Gastroesophageal adenocarcinoma metastasizing to the chest wall: A case report and mini­review of the literature.

Subcutaneous metastasis from esophageal cancer (EC), particularly to the chest wall, is a very rare phenomenon. The present study describes a case of gastroesophageal adenocarcinoma that metastasized to the chest wall, invading the fourth anterior rib. A 70-year-old female presented with acute chest pain 4 months after undergoing Ivor-Lewis esophagectomy for gastroesophageal adenocarcinoma. A chest ultrasound revealed a solid hypoechoic mass on the right side of the chest. A contrast-enhanced computed tomography scan of the chest revealed a destructive mass on the right anterior fourth rib (7.5x5 cm). Fine needle aspiration revealed a metastatic moderately differentiated adenocarcinoma to the chest wall. Fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography revealed a large FDG avid deposit on the right side of the chest wall. Under general anesthesia, a right-side anterior chest incision was made and the second, third and fourth ribs were resected with overlying soft tissues, including the pectoralis muscle and overlying skin. The histopathological examination confirmed a metastasized gastroesophageal adenocarcinoma to the chest wall. There are two common assumptions regarding chest wall metastasis from EC. The first one states that this metastasis can occur due to the implantation of the carcinoma during tumor resection. The latter supports the notion of tumor cell dissemination along the esophageal lymphatic and hematogenous systems. Chest wall metastasis from EC invading ribs is an extremely rare incident. However, its likelihood of occurrence should not be neglected following primary cancer treatment.

Functional ear symptoms referred to an otology clinic: incidence, co-morbidity, aetiological factors and a new experience-driven clinical model.

OBJECTIVE: This study aimed to review the incidence and co-morbidity of functional ear symptoms in new referrals to an adult otology clinic and present a clinical model based on neuroscientific concepts. METHOD: This was a retrospective review of 1000 consecutive new referrals to an adult otology clinic. RESULTS: Functional disorder was the primary diagnosis in 346 patients (34.6 per cent). Functional ear symptoms included tinnitus (69.7 per cent), imbalance (23.7 per cent), otalgia (22.8 per cent) and aural fullness (19.1 per cent), with more than one symptom occurring in 25.1 per cent of patients. Co-morbidities included sensorineural hearing loss (39 per cent), emotional stress (30 per cent) and chronic illness (22 per cent). CONCLUSION: Functional disorders commonly present to the otology clinic, often in the presence of emotional stress or chronic illness. They occur because of adaptation of brain circuitry to experience, including adverse events, chronic illness and fear learning. This study presented an experience-driven clinical model based on these concepts. An understanding of these principles will significantly aid otolaryngologists who encounter patients with functional ear symptoms.

Medication-overuse headache in patients with cluster headache.

OBJECTIVE: Medication-overuse headache (MOH) in cluster headache (CH) patients is incompletely described, perhaps because of the relatively low prevalence of CH. METHODS: The authors describe a retrospective series of 17 patients (13 men, 4 women) with CH who developed MOH in association with overuse of a wide range of monotherapies or varying combinations of simple analgesics (n = 9), caffeine (n = 1), opioids (n = 10), ergotamine (n = 3), and triptans (n = 14). The series includes both episodic (n = 7) and chronic (n = 10) CH patients. RESULTS: A specific triptan-overuse headache diagnosis was made in 3 patients, an opioid-overuse headache diagnosis was made in 1 patient, and an ergotamine-overuse headache diagnosis was made in 1 patient. In approximately half of the patients (n = 8), the MOH phenotype was a bilateral, dull, and featureless daily headache. In the other 9 patients, the MOH was characterized by at least one associated feature, most commonly nausea (n = 6), exacerbation with head movement (n = 5), or throbbing character of the pain (n = 5). The common denominator in 15 patients was a personal or family history, or both, of migraine. The 2 other patients gave a family history of unspecified headaches. Medication withdrawal was attempted and successful in 13 patients. CONCLUSIONS: Medication-overuse headache is a previously underrecognized and treatable problem associated with cluster headache (CH). CH patients should be carefully monitored, especially those with a personal or family history of migraine.

