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Application of radiosurgery to the newly diagnosed or post-operative residual perioptic lesions has been proved to improve tumor control. However, risk of vision injury induced by radiosurgery may increase substantially if the radiation dose is too high or tumor is close to the optic apparatus. The purpose of this study was to evaluate the safety and the effectiveness of fractionated stereotactic radiosurgery (FSRS) for perioptic tumors. We retrospectively analyzed 60 consecutive patients with 53 meningiomas and 7 schwannomas treated with FSRS between October 2007 and February 2020. We administered a marginal dose of 6–7 Gy (mean 6.8 Gy) per fraction and delivered 3 fractions in 3 consecutive days. The median tumor volume was 6.31 cm3 (range 0.3–58.23 cm3). The mean minimum lesion-optic distance (MLOD) is 0.85 mm (range 0–3 mm). After mean follow-up period of 69.6 months (range 6.82–156.32 months; median 58.9 months), the tumor control rates at 1, 3, 5, 8 and 13 years were 98.3%, 93.4%, 90.60%, 88.4% and 88.4%, respectively. Four out of the 60 tumors (6.7%) experienced a transient volume increase after FSRS. None of the patients developed visual impairment related to radiation induced optic neuropathy (RION) after FSRS. In conclusion, FSRS offers an alternative treatment option in treating perioptic meningiomas and schwannomas with acceptable tumor control rates and good visual preservation in the present study.

BackgroundWe sought to investigate the prognostic impact of missed RT sessions in patients who had undergone surgery for oral cavity squamous cell carcinoma (OCSCC).MethodsThe study sample consisted of 905 patients with surgically treated OCSCC who fulfilled criteria of RT course ≤8 weeks. The study participants were divided into three groups based on the characteristics of missed RT, as follows: 1) early missed RT, 2) late missed RT, and 3) RT as scheduled.ResultsThe 5-year overall survival (OS) rates in the early missed RT, late missed RT, and RT as scheduled groups were 53.0, 58.1, and 64.5%, respectively (p = 0.046). In multivariate analysis, early missed RT was independently associated with both OS (hazard ratio (HR) = 1.486; 95% confidence interval (CI): 1.122–1.966;p = 0.006) and the occurrence of distant metastasis (HR = 1.644; 95% CI: 1.047–2.583;p = 0.031).ConclusionEarly missed RT was independently associated with a higher occurrence of distant metastasis and less favorable OS in patients who had undergone surgery for OCSCC.

OBJECTIVE To investigate the clinical utility of short-course induction chemotherapy followed by low-dose radiotherapy without a tumor bed boost in patients with primary central nervous system (CNS) germinomas. METHODS We retrospectively reviewed the clinical records of patients with primary CNS germinomas who received short-course induction chemotherapy (2 cycles of cisplatin 20 mg/m2 plus etoposide 40 or 100 mg/m2 for 5 days) followed by low-dose radiotherapy (dose: 2340 cGy) without a tumor bed boost. Disease-free survival and overall survival served as the main outcome measures. RESULTS Between February 2002 and June 2018, 24 patients (20 males and 4 females; median age: 14.1 y; age range: 7.9 to 21.2 y) with pathology-proven CNS germinomas were included. The median follow-up time was 106 months (range: 17 to 169 mo). Isolated and multifocal lesions were identified in 13 and 11 patients, respectively. Tumor location was as follows: pineal gland (n=17), suprasellar region (n=13), periventricular region (n=7), and basal ganglia (n=2). Five patients had increased levels (>5 mIU/mL) of beta-human chorionic gonadotropin (β-hCG), whereas alpha-fetoprotein concentrations were within the reference range in all participants. A total of 16 patients achieved remission after induction chemotherapy. The complete response rates of patients with increased and normal β-hCG levels were 40.0% and 72.2%, respectively (P=0.208). Low-dose radiotherapy without a tumor bed boost was subsequently delivered to either the whole ventricle (n=16) or the whole brain (n=8), resulting in complete remission in all participants. Compared with patients without increased β-hCG levels, those with β-hCG-secreting germinomas had less favorable 5-year disease-free survival rates (100% vs. 60%, respectively, P=0.000115). CONCLUSIONS Some children with primary CNS germinoma may benefit from short-course induction chemotherapy followed by low-dose radiotherapy to the whole ventricle without a tumor bed boost. The validity of our findings needs to be confirmed in a randomized phase II study for children with β-hCG levels

