Clinical Analysis on Open Thoracic Cordotomy of the Cancer Pain

Patients with pain syndromes resulting from recurrent or metastatic cancer should be evaluated carefully to determine the cause of their pain and the need for appropriate antitumor treatment. The most effective ablative pain control procedure at the current time is cordotomy, which is indicated in patients with unilateral pain. The authors results of 12 antero-lateral thoracic cordotomies performed for intractable cancer pain between 1996-1998. The follow-up of these patients was continued for at least 12 months or until death to determine the late success of this procedure. Excellent surgical results were obtained in 100% after one week and in 50% in 6 months after operation. The operation was considered to be successful for patients with malignant disease of short life expectancy.

Three Cases of Primary Spinal Malignant Schwannomas: Case Reports

Malignant peripheral nerve sheath spinal tumours are relatively rare. A primary spinal location at the first onset is rarely reported in the literature, thus the clinical features and therapeutic results of these spinal malignant tumours are not defined. We describle three patients with primary spinal malignant schwannomas and stress the surgical mananement of these cases.

Clinical Analysis of 178 Metastatic Brain Tumors

OBJECTIVE: A retrospective clinical analysis for metastatic brain tumors was undertaken to understand demographic feature, to determine the survival rate, prognostic factors and to decide the role of surgery. PATIENTS AND METHODS: From 1987 to 1994, 178 patients with brain metastases were treated at our hospital. Data regarding the primary disease and characteristics of brain metastases were retrospectively collected. We used Kaplan-Meier method to assess survival rate, and log-rank test to compare survival rates between subgroups. RESULTS: The most common age at the time of diagnosis was sixth and seventh decade(62%). The male to female ratio was 97:81. The supratentorial lesions were in 128(77%, n=67) and multiple lesions were in 84(55%, n=52). The most common primary cancer was lung cancer(80, 45%), and metastases of unknown origin(28, 16%), breast(27, 15%), head and neck(11, 6%), colorectal cancer(7, 4%), and stomach cancer(6, 3%). The time to metastasis was shortest in lung cancer(15 months), and longest in head and neck cancer(61 months). The overall 1 year survival rate(1YSR) was 25.4% and median survival time(MST) was 5.6 months. There was no statistically significant difference in MST and 1YSR between single and multiple metastases. The 1YSR of metastatic brain tumor from head and neck cancer was 62.5% and that from breast, lung, and GI tract was 37.7%, 25.7%, and 8.3% respectively. The overall 1YSR and MST of resected group in single metastasis(n=0, resection plus whole brain radiation therapy; WBRT) were 33.3% and 6.6 months, and those of non-resected group(n=5, WBRT) were 31.5% and 5.6 months. The 1YSR and MST of resected group in single metastasis from lung cancer(n=) were 37.5% and 8.4 months, and those of non-resected group(n=6) were 25% and 4.8 months. But there were no statistically significant differences. Karnofsky performance scale score was improved in 37% of resected group, compared with 24% of non-resected group. CONCLUSION: Surgical removal of metastatic brain tumor in selected patients results in increased survival time and better quality of life. For the statistical significance, multi-institutional well-designed prospective randomized study is needed.

One-Stage Vertebral Reconstruction Combined with Posterior Instrumentation by Posterolateral Approach for Spinal Metastasis

The authors present a series of 12 patients who underwent one-stage spondylectomy, vertebral reconstruction, posterior segmental stabilization for malignant metastatic disease. Major indication for this approach includes three column involvement or untolerable thoracotomy. This operative method involved the spondylectomy via a bilateral transpedicular or unilateral extracavitary approach, vertebral body reconstruction with methlymethacrylate (MMA), and posterior stabilization with sublaminar wiring in one stage. Postoperatively, all patients improved neurologically. Average neurologic improvement was 1.5 Frankel grade. Pain relief was obtained in all patients. Recovery of sphincter change was obtained 7(88%) of the 8 patients. One patient died postoperatively due to pneumonia. Spinal alignment was maintained in all. The major advantage of this approach is that circumferential decompression of the spine and stabilization can be obtained safely by one stage.