Diagnostic delays and mis-management in cluster headache.

OBJECTIVES: Cluster headache is a stereotyped form of primary headache that while common in terms of neurologic illnesses is much less common as a cause of disabling headache than migraine. MATERIALS AND METHODS: We directly interviewed 230 patients with cluster headache. National support groups contributed 76% and 24% came from the National Hospital for Neurology and Neurosurgery Headache Clinic. RESULTS: Seventy-two percent were men and 28% women, giving a male to female (M:F) ratio of 2.5:1. Episodic cluster headache (ECH) was recorded in 79% while 21% had chronic cluster headache (CCH). The mean time to diagnosis has dropped from 22 years in the 1960s to 2.6 years in the 1990s, although the mean number of GPs seen before a diagnosis was made remains at three. CONCLUSIONS: While there has been improvement in the time to diagnosis for cluster headache, a number of physicians will be consulted, and better education is likely to reduce the overall patient suffering.

Intranasal sumatriptan in cluster headache: randomized placebo-controlled double-blind study.

BACKGROUND: Current evidence-based acute treatments of cluster headache are limited to oxygen inhalation and subcutaneous sumatriptan. Intranasal sumatriptan is a new formulation with better tolerability than the subcutaneous route. Two open-label studies suggested efficacy of intranasal sumatriptan in cluster headache. METHODS: In a double-blind placebo-controlled randomized trial, patients with episodic or chronic cluster headache whose attacks lasted at least 45 minutes each treated one attack with 20 mg sumatriptan nasal spray and another one, at least 24 hours later, with matching placebo. They scored their headache on a five-point scale (very severe, severe, moderate, mild, or none) at 5, 10, 15, 20, and 30 minutes. The primary outcome measure was headache response (a decrease in pain from very severe, severe, or moderate to mild or none) at 30 minutes. Secondary outcome measures included pain-free rates, relief of associated symptoms, and rates of adverse events. Multilevel multivariate analysis was used for statistical analysis. RESULTS: Five study centers enrolled 118 patients in whom 154 attacks were treated: 77 with sumatriptan and 77 with placebo. The responder rates at 30 minutes were 57% for sumatriptan and 26% for placebo (p = 0.002). Pain-free rates at 30 minutes were 47% for sumatriptan and 18% for placebo (p = 0.003). Sumatriptan was also superior to placebo considering initial response, meaningful relief, and relief of associated symptoms. There were no serious adverse events. CONCLUSION: Sumatriptan nasal spray is effective and well tolerated in the acute treatment of cluster headache attacks of at least 45 minutes' duration.

No change in the structure of the brain in migraine: a voxel-based morphometric study.

Migraine is a common, disabling form of primary neurovascular headache. For most of the twentieth century it was regarded as a vascular headache whose primary pathophysiology lay in the cranial vasculature. Functional brain imaging using positron emission tomography has demonstrated activation of the rostral brain stem in acute migraine. Voxel-based morphometry is a new fully automated whole brain technique that is sensitive to subtle macroscopic and mesoscopic structural differences between groups of subjects. In this study 11 patients suffering from migraine with aura (10 females, one male: 23-52 years, mean 31); 11 controls (10 females, one male: 23-52, mean 31); 17 patients with migraine without aura (16 females, one male: 24-57, mean 34); 17 controls (16 females, one male: 24-57, mean 34) were imaged with high resolution volumetric magnetic resonance imaging. There was no significant difference in global grey or white matter volumes between either patients with migraine and controls, or patients with aura and without aura. This study did not show any global or regional macroscopic structural difference between patients with migraine and controls, with migraine sufferers taken as homogenous groups. If structural changes are to be found, other methods of phenotyping migraine, such as by genotype or perhaps treatment response, may be required to resolve completely whether there is some subtle structural change in the brain of patients with migraine.

