Case Report of Cerebellar Endometriosis.

Endometriosis is a disorder in women which is characterized by extrauterine manifestations. We describe a case of cerebellar endometriosis in a 39-year-old woman who underwent posterior fossa decompression multiple times without establishing a correct diagnosis. Her neurologic status progressively worsened due to chronic hydrocephalus and brainstem compression by cysts. Late in the clinical course, histology from the cyst wall was taken that revealed endometriosis with clear cells and positive immunohistology for progesterone and estrogen receptors. Treatment with gestagens was started but did not improve the patient's status. In patients with chronic recurring intracranial cysts and hydrocephalus, cerebral endometriosis should be considered.

Dual-Use Intraoperative MRI in Glioblastoma Surgery: Results of Resection, Histopathologic Assessment, and Surgical Site Infections.

BACKGROUND: To achieve maximal resection in glioblastoma (GBM) surgery, intraoperative imaging is important. An intraoperative magnetic resonance imaging (iMRI) suite used for both diagnostic and intraoperative imaging is considered being a reasonable concept for modern hospital management. It is still discussed if the dual use increases the risk of surgical site infections (SSI). This article assesses the rate of gross total resection (GTR), extent of resection (EOR), and histopathology after iMRI-guided resections in patients with GBM. The rate of surgical site infections (SSIs) is evaluated. METHODS: In all, 79 patients with GBM were operated on with iMRI. Additional resection was performed if iMRI depicted contrast enhancing tissue suggestive of residual tumor. GTR and EOR were determined by segmentation and volumetric analysis of the MR images. SSIs and the role of intravenous only or intravenous plus intrathecal antibiotics were evaluated. Statistical analysis was performed to detect the sensitivity, specificity, positive predictive value, and negative predictive value of iMRI-guided extended resections. Pearson's two-tailed chi-square test was performed to evaluate the rates of GTR and variables associated with SSI. RESULTS: GTR was achieved in 59 patients (74.68%). Rate of GTR was 35.44% before iMRI and additional resections (p < 0.0001). Mean EOR was 96.27%. Positive predictive value for tumor cells in the additionally resected tissue was 88.6%, negative predictive value was 100%, sensitivity was 100%, and specificity was 70. 6%. Rate of SSIs was 5.06% (n = 4). Two superficial SSIs, one subdural empyema and one cerebritis, were seen. SSI rates with parenteral only and additional intrathecal antibiotics were 0% and 8%, respectively (p = 0.133). CONCLUSION: Increase of extent of tumor resection using iMRI is evident. SSI rate is within the normal range of neurosurgical procedures. A dual-use iMRI suite is a safe concept.

Clinical Impact of Rare and Compound Mutations of Epidermal Growth Factor Receptor in Patients With Non-Small-Cell Lung Cancer.

BACKGROUND: Standard therapy of advanced non-small-cell lung cancer harboring an activating mutation in the epidermal growth factor receptor (EGFR) gene is treatment with tyrosine kinase inhibitors (TKI). However, for rare and compound mutations of the EGFR gene, the clinical evidence of TKI therapy is still unclear. PATIENTS AND METHODS: A total of 2906 lung cancer samples were analyzed for EGFR mutations during routine analysis between 2010 and 2017. The samples have been investigated by Sanger sequencing and since 2014 by next-generation sequencing. RESULTS: We detected EGFR mutations in 408 specimens (14%). Among these, we found 41 samples with rare and 22 with compound mutations. In these 63 samples, 56 different rare EGFR mutations occurred. Information about the clinical outcome was available for 37. Among those with rare mutations, only one patient harboring the mutation p.G874D had disease that responded to first-generation TKI therapy. In contrast, the disease of all patients with compound mutations responded to first- or second-generation TKI therapy. Furthermore, we collected data on clinical relevance regarding TKI therapy from different databases and from an additional literature search, and only found data for 36 of the 56 detected rare mutations. CONCLUSION: Information about the clinical outcome of patients with rare and compound EGFR mutations remains limited. At present, second- and third-generation TKIs are available, which may represent new treatment strategies for these patients. Therefore, it is becoming increasingly important to maintain databases concerning rare EGFR mutations.