Surgical Treatment of Metastatic Spinal Tumor

The authors present a series of 35 patients who underwent operation for metastatic spinal tumor. Patients were operated via anterior, posterior or posterolateral and combined anterior-posterior approach. The anterior approach was used in cases where there was no involvement of the posterior column, tolerable of a thoracotomy and involvement of three or less adjacent vertebral bodies. The posterior or posterolateral approach was used in cases with involvement of the posterior column, disease at two seperated locations, intolerable of a thoracotomy and involvement of three columns. The combined anterior-posterior approach was used when it was not enough to obtain stabilization with anterior or posterior approach alone and expected greater than 1 year life expectancy. Twenty-five(89%) of the 28 patients improved neurologically following surgery. Average neurologic improvement was 1.3 Frankel grade. Pain relief was obtained in twenty-six(93%) of the 28 patients. Recovery of spincter change was obtained twelve(80%) of the 15 patients. Two patients died postoperatively due to DIC and pneumonia. Prior to operation, selective spinal angiography and embolization were performed in nine patients with metastases from renal carcinoma, thyroid cancer and hepatoma to reduce intraoperative bleeding. The authors believe that the choice of surgical approach has to be individualized for each patient depending on extent and location of the tumor, general condition of patient, goal of therapy and life expectancy.

A Clinical Analysis of Metastatic Spine Tumors: Analysis of Prognostic Factors and Scoring System for Prognostic Evaluation

The purpose of treatment for metastatic spine tumor is to improve the quality of life. So, it is very important to carefully select the surgical candidates to prevent unnecessary surgery-related morbidity and mortality. For this purpose, the authors have surveyed 200 cases of spinal metastasis treated by radiotherapy alone or radiotherapy plus surgery to determine prognostic factors. In this study, we attempted to examine retrospectively the four factors, e.g.,primary tumor, pretreatment neurologic status, general condition and degree of cancer extension, affecting the prognosis of metastatic spine tumors. Each factor was ranked from 1 to 3 points according to the severity and the total score for each patient was obtained by adding the these points. As a result, it was found that the total score was highly correlated to the survival period. While the patients with a total score of 6 or lower survived 100 days or less, those of 10 or higher survived 300 days or more on average. Therefore, authors believe this scoring system would be helpful to the determine treatment modalities and the selection of the most suitable operative procedures.

Brain Stem Gliomas in Adult: Correlation between MRI, Clinical Findings and Outcome: Preliminary Report

An analysis of 13 patients with brain stem glioma in adult, treated between 1988 and 1995, was undertaken. The purpose of this study is to establish the correlations between the MRI appearance, clinical findings and the prognosis. Based on the MRI appearance of the tumor at the time of clinical diagnosis, tumors were divided into four types: intrinsic diffuse, intrinsic focal, intrinsic cervicomedullary and exophytic type. Five patients were diagnosed pathologically by means of stereotactic biopsy(2 patients) and open surgery(3 patients), the rest were diagnosed on the basis of MRI appearance. All patients had received radiation therapy, and 11 patients had received chemotherapy during or immediately after radiation therapy. The methods of radiation therapy were either conventional or hyperfractionated type. The histological features were not always correlated with the prognosis. MRI and clinical findings could suggest the prognosis and probably the histological nature of the tumors. Moreover, response to initial radiotherapy and chemotherapy was considered to be a good prognostic factor. Seven of the 13 patients had response to the initial radiotherapy and chemotherapy. The poor prognostic factors determined in our study were 1) diffuse type 2) rapid growing with rim enhancement in spite of initial radiotherapy and chemotherapy 3) malignant pathologic finding 4) intratumoral necrosis after radiotherapy 5) multiple site involvement. The good prognostic factors were 1) intrinsic focal type 2) intrinsic cervicomedullary type 3) no cranial nerve involvement 4) good response to initial radiotherapy and chemotherapy.

Treatment of Recurrent Gliomas with PCV Chemotherapy : A Preliminary Report

Twelve patients with recurrent malignant glioma were treated with combination chemotherapy, consisting of procarbazine(60mg/m2, 8th-21th day), CCNU(110mg/m2, 1st day), and vincristine(1.4mg/m2, 8th and 29th day) every 6 weeks. Most patients had undergone initial resection of primary tumor, postoperative radiotherapy, and another form of chemotherapy. Response or progression was defined as improvement or deterioration in MRI scan. Assessment of response followed evaluation of MRI obtained after the completion of each two cycles of chemotherapy, if possible. Partial(more than 50% reduction of tumor mass) response at 15+ to 47+ weeks after chemotherapy was noted in three(60%) of the five patients with recurrent oligodendrogliomas. But in patients with recurrent anaplastic astrocytoma or gllioblastoma, partial response at 8+ weeks after chemotherapy was noted in one(14%) of the seven patients. It is suggested that PCV chemotherapy is more effective for patients with recurrent oligodendrogliomas than other recurre nt gliomas.

Contralateral Trigeminal Neuralgia Caused by Acoustic Neurinoma

Acase of trigeminal neuralgia caused by a contralateral acoustic neurinoma is presented. After removal of the tumor, the neuralgic pain has completely disappeared. The pathophysiology of this entity is briefly reviewed. The neuralgic pain may be caused by the compression of the contralateral trigeminal nerve by the mass effect in this case.

