Long-Term Outcome of Unilateral Acoustic Neuromas With or Without Hearing Loss: Over 10 Years and Beyond After Gamma Knife Radiosurgery

Background@#Since the long-term outcomes of 162 patients who underwent gamma knife radiosurgery (GKS) as an initial or adjuvant treatment for acoustic neuromas (ANs) with unilateral hearing loss were first reported in 1998, there has been no report of a comprehensive analysis of what has changed in GKS practice. @*Methods@#We performed a retrospective study of the long-term outcomes of 106 patients with unilateral sporadic ANs who underwent GKS as an initial treatment. The mean patient age was 50 years, and the mean initial tumor volume was 3.68 cm 3 (range, 0.10–23.30 cm 3 ).The median marginal tumor dose was 12.5 Gy (range, 8.0–15.0 Gy) and the median follow-up duration was 153 months (range, 120–216 months). @*Results@#The tumor volume increased in 11 patients (10.4%), remained stationary in 27 (25.5%), and decreased in 68 patients (64.2%). The actuarial 3, 5, 10, and 15-year tumor control rates were 95.3 ± 2.1%, 94.3 ± 2.2%, 87.7 ± 3.2%, and 86.6 ± 3.3%, respectively.The 10-year actuarial tumor control rate was significantly lower in the patients with tumor volumes of ≥ 8 cm 3 (P = 0.010). The rate of maintaining the same Gardner-Robertson scale grade was 28.6%, and that of serviceable hearing was 46.4%. The rates of newly developed facial and trigeminal neuropathy were 2.8% and 4.7%, respectively. The patients who received marginal doses of less than 12 Gy revealed higher tumor control failure rates (P = 0.129) and newly occurred facial or trigeminal neuropathy rates (P = 0.040 and 0.313, respectively). @*Conclusion@#GKS as an initial treatment for ANs could be helpful in terms of tumor control, the preservation of serviceable hearing, and the prevention of cranial neuropathy. It is recommended to perform GKS as soon as possible not only for tumor control in unilateral ANs with hearing loss but also for hearing preservation in those without hearing loss.

Update on Pathologic and Radiologic Diagnosis of Combined Hepatocellular-Cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a malignant primary liver carcinoma characterized by the unequivocal presence of both hepatocytic and cholangiocytic differentiation within the same tumor. Recent research has highlighted that cHCC-CCAs are more heterogeneous than previously expected. In the updated consensus terminology and WHO 2019 classification, “classical type” and “subtypes with stem-cell features” of the WHO 2010 classification are no longer recommended. Instead, it is recommended that the presence and percentages of various histopathologic components and stem-cell features be mentioned in the pathologic report. The new terminology and classification enable the exchange of clearer and more objective information about cHCC-CCAs, facilitating multi-center and multinational research. However, there are limitations to the diagnosis of cHCC-CCA by imaging and biopsy. cHCC-CCAs showing typical imaging findings of HCC could be misdiagnosed as HCC and subjected to inappropriate treatment, if other clinical findings are not sufficiently considered. cHCC-CCAs showing at least one of the CCA-like imaging features or unusual clinical features should be subjected to biopsy. There may be a sampling error for the biopsy diagnosis of cHCC-CCA. An optimized diagnostic algorithm integrating clinical, radiological, and histopathologic information of biopsy is required to resolve these diagnostic pitfalls.

Long-term Outcome of Microscopic Transsphenoidal Surgery for Prolactinomas as an Alternative to Dopamine Agonists

Background@#Although long-term dopamine agonist (DA) therapy is recommended as a first-line treatment for prolactinoma, some patients may prefer surgical treatment because of the potential adverse effects of long-term medication, or the desire to become pregnant. This study aimed to determine whether surgical treatment of prolactinomas could be an alternative to DA therapy. @*Methods@#In this retrospective study, 96 consecutive patients (74 female, 22 male) underwent primary pituitary surgery without long-term DA treatment for prolactinomas at a single institution from 1990 to 2010. All patients underwent primary surgical treatment in the microscopic transsphenoidal approach (TSA). @*Results@#The median age and median follow-up period were 31 (16–73) years and 139.1 (12.2–319.6) months, respectively. An initial overall remission was accomplished in 47.9% (46 of 96 patients, 33 macroadenomas, and 13 microadenomas) of patients. DA dose reduction was achieved in all patients after TSA. A better remission rate was independently predicted by lower diagnostic prolactin levels and by a greater extent of surgical resection. Overall remission at the last follow-up was 33.3%, and the overall recurrence rate was 30.4%. The permanent complication rate was 3.1%, and there was no mortality. @*Conclusion@#TSA can be considered a safe and potentially curative treatment for selective microprolactinomas as an alternative to treatment with a long-term DA.

