Neurological Change after Gamma Knife Radiosurgery for Brain Metastases Involving the Motor Cortex

BACKGROUND: Although Gamma Knife radiosurgery (GKRS) can provide beneficial therapeutic effects for patients with brain metastases, lesions involving the eloquent areas carry a higher risk of neurologic deterioration after treatment, compared to those located in the non-eloquent areas. We aimed to investigate neurological change of the patients with brain metastases involving the motor cortex (MC) and the relevant factors related to neurological deterioration after GKRS. METHODS: We retrospectively reviewed clinical, radiological and dosimetry data of 51 patients who underwent GKRS for 60 brain metastases involving the MC. Prior to GKRS, motor deficits existed in 26 patients (50.9%). The mean target volume was 3.2 cc (range 0.001–14.1) at the time of GKRS, and the mean prescription dose was 18.6 Gy (range 12–24 Gy). RESULTS: The actuarial median survival time from GKRS was 19.2±5.0 months. The calculated local tumor control rates at 6 and 12 months after GKRS were 89.7% and 77.4%, respectively. During the median clinical follow-up duration of 12.3±2.6 months (range 1–54 months), 18 patients (35.3%) experienced new or worsened neurologic deficits with a median onset time of 2.5±0.5 months (range 0.3–9.7 months) after GKRS. Among various factors, prescription dose (>20 Gy) was a significant factor for the new or worsened neurologic deficits in univariate (p=0.027) and multivariate (p=0.034) analysis. The managements of 18 patients were steroid medication (n=10), boost radiation therapy (n=5), and surgery (n=3), and neurological improvement was achieved in 9 (50.0%). CONCLUSION: In our series, prescription dose (>20 Gy) was significantly related to neurological deterioration after GKRS for brain metastases involving the MC. Therefore, we suggest that careful dose adjustment would be required for lesions involving the MC to avoid neurological deterioration requiring additional treatment in the patients with limited life expectancy.

Radiation-Induced Intratumoral Necrosis and Peritumoral Edema after Gamma Knife Radiosurgery for Intracranial Meningiomas

OBJECTIVE: To study the clinical significance and relevant factors of radiation-induced intratumoral necrosis (RIN) and peritumoral edema (PTE) after Gamma knife radiosurgery (GKRS) for intracranial meningiomas. METHODS: We retrospectively analyzed the data of 64 patients who underwent GKRS for intracranial meningioma. The mean lesion volume was 4.9 cc (range, 0.3-20), and the mean prescription dose of 13.4 Gy (range, 11-18) was delivered to the mean 49.9% (range, 45-50) isodose line. RIN was defined as newly developed or enlarged intratumoral necrosis after GKRS. RESULTS: RIN and new development or aggravation of PTE were observed in 21 (32.8%) and 18 (28.1%) cases of meningioma, respectively during the median follow-up duration of 19.9+/-1.0 months. Among various factors, maximum dose (>25 Gy) and target volume (>4.5 cc) were significantly related to RIN, and RIN and maximum dose (>24 Gy) were significantly related to the development or aggravation of PTE. In 21 meningiomas with development of RIN after GKRS, there was no significant change of the tumor volume itself between the times of GKRS and RIN. However, the PTE volume increased significantly compared to that at the time of GKRS (p=0.013). The median interval to RIN after GKRS was 6.5+/-0.4 months and the median interval to new or aggravated PTE was 7.0+/-0.7 months. CONCLUSION: A close observation is required for meningiomas treated with a maximum dose >24 Gy and showing RIN after GKRS, since following or accompanying PTE may deteriorate neurological conditions especially when the location involves adjacent critical structures.