Background Unresectable esophageal cancer harbors high mortality despite chemoradiotherapy. Better patient selection for more personalized management may result in better treatment outcomes. We presume the ratio of maximum standardized uptake value (SUV) of metastatic lymph nodes to primary tumor (NTR) in 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (FDG PET/CT) may provide prognostic information and further stratification of these patients. Methods The patients with non-metastatic and unresectable esophageal squamous cell carcinoma (SCC) receiving FDG PET/CT staging and treated by chemoradiotherapy were retrospectively reviewed. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cut-off value for NTR. Kaplan-Meier method and Cox regression model were used for survival analyses and multivariable analyses, respectively. Results From 2010 to 2016, 96 eligible patients were analyzed. The median follow-up time was 10.2 months (range 1.6 to 83.6 months). Using ROC analysis, the best NTR cut-off value was 0.46 for prediction of distant metastasis. The median distant metastasis-free survival (DMFS) was significantly lower in the high-NTR group (9.5 vs. 22.2 months, p = 0.002) and median overall survival (OS) (9.5 vs. 11.6 months, p = 0.013) was also significantly worse. Multivariable analysis revealed that NTR was an independent prognostic factor for DMFS (hazard ratio [HR] 1.81, p = 0.023) and OS (HR 1.77, p = 0.014). Conclusions High pretreatment NTR predicts worse treatment outcomes and could be an easy-to-use and helpful prognostic factor to provide more personalized treatment for patients with non-metastatic and unresectable esophageal SCC.

We aimed to determine whether body composition assessment before treatment can predict outcomes in patients with head and neck cancer (HNC). All 881 patients with locoregional head and neck cancer treated with curative intent radiotherapy (RT) between 2005 and 2012 were retrospectively investigated. Body composition was analyzed via pre‐RT planning computed tomography (CT) images. Subcutaneous adipose tissue (SAT) and skeletal muscle (SM) indices were measured cross‐sectionally at the level of the third thoracic vertebra. Overall survival (OS), locoregional control (LRC), and distant metastasis‐free survival (MFS) were analyzed by body composition index and body mass index (BMI). Survivors were followed up for a median of 4.68 years. The SAT indices in female patients were significantly higher than those in males (P

We aimed to compare the overall survival (OS) of patients with bone metastases (BM) from solid tumors after standard‐dose radiotherapy ([RT]; 30 Gy administered in 10 fractions; EQD2Gy = 32.5 Gy) and dose‐escalated RT (EQD2Gy > 32.5 Gy). We retrospectively reviewed the clinical charts of 1795 patients (median age, 62.3 years; age range, 18–96 years) with BM from solid tumors who were referred for RT to our institute between 2000 and 2013. These patients were assigned to the standard‐dose (n = 1125; 63%) and dose‐escalated (n = 670; 37%) RT groups. OS, estimated as the duration between the first RT session and death, served as the main outcome measure. The dose‐escalated RT group had a significantly better OS than the standard‐dose RT group (P = 0.000). After allowing potential confounders in multivariate analysis, the RT dose retained its independent association with OS (hazard ratio [HR], 0.837; 95% confidence interval [CI], 0.753–0.929, P = 0.001). After propensity score matching of the baseline characteristics of both groups, RT dose retained its independent association with OS (HR, 0.887; 95% CI, 0.737–0.951; P = 0.011) on multivariate analysis. Dose‐escalated RT exerted more favorable effects on OS in patients with non‐lung cancer, those without multiple metastases, those without symptoms, and those with favorable prognosis. Dose‐escalated RT was significantly associated with better OS in patients with BM from solid malignancies, particularly among those with non‐lung cancer, those without multiple metastases, those without symptoms, and those with favorable prognosis.

