Central Nervous System Lymphomatoid Granulomatosis Presenting with Parkinsonism

Lymphomatoid granulomatosis (LG) is a potentially malignant lymphoproliferative disorder. The lung is the most common involved site, followed by the skin and nervous system. However, LG of the central nervous system presenting with Parkinsonism is very rare. We report a patient with LG who presented with parkinsonian features such as bilateral rigidity, bradykinesia, and agitation. Brain magnetic resonance imaging showed multifocal punctuate enhanced lesions in both supra- and infratentorial areas. Steroid pulse therapy resulted in a dramatical improvement in the symptoms and MRI abnormalities.

MR Imaging Findings of the Pituitary Gland in Patients with Transfusional Hemochromatosis: Two Case Reports

Hemochromatosis is a disorder caused by excessive iron deposition in parenchymal cells that leads to cellular damage and organ dysfunction. The excessive iron overload of secondary hemochromatosis is associated with chronic disorders of erythropoiesis that are treated with prolonged repeated blood transfusions. We experienced two cases of transfusional hemochromatosis involving the pituitary gland, and we report the findings of the MR imaging.

CT Findings of the Osteoma of the External Auditory Canal

PURPOSE: We wanted to report the CT image findings of the osteoma of the external auditory canal. MATERIALS AND METHODS: Temporal bone CT scanning was performed on eight patients (4 males and 4 females aged between 8 and 41 years) with pathologically proven osteoma of the external auditory canal after operation, and the findings of the CT scanning were retrospectively reviewed. Not only did we analyze the size, shape, distribution and location of the osteomas, we also analyzed the relationship between the lesion and the tympanosqumaous or tympanomastoid suture line, and the changes seen on the CT scan images for the patients who were able to undergo follow-up. RESULTS: All the lesions of the osteoma of the external auditory canal were unilateral, solitary, pedunculated bony masses. In five patients, the osteomas occurred on the left side and for the other three patients, the osteomas occurred on the right side. The average size of the osteoma was 0.6 cm with the smallest being 0.5 cm and the largest being 1.2 cm. Each of the lesions was located at the osteochondral junction in the terminal part of the osseous external ear canal. The stalk of the osteoma of the external auditory canal was found to have occurred in the anteroinferior wall in five cases (63%), in the anterosuperior wall (the tympanosqumaous suture line) in two cases (25%), and in the anterior wall in one case. The osteoma of the external auditory canal was a compact form in five cases and it was a cancellous form in three cases. One case of the cancellous form was changed into a compact form 35 months later due to the advanced ossification. CONCLUSION: Osteoma of the external auditory canal developed in a unilateral and solitary fashion. The characteristic image findings show that it is attached to the external auditory canal by its stalk. Unlike our common knowledge about its occurrence, osteoma mostly occurred in the tympanic wall, and this is regardless of the tympanosquamous or tympanomastoid suture line.

Brain Magnetic Resonance Imaging in Children with CNS Manifestations

PURPOSE: This study is to examine the relationship between clinical manifestations and MRI findings of children with CNS symptoms and signs. METHODS: A total of 447 inpatients with CNS symptoms and signs took brain MRI's at the Department of Pediatrics of Chungnam National University Hospital from July 2001 to June 2004. The results were retrospectively evaluated in terms of age, gender, chief complaints, and the findings of MRI and EEG based on the medical records. RESULTS: The overall incidence of abnormal MRI findings was 30.4%, of whom 44.7% were aged from one month to one year. The MRI findings were markedly different between under and over 6 years olds. In the former group, hydrocephalus, periventricular leukomalacia and hemorrhage were common while vascular malformation and brain tumor were more common in the latter group. Periventricular leukomalacia and hydrocephalus were shown to be the most frequent abnormal findings. 42.9% of those with seizures had abnormal MRI findings. Headache was common with 10.5% low incidence rate of abnormalies in MRI. The EEG findings were normal in 33.9% of the patients and there were not any articular correlations between EEG and MRI findings. CONCLUSION: MRI is important in the diagnosis of neurological disorders. However, caution should be taken in selecting patients since the MRI findings were normal in 69.6 % of the children with CNS symptoms and signs. This is the reason why more detailed standards of MRI for CNS manifestations are required.