Therapeutic Effect of Gamma Knife Radiosurgery for Multiple Brain Metastases

OBJECTIVE: The aim of this study is to evaluate the therapeutic effects of gamma knife radiosurgery (GKRS) in patients with multiple brain metastases and to investigate prognostic factors related to treatment outcome. METHODS: We retrospectively reviewed clinico-radiological and dosimetric data of 36 patients with 4-14 brain metastases who underwent GKRS for 264 lesions between August 2008 and April 2011. The most common primary tumor site was the lung (n=22), followed by breast (n=7). At GKRS, the median Karnofsky performance scale score was 90 and the mean tumor volume was 1.2 cc (0.002-12.6). The mean prescription dose of 17.8 Gy was delivered to the mean 61.1% isodose line. Among 264 metastases, 175 lesions were assessed for treatment response by at least one imaging follow-up. RESULTS: The overall median survival after GKRS was 9.1+/-1.7 months. Among various factors, primary tumor control was a significant prognostic factor (11.1+/-1.3 months vs. 3.3+/-2.4 months, p=0.031). The calculated local tumor control rate at 6 and 9 months after GKRS were 87.9% and 84.2%, respectively. Paddick's conformity index (>0.75) was significantly related to local tumor control. The actuarial peritumoral edema reduction rate was 22.4% at 6 months. CONCLUSION: According to our results, GKRS can provide beneficial effect for the patients with multiple (4 or more) brain metastases, when systemic cancer is controlled. And, careful dosimetry is essential for local tumor control. Therefore, GKRS can be considered as one of the treatment modalities for multiple brain metastase.

Clinical Features of Intestinal Tuberculosis in Recent Ten Years (2001-2010)

BACKGROUND/AIMS: Intestinal tuberculosis (ITB) evades early diagnosis due to non-specific clinical manifestations and difficulties in confirming the disease process. In the current study, we determined the diagnostic appearance and clinical manifestations of ITB in recent 10 years according to diagnostic guidelines, as proposed by the IBD Study Group of Korean Association for the Study of the Intestinal Diseases (KASID). METHODS: Fifty-six patients with ITB who were diagnosed at Seoul Paik Hospital between January 2001 and August 2010 were retrospectively reviewed. The diagnosis of ITB was defined as definite or probable in accordance with the diagnostic guidelines and the clinical features were analyzed in comparison with previous studies involving ITB in Korea. RESULTS: The mean age at the time of diagnosis was 45+/-15 years (range, 17-71 years). Definite and probable diagnoses were obtained in 29% and 71% of the patients, respectively. Twenty-three percent of the patients had synchronous active pulmonary TB and 14% of the patients had other forms of abdominal TB, such as TB mesenteric lymphadenitis or peritonitis. The most common symptoms were abdominal pain (43%), followed by diarrhea (30%), weight loss (14%). Twenty-seven percent of the patients (15 cases) were asymptomatic and diagnosed on comprehensive health care or post-operative surveillance. Only 2 patients (3.6%) underwent surgery for complications, such as intestinal obstruction and perforation. CONCLUSIONS: ITB is still prevalent in Korea; however, in the recent 10 years the symptoms of ITB have been milder than previously reported. In addition, the complication rates of ITB were remarkably decreased, suggesting that early diagnosis of ITB was increased.

The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation. METHODS: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively. RESULTS: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications. CONCLUSIONS: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.

A Case of Esophageal Hemangioma Treated by Endoscopic Mucosal Resection / 대한소화기내시경학회지

Esophageal hemangioma occurs in fewer than three percent of all benign esophageal neoplasm. To treat symptomatic esophageal hemangioma, surgical resection can be performed. A case of esophageal hemangioma was successfully treated by endoscopic mucosal resection (EMR). The patient was a 50-year-old man who presented with dysphagia and epigastric discomfort. An endoscopic ultrasonography examination revealed an esophageal submucosal mass confined to the submucosal layer, with no continuity with adjacent vessels without regional lymphadenopathy. For diagnosis and symptomatic relief, EMR was performed. The final diagnosis was benign esophageal cavernous hemangioma. No complications have been evident during a 3-year follow-up.