Treatment options for older patients with malignancies remain suboptimal. An accurate prognostic stratification could inform treatment decisions, which can potentially improve patient outcomes. Here, we sought to investigate whether the neutrophil-to-lymphocyte ratio (NLR) may have prognostic significance in patients with metastatic malignant tumors, with a special focus on older individuals.We retrospectively reviewed the clinical records of 3981 patients with histology-proven metastatic cancer who underwent radiotherapy between 2000 and 2013. The pretreatment NLR was determined within 7 days before treatment initiation. Patients aged ≥65 years were considered as older. We analyzed the prognostic significance of NLR for overall survival (OS) across all age groups.Compared with their younger counterparts, older patients showed a higher NLR (P 0.001) and a lower OS (P 0.001). Multivariate analysis revealed that a pretreatment NLR below the median was an independent favorable predictor of OS in both older (hazard ratio [HR]: 0.669, 95.0% CI: 0.605-0.740; P 0.001) and younger patients (HR: 0.704; 95.0% CI: 0.648-0.765; P 0.001). Regardless of age, patients who underwent systemic therapy showed more favorable OS, especially when NLR was low. In the older subgroup, the OS of patients with a low pretreatment NLR who did not undergo systemic therapy and of those with high pretreatment NLR who underwent systemic therapy was similar.A low pretreatment NLR predicts a more favorable OS in older patients with metastatic cancer. The most favorable OS was observed in patients with a low pretreatment NLR who received systemic therapy.

Key Points Question What are the optimal factors to use for constructing a nomogram to assess the probability of survival in patients with bone metastases arising from lung cancer? Findings This prognostic study of 477 patients with metastatic lung cancer found that age, histological type, smoking status, epidermal growth factor receptor mutation status, body mass index, and neutrophil to lymphocyte ratio were ideal parameters to construct a nomogram for potentially indicating 3-, 6-, and 12-month survival. This nomogram was successfully validated in a separate cohort of 235 patients at another institution. Meaning The study’s nomogram can guide radiation oncologists in making treatment decisions and determining the proper timing for end-of-life discussions and/or hospice referrals., Importance A survival prediction model for patients with bone metastases arising from lung cancer would be highly valuable. Objective To develop and validate a nomogram for assessing the survival probability of patients with metastatic lung cancer receiving radiotherapy for osseous metastases. Design, Setting, Participants In this prognostic study, the putative prognostic indicators for constructing the nomogram were identified using multivariable Cox regression analysis with backward elimination and model selection based on the Akaike information criterion. The nomogram was subjected to internal (bootstrap) and external validation; its calibration and discriminative ability were evaluated with calibration plots and the Uno C statistic, respectively. The training and validation set cohorts were from a tertiary medical center in northern Taiwan and a tertiary institution in southern Taiwan, respectively. The training set comprised 477 patients with metastatic lung cancer who received radiotherapy for osseous metastases between January 2000 and December 2013. The validation set comprised 235 similar patients treated between January 2011 and December 2017. Data analysis was conducted May 2018 to July 2018. Main Outcomes and Measures The nomogram end points were death within 3, 6, and 12 months. Results Of 477 patients in the training set, 292 patients (61.2%) were male, and the mean (SD) age was 62.86 (11.66) years. Of 235 patients in the validating set, 113 patients (48.1%) were male, and the mean (SD) age was 62.65 (11.49) years. In the training set, 186 (39%), 291 (61%), and 359 (75%) patients died within 3, 6, and 12 months, respectively, and the median overall survival was 4.21 (95% CI, 3.68-4.90) months. In the validating set, 84 (36%), 120 (51%), and 144 (61%) patients died within 3, 6, and 12 months, respectively, and the median overall survival was 5.20 (95% CI, 4.07-7.17) months. Body mass index (18.5 to, This prognostic study develops and validates a nomogram to assess the probability of survival at 3, 6, and 12 months in patients from Taiwan with metastatic lung cancer who were referred for radiotherapy to treat osseous metastases.

