have resolved.

Endoscopic transglabellar approach to the anterior fossa and paranasal sinuses.

Historically, surgical management of tumors of the anterior cranial fossa with extension to the paranasal sinuses has been problematic. Wide exposure of these lesions has traditionally called for prolonged retraction of the frontal lobes or potentially disfiguring transfacial approaches, subjecting patients to undesirable neurological and cosmetic morbidity. With the introduction of progressively less invasive procedures, however, intracranial tumors with craniofacial involvement have become amenable to en bloc resection with a minimum of deleterious consequences. Increasing experience with endoscopy as an imaging modality in intracranial and extracranial surgery has led to the adaptation of endoscopic techniques to this setting. We have used an entirely endoscopic transglabellar approach to the anterior fossa to resect suprasellar tumors in two patients. The use of endoscopy allowed thorough visualization of all critical structures at the paramedian skull base without the need for a bicoronal scalp flap, bifrontal osteotomies, or brain retraction. Both lesions were resected in their entirety with no perioperative complications and with acceptable cosmetic results. These cases demonstrate how the application of endoscopy to surgery of the anterior skull base and craniofacial skeleton can eliminate the need for excessively invasive techniques without compromising surgical success.

Congenital teratoma of the oropharyngeal cavity with intracranial extension: case report and literature review.

Congenital teratoma of the oropharyngeal cavity is a unique clinical entity that poses immediate threats to the neonate in the postpartum period. Establishment of a secure airway is a primary goal after delivery; complete surgical resection is the subsequent guiding principle of management. Even more rare than teratomas confined to the oropharynx are tumors that extend into the intracranial cavity during development. Descriptions of these lesions in the medical literature are uncommon. In the majority of these reports, the tumors are associated with stillbirth, perinatal death, or significant morbidity after attempted resection. We present the rare case of a patient with congenital oropharyngeal teratoma with intracranial extension who has demonstrated long-term survival without any neurological or functional deficits. A unique delayed staged approach to resection of the extracranial and intracranial components of the tumor is described.

Fully endoscopic vascular decompression of the trigeminal nerve.

Microvascular decompression of the trigeminal nerve is an accepted and effective means of treating patients with trigeminal neuralgia in whom compression of the nerve by a vascular structure is implicated in the pathogenesis of the disease. The current standard technique uses the binocular operating microscope for all intra-operative visualization. Posterior fossa endoscopy has demonstrated that the endoscope provides more comprehensive views of the anatomy of the cerebellopontine angle than does the operating microscope. To date, endoscopy has only been used to supplement microscopy in cranial nerve decompression surgery. In this report, we describe our completely endoscopic surgical technique as we present the case of a patient with trigeminal neuralgia who underwent successful vascular decompression by this approach. Using this technique the offending vessel was separated from the nerve with minimal brain retraction or dissection of surrounding structures. This report represents the first documented case where the endoscope was used as the exclusive imaging modality for decompression of the trigeminal nerve. From our experience we conclude that the endoscope's superior visualization more accurately identifies neurovascular conflicts, and provides a comprehensive evaluation of the completeness of the decompression. Additionally, this new method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. From this study we conclude that completely endoscopic vascular decompression represents the next step forward in the safe and effective surgical treatment of trigeminal neuralgia.

A rare symptomatic presentation of ecchordosis physaliphora and unique endoscope-assisted surgical management.

We report on the presentation, diagnosis, and surgical management of a rare symptomatic case of ecchordosis physaliphora, including the use of endoscopy as a valuable imaging device in its operative management. A 49-year-old male presented with a intradural extra-axial mass located to the left of the basilar artery in the prepontine space. The tumor was exposed via a transmaxillary transclival approach and resected under binocular microscopic visualization. Prior to and following resection, endoscopes were introduced into the surgical field to conduct anatomic surveys of the region and to assess the completeness of tumor removal. Ecchordosis physaliphora is an uncommon benign lesion originating from embryonic notochordal remnants. It rarely causes clinical symptoms due to its slow growth patterns. Although similarities between EP of the spheno-occiput and chordomas of the clivus make distinction obscure, differentiation is important. Differences in these lesions impact upon patient prognosis as well as therapeutic strategies. The use of endoscopy in the resection of this mass marks an innovative approach to intraoperative imaging of the clival region; improved visualization of the prepontine area allows for more accurate defintion of the surgical anatomy of the tumor and for thorough assessment of the completeness of tumor removal.

Pituitary lymphoma: a case report and literature review.

We report the case of a B-cell type pituitary lymphoma in a 65 year-old male immunocompetent patient who presented with hypogonadotropic hypogonadism and central hypothyroidism and subsequently developed pulmonary lymphoma. Only three cases of pituitary lymphoma have been previously reported, one in a patient with acquired immunodeficiency syndrome, one case of T-cell lymphoma reported in the Japanese literature, and one case of B-cell lymphoma. The previously reported immunocompetent patients presented with signs and symptoms of optic chiasm compression as contrasted to our patient's endocrinologic presentation. B-cell lymphoma of the pituitary gland is a exceedingly rare though distinct clinical entity.