Should Threshold Growth Be Considered a Major Feature in the Diagnosis of Hepatocellular Carcinoma Using LI-RADS?

Objective@#Based on the Liver Imaging Reporting and Data System version 2018 (LI-RADS, v2018), this study aimed to analyze LR-5 diagnostic performance for hepatocellular carcinoma (HCC) when threshold growth as a major feature is replaced by a more HCC-specific ancillary feature, as well as the frequency of threshold growth in HCC and non-HCC malignancies and its association with tumor size. @*Materials and Methods@#This retrospective study included treatment-naive patients who underwent gadoxetate disodiumenhanced MRIs for focal hepatic lesions and surgery between January 2009 and December 2016. The frequency of major and ancillary features was evaluated for HCC and non-HCC malignancies, and the LR-category was assessed. Ancillary features that were significantly more prevalent in HCC were then used to either replace threshold growth or were added as additional major features, and the diagnostic performance of the readjusted LR category was compared to the LI-RADS v2018. @*Results@#A total of 1013 observations were analyzed. Unlike arterial phase hyperenhancement, washout, or enhancing capsule which were more prevalent in HCCs than in non-HCC malignancies (521/616 vs. 18/58, 489/616 vs. 19/58, and 181/616 vs. 5/58, respectively; p 0.999) were comparable to the LI-RADS v2018. @*Conclusion@#Threshold growth is not a significant diagnostic indicator of HCC and is more common in non-HCC malignancies. The diagnostic performance of LR-5 was comparable when threshold growth was recategorized as an ancillary feature and replaced by a more HCC-specific ancillary feature.

Update on Pathologic and Radiologic Diagnosis of Combined Hepatocellular-Cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a malignant primary liver carcinoma characterized by the unequivocal presence of both hepatocytic and cholangiocytic differentiation within the same tumor. Recent research has highlighted that cHCC-CCAs are more heterogeneous than previously expected. In the updated consensus terminology and WHO 2019 classification, “classical type” and “subtypes with stem-cell features” of the WHO 2010 classification are no longer recommended. Instead, it is recommended that the presence and percentages of various histopathologic components and stem-cell features be mentioned in the pathologic report. The new terminology and classification enable the exchange of clearer and more objective information about cHCC-CCAs, facilitating multi-center and multinational research. However, there are limitations to the diagnosis of cHCC-CCA by imaging and biopsy. cHCC-CCAs showing typical imaging findings of HCC could be misdiagnosed as HCC and subjected to inappropriate treatment, if other clinical findings are not sufficiently considered. cHCC-CCAs showing at least one of the CCA-like imaging features or unusual clinical features should be subjected to biopsy. There may be a sampling error for the biopsy diagnosis of cHCC-CCA. An optimized diagnostic algorithm integrating clinical, radiological, and histopathologic information of biopsy is required to resolve these diagnostic pitfalls.

Long-term Outcome of Microscopic Transsphenoidal Surgery for Prolactinomas as an Alternative to Dopamine Agonists

Background@#Although long-term dopamine agonist (DA) therapy is recommended as a first-line treatment for prolactinoma, some patients may prefer surgical treatment because of the potential adverse effects of long-term medication, or the desire to become pregnant. This study aimed to determine whether surgical treatment of prolactinomas could be an alternative to DA therapy. @*Methods@#In this retrospective study, 96 consecutive patients (74 female, 22 male) underwent primary pituitary surgery without long-term DA treatment for prolactinomas at a single institution from 1990 to 2010. All patients underwent primary surgical treatment in the microscopic transsphenoidal approach (TSA). @*Results@#The median age and median follow-up period were 31 (16–73) years and 139.1 (12.2–319.6) months, respectively. An initial overall remission was accomplished in 47.9% (46 of 96 patients, 33 macroadenomas, and 13 microadenomas) of patients. DA dose reduction was achieved in all patients after TSA. A better remission rate was independently predicted by lower diagnostic prolactin levels and by a greater extent of surgical resection. Overall remission at the last follow-up was 33.3%, and the overall recurrence rate was 30.4%. The permanent complication rate was 3.1%, and there was no mortality. @*Conclusion@#TSA can be considered a safe and potentially curative treatment for selective microprolactinomas as an alternative to treatment with a long-term DA.