Recent studies conducted in patients with chronic diseases have reported an inverse association between body mass index (BMI) and mortality. However, the question as to whether BMI may predict prognosis in patients with metastatic cancer remains open. We therefore designed the current retrospective study to investigate the potential association between BMI and overall survival (OS) in patients with distant metastases (DM) and a favorable performance status. Between 2000 and 2012, a total of 4010 cancer patients with DM who required radiotherapy (RT) and had their BMI measured at the initiation of RT were identified. The relation between BMI and OS was examined by univariate and multivariable analysis. The median OS time was 3.23 months (range: 0.1–122.17) for underweight patients, 6.08 months (range: 0.03–149.46) for normal‐weight patients, 7.99 months (range: 0.07–158.01) for overweight patients, and 12.49 months (range, 0.2–164.1) for obese patients (log‐rank: P

Background Growing evidence indicates that measures of body composition may be related to clinical outcomes in patients with malignancies. The aim of this study was to investigate whether measures of regional adiposity–including subcutaneous adipose tissue index (SATI) and visceral adipose tissue index (VATI)–can be associated with overall survival (OS) in Taiwanese patients with bone metastases. Methods This is a retrospective analysis of prospectively collected data. We examined 1280 patients with bone metastases who had undergone radiotherapy (RT) between March 2005 and August 2013. Body composition (SATI, VATI, and muscle index) was assessed by computed tomography at the third lumbar vertebra and normalized for patient height. Patients were divided into low- and high-adiposity groups (for both SATI and VATI) according to sex-specific median values. Results Both SATI (hazard ratio [HR]: 0.696; P

Confirming the status of residual tumors is crucial. In stationary or spontaneous regression cases, early treatments are inappropriate. The long-used geometric calculation formula is 1/2 (length × width × height). However, it yields only rough estimates and is particularly unreliable for irregularly shaped masses. In our study, we attempted to propose a more accurate method. Between 2004 and 2014, 94 patients with pituitary tumors were enrolled in this retrospective study. All patients underwent transsphenoidal surgery and received magnetic resonance imaging (MRI). The pre- and postoperative volumes calculated using the traditional formula were termed A1 and A2, and those calculated using the proposed method were termed O1 and O2, respectively. Wilcoxon signed rank test revealed no significant difference between the A1 and O1 groups (P = 0.1810) but a significant difference between the A2 and O2 groups (P

Oculomotor nerve palsy is a relatively rare symptom in pituitary adenoma compared to visual compromise or endocrine deficiency. The causes and recovery remain unclear. A total of 23 patients with pituitary adenomas presenting with oculomotor nerve palsy were reviewed. Patients were treated immediately with glucocorticoid therapy. Elective pure-endoscopic transsphenoidal surgery was used for decompression and histopathological confirmation. The clinical differences of patients with apoplectic (hemorrhage or infarction) (20 patients) and non-apoplectic tumors (three patients) were compared. In the apoplectic group, hemorrhage was noted in 13 patients and infarction in seven. Most patients presented with ptosis, followed by limited gaze and diplopia. In the long-term follow-up, the overall complete recovery rate was 19/23 (82.6%): 18/20 in the apoplectic group (90%), and one in three patients in the non-apoplectic group (33%). The median recovery time was 9 days after surgical decompression; and early treatment resulted in early recovery (p = 0.03). Patients with pupil-sparing pituitary adenoma recovered more rapidly than those with pupil involvement (p = 0.012). Patients with minor symptoms recovered earlier than patients with complete palsy (p = 0.003). MRI revealed that the tumor had invaded the interclinoid ligament region in all patients. We conclude that oculomotor nerve palsy usually occurs in patients with apoplectic adenomas, especially those with hemorrhage. Early treatment, pupil-sparing, and minor oculomotor symptoms are factors indicating a good recovery. Endoscopic transsphenoidal surgical decompression achieved good results in this study.