Two Cases of Adrenal Cysts Assessed by Endoscopic Ultrasound-Guided Fine Needle Aspiration for Diagnostic and Therapeutic Purposes / 대한소화기내시경학회지

Adrenal cyst is a rare disease and its incidence rate is about 0.06~0.18%. Many cases of adrenal cysts are diagnosed incidentally. Surgical excision is generally performed to rule out malignancy when an adrenal cyst is detected. However, a reviewing the overall cases revealed that only 7% of adrenal cysts were malignant or potentially malignant. Thus, it has been suggested to observe an asymptomatic simple benign cyst after aspiration. From this point of view, it is necessary to perform a functional hormonal test and fine needle aspiration cytology for investigating the nature of adrenal cysts. Adrenal cyst drainage can be performed when surgical resection is not indicated. Computed tomography or ultrasonography guided percutaneous aspiration and drainage has been performed, but linear endoscopic ultrasound has not yet been used for this purpose. We have performed endoscopic ultrasound guided fine needle aspiration of adrenal cysts for cytologic and hormonal examination and endoscopic ultrasound guided adrenal cyst drainage, and we report here on our experiences with this technique.

Study of Acute Myelocytic Leukemia Patient Treatment That Used Total Skin Electron Beam / 의학물리

Total Skin Electron Beam Therapy (TSEBT) of linear accelerator has become use so as to be useful, 2~9 MeV of energy territories came to be used with mycosis fungoides and cutaneous lymphomas in the superficial lesion treatment which covers the major portion of the body. I treat a patient to Stanford technique in this study, and it is 60 degrees around the patients whom Stanford technique irradiated electronic beam to a linear accelerator in horizontal directions and there is a way a standard of TSEBT treat it to six located field (anterior, posterior, and four obliques) becoming. An each field does horizontally it and consist to beam of the two component which fitted the center to a suitable angle. a patient treats it to three dual field a day in order to make short treatment time. when a first day, we treat one dual field at anterior position and two dual field at posterior position. when the second day, treat one dual field at posterior position and two dual field at anterior position. Therefore, six dual field is finished in perfect periodic two days. we made cylindrical acrylic phantom, and I inserted a dosimeter film between phantom. in order to measure a dose distribution calculation before treat a patient, and a patient checked it in six field directions that got from a treatment. It is after that thermoluminescent dosimetry (TLD) as it uses Rando phantom and then measurement dose distribution in six field directions after attaching at chest, the right and left flank, a back after irradiation.

Study of Acute Myelocytic Leukemia Patient Treatment That Used Total Skin Electron Beam / 의학물리

Total Skin Electron Beam Therapy (TSEBT) of linear accelerator has become use so as to be useful, 2~9 MeV of energy territories came to be used with mycosis fungoides and cutaneous lymphomas in the superficial lesion treatment which covers the major portion of the body. I treat a patient to Stanford technique in this study, and it is 60 degrees around the patients whom Stanford technique irradiated electronic beam to a linear accelerator in horizontal directions and there is a way a standard of TSEBT treat it to six located field (anterior, posterior, and four obliques) becoming. An each field does horizontally it and consist to beam of the two component which fitted the center to a suitable angle. a patient treats it to three dual field a day in order to make short treatment time. when a first day, we treat one dual field at anterior position and two dual field at posterior position. when the second day, treat one dual field at posterior position and two dual field at anterior position. Therefore, six dual field is finished in perfect periodic two days. we made cylindrical acrylic phantom, and I inserted a dosimeter film between phantom. in order to measure a dose distribution calculation before treat a patient, and a patient checked it in six field directions that got from a treatment. It is after that thermoluminescent dosimetry (TLD) as it uses Rando phantom and then measurement dose distribution in six field directions after attaching at chest, the right and left flank, a back after irradiation.