Should Threshold Growth Be Considered a Major Feature in the Diagnosis of Hepatocellular Carcinoma Using LI-RADS?

Objective@#Based on the Liver Imaging Reporting and Data System version 2018 (LI-RADS, v2018), this study aimed to analyze LR-5 diagnostic performance for hepatocellular carcinoma (HCC) when threshold growth as a major feature is replaced by a more HCC-specific ancillary feature, as well as the frequency of threshold growth in HCC and non-HCC malignancies and its association with tumor size. @*Materials and Methods@#This retrospective study included treatment-naive patients who underwent gadoxetate disodiumenhanced MRIs for focal hepatic lesions and surgery between January 2009 and December 2016. The frequency of major and ancillary features was evaluated for HCC and non-HCC malignancies, and the LR-category was assessed. Ancillary features that were significantly more prevalent in HCC were then used to either replace threshold growth or were added as additional major features, and the diagnostic performance of the readjusted LR category was compared to the LI-RADS v2018. @*Results@#A total of 1013 observations were analyzed. Unlike arterial phase hyperenhancement, washout, or enhancing capsule which were more prevalent in HCCs than in non-HCC malignancies (521/616 vs. 18/58, 489/616 vs. 19/58, and 181/616 vs. 5/58, respectively; p 0.999) were comparable to the LI-RADS v2018. @*Conclusion@#Threshold growth is not a significant diagnostic indicator of HCC and is more common in non-HCC malignancies. The diagnostic performance of LR-5 was comparable when threshold growth was recategorized as an ancillary feature and replaced by a more HCC-specific ancillary feature.

Feasibility of Simultaneous Multislice Acceleration Technique in Diffusion-Weighted Magnetic Resonance Imaging of the Rectum

Robotic Single-Site Hysterectomy versus Robot-Assisted Multiport Hysterectomy in Benign Gynecologic Diseases: A Retrospective Comparison of Clinical and Surgical Outcomes

OBJECTIVE: The purpose of this study was to compare clinical and surgical outcomes of robotic single-site hysterectomy (RSSH) and robot-assisted multiport hysterectomy (RH) in benign disease. METHODS: We retrospectively reviewed the medical records of 38 women who underwent RSSH (N=12) or RH (N=26) for the treatment of benign uterine disease between June 2015 and November 2017. RESULTS: There were no intergroup differences in parity, comorbidities, and number of previous abdominal surgery. Mean age was older (49.5±5.05 years vs. 44.4±3.54 years, P=0.001) and mean body mass index was higher (27.4±2.47 kg/m2 vs. 25.3±3.12 kg/m2, P=0.045) in RSSH group than RH group. Surgical outcomes, including operative time (165.0 minutes vs. 159.2 minutes, P=0.727), estimated blood loss (115.8±33.15 mL vs. 108.1±56.42 mL, P=0.662), uterus weight (445.9±157.21 g vs. 374.5±197.91 g, P=0.291), postoperative hospital stay (5.4±0.51 days vs. 5.8±1.20 days, P=0.289), postoperative hemoglobin change in day 1 (1.8±0.89 g/dL vs. 1.4±1.53 g/dL, P=0.431) and day 3 (2.1±1.32 g/dL vs. 1.7±1.83 g/dL, P=0.601), and perioperative complications did not significantly differ between two groups. The use of additional analgesics after 6 hours, 24 hours, and 48 hours, and mean NRS score after 6 hours, 24 hours, and 48 hours were not significantly different between two groups. CONCLUSION: RSSH might be an effective and safe alternative to RH, even if in older and/or obese women with large uteri.