Brainstem activation specific to migraine headache.

Findings from functional imaging studies have shown activation of the brainstem during migraine without aura (MWOA) and activation of the hypothalamus during cluster headache. We assessed a patient with cluster headache and migraine by positron emission tomography during an active cluster headache after he had taken 1.2 glyceryl trinitate. The patient developed a typical MWOA, during which we saw activation in the dorsal rostral brainstem. There was no activation in the region of the hypothalamus. Our findings provide evidence that migraine involves the brainstem, and show several areas involved in cluster headaches. Our data show the potential for objective distinction between primary headache syndromes with functional imaging, in disorders hitherto distinguished on clinical grounds.

PET and MRA findings in cluster headache and MRA in experimental pain.

BACKGROUND: Cluster headache (CH), like migraine, is still regarded as a vascular headache although in both conditions a CNS cause has been suggested. OBJECTIVE: To examine neurovascular mechanisms in CH. METHODS: The authors used functional imaging with PET to investigate 18 CH patients (25 to 62 years old). Ten were in the active period (nine patients with induced attacks and one with spontaneous attack) and eight were out of their bout. In addition, the authors studied spontaneous CH and experimental pain in volunteers using MR angiography. RESULTS: When an acute CH attack was triggered with nitroglycerin (NTG), activation occurred in the ipsilateral posterior inferior hypothalamic gray, the contralateral ventroposterior thalamus, the anterior cingulate cortex, the ipsilateral basal ganglia, the right anterior frontal lobe, and both insulae. In patients out of the bout who experienced only a mild NTG headache, activation was seen bilaterally in the insulae and frontal cortices, the anterior cingulate cortex, the right thalamus, and the left basal ganglia, but not in the hypothalamic gray area. In addition, the authors found a significant activation (vasodilatation) in the region of the major basal arteries that was caused in part by NTG but was also observed in the spontaneous case and could be induced by capsaicin injection into the forehead. Therefore, the vasodilatation is likely to be mediated by neural mechanisms involved in the acute CH attacks that are present in every human being. CONCLUSIONS: Dilatation of cranial vessels is not specific to any particular headache syndrome but generic to cranial neurovascular activation, probably mediated by the trigeminoparasympathetic reflex. These data confirm that CH is a CNS disorder best considered as a form of neurovascular headache.

Oral zolmitriptan is effective in the acute treatment of cluster headache.

OBJECTIVE: To evaluate the efficacy and tolerability of oral zolmitriptan 5 mg and 10 mg and placebo in cluster headache. METHODS: A multicenter, double-blind, randomized, three-period, crossover, outpatient study. Adult patients received placebo and zolmitriptan 5 mg and 10 mg orally for the acute treatment of episodic or chronic cluster headache. Headache intensity was rated by a five-point scale: none, mild, moderate, severe, or very severe. Patients only treated moderate to very severe headaches. The primary efficacy measure was headache response (two-point or greater reduction from baseline in the cluster headache rating scale) at 30 minutes. Secondary efficacy measures included proportion of patients with initial headache relief within 15 and 30 minutes, mild or no pain at 30 minutes, meaningful headache relief, and use of escape medication. RESULTS: A total of 124 patients took at least one dose of study medication, with 73% having episodic and 27% chronic cluster headache. For the primary endpoint, there was a treatment-by-cluster-headache-type interaction (p = 0.0453). Therefore, results are presented separately for chronic and episodic cluster headache. In patients with episodic cluster headache, the difference between zolmitriptan 10 mg and placebo at 30 minutes reached significance (47% versus 29%; p = 0.02). Mild or no pain at 30 minutes was reported by 60%, 57%, and 42% patients treated with zolmitriptan 10 mg, zolmitriptan 5 mg, and placebo (both p

Functional magnetic resonance imaging in spontaneous attacks of SUNCT: short-lasting neuralgiform headache with conjunctival injection and tearing.