A Case of Cytomegalovirus-Associated Esophageal and Duodenal Ulcers in a Critically Ill Immunocompetent Patient / 대한소화기내시경학회지

Cytomegalovirus (CMV) infection usually occurs in immunocompromised individuals such as patients who receive chemotherapy, glucocorticoid therapy, and patients infected with human immunodeficiency virus (HIV). CMV infection can also occur in immunocompetent adults, but active infection is apparently rare. CMV infection can present anywhere in the gastrointestinal tract, most commonly in the colon and rarely in the small intestine. Simultaneous CMV infection in the stomach, small bowel and colon of immunocompetent adults has rarely been reported. We report a case of cytomegalovirus-associated esophageal and duodenal ulcers in an immunocompetent adult where the patient had undergone a neurosurgical operation.

A Case of Endoscopic Ultrasound Guided Cholangiography with Antegrade Drainage / 대한소화기내시경학회지

An 84-year-old woman presented with obstructive jaundice due to unresectable gallbladder cancer with a left renal cell carcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) were unsuccessful because of tumor obstruction of the duodenal bulb, right hepatic duct and distal common bile duct. Endoscopic ultrasound (EUS)-guided biliary drainage with a transgastric approach was performed. A guide-wire was passed through the biliary obstruction and was successfully advanced into the duodenum via the ampulla. The procedure was completed in an antegrade fashion. The obstructed biliary system was successfully decompressed by the insertion of a biliary covered metal stent through the malignant stricture. There were no complications related to the use of this procedure.

Tracheal collapsibility measured using end-expiratory chest CT in chronic airway disease / 대한내과학회지

BACKGROUND/AIMS: Partial tracheal narrowing can occur during expiration in the normal population. It is not certain whether the trachea collapses more readily in chronic airway disease. We evaluated the tracheal narrowing at end-expiration using computed tomography (CT). METHODS: We investigated 45 patients and 22 normal subjects who underwent high-resolution CT and pulmonary function tests. In each subject, two CT images at the same level of the aortic arch were compared: one at end-inspiration and the other at end-expiration. The cross-sectional area and sagittal diameter of the trachea were measured using a hand-tracing method, using the in-program measuring tools of Medical Image Viewer, and the percentage changes of each value were calculated. RESULTS: Of the 45 patients with chronic airway disease, 21 had chronic obstructive pulmonary disease, 16 had bronchial asthma, and 8 had bronchiectasis. The mean change in the cross-sectional area was 13.3% in the patients and 9.0% in the normal subjects (p0.05). The decrease in tracheal cross-sectional area was greatest in bronchiectasis, while the greatest decrease in sagittal diameter was in bronchial asthma. There was no significant difference in tracheal collapsibility among the disease groups. The percent change in the tracheal cross-sectional area was correlated with the % predicted FVC (r=-0.033, p<0.05) and FEV1 (r= 0.277, p<0.05) in both the patients and normal controls. CONCLUSIONS: The decrease in tracheal cross-sectional area at end-expiration measured using chest CT was greater in chronic airway disease than in normal subjects, and was associated with ventilatory function.

A Case of Treatment with Etanercept in Rheumatoid Arthritis Patient on Hemodialysis / 대한류마티스학회지

Disease-modifying antirheumatic drugs (DMARDs) have been used for rheumatoid arthritis (RA) with the aim of controlling synovitis and reducing radiologic progression. Although methotrexate (MTX) is one of the most effective DMARDs, it may cause severe adverse effects. Especially, hematologic toxicity including leukopenia, thrombocytopenia, and fatal pancytopenia is reported in patients with impaired renal function, since renal excretion constitutes the major route of MTX elimination. Tumor necrosis factor-alpha (TNF alpha) inhibitors are well-established biologic agents for the treatment of RA and their clinical efficacy and safety are already demonstrated. But there were few reports on the efficacy and safety in dialysis patients. We described a case of hemodialysis patient with refractory RA that was successfully treated with etanercept, and discussed with literature review.