Nutrient Intakes of Male College Combat Sport Athletes by Weight Control Status / 대한지역사회영양학회지

OBJECTIVES: Weight control practices are common in combat sport athletes. This study was performed to examine nutrient intakes of male college combat sport athletes (taekwondo, boxing, judo) by weight control (WC) status. METHODS: Subjects were male combat sport athletes (n=90) from colleges in Gyeonggi Province. Survey was conducted during 2016. Questionnaire included general characteristics, weight control, and dietary intakes during the period of training, weight control, weigh-in ~ before competition and between competitions. Subjects were grouped into high- and normal WC groups. T-test, χ²-test, Fisher's exact test and ANCOVA were used to analyze the data. RESULTS: During training, energy intake was 75.4% of EER and C:P:F ratio was 57.5:13.9:28.7. Iron and zinc intakes were different by WC groups (p<0.05). During weight control, energy intake was 44.7% of EER in normal WC and 30.5% in high WC group (p<0.05). C:P:F ratio was 69:11.1:19.5, and ratio from protein and fat was lower in the high WC group (p<0.05). Most nutrient intakes during weight control were less than 50% of 2015 KDRIs (RNI or AI), and intakes including thiamin (p<0.01), vitamin A, riboflavin, niacin, folate, calcium, potassium and zinc (p<0.05) were significantly lower in the high WC. Energy intake after weighing before the competition was 1,315 kcal, and energy (kcal/kg BW, p<0.05) and carbohydrate intakes (g/kg BW, p<0.01) were significantly higher in the high WC group. Energy intake between competitions was 691.1 kcal, with no difference by the WC group. CONCLUSIONS: Nutrients intakes of combat sport athletes were inadequate. Dietary intakes during weight control were much below than the KDRIs, especially in the high WC group. It is needed to develop nutrition education programs for combat sport athletes to avoid severe energy restrictions and to apply specific dietary guides to each period of training and weight control.

NAMPT enzyme activity regulates catabolic gene expression in gingival fibroblasts during periodontitis

Periodontal disease is one of the most prevalent chronic disorders worldwide. It is accompanied by inflammation of the gingiva and destruction of periodontal tissues, leading to alveolar bone loss. Here, we focused on the role of adipokines, which are locally expressed by periodontal tissues, in the regulation of catabolic gene expression leading to periodontal inflammation. The expression of the nicotinamide phosphoribosyltransferase (NAMPT) adipokine was dramatically increased in inflamed human and mouse gingival tissues. NAMPT expression was also increased in lipopolysaccharide- and proinflammatory cytokine-stimulated primary cultured human gingival fibroblasts (GF). Adenovirus-mediated NAMPT (Ad-Nampt) overexpression upregulated the expression and activity of COX-2, MMP1 and MMP3 in human GF. The upregulation of IL-1β- or Ad-Nampt-induced catabolic factors was significantly abrogated by the intracellular NAMPT (iNAMPT) inhibitor, FK866 or by the sirtuin (SIRT) inhibitor, nicotinamide (NIC). Recombinant NAMPT protein or extracellular NAMPT (eNAMPT) inhibition using a blocking antibody did not alter NAMPT target gene expression levels. Moreover, intragingival Ad-Nampt injection mediated periodontitis-like phenotypes including alveolar bone loss in mice. SIRT2, a part of the SIRT family, was positively associated with NAMPT actions in human GF. Furthermore, in vivo inhibition of the NAMPT-NAD⁺-SIRT axis by NIC injection in mice ameliorated the periodontal inflammation and alveolar bone erosion caused by intragingival injection of Ad-Nampt. Our findings indicate that NAMPT is highly upregulated in human GF, while its enzymatic activity acts as a crucial mediator of periodontal inflammation and alveolar bone destruction via regulation of COX-2, MMP1, and MMP3 levels.

Porocarcinoma Arising in a Ganglion Cyst: A Case Report and Review of the Literature

Eccrine porocarcinoma is a rare malignant neoplasm of the eccrine sweat gland that often occurs in the lower extremities, and usually affects elderly individuals. Most cases of eccrine porocarcinoma arise de novo. We encountered a case of a large porocarcinoma arising in a pre-existing ganglion cyst in the knee. The malignant tumor was excised widely, and the defect was reconstructed using a free anterolateral thigh flap.

