Expression of vascular endothelial growth factor is a clinically useful predictor for aggressive basal cell carcinoma / 고신대학교의과대학학술지

OBJECTIVES: Basal cell carcinoma (BCC) tumors are locally invasive but rarely metastatic. However, aggressive metastatic variants are being increasingly reported in elderly people. Here we investigated the clinical utility of vascular endothelial growth factor (VEGF) as a predictive biomarker for aggressive BCC variants. METHODS: Thirty-five pathologically confirmed cases of BCC that underwent surgical removal in the Plastic Surgery Department between January 1, 2011 and December 31, 2012 were studied. VEGF expression was analyzed in formalin-fixed paraffin-embedded tumor tissue by immunohistochemical staining. Positive staining was defined as more than 10% of the tumor cells showing immunoreactivity. The associations of VEGF expression with various clinicopathologic parameters were analyzed. RESULTS: The face was the most prevalent site (28/35), with 15 cases from the nose, 6 cases from the eyelid, and 5 cases from the cheek. The patients were aged between 41 and 86 years, with a mean age of 69.26 ± 173.903 years. The mean BCC size was 1.34 ± 3.853 cm, with a range of 0.3 cm to 12.0 cm. The mean tumor invasion depth from the basement epidermal membrane was 0.17 ± 0.035 cm, with a range of 0.03 cm to 1.10 cm. A mean of 5.66 ± 20.938 intraoperative frozen section slides were examined. VEGF was not expressed in 14 of the 35 patients (40.0%), whereas 42.9% of the patients had low expression and 17.1% of the patients had high expression. VEGF expression was significantly associated with age (P = 0.022), size (P = 0.030), site (P = 0.013), tumor invasion depth (P = 0.019), and number of intraoperatively frozen sections (P = 0.003). CONCLUSIONS: These results suggest that VEGF expression as assessed by immunohistochemistry can predict aggressive or poor prognosis in BCC.

Effects of Percutaneous Sacroplasty on Pain and Mobility in Sacral Insufficiency Fracture

OBJECTIVE: Sacral insufficiency fracture (SIF) contributes to severe low back pain. Prolonged immobilization resulting from SIF can cause significant complications in the elderly. Sacroplasty, a treatment similar to vertebroplasty, has recently been introduced for providing pain relief in SIF. The purpose of this study is to investigate the clinical short-term effects of percutaneous sacroplasty on pain and mobility in SIF. METHODS: This study is conducted prospectively with data collection. Sixteen patients (3 men and 13 women) with a mean age of 77.5 years (58 to 91) underwent sacroplasty. Patients reported visual analogue scale (VAS; 0–10) and Oswestry disability index (ODI; 0–100%) scores. VAS and ODI scores were collected preoperatively and again at one day, one month, and three months postoperatively. Questionnaires measuring six activities of daily living (ADLs) including ambulating, performing housework, dressing, bathing, transferring from chair, and transferring from bed were collected. Ability to perform ADLs were reported preoperatively and again at three months postoperatively. RESULTS: The mean preoperative VAS score (mean±SD) of 7.5±0.8 was significantly reduced to 4.1±1.6, 3.3±1.0, and 3.2±1.2 postoperatively at one day, one month, and three months, respectively (p<0.01). The mean ODI score (%) also significantly improved from 59±14 preoperatively to 15.5±8.2 postoperatively at one month and 14.8±8.8 at three months (p<0.01). All ADL scores significantly improved at three months postoperatively (p<0.01). CONCLUSION: Percutaneous sacroplasty alleviates pain quickly and improves mobility and quality of life in patients treated for SIF.

Tapia's Syndrome after Posterior Cervical Spine Surgery under General Anesthesia

We present a case report to remind surgeons of this unusual complication that can occur in any surgery, even posterior cervical spine surgery under general anesthesia and discuss its causes, treatment methods, and the follow-up results in the literature. The peripheral Tapia's syndrome is a rare complication of anesthetic airway management. Main symptoms are hoarseness of voice and difficulty of tongue movement. Tapia's syndrome after endotracheal general anesthesia is believed to be due to pressure neuropathy of the vagus nerve and the hypoglossal nerve caused by the endotracheal tube. To our knowledge, no report has been published or given an explanation for Tapia's syndrome after posterior cervical spine surgery. Two patients who underwent posterior cervical surgery complained hoarseness and tongue palsy postoperatively. There is no direct anatomical relation between the operation, the vagus nerves and the hypoglossal nerves, and there is no record of displacement or malposition of the endotracheal tube. After several months, all symptoms are resolved. To avoid this problem in posterior cervical spine surgery, we suggest paying special attention to the position of the endotracheal tube to avoid excessive neck flexion before and during the positioning of the patient.