A 71-year-old woman presented with a short history of episodes of severe left-sided orbital and temporal pain in paroxysms lasting 60 to 90 seconds, and accompanied by ipsilateral lacrimation of the eye, rhinorrhea, and conjunctival injection. Results of clinical examination and structural imaging were normal and a clinical diagnosis of SUNCT (short-lasting unilateral neuralgiform pains with conjunctival injection and tearing) was made. The patient had a BOLD contrast-magnetic resonance imaging study in which significant activation was seen in the region of the ipsilateral hypothalamic gray, comparing the pain to pain-free state. The region of activation was the same in this patient as has been reported in acute attacks of cluster headache.

Coincidence of familial hemiplegic migraine and hemicrania continua? A case report.

A case is presented of a 39-year-old woman with a history of simultaneous Familial hemiplegic migraine (FHM) and hemicrania continua (HC). The family history of the patient revealed different types of migraine and cyclic syndromes in childhood in four generations. The possible links between FHM and HC are discussed. The pedigree gives further evidence that cyclic syndromes in childhood belong to the spectrum of migraine.

Intracranial vessels in trigeminal transmitted pain: A PET study.

The underlying principle in interpreting data from positron emission tomography (PET) is that increases and decreases of synaptic activity in the brain are accompanied by equivalent changes in regional blood flow. However, given the relatively low spatial resolution of PET, regional indices of neural activity can be influenced by signals from nonneural elements in the intracranial space. We have used PET to study the functional neuroanatomy of headache syndromes, such as cluster headache and experimental headache, by observing activation in brain that is due to synaptic activity. In these studies we noted a bilateral activation in midline structures over several planes that, based on its anatomy, is likely to arise from bilateral large intracranial arteries in the region of the cavernous sinus. We have observed this activity in two different group studies and in 11 of 17 single-subject studies. The most likely explanation for this "activation" is the increased volume of space occupied by dilated large vessels containing H215O. We further defined the anatomy of the PET findings using magnetic resonance angiography, which showed bilateral vasodilatation of the internal carotid artery and the basilar artery in nitroglycerin-induced cluster headache attacks. While the fact that vascular structures can contaminate PET-based blood flow studies may be well known to methodological experts, the issue is less well recognized outside the immediate field.

Cough headache responsive to methysergide.

Cough headache is a very distinct syndrome of headache precipitated by coughing, lifting, bending, sneezing, laughing, or straining. The pain can be severe and, if precipitation is difficult to avoid, certainly distressing. The usual treatment is indomethacin, which can be highly effective although recently lumbar puncture has again been advocated. We encountered a patient in whom indomethacin use was relatively contraindicated and who had an apparent response to methysergide.

Hypothalamic activation in cluster headache attacks.

BACKGROUND: Cluster headache, one of the most severe pain syndromes in human beings, is usually described as a vascular headache. However, the striking circadian rhythmicity of this strictly half-sided pain syndrome cannot be readily explained by the vascular hypothesis. We aimed to assess changes in regional cerebral blood flow (rCBF) in patients with cluster headache. METHODS: We used positron emission tomography (PET) to assess the changes in rCBF, as an index of synaptic activity, during nitroglycerin-induced cluster headache attacks in nine patients who had chronic cluster headache. Eight patients who had cluster headache but were not in the bout acted as a control group. FINDINGS: In the acute pain state, activation was seen in the ipsilateral inferior hypothalamic grey matter, the contralateral ventroposterior thalamus, the anterior cingulate cortex, and bilaterally in the insulae. Activation in the hypothalamus was seen solely in the pain state and was not seen in patients who have cluster headache but were out of the bout. INTERPRETATION: Our findings establish central nervous system dysfunction in the region of the hypothalamus as the primum movens in the pathophysiology of cluster headache. We suggest that a radical reappraisal of this type of headache is needed and that it should in general terms, be regarded as a neurovascular headache, to give equal weight to the pathological and physiological mechanisms that are at work.