Citations

Object Synovial cysts of the cervical spine are rare. Further, synovial cysts of the C1–2 articulation, or retroodontoid cysts, are very rare, with fewer than 20 cases reported overall. The authors report on a single-institution series of 10 patients with C1–2 retroodontoid synovial cysts. Methods The charts of 10 patients with pathologically confirmed synovial cysts following resection between January 1998 and June 2009 were reviewed. The clinical presentation, radiographic findings, surgical management, and pre- and postoperative functional levels (reported as a modified Rankin outcome) are reported. Results All 10 patients underwent attempts at complete resection of the synovial cyst; none of the lesions were simply aspirated. All 4 patients with an initial recommendation of observation alone ultimately underwent surgery because of their swift neurological deterioration. The mean age at surgery was 75.4 ± 4.6 years (range 54–81 years). The mean presenting cyst volume was 4.6 ± 1.7 cm3. Nine of 10 patients underwent transoral resection of the cyst with posterior fusion. Six of the 10 patients underwent additional posterior laminectomy for decompression. The hospital length of stay varied from 2 to 45 days, with a mean of 19 ± 7 days. All patients undergoing transoral decompression had varying degrees of difficulty with postoperative dysphagia, diagnosed using videofluoroscopy. All patients improved in their modified Rankin Scale score after surgical intervention with a mean follow-up of 42 months (95% CI 12–72 months). Conclusions Synovial cysts of the atlantoaxial joint are rare. They occur in older patients in whom clinical deterioration is likely to occur. In most cases, these cysts can be diagnosed preoperatively. Transoral decompression with posterior fusion is an effective treatment for C1–2 degenerative cysts and can be accomplished with few complications. However, the ideal treatment for these lesions remains unknown.

Background: Historical outcomes in anaplastic thyroid carcinoma (ATC) are poor, with a median survival of only 5 months and <20% of patients surviving 1 year from diagnosis. We hypothesized that survival in newly diagnosed patients with stages IVA and IVB locoregionally confined ATC might be improved by utilizing an aggressive therapeutic approach, prioritizing both the eradication of disease in the neck and preemptive treatment of occult metastatic disease. Methods: Between January 1, 2003, and December 31, 2007, 25 new ATC patients were evaluated at our institution. Of these 25 patients, 10 (40%) had metastatic disease at diagnosis and therefore underwent palliative treatment, whereas 5 (20%) had regionally confined disease and desired treatment at their local medical facilities. The remaining 10 consecutive patients (40%) had regionally confined ATC and elected aggressive therapy combining individualized surgery (where feasible), intensity-modulated radiation therapy (IMRT), and radiosensitizing + adjuvant chemotherapy intending four cycles of docetaxel + doxorubicin. Outcomes were assessed on an intention to treat basis. Results: There were no deaths from therapy, but hospitalization was required in two patients (20%) because of treatment-related adverse events. Five patients (50%) are alive and cancer-free, all having been followed >32 months (range: 32–89 months; median: 44 months) with a median overall Kaplan–Meier survival of 60 months. Overall survival at 1 and 2 years was 70% and 60%, respectively, compared to <20% historical survival at 1 year in analogous patients previously treated with surgery and conventional postoperative radiation at our and other institutions. Conclusions: Although based upon a small series of consecutively treated patients, an aggressive approach combining IMRT and radiosensitizing plus adjuvant chemotherapy appears to improve outcomes, including survival in stages IVA and IVB regionally confined ATC, but remains of uncertain benefit in patients with stage IVC (metastatic) disease. Also uncertain is the optimal chemotherapy regimen to use in conjunction with IMRT. Further multicenter randomized trials are required to define optimal therapy in this rare but deadly cancer.