"Bis-phossy jaws" - high and low risk factors for bisphosphonate-induced osteonecrosis of the jaw.

INTRODUCTION: Bisphosphonates (BPs) have transformed our ability to treat certain malignancies, osteoporosis and hypercalcaemia. This class of drug is assumed to be well tolerated by most. There are some important caveats to this assumption, however, one of the significances being the risk of osteonecrosis of the jaw (ONJ). MATERIAL AND METHODS: This multi-centre retrospective study examined the role of different BPs on the development of ONJ, its clinical presentation and the efficacy of various treatment modalities, comparing these findings with the available literature. RESULTS: A total of 78 patients from 17 centres were identified with ONJ. A majority of patients identified with ONJ had used Pamidronate or Zoledronate (93.6%) intravenously. 94.9% of patients had received BP in the course of treatment for malignancies and a majority had also received prior chemotherapy or exogenous steroids. 82.1% of patients had received BP for more than 1 year. The mean time from the introduction of BP to the development of ONJ in 24 patients from our department was 31.8 months. CONCLUSIONS: The most common intraoral manifestation was exposed necrotic jawbone. Tooth extractions and oral surgical intervention appear to place patients on BP therapy at risk of ONJ, especially after intravenous BP treatments. ONJ proved in this study to be remarkably refractory to treatment, with radical resection being the only curative approach. We recommend that all patients receive necessary dental treatment prior to commencing BP therapy.

Accuracy of High-Field Intraoperative MRI in the Detectability of Residual Tumor in Glioma Grade IV Resections.

Objective To assess the sensitivity/specificity of tumor detection by T1 contrast enhancement in intraoperative MRI (ioMRI) in comparison to histopathological assessment as the gold standard in patients receiving surgical resection of grade IV glioblastoma. Materials and Methods 68 patients with a primary or a recurrent glioblastoma scheduled for surgery including fluorescence guidance and neuronavigation were included (mean age: 59 years, 26 female, 42 male patients). The ioMRI after the first resection included transverse FLAIR, DWI, T2-FFE and T1 - 3 d FFE +/- GD-DPTA. The second resection was performed whenever residual contrast-enhancing tissue was detected on ioMRI. Resected tissue samples were histopathologically evaluated (gold standard). Additionally, we evaluated the early postoperative MRI scan acquired within 48 h post-OP for remaining enhancing tissue and compared them with the ioMRI scan. Results In 43 patients ioMRI indicated residual tumorous tissue, which could be confirmed in the histological specimens of the second resection. In 16 (4 with recurrent, 12 with primary glioblastoma) cases, ioMRI revealed truly negative results without residual tumor and follow-up MRI confirmed complete resection. In 7 cases (3 with recurrent, 4 with primary glioblastoma) ioMRI revealed a suspicious result without tumorous tissue in the histopathological workup. In 2 (1 for each group) patients, residual tumorous tissue was detected in spite of negative ioMRI. IoMRI had a sensitivity of 95 % (94 % recurrent and 96 % for primary glioblastoma) and a specificity of 69.5 % (57 % and 75 %, respectively). The positive predictive value was 86 % (84 % for recurrent and 87 % for primary glioblastoma), and the negative predictive value was 88 % (80 % and 92 %, respectively). Conclusion ioMRI is effective for detecting remaining tumorous tissue after glioma resection. However, scars and leakage of contrast agent can be misleading and limit specificity. Key points · Intraoperative MRI (ioMRI) presents with a high sensitivity for residual contrast-enhancing tumorous tissue during glioma resection.. · Contrast leakage due to bleeding and scars with reactive contrast enhancement can cause possible misleading artifacts in ioMRI, leading to a limited specificity of ioMRI.. · Bleeding control in glioma resection is crucial for successful usage of ioMRO for glioma resection.. Citation Format · Heßelmann V, Mager A, Goetz C et al. Accuracy of High-Field Intraoperative MRI in the Detectability of Residual Tumor in Glioma Grade IV Resections. Fortschr Röntgenstr 2017; 189: 519 - 526.