Clinical Experience in Conformal Stereotactic Radiotherapy of Irregularly Shaped Intracranial Tumors / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The dosimetric advantages of multiple non-coplanar stationary fields for stereotactic radiotherapy or adiosurgery (SRT/S) are well known. However, this technique is not widely used due to the logistical problems associated with producing and testing customized collimators. We report our experience of SRT/S using multiple non-coplanar stationary fields (conformal SRT/ S). MATERIALS AND METHODS: Between August 1997 and February 2002, we performed frameless SRT/S in 63 patients. We chose conformal SRT/S when the tumor was of a very irregular shape or larger than 4 cm. We obtained three pieces of information: 1) the couch translations required to bring the target point to the isocenter, 2) the distance between the stereotaxic markers in the CT study, and the distance between the markers determined from orthogonal beam films, taken in the anterior- posterior and lateral directions, and 3) the rotational movement of the head position between the CT study and actual treatment position. We evaluated two kinds of data: 1) the precision of the isocenter setup, and 2) the reproducibility of the head position in the a) translational and b) rotational components. RESULTS: Twenty-six of the 63 patients receiving stereotactic treatment received conformal SRT/S. The precision of the isocenter setup for the conformal SRT/S was x=-0.03+/-0.26 mm, y=0.19+/-0.25 mm and z=-0.20+/-0.27 mm. The reproducibilities of the head position with the conformal SRT/S were 0.5 mm and less than 1degrees C, for the translational and rotational components, in any plane. CONCLUSION: We were able to apply conformal stereotactic irradiation, which has a dosimetric advantage, to irregularly shaped intracranial tumors, with precision and reproducibility of head position for the isocenter setup nearly equivalent to that of frame-based SRS or multiple-arc SRT/S.

Detection of Brain Metastatses Using Limited Brain MR Imaging ; Usefulness of Limited Contrast-Enhanced MR Imaging in Brain Metastasis / 결핵

BACKGROUND: The brain is a common site of a metastasis in lung cancer patients. If left untreated, the patients succumb to progressive neurological deterioration with a lower survival rate than with other metastases sites. Contrast-enhanced MR imaging in the absence of symptoms or clinical signs is not recommended for identifying a cerebral metastasis in lung cancer patients because of management effectiveness. This pilot study was performed to estimate whether or not limited brain MR imaging, which has a lower cost, could be used to replace conventional brain MR imaging. METHOD: Between April 1999 and March 2001, 43 patients with a primary lung cancer and the others (breast cancer, stomach cancer, colon cancer, malignant melanoma etc), who had neurological symptoms and signs, were examined using conventional brain MR imaging to examine brain metastases. The control group involved four patients who had no evidence of brain metastases the sensitivity, specificity and correlation of limited brain MR imaging were compared with conventional brain MR imaging. RESULTS: All the 43 patients who were examined with conventional brain MR imaging showed evidence of brain metastases, whereas limited brain MR imaging indicated that 42 patients had brain metastases(sensitivity=97.67%). One patient in whom limited brain MR imaging showed no brain metastasis had a metastasis in the cerebellum, as shown by the contrast-enhanced T1 weighted axial view using conventional brain MR imaging. The conventional brain MR imaging and the limited brain MI imaging of the 4 control patients both indicated no brain metastases (specificity=100 %). The Pearson Correlation of the two groups was 0.884(Confidence Interval : 99%) observed. CONCLUSION: Limited brain MR imaging can detect a brain metastasis with the same accuracy. In addition, it is cost-effective (229,000 won, 180$) compared to conventional brain MR imaging(529,000 won, 480$) when patients had neurological symptoms and signs or staging.

Brain Injuries Due to Neonatal Hypoglycemia: Case Report

Although hypoglycemia may be common among neonates, brain injuries resulting from isolated neonatal hypoglycemia are rare. The condition may cause neurological symptoms such as stupor, jitteriness, and seizures, though in their absence, diagnosis is delayed or difficult. Hypoglycemia was diagnosed in a three-day-old neonate after he visited the emergency department with loose stool, poor oral intake, and decreased activity, first experienced two days earlier. Two days after his visity, several episodes of seizure occurred. T2 and diffusion-weighted magnetic resonance (MR) scanning, performed at 11 days of age, revealed bilateral and symmetrical high signal intensity lesions in occipital, parietal, and temporal lobes. We report the MR findings of hypoglycemic encephalopathy in a neonate.