Usefulness of Gracilis Flap for Perineal Area Reconstruction

PURPOSE: Due to the closed and humid condition of the perineal area, wound problems occurring at this site are sometimes complicated, especially following postoperative radiation therapy. Moreover, the anal sphincter is a very important functional structure but reconstruction of the anal sphincter after severe trauma poses a challenging problem to plastic surgeons. In this article, we demonstrate the usefulness of the pedicled gracilis flap in the reconstruction of the perineal area. METHODS: From September 2008 to November 2009, 6 patients, 4 males and 2 females, underwent surgery of the perineal area. The age of the patients ranged from 21 to 62 years (mean age was 48). The mean follow up period was 14 months. In 4 cases, the patient presented with wound problems after postoperative radiation therapy for anal cancer. In 2 cases, the patient presented with traumatic sphincter damage. Only the gracilis muscle was used in the 4 cases and a musculocutaneous flap was used in the 2 cases involving skin defects, respectively. RESULTS: Among the 6 patients, 1 patient underwent hematoma evacuation of the donor site, and 1 patient presented with prolapse of the vaginal mucosa which recovered spontaneously. There were no report of other complications and there were no wound recurrences. Minimal incontinence was observed in all patients who underwent sphincter reconstruction, but all were satisfied with the overall results. CONCLUSION: The gracilis flap is useful in the reconstruction of the perineal area, such as in cases of radiotherapy induced wound problems and sphincter damage following severe trauma, due to its easy accessibility, rich vascularity, and minimal donor site morbidity.

Treatment of Nasal Bone Fracture without Nasal Packing

PURPOSE: The majority of nasal bone fractures have been managed by routine procedure of closed reduction, intranasal packing or intranasal Kirschner wire (K-wire) splinting. But it leaves rooms for many complaints from patients such as pain, rhinorrhea and nasal obstructioon. Another option is, of course, no packing at all. The study was initiated to assess the necessity to pack or splint the nasal bone after routine closed reduction. METHODS: We analysed the medical records of 35 patients with nasal bone fracture who were operated by closed reduction in the last 2 years. We evaluated the postoperative CT scan scores and external deviation criterias 1 month after the operation. RESULTS: The postoperative deviation criteria and postoperative CT scan score were favorable and there were no serious complications using this technique. CONCLUSION: The present study demonstrates that the use of packing or splinting need not be routine in the majority of cases. The risks and discomforts associated with these procedures can often be avoided.

Clinical and Computed Tomography Evaluation of Plate and Screw on the Cervical Lateral Mass: A Modified Magerl's Technique

OBJECTIVE: To determine the clinical and radiological safety of 15 consecutive patients managed with plate and screw fixation systems applied to the cervical lateral mass. METHODS: 15 patients who underwent posterior cervical and T1 arthrodesis were reviewed from Jan 2002 to Dec 2004. Posterior cervical screw and plate fixation was applied on the lateral mass of the cervical spine. The authors have tried lateral mass screw fixation using a modified Magerl's technique (20 degrees lateral and 20~30 degrees rostral screw trajectory) under preliminary radiological study. The average patient age was 39.73 degrees+/-11.00 years, and the average follow-up period was 9.73 degrees+/-6.77 months. Computed tomography scans taken after surgery were reviewed to confirm the attempted screw trajectory correct and safety. RESULTS: Three of 93 lateral mass screws were malpositioned but clinical damage was not noted. Two of 8 pedicle screws on the T1 vertebrae were not placed on the correct pedicle area. Screw and plate loosening was observed in one case but was not subjected to an additional procedure because of maintained screw position observed during follow-up periods. CONCLUSION: The results of this study indicate that lateral mass screw fixation using the Modified Magerl's technique on the cervical lateral mass may provide safe and effective application on the patients. In addition, the chance of incorrectly placed screws was higher in T1 pedicle screw fixation than in lateral mass screw fixation of the cervical area.

Malignant Peripheral Nerve Sheath Tumor of the Cauda Equina in Type I Neurofibromatosis: Case Report

We report a case of malignant peripheral nerve sheath tumor in the cauda equina, which was associated with neurofibromatosis type I. The tissue specimen acquired from the mass of cauda equina was transformed from benign to malignant form within 3 months. We report this case with review of the literatures.

Clinical Analysis of Spontaneous Intracranial Hypotension

OBJECTIVE: Spontaneous intracranial hypotension(SIH) is a rare condition presented with cardinal postural headache and low CSF pressure. The authors describe the characteristic clinical features, imaging findings, and treatment methods in the patients with spontaneous intracranial hypotension. METHODS: Between May 1994 and Aug. 2001, eight patients were diagnosed with spontaneous intracranial hypotension based on characteristic radiologic and clinical findings in our department. All cases were shown diffuse meningeal enhancement(DME) on magnetic resonance(MR) image. Two cases had subdural hematoma. RESULTS: The most characteristic feature on Brain MR image is DME with/without subdural fluid collection. Radionuclide image reveals direct leaking point and rapid appearance of urinary bladder activity. Direct leaking points were detected in all four cases who performed radioisotope study. Autologous epidural blood patches were applied to four cases, and all of them were improved without complication. Among four patients treated with conservative method, three were improved, but one patient was died of spontaneous chronic subdural hematoma. CONCLUSION: We suggest that 1) meticulous studies need to be performed aggressively if SIH is diagnosed clinically and radiologically, 2) the most effective study may be radioisotope study, and 3) if leaking point is found, aggressive management such as autologous epidural blood patches is recommended.