Determining the primary site of a brain metastasis can be difficult, particularly if there is no organ-specific tumor histology. Thyroid transcription factor-1 (TTF-1) is a marker commonly expressed in lung and thyroid carcinomas. We studied the value of TTF-1 staining to identify brain metastases from a lung primary. Forty-three consecutive patients metastatic carcinomas of the brain were reviewed from a 4 year period. Twenty-one (75%) of the 28 metastatic pulmonary carcinomas were TTF-1 positive (+), whereas only one metastatic papillary thyroid carcinoma (7%) out of 15 metastatic non-pulmonary carcinomas was TTF-1 (+). We also studied the cytokeratin profile of these tumors. However, cytokeratin profile, either alone or combined with TTF-1 staining, was not better than TTF-1 staining alone in identifying brain metastases of pulmonary origin. Overall, TTF-1 positivity is a useful indicator of pulmonary origin in brain metastases, with a very high positive predictive value (95%) and a moderate negative predictive value (67%).

Non-functioning pituitary macroadenomas (NFPAs) are the most prevalent pituitary macroadenomas. One common symptom of NFPA is hypogonadism, which may require long-term hormone replacement. This study was designed to clarify the association between the pre-operative tumor volume, pre-operative testosterone level, intraoperative resection status and the need of long-term post-operative testosterone replacement. Between 2004 and 2012, 45 male patients with NFPAs were enrolled in this prospective study. All patients underwent transsphenoidal surgery. Hypogonadism was defined as total serum testosterone levels of

Background: Whole brain radiotherapy (WBRT) is the treatment of choice for patients with brain metastases. However, neurocognitive functions (NCFs) decline due to impaired hippocampal neurogenesis might occur thereafter. It is hypothesized that conformal hippocampal avoidance during the course of WBRT (HA-WBRT) might provide meaningful NCF preservation. Our study aims to demonstrate the impact of delivering HA-WBRT on NCF changes in patients receiving WBRT. Methods: Twenty-five patients who were referred for prophylactic cranial irradiation (PCI) or treating oligometastatic brain disease were enrolled in the study. Before the HA-WBRT course, all participants should receive baseline neurocognitive assessment, including memory, executive functions, and psychomotor speed. The primary endpoint was delayed recall, as determined by the change/decline in verbal memory [Wechsler Memory Scale - 3 rd edition (WMS III)- Word List score] from the baseline assessment to 4 months after the start of HA-WBRT. Results: Only three patients belonged to the clinical setting of PCI; the remaining 22 patients had oligometastatic brain disease. Regarding neurocognitive outcomes, no statistically significant differences were found between various NCF scores obtained at baseline and at post-radiotherapy intervals, in immediate verbal memory and non-verbal memory, except for delayed recall memory on Word List ( F = 5.727, p = 0.048). Conclusions: Functional preservation by hippocampal sparing during WBRT could largely be achieved in this study, which also suggests that HA-WBRT should be a feasible technique preserving neurocognitive functions while maintaining intracranial control.

Corpus callosum involvement is associated with poorer survival in high grade glioma (HGG), but the prognostic value in low grade glioma (LGG) is unclear. To determine the prognostic impact of corpus callosum involvement on progression free survival (PFS) and overall survival (OS) in HGG and LGG, the records of 233 glioma patients treated from 2008 to 2011 were retrospectively reviewed. Preoperative magnetic resonance (MR) images were used to identify corpus callosum involvement. Age, sex, preoperative Karnofsky performance scale, postoperative Eastern Cooperative Oncology Group (ECOG) score and extent of resection (EOR) were evaluated with respect to PFS and OS. The incidence of corpus callosum involvement was similar among HGG (14 %) and LGG (14.5 %). Univariate analysis revealed that PFS and OS were significantly shorter in both WHO grade II and grade IV glioma with corpus callosum involvement (both, p