Intracranial Metastatic Adenoid Cystic Carcinoma: Report of Two Cases

The authors describe two cases of unusual intracranial metastatic adenoid cystic carcinomas. A 42-year-old woman had a right parietal epidural metastatic mass, presumed hematogenous, spread from a primary tumor in the parotid gland. In second case, a 32-year-old man had a intracranial metastatic adenoid cystic carcinoma mimicking calcified psammomatous meningioma on CT scans. We present the unusual cases with a review of relevant literature and a discussion of possible pathogenesis.

Intracranial Metastatic Adenoid Cystic Carcinoma: Report of Two Cases

The authors describe two cases of unusual intracranial metastatic adenoid cystic carcinomas. A 42-year-old woman had a right parietal epidural metastatic mass, presumed hematogenous, spread from a primary tumor in the parotid gland. In second case, a 32-year-old man had a intracranial metastatic adenoid cystic carcinoma mimicking calcified psammomatous meningioma on CT scans. We present the unusual cases with a review of relevant literature and a discussion of possible pathogenesis.

Continuous Free External Ventricular Drainage in Hypertensive Intracerebral Hemorrhage with Ventricular Rupture

There are several methods in the surgical treatment of hypertensive intracerebral hemorrhage, such as craniotomy and hematoma removal, stereotaxic aspiration of hematoma and external ventricular drainage with maintaining physiologic ventricular pressure(over-pressure EVD). In spite of all these methods, surgical treatment yields unsatisfactory results when the patient is comatous and show herniation signs preoperatively. We treated 9 cases of hypertensive intracerebral hemorrhage with ventricular rupture by hematoma removal and continuous free external ventricular drainage instead of over-pressure drainage. In 4 cases, during the drainage, obstruction of the drainage catheter by blood clots or clamping resulted in immediate deterioration of the patient's condition, which was reversed by maintaining the patency suggesting that postoperative control of ICP was essential in treating hypertensive intracerebral hemorrhage in addition to hematoma removal. 7 out of 9 cases regained consciousness and improved gradually with mild to serve neurologic deficit. One patient died of rebleeding in the midbrain and one was discharged by family's will.

Delayed Epidural Hematoma

Four cases of delayed post-traumatic epidural hematoma which had not been present on initial CT scan were found on repeated CT scan. The delayed epidural hematoma was developed after evacuation of a hematoma in all cases. And a skull fracture was present at the site of the delayed hematoma in two cases. The neurologic deterioration heralded the onset of delayed epidural hematoma after decompressive therapy by either surgical or medical means. Repeated CT scan is indicated if anticapated improvement from does not occur after decompression by either surgical or medical means, recovery from shock, or whenever there is evidence of even minimal bleeding under a skull fracture on the initial CT scan.

The Change of Total Ascorbic Acid Level in the Experimental Spinal Cord Injury

The changes of total ascorbic acid level in the spinal cord tissues following experimental spinal cord injury were observed in the 20 cats. Three small areas (2x1.5cm sized) in the thoracic cord following laminectomy were made and the specimens were removed in one control and the other two areas after 5 & 30 minutes following impact injury respectively in each cat. The significant decrease of the total ascorbic acid level after 5 & 30 minutes following experimental spinal cord injury was found.

A Case of Racemose Cysticercus Infection

Racemose cysticercosis, which is almost exclusively found in intracranial cavity in vary rare occasions, was recognized in a 54-year-old Korean woman. Brain CT revealed a large lobated cystic mass without marginal enhancement, in the right frontotemporal lobe, together with irregularly distributed calcified spots in the parietal area. A 5x6x7cm sized irregularly lobated mass in the subarachnoid space, containing 38ml of xanthochromic fluid was removed. Pathologically the cyst was a racemose cysticercus without scolex. The serum and CSF of the patient showed positive reaction with antigen of Cysticercose celluosae by micro-ELISA for their specific IgG antibody. After the surgery, the patient was treated with Praziquantel for remaining worms(as revealed by calcified spots on brain CT). Follow-up examinations showed improvement in both clinical symptoms and brain CT findings, but Cysticercus-specific IgG antibody level did not fall to normal for 1 year. The rarity of racemose cysticercus infection, together with evidences of concomitant occurrence with C. cellulosae warranted one's case report.

Fracture of the Dorsum Sella

Fracture involving the sella turcica is a rare complication of head injury but draws attention of neurosurgeon because it can result in serious neurological, vascular and endocrine complications. Anatomically the sella being located central within the extensive basal dural attachments to the cranial vault, shearing force is transmitted directly to this structure and results in isolated complications. We recently experienced a case of fractured dorsum sellae complicated with cranial nerve palsy and report here with some references.