Bone Framework Graft through an Intraoral Approach in a Patient with Columellar Scar Contracture

We present our experience with calvarial bone framework insertion through an intraoral approach for a patient who was at risk for columellar necrosis due to a previous open rhinoplasty. A 58-year-old woman exhibited severe columellar contracture, so that the columellar tissue was too fragile to be touched. We could not incise the columella and insert a new nasal implant through the bilateral rim incision. Moreover, the patient had septal cartilage perforation and collapse. The patient needed columellar support as well as nasal dorsum reconstruction. The authors decided to graft an autogenous L-strut bone framework through an intraoral approach. Two pieces of 5-cm × 1-cm sized split calvarial bone were harvested and trimmed to fit the width and length of the nasal dorsum and columella. The right-angle-shaped bone framework was made with an absorbable plate and screws. Through a gingivobuccal incision, the bone framework graft was inserted and the graft was fixed with absorbable screws. The patient did not experience complications such as skin necrosis or inflammation. A bone framework grafted through an intraoral approach can be a good choice for patients who have experienced scar contracture in the columella, septal cartilage perforation, and collapse.

Cryptogenic Temporal Hollowing

Temporal hollowing is a common complication that occurs after coronal approach surgeries. However, temporal hollowing without previous nerve damage or trauma history is rare. Herein, we present a patient with cryptogenic temporal hollowing. A 22-year-old man without any history of craniofacial interventions or trauma presented with temporal hallowing. Magnetic resonance imaging revealed fatty degeneration of the left temporalis muscle. Electromyography and nerve conduction study showed no signs of neurologic abnormalities. The patient received autologous fat injection of 30 mL harvested from the left thigh using the modified Coleman technique. Temporal hollowing is commonly caused by atrophy of the superficial temporal fat pad. Its incidence is reported to be as high as 6% after coronal approach operation. Augmentation using porous hydroxyapatite or titanium mesh is a treatment option. Autologous fat graft can also be an option for mild to moderate temporal hollowing. In this case, a patient with no history of trauma, surgery, or myogenic disease developed temporal hollowing. Further study of the littleknown cryptogenic form of temporal hollowing is warranted.

Acquired Palatal Fistula in Patients with Submucous and Incomplete Cleft Palate before Surgery

It is uncommon for a palatal fistula to be detected in individuals who have not undergone surgery, and only sporadic cases have been reported. It is even more difficult to find cases of acquired palatal fistula in patients with submucous or incomplete cleft palate. Herein, we present 2 rare cases of this phenomenon. Case 1 was a patient with submucous cleft palate who acquired a palatal fistula after suffering from oral candidiasis at the age of 5 months. Case 2 was a patient with incomplete cleft palate who spontaneously, without trauma or infection, presented with a palatal fistula at the age of 9 months.

The Epidemiology and Importance of Osteoporotic Spinal Compression Fracture in South Korea

STUDY DESIGN: Review of the literature on the epidemiology and importance of osteoporotic spinal fractures. OBJECTIVES: To determine the epidemiology and importance of osteoporotic spinal fractures. SUMMARY OF LITERATURE REVIEW: Osteoporotic spinal fractures have been increasing in recent years. MATERIALS AND METHODS: Review of the literature. RESULTS: Osteoporotic spinal fractures can lead to a reduced quality of life and reduced life expectancy with increasing morbidity. They can also be a major cause of additional spinal fractures or secondary fractures. CONCLUSIONS: In an aging society, osteoporotic spinal fractures are considered a social problem. Preventive care should be emphasized.

Perioperative Blood Loss in Intramedullary Hip Screw for Intertrochanteric Fracture: Analysis of Risk Factors

PURPOSE: We compared visible blood loss and calculated blood loss after intramedullary fixation in intertrochanteric fracture, and evaluated correlation between blood loss and its risk factors. MATERIALS AND METHODS: A total of 256 patients who underwent closed reduction and intramedullary fixation in femoral intertrochanteric fracture between 2004 and 2013 were enrolled in this study. The total blood loss was calculated using the formula reported by Mercuiali and Brecher. We analyzed several factors, including fracture pattern (according to Evans classification), gender, age, body mass index (BMI), anesthesia method, cardiovascular and cerebrovascular disease, preoperative anemia, American Society of Anesthesiologists (ASA) score and use of antithrombotic agents. RESULTS: Total calculated blood loss (2,100+/-1,632 ml) differed significantly from visible blood loss (564+/-319 ml). In addition, the blood loss of unstable fracture patient was 2,496+/-1,395 ml and multivariate analysis showed a significant relationship between blood loss and fracture pattern (p<0.01). However, other factors showed no statistically significant difference. CONCLUSION: Total calculated blood loss was much greater than visible blood loss. Patients with unstable intertrochanteric fracture should be treated with care in order to reduce blood loss.