Background: Anaplastic thyroid carcinoma (ATC) is one of the most aggressive solid tumors in humans. The use of positron emission tomography (PET) with 18 F-fluorodeoxyglucose ( 18 F-FDG) in ATC has not been studied, and only a few case reports have been published. The objective of this study was to investigate the potential contribution of 18 F-FDG PET to the clinical management of patients with ATC. Methods: All patients with ATC studied with 18 F-FDG PET from August 2001 through March 2007 were included. The PET results were correlated with computed tomography, ultrasound, magnetic resonance imaging, bone scan, histology, and clinical follow-up. The FDG uptake was semiquantified as maximum standard uptake value. Any change in the treatment plan as a direct result of the PET findings as documented in the clinical notes was recorded. Results: Sixteen patients were included. True-positive PET findings were seen for all primary tumors, in all nine patients with lymph node metastases, in five out of eight patients with lung metastases, and in two patients with distant metastases other than lung metastases. In 8 of the 16 patients, the medical records reported a direct impact of the PET findings on the clinical management. Conclusions: ATC demonstrates intense uptake on 18 F-FDG PET images. In 8 of the 16 patients (50%), the medical records reported a direct impact of the PET findings on the management of the patient. PET may improve disease detection and have an impact on the management of patients with ATC relative to other imaging modalities.

Hemangiopericytomas are rare tumors of vascular origin most commonly found in the extremities or retroperitoneal area. When they originate from the nasal cavity and paranasal sinuses, they tend to be less aggressive and generally do not metastasize. The term “hemangiopericytoma-like lesion” has been coined for sinonasal hemangiopericytomas that display more benign histologic and growth characteristics than do those located elsewhere. Fifteen cases of hemangiopericytoma of the nasal cavity and paranasal sinuses were reviewed over the period 1951 to 1990; included are follow-up data on cases reported earlier from this institution. The clinical course, management, and outcome was evaluated and correlated with the histologic characteristics of the tumors. The recurrence rate in our series was 13.3%; the mean follow-up was 11 years. No patients died of their disease or had evidence of metastatic disease. This clinicopathologic review suggests that sinonasal hemangiopericytomas should not be classified as “hemangiopericytoma-like” lesions; rather, they should be expected to have significant local recurrence rates with low rates of distant metastasis and mortality. Long-term follow-up is essential as there can be local recurrence after many years.

Mucins are the major glycoprotein component of respiratory tract secretions. Little is known about their expression in the upper respiratory tract. In order to define this expression, in situ hybridization was performed on 19 normal and 4 vasomotor rhinitis (VMR) inferior turbinates to identify mucin mRNA. MUC1, MUC2, MUC4, MUC5AC, MUC5B, and MUC7 were expressed in both the normal and VMR turbinates. MUC 4 and MUC5AC were the most highly expressed mucins. MUC1, MUC2, MUC4, and MUC5AC were expressed mainly by the epithelial border, whereas MUC5B and MUC7 were expressed by the submucosal glands. MUC1 and MUC4 exhibited a diffuse expression by multiple cell types along the mucosal border, whereas MUC2 and MUC5AC expression appeared to be limited to a subpopulation of epithelial cells, most likely goblet cells. Although MUC1, MUC4, and MUC5AC showed sporadic submucosal glandular expression, MUC5B and MUC7 appeared to be the predominant submucosal gland mucins in the inferior turbinates. MUC3 and MUC6 expression, which have been found primarily in the gastric mucosa, were not seen in any of the inferior turbinate samples examined. The only difference seen between normal and VMR turbinates was a slight decrease in MUC1 expression in the VMR group. The variety of mucins expressed and the diversity of their expression patterns may have significance in terms of the rheologic and particle clearance properties of nasal secretions. Understanding the expression patterns in normal turbinates will serve as the foundation for further study of these mucins in disease states.