Nasopharyngeal Teratoma in an Adult: A Case Report

Nasopharyngeal teratomas are rare congenital tumors which mainly cause neonatal respiratory difficulty or feeding problems. We report an extremely rare case of nasopharyngeal teratoma in which a 34-year-old woman experienced a foreign body sensation. Simple radiographs and CT scans revealed the presence of an exophytically growing mass with a region of fatty attenuation and a well-formed tooth in the nasopharyngeal wall. The mass was surgically removed, and found at histopathology to be a mature teratoma.

Fractionated Stereotactic Radiotherapy for Metastatic Brain Tumor in Non-Small Cell Lung Cancer

PURPOSE: To evaluate the results of treatment with fractionated stereotactic radiotherapy for metastatic brain tumors in non-small cell lung cancer. MATERIALS AND METHODS: Between August 1997 and August 2001, 17 patients, with metastatic brain tumors in non-small cell lung cancer (26 lesions), completed frameless fractionated stereotactic radiotherapy. All patients received a 30~36 Gy/10~20 fx external beam irradiation to the whole brain. Twelve received fractionated stereotactic radiotherapy for a single lesion, 3 for 2 lesions and 1 each for 3 and 5 lesions. The median tumor volume was 1.7 cc (0.3~55.2 cc). The fractionation schedule for the fractionated stereotactic radiotherapy was 21 Gy/3 fx in 8 lesions, 25 Gy/5 fx in 7, 18 Gy/1 fx in 6, 30 Gy/5 fx in 4 and 15 Gy/5 fx in 1. Multiple-arc, and 3D conformal, fractionated stereotactic radiotherapy, were delivered to 24 and 2 lesions, respectively. Follow-up was possible in all patients. RESULTS: Nine out of 13 patients with follow-up radiological evaluations achieved a complete response (CR). The overall median survival, and 1 and 2 year survival rates were 20 months, and 64 and 28%, respectively. The median survival, and the 1 and 2 year survival rate of CR group were 20 months, and 73 and 22%, respectively. No patient has experienced any acute side reactions or late complications from the fractionated stereotactic radiotherapy. CONCLUSION: Although the number of patients treated with fractionated stereotactic radiotherapy was small, and follow-up period short, this study suggests that external beam irradiation to the whole brain, with 30 Gy/10 fx followed by fractionated stereotactic radiotherapy, could be a good treatment option for patients with metastatic brain tumors in non-small cell lung cancer.

Reversible Posterior Leukoencephalopathy Syndrome

PURPOSE: To review reversible posterior leukoencephalopathy syndrome. MATERIALS AND METHODS: We reviewed 22 patients (M:F=3:19; age, 17-46 years) with the characteristic clinical and imaging features of reversible posterior leukoencephalopathy syndrome. All underwent brain MRI, and in three cases both CT and MRI were performed. In one, MRA was obtained, and in eleven, follow-up MR images were obtained. We evaluated the causes of this syndrome, its clinical manifestations, and MR findings including the locations of lesions, the presence or absence of contrast enhancement, and the changes seen at follow-up MRI. RESULTS: Of the 22 patients, 13 had eclampsia (six during pregnancy and seven during puerperium). Four were receiving immunosuppressive therapy (three, cyclosporine; one, FK 506). Four suffered renal failure and one had complicated migraine. The clinical manifestations included headache (n=12), visual disturbance (n=13), seizure (n=15), focal neurologic sign (n=3), and altered mental status (n=2). Fifteen patients had hypertension and the others normotension. MRI revealed that lesions were bilateral (n=20) or unilateral (n=2). In all patients the lesion was found in the cortical and subcortical areas of the parieto-occipital lobes; other locations were the basal ganglia (n=9), posterior temporal lobe (n=8), frontal lobe (n=5), cerebellum (n=5), pons (n=2), and thalamus (n=1). All lesions were of high signal intensity on T2-weighted images, and of iso to low intensity on T1-weighted images. One was combined with acute hematoma in the left basal ganglia. In eight of 11 patients who underwent postcontrast T1-weighted MRI, there was no definite enhancement; in one, enhancement was mild, and in two, patchy. CT studies showed low attenuation, and MRA revealed mild vasospasm. The symptoms of all patients improved. Follow-up MRI in nine of 11 patients depicted complete resolution of the lesions; in two, small infarctions remained but the extent of the lesions had decreased. CONCLUSION: Reversible posterior leukoencephalopathy syndrome develops in patients with toxemia of pregnancy, renal insufficiency or complicated migraine, and those who undergo immonosuppresive therapy. The characteristic MR finding is edema in cortical or subcortical areas of the parietal and occipital lobes, without enhancement after Gd-DTPA injection. Early recognition of this readily treatable condition may obviate the need for extensive, invasive investigations, and prompt treatment can lead to a favorable prognosis.