A Case of a False Positive FDG-PET/CT Scan in Esophageal Leiomyoma / 대한소화기내시경학회지

Esophageal leiomyoma is relatively rare disease, but can appears with a high uptake of fluorodeoxuglucose (FDG), a false-positive finding on a FDG PET/CT scan. A 64- year-old woman after a total thyroidectomy due to papillary and follicular carcinoma showed a high uptake of FDG in the distal esophagus on a subsequent FDG PET/ CT scan. The presence of an esophageal leiomyoma was suspicious from preoperative findings of endoscopic ultrasound and computed tomography, and an esophagectomy and proximal gastrectomy were performed, as the presence of a malignant lesion could not be excluded. As high uptake of FDG in the lesion on an FDG PET/CT scan corresponds to an esophageal cancer, an esophagectomy and proximal gastrectomy were performed and the lesion was confirmed as an esophageal leiomyoma after surgical biopsies. We report this case with a review of the relevant literature.

Chronic Sclerosing Dacryoadenitis: Report of 2 Cases

Chronic sclerosing dacryoadenitis is a rare and under-recognized chronic inflammatory disease of the lacrimal gland. We describe 2 patients with a localized type of chronic sclerosing dacryoadenitis. Both patients presented with a slowly growing painless mass of the eyelid mimicking a tumorous lesion. The morphologic findings of the masses excised under the clinical diagnosis of lymphoma closely recapitulate those of chronic sclerosing sialadenitis (Kuttner tumor). Immunohistochemical staining demonstrated an increased population of IgG4-positive plasma cells confirming that this disease also belongs to the spectrum of a recently described IgG4-related sclerosing disease.

Paradoxical Response Developed during the Antituberculous Treatment in Tuberculous Pleurisy / 결핵및호흡기질환

BACKGROUND: A paradoxical response is defined as the radiological and clinical worsening of a previous lesion or the development of new lesion after initial improvement during theprocess of antituberculous treatment. The related factors for the development of a paradoxical response in patients with tuberculous pleurisy are not certain. METHODS: We selected patients with tuberculous pleurisy who had been treated for more than 4 months. The changes onthe serial chest X-ray findings before and after treatment were reviewed. Paradoxical responses were regarded as any worsening or development of new lesion at least 2 weeks after the initiation of treatment. The baseline clinical characteristics and laboratory findings of the peripheral blood and pleural fluid were compared between the patients with a paradoxical response and the patients without a paradoxical response. RESULTS: Paradoxical responses appeared in sixteen patients (21%) among the 77 patients.It took a mean of 38.6 days after the treatment and the time to resolve the paradoxical response was a mean of 32.1 days. For the patients with a paradoxical response, the median age was younger (30.5 years vs 39.0 years, respectively) and the lymphocytic percentage of white blood cells in the pleural fluid was higher (82.1% vs 69.6%, respectively) than for the patients without a paradoxical response. CONCLUSION: The development of a paradoxical response during the treatment of patients with tuberculous pleurisy was not rare and this was related with the age of the patients and the percentage of lymphocytic white blood cells in the pleural fluid.

A case of gastrointestinal stromal tumor of the stomach showing exophytic growth / 대한내과학회지

Gastroinstestinal stromal tumors (GISTs) are defined as a group of KIT (CD117) positive mesenchymal tumors. Approximately 70% of those tumors are found in the stomach followed in order by the small bowel, colon and rectum, esophagus. The common clinical presentation of GISTs varies according to the size and location of the tumors, ranging from massive gastrointestinal bleeding to vague abdominal pain. We detected a GIST of the stomach incidentally during chest-computed tomography examination of a 68-year-old-woman. Esophagogastroduodenoscopy showed an 8 cm sized protruded lesion with normal mucosal covering on the posterior wall of the gastric body, and endoscopic ultrasonography showed a cystic mass originating in the fourth layer of the stomach. The patient was treated with a subtotal gastrectomy. Immunohistochemical studies on the surgical resection specimen showed CD117(+) and CD34(+). The final diagnosis was a GIST of the stomach showing exophytic growth.

Factors affecting the outcome of the ankle fractures / 대한정형외과학회잡지

No abstract available.