Incidence of Primary Spinal Cord, Spinal Meninges, and Cauda Equina Tumors in Korea, 2006-2010 / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Primary spinal cord and appendage tumors (PSCAT) originating from the spinal cord, spinal meninges, and cauda equina are uncommon. Worldwide, population-based cancer registry data are mostly based on malignant tumors only, which means few data are available on PSCATs, including non-malignant tumors. Therefore, the objective of this study was to provide information regarding the incidence of both non-malignant and malignant PSCATs in Korea on a national level. MATERIALS AND METHODS: Incidence of PSCATs was estimated from cases diagnosed between 2006 and 2010 using the National Cancer Incidence Database in Korea. Age-adjusted rates were calculated using the world standard population, and male-to-female rate ratios were calculated by histology type. RESULTS: Of all PSCATs registered (n=3,312), 86.6% were non-malignant. The overall age-adjusted incidence of PSCATs was 1.08 per 100,000 person-years, with an incidence of 0.99 per 100,000 in females and 1.15 in males. The most common site of PSCATs was the spinal cord (83.4%), followed by spinal meninges (16.1%) and cauda equina (0.5%). The most common histological type was neurilemmoma (41.3%), followed by meningiomas (20.1%) and ependymomas (7.6%). Men had significantly higher rates than women for ependymomas and lymphomas but had lower rates for meningiomas. CONCLUSION: This study provides the first population-based analysis of PSCATs in Korea.

Regional Bone Loss as a Risk Factor for Distal Radius Fracture in Women under 60 Years Old / 대한골다공증학회지

OBJECTIVES: Some studies have suggested that lumbar spine and hip bone mineral density (BMD) are not associated with distal radius fractures (DRF), and a few studies have investigated regional BMDs at the fracture site, not just the lumbar or hip. We correlated distal radius BMD with DRF in postmenopausal women or =50 years old with DRF were enrolled in the fracture group, and 72 women without fractures were included as a control group. We measured distal radius BMD in the distal radius contralateral to the fractured bone in the fracture group and that of the lumbar body 5 days after the trauma. BMDs at the distal radius of each group were compared in three age groups (50~59, 60~69, and > or =70 years). Age- and site-specific BMDs were analyzed in each group. RESULTS: No significant differences in the rate of osteoporosis at the distal radius or lumbar spine were observed in patients > or =60 years old. However, BMD and T-score values of the distal radius in female patients were lower than those in controls <60 years old. BMD and T-score values of the distal radius were lower than those of the lumbar spine in the fracture group <60 years old. BMD of the distal radius also carried a higher relative risk. CONCLUSIONS: Low BMD of the distal radius was an indicator of regional BMD and could be a sensitive risk factor for DRF in women <60 years.

Inflamed Symptomatic Sellar Arachnoid Cyst: Case Report

Sellar arachnoid cysts are rare; an infected arachnoid cyst is extremely rare as only one case has been reported to date in the literature. Here, we report a patient with an infected or inflamed sellar arachnoid cyst that was successfully treated with transsphenoidal surgery (TSA). A 53-year-old female with a history of chronic sinusitis developed a headache 5 months ago, and one month before admission polyuria, polydipsia, and abnormal vaginal bleeding occurred. The magnetic resonance imaging (MRI) showed a sellar cystic mass with a thickened pituitary stalk. Preoperative hormonal study revealed normal pituitary hormone levels except for a moderate elevation of prolactin. She was diagnosed with diabetes insipidus of the central nervous system origin based on a water-deprivation test. TSA was performed under an impression of symptomatic Rathke's cleft cyst according to the MRI findings. Intraoperative findings showed confirmation of turbid intracystic contents, but micro-organisms were unidentified on microbial culture. Pathology of the cyst wall revealed inflamed meningoepithelial lining cells compatible with an arachnoid cyst.