Thin Slice Thickness Double-Dose Contrast-Enhanced CT in the Detection of Brain Metastases

PURPOSE: To compare the usefulness of double-dose contrast-enhanced CT (DDCE-CT) and conventional contrast-enhanced CT (CCE-CT) in the detection of metastatic brain lesions. MATERIALS AND METHODS: Sixteen patients with brain metastases were evaluated with both CCE-CT and thinslice DDCE-CT. For CCE-CT, an initial injection of 100 ml contrast medium was given, and DDCE-CT with both 10-mm and 5-mm thickness was performed after the addition of an extra 100 ml of contrast medium. The numbers of metastatic lesions detected by CCE-CT and by DDCE-CT were compared, as were the findings of contrast-enhanced MRI (CE-MRI) and thin-slice DDCE-CT in seven patients who underwent both these procedures. RESULTS: Fourteen metastatic brain lesions were detected by CCE-CT, 22 by 10-mm-thickness DDCE-CT, and 36 by 5-mm thickness DDCE-CT. Thus, almost 2.6 times more lesions were detected by thin-slice DDCE-CT than by CCE-CT. Metastatic lesions were detected by 10-mm-thickness DDCE-CT in 16 patients and by CCECT in seven; in five, edema only was detected, while in four there were no detectable metastases. CCE-CT detected four lesions of less than 5 mm in diameter, while 10-mm-thickness DDCE-CT and 5-mm-thickness DDCE-CT detected seven and 18 lesions, respectively. Eleven lesions were detected by thin-slice DDCE-CT and 17 by CE-MRI in the seven patients who underwent both CE-MRI and DDCE-CT. The lesions detected only by CE-MRI were less than 5 mm in diameter and were discovered in the cerebellum or inferior temporal lobe. CONCLUSION: Thin-slice DDCE-CT was superior to CCE-CT in detecting metastatic brain lesions.

Results of Radiation Therapy in Nasopharyngeal Cancer / 대한방사선종양학회지

PURPOSE: This is a retrospective study to evaluate the results of radiation therapy in nasopharyngeal carcinoma. MATERIALS AND METHODS: From September 1989 to October 1996, 19 patients with nasopharyngeal carcinoma completed planned radiation therapy course. Stages were I in 2 patients, II in 6, III in 2 IV in 9 patients, respectively. Pathology was squamous cell carcinoma in 5 patients, undifferentiated cell carcinoma in 14 patients. Fourteen patients were treated with radiation therapy only. Five patients received chemotherapy. The follow-up period ranged from 5 months to 115 months with a median of 33 months. Follow-up was possible in all patients. RESULTS: Responses to radiation therapy were complete response in 15 patients, partial response in 2, and no response in 2, respectively. Patterns of failure were as follows : locoregional recurrence in 6 patients and distant metastasis in 4 patients. The sites of distant metastasis were bone, liver and lung. Five year survival rate was 47.8% and five year disease free survival rate was 48.1%. Stage, T-stage, N-stage, central nervous system involvement, pathology type, performance status, response, radiation dose, chemotherapy were not significant prognostic factors. CONCLUSION: 5-year survival rate was 47.8% and 5-year disease free survival rate was 48.1%. The advances in radiation therapy techniques and chemotherapy are needed.

Initial Experience of Fractionated Stereotactic Radiotherapy for Metastatic Brain Tumors / 대한암학회지