Long Term Follow up of complications in 43 Cases after Skull Base Approach

Skull base surgery has developed through the evolution of imaging, anatomic research, surgical approach and reconstructive techiques. The basic disciplines of approaching skull base lesions are to provide direct vision, minimize brain retraction, allow excellent exposure and minimal blood loss. Although many advantages listed above are reported, objective long-term follow up results about post-operative complications of this procedures were not introduced. This study was designed to review the complications of skull base approach that we experienced 43 cases by a team approach with neurosurgery-supraorbital rim osteotomy, orbitozygomatic osteotomy, orbitozygom aticoglen-oidotomy, orbitozygomaticoglenoidocondylotomy, and transfrontonasomaxillary osteotomy-through objective evalutation criteria. The result of this study demonstrated that the type of complications were consisted with perioperative infection (5 cases), subdural empyema (1 case), CSF leakage(1 case), hematoma (1 case), meningitis (3 cases), ophthalmic nerve injury (1 case),facial nerve injury (2 cases), T-M joint problem ( 2 cases), & enophthalmos ( 2cases). In conclusion, after performing the different skull base approaches, we analyzed several complications of the above procedures. We analyzed with the purpose of preventing complications in the next skull base approach.

The reconstruction of soft tissue defects of cranioface using modified lower trapezius musculocutaneous flap

Reconstruction of extensive soft tissue defect of the head and neck after or resection or injury has improved with advances in surgical techniques. Traditional local flap techniques are not easy to reconstruct the extensive soft tissue defects and irradiated or contaminated recipient beds. Then musculocutaneous flaps such as pectoralis major flap, trapezius flap, latissimus dorsi flap and sternocleidomastoid flap have been performed. These musculocutaneous flaps are effective in resurfacing the neck and lower face, for example, mandibular area but difficult to reconstruct the upper face and scalp and the result is poor. Other alternative flap used to cover this area is free flap, but this flap has many limitation too and therefore reconstructive surgeons have attempted to develop new flaps. There are three distinct musculocutaneous flaps, the superior, the lateral island, and the lower island flaps, that can be harvested from the trapezius muscle that are used in head and neck reconstruction. The lower trapezius musculocutaneous flap provides a long paddle of thin, pliable skin and muscle and offers the long are of rotation and thus the greater versatility of the three types of trapezius flaps. But this lower trapezius musculocutaneous flap has may problems to reconstruct the upper part of face and scalp by traditional method and has used mainly to resurface the neck and lower face. Thus, authors modified the procedure of lower trapezius flap and tried to reconstruct the upper part of face and scalp. The modification is that during the dissection, the trapezius muscle must be totally mobilized and the dorsal scapular artery must be preserved. By this procedure, blood flow can circulate effectively to the distal portion of flap and then modified flap has greater are of rotation and reliably reach higher portion of face and scalp. The operative results me that among the eight cases performed by modified lower trapezius musculocutaneouas flap, seven were reconstructed successfully, and remaining one presented partial flap necrosis and secondary procedure was needed. The functional defecits of donor site were minimal in all cases.

Atypical manifestation of solid and papillary epithelial neoplasm of the pancrease: case report

We report a rescently experienced case with atypical radiologic manifestation of solid and papillary epithelial neoplasm of the pancreas in a 37 years old female patient. The tumor had heavy calcification on its capsule wall and septa. Instead of the usual encapsulated lesion with partly solid and partly cystic-hemorrhagic components, the lesion consisted of numerous fine cavitations containing air without fluid component except focal abscess fluid.

A Case of Atrial Septal Aneurysm Associated with Atrial Septal Defect

The diagnosis of atrial septal defect by transthoracic echocardiography remains difficult in a small subset of patients because of either suboptimal acoustic windows or unusual anatomy, for example, fenestrated defects. wer report the case of a 52-year-old woman with a fenestratdd atrial septal aneurysm that was incompletely visualized by transthoracic echocardiography. Subsequent transesophageal echocardiography demonstrated atrial septal defect and two fenestrations within the atrial septal aneurysm with left-to-right shunting. All echocardiographic findings were confirmed at surgery. This case demonstrates the addinional diagnostic accuracy of transesophageal echocardiography for detecting disease of the atrial septum.