BACKGROUND Nasopharyngeal carcinoma (NPC) is the most common head and neck malignancy in southeastern China and Taiwan. Early detection of the local disease followed by timely and appropriate treatment is essential to increasing cure and survival rates. Detection of Epstein–Barr virus (EBV) genomic DNA, such as the latent membrane protein 1 gene (LMP-1), in patients postirradiation during follow-up may indicate mucosal recurrence. METHODS Seventy-one patients with NPC underwent serial nasopharyngeal swabs for LMP-1 polymerase chain reaction assay before, during, and after irradiation. All of patients achieved a complete disease remission of the LMP-1 gene after irradiation that lasted for at least 6 months. RESULTS The median LMP-1 disease remission time after the beginning of irradiation was 4.3 weeks. Patients with early LMP-1 disease remission (≤ 4 weeks after the beginning of irradiation) and delayed LMP-1 disease remission (> 4 weeks) had 3-year local control rates of 93.5% and 76.9%, respectively (P = 0.0529). The LMP-1 gene was detected again (reexpression of LMP-1 [re-LMP-1]) in 10 patients after irradiation with at least 6 months of follow-up. Nine of 10 patients (90%) in the re-LMP-1 positive group and 2 of 61 patients (3.3%) in the re-LMP-1 negative group developed local recurrence. Mucosal recurrence developed in nine patients, and all displayed re-LMP-1. By detecting re-LMP-1 using nasopharyngeal swabs, mucosal recurrence was diagnosed with a sensitivity of 100% (9 of 9 patients) and a specificity of 98.4% (61 of 62 patients). The 3-year overall survival rate, the disease free survival rate for the entire group, and the estimated local mucosal control rates in the re-LMP-1 positive and re-LMP-1 negative groups were 86.5%, 76.5%, 19.4%, and 96.7%, respectively. CONCLUSIONS Expression of EBV LMP-1 in nasopharyngeal swab specimens from patients with irradiated/treated NPC can provide a highly sensitive and specific method of forecasting mucosal recurrence. This investigation confirmed the reliability and feasibility of nasopharyngeal swabs in screening for mucosal recurrences in patients with NPC. Cancer 2003. © 2003 American Cancer Society.

Background Stereotactic radiosurgery has been used to treat intracranial tumors. Recently, it has also been used for the treatment of head and neck tumors involving the base of skull, including recurrent NPC. Methods From October 1994 to April 1999, 36 patients with recurrent NPC, were retreated by stereotactic radiosurgery. These patients received radiosurgery as a boost treatment after reirradiation for recurrence. The external RT dose ranged from 20 to 60 Gy. The tumor volume ranged from 3.58 to 24.6 cc. The target surface dose ranged from 8 to 20 Gy. The median follow-up was 22.1 months. Results The 3-year local control rate was 56%. The 5-year overall survival was 49%. Persistence after radiosurgery had a worse survival than those who had secondary recurrence. Age and gender were marginally significant. No patient had new severe complications after retreatment. Four patients (11%) had nasopharyngeal necrosis after radiosurgery, none had nasal bleeding or headache, but a foul odor was present in one patient. Conclusions Conformal radiotherapy and stereotactic radiotherapy provide good local control and survival without severe complications for patients with recurrent NPC. © 2002 Wiley Periodicals, Inc. Head Neck 24: 748–753, 2002

Purpose: To investigate the association of pretreatment body mass index (preT BMI) with outcomes of head-and-neck cancer in patients treated with radiotherapy (RT). Methods and Materials: All 1,562 patients diagnosed with head-and-neck cancer and treated with curative-intent RT to a dose of 60 Gy or higher were retrospectively studied. Body weight was measured both at entry and at the end of RT. Cancer-specific survival (CSS), overall survival (OS), locoregional control (LRC), and distant metastasis (DM) were analyzed by preT BMI ( =}25 kg/m{sup 2}). The median follow-up was 8.6 years. Results: Patients with lower preT BMI were statistically significantly associated with poorer CSS and OS than those with higher preT BMI. There was no significant difference between preT BMI groups in terms of LRC and DM. Body weight loss (BWL) during radiation did not influence survival outcomes. However, in the group with