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The spine is the third most common site for metastatic disease following the lung and the liver. Approximately 60-70% of patients with metastatic cancer will have metastasis to the spine, but only 10% of these will be symptomatic. Metastases to the spine may involve the bone, epidural space, or the spinal cord. While chemotherapy and radiation therapy are the primary treatments for metastatic disease, spinal cord compression is an indication for surgical intervention. For vertebral body lesions, anterior vertebral reconstruction and stabilization also have the advantage of providing immediate stability to the vertebral column, but this anterior surgical approach to the upper thoracic spine is fraught with complications. The approach typically involves some combination of thoracotomy, sternotomy, or clavicle resection with anterior dissection into the superior mediastinum. To avoid unnecessary sternotomy and its associated complications, surgical access without sternotomy can be performed in certain cases. A sagittal MRI scan of the spine can be used to evaluate the level of the sternal notch in relation to the upper thoracic spine. If a tangential line can be drawn superior to the sternal notch and inferior to the level of the involved vertebra, surgical access without sternotomy can be performed. We present a case of a 52-year-old female with metastases to the upper thoracic vertebrae who underwent successful T2 corpectomy and T1-3 anterior fusion via a low anterior cervical approach, without sternotomy or clavicle resection., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Babici et al.)

Aneurysms of the petrous segment of the internal carotid artery (ICA) are exceedingly rare. They are thought to arise from traumatic, mycotic, or congenital etiologies. We present a case of bilateral giant fusiform aneurysms of the petrocavernous ICA treated with bilateral flow-diverting stent placement. An 18-year-old male presented to our institution with headaches, nausea, vomiting and blurry vision that had been present since the day prior. Visual exam revealed decreased visual acuity bilaterally and a temporal field cut superiorly and inferiorly of the left eye. CT and MR imaging revealed bilateral lesions of the petrous segment of the ICA bilaterally. Catheter angiography demonstrated bilateral giant fusiform aneurysm of the petrocavernous ICA. The patient was treated with aspirin 325 mg and clopidogrel 75 mg orally daily for one week prior to the exam. VerifyNow (Accriva; San Diego, CA) confirmed adequate platelet inhibition. The right ICA was treated first, with a multiple flow-diverting stent construct. No complications were noted and the patient was discharged to home two days later. He was brought back three weeks later, and the left ICA was treated with a multiple flow-diverting stent construct. Again, no complications were noted and the patient was discharged uneventfully. The patient returned for his six-month follow-up angiogram with improvement of his visual acuity and resolution of headaches. However, the patient had ceased taking both anti-platelet medications six weeks prior. Angiography revealed no filling of the aneurysm in the right ICA, however, the left ICA was occluded at the origin. The patient was resumed on daily aspirin 325 mg orally and will have follow-up catheter angiography at 12 months. Petrous segment ICA aneurysms are rare. Most are thought to arise from trauma, infection, or congenital etiologies. These aneurysms are typically fusiform in nature, and can extend into the cavernous segment of the ICA. The natural history of these aneurysms is not well understood given their rarity. Current literature advocates for asymptomatic patients to be treated conservatively given that the natural history is not well known. Treatment is recommended in symptomatic patients, who may present with symptoms of local mass effect or ischemic stroke due to emboli. Endovascular options include flow diverting stent or covered stent placement, coil embolization with or without stent-assistance, or ICA occlusion. Open surgical options include trapping and high-flow bypass. When bilateral lesions are present, the management algorithm must be amended. We elected to treat the asymptomatic side first (right ICA), due to the presence of a significant kink within the aneurysm on the left. Once the right side was treated successfully, the symptomatic side was treated with a multiple stent construct. The patient's six-month angiogram demonstrated occlusion of the left ICA, likely due to non-compliance with antiplatelet medications. This further reiterates the need for dual-antiplatelet therapy and patient education and compliance with flow diverting stents. We report a rare case of bilateral giant fusiform petrocavernous aneurysms treated with bilateral Pipeline embolization devices in multiple device construct, demonstrating the feasibility and safety of this treatment option for this pathology., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Mantripragada et al.)

Metastatic Merkel cell carcinoma (MCC) is a lethal, Merkel cell polyomavirus (MCPyV) cancer with no currently available effective therapy. Harnessing the immune system through an immune checkpoint blockade is an attractive option because the immune system appears to be dysfunctional in the Merkel cell tumor microenvironment. Although MCPyV is expressed in 80% of MCCs and serves as a powerful antigen for stimulating host immune response, intratumoral CD8+ T-cell infiltration is seen only in 18% of MCCs. In contrast, about 50% of MCPyV-positive MCCs express the programmed death-ligand 1 (PD-L1) on multiple cell types in the tumor microenvironment. We present a case of a young patient with MCC involving the heart and pancreas that showed an impressive response after treatment with four cycles of the anti-PD-1 monoclonal antibody, nivolumab.