PURPOSE: This study aimed to evaluate the preliminary treatment results of fractionated stereotactic radiotherapy (FSRT) for metastatic brain tumors. MATERIALS AND METHODS: Between August 1997 and December 1998, frameless FSRT was performed in 11 patients with metastatic brain tumor (1S lesions). Primary sites were lung in 7 patients, breast in 2, stomach in 1, and malignant melanoma in 1, All patients received 30-36 Gy/10-20 fx external beam irradiation to whole brain. Eight patients received FSRT for 1 lesion, one for 2 lesions, and two for 4 lesions. Fractionation schedule was 25 Gy/5 fx in 11 lesions, 18 Gy(1 fx in 3, 30 Gy/5 fx in 2, 15 Gy/5 fx in 1. Mean tumor volume was 7.0 cc (0.39~55.23 cc). Multiple-arc FSRT was delivered to 16 lesions and conformal FSRT through irregular ports shaped to tumor profile to 2 lesions. RESULTS: No patient experienced any acute side reaction from FSRT. Follow-up radiologic evaluation was available in 9 patients. Six of nine patients achieved the complete response, but two showed the partial response and one showed no response on follow-up radiologic studies. Among six patients with complete response, 5 patients survived from 5 to 15 months and showed no evidence of metastatic brain d#isease clinically and/or radiologically at last follow-up. Among two patients who did not have radiologic evaluation, one showed clinically complete response until death and the other died just after FSRT caused by intercurrent disease. One patient with no response radiologically survived 7 months and showed nearly complete disappearance of clinical symptom with stable status radiologically, CONCLUSION: Initial experience in this study suggests that the external beam irradiation to whole brain with 30 Gy/10 fx followed by FSRT with 20~30 Gy/5~6 fx could be the good treatment option to the patients with metastatic brain tumor. This study suggests that the fractionation schedule for FSRT should be determined in consideration of performance status, number of metastasis, tumor volume, location, presence of extracranial disease, and age.

The Comparison of DVH between Multiple arc FSRT and Conformal FSRT / 대한방사선종양학회지

PURPOSE: .In FSRT (Fractionated stereotactic radiotherapy) planning, we studied the usefulness between multiple arc FSRT and conformal FSRT by comparing tumor shape and DVH(dose volume histogram). MATERIALS AND METHDS: In Chungnam Univ. hospital, we had treated the sixteen patients with FSRT from Aug. 1997 to Dec. 1998. In choosing multiple arc FSRT or conformal FSRT, we had considered multiple arc FSRT if tumor shape was similar to sphere or the value of IF was less than 1.25, conformal FSRT if tumor shape was very irregular or IF was more than 1.3. For evaluation of treatment planning, we had considered the appropriate DVH for tumor volume and for critical organs. RESULT: The errors between reference point and the coordinates point on AP, Lat radiography were less than 1 mm before treatment. We had planned 3~5 arcs for multiple arc FSRT, 5~6pots for conformal FSRT. The mean dose distribution of tumor volume of cumulative DVH between multiple arc FSRT and conformal FSRT was 90.6, 86%, respectively. The dose of critical organs irradiated was less than 5% maximum dose of cumulative DVH. CONCLUSION: We had obtained the similar value between multiple arc FSRT and conformal FSRT, so that we had appropriate treatment planning of FSRT for multiple arc FSRT and conformal FSRT according to tumor shape and size.

MR Imaging Findings of Ring Apophyseal Fractures in Lumbar Vertebrae

PURPOSE: To assess the location and associated findings of fractures of the posterior lumbar vertebral ring apophysis as seen on MRI. MATERIALS AND METHODS: We retrospectively evaluated MR findings in 77 patients (86 lesions) with lumbar apophyseal ring fractures. Their age ranged from ten to 67 (mean 33-1) years. To confirm the presence of verterbral ring fractures, CT was performed in 29 patients (31 lesions) within two weeks of MR imaging. Open laminectomy was performed in ten patients, percutaneous automated nucleotomy in three, and LASER operation in four. RESULTS: The most common location of fractures was the superior margin of L5 (36 lesions 41.9%), next was superior margin of S1 (21 lesions, 24.4%). On CT, a bony fragment was seen in 28 patients (30 lesions); the positive predictive value of MR was 99.7 %. Multiple lesions were seen in nine patients. Associated disc herniation and bulging were noted in 64 (74.4%) and 15 lesions (17.4%), respectively, and a high signal intensity rim aound the bony fragment on T1 weighted image was noted in 33 (38.4%). Other associated findings were spondylolysis in eight patients, retrolisthesis in five, and spondylolisthesis in three. Operative outcomes were variable. The results of open laminectomy were better than those of percutaneous automated laminectomy or LASER operation. CONCLUSION: In patients with lumbar apophyseal ring fractures, their exact location and associated findings could be evalvated by MRI, which was therefore useful in the planning of appropriate surgery.