The increasing use of endonasal techniques and a new 3-dimensional CT-guided imaging system have allowed us to develop a combined, minimally invasive endonasal approach to the pituitary gland. Thus far, more than 30 patients have undergone an endonasal transsphenoidal approach to the sella using a combined endoscopic approach, with additional selective use of the Instatrak CT-guided imaging system for realtime imaging. Our current technique involves obtaining a preoperative CT using a plastic head frame with registration markers. By using this head frame intraoperatively, real-time localization with CT images in axial, coronal, and sagittal planes can be performed. Using endoscopic techniques and a Papavero-Caspar speculum, the sella is exposed. A combined approach using endoscopes, the operating microscope, and real-time localization is undertaken to expose and resect tumors. We have encountered minimal associated complications in our series, and this method has been progressively modified to improve exposure and safety. Because we are able to visualize the sella without a sublabial incision or septal resection, we have nearly eliminated the need for nasal packing, reduced the average hospital stay to 2.5 days, and improved patient satisfaction.

The use of the transseptal transsphenoidal approach to the pituitary gland has gained acceptance as a safe, relatively atraumatic means of removing pituitary tumors. The outcome in adult patients has been successful; however, the outcome in pediatric patients whose noses may still be developing is not well described. We reviewed the outcomes in 41 patients younger than age 18 years who underwent transseptal transsphenoidal pituitary surgery at our institution between 1986 and 1997 (20 boys and 21 girls; age, 3 to 17 years; mean age, 13.4 years). The most common diagnosis was prolactin-secreting adenoma (14 patients), followed by craniopharyngioma (7 patients). Presenting symptoms included headache (20 patients), galactorrhea (13 patients), and menstrual irregularities (11 patients). The most common early complication was transient diabetes insipidus (20 patients). No patient experienced serious bleeding at pack removal and no patient developed a cerebrospinal fluid leak postoperatively. Follow-up ranged from 3 months to 12.7 years, with 7 patients experiencing recurrent or residual disease between 6 days and 2 years after their original transseptal procedure. The most common long-term surgical complication was nasal obstruction in 5 patients, 3 of whom also complained of seasonal allergies. Four patients complained of recurrent sinus infections, and 4 patients noted an external nasal deformity as a result of the surgery.

ObjectiveMicrovascular reconstruction requires postoperative monitoring to prevent vascular occlusion and flap failure. These methods require skilled personnel and can delay diagnosis and treatment of threatened flap failures. The Cook‐Swartz implantable Doppler flow system provides continual feedback on vascular pedicle status, which in turn provides rapid assessment of minute‐to‐minute changes in flap vasculature that may allow intervention before total vascular occlusion and expeditious reexploration for threatened flap failure, possibly improving flap salvage.Study Design and SettingCharts of 24 patients with microvascular free‐flap reconstruction and implantation of Doppler flow system at Mayo Clinic Rochester were retrospectively reviewed. Surgical technique and flap outcomes were evaluated.ResultsMicrovascular reconstruction and implantation of Doppler flow system were successful in all patients. Complications were minimal, and postoperative monitoring system facilitated rapid reexploration when necessary. Flap viability was 96%.ConclusionDoppler flow system is reliable for monitoring minute‐to‐minute changes in microvascular flap vascular status postoperatively, and allows rapid recognition of complications and facilitating reexploration. This is a valuable, easily mastered tool for microvascular reconstructive surgery.SignificanceMay alter postoperative monitoring techniques of microvascular surgeons.

OBJECTIVETo illustrate the safety and efficacy of the endoscopic laser approach for cricopharyngeal myotomy (CPM) compared to the traditional transcervical approach.STUDY DESIGN AND SETTINGRetrospective chart review of 22 patients undergoing CPM from 1996 to 2003 at the Mayo Clinic, Jacksonville.RESULTSThe laser CPM technique was used in 14 patients, and an open approach in 8. The mean hospital stay and operative times were shorter for the laser group. Functional outcome analyses showed improvement in both groups. There were no major complications in the laser group, while 1 patient in the transcervical group had a pharyngocutaneous fistula.CONCLUSIONSThe laser technique is at least as effective as the transcervical approach for CPM to improve dysphagia symptoms in the properly selected patient, with a low risk of major complications.SIGNIFICANCEIn this report, we provide the reader with data to support the safety and efficacy of laser CPM.EBM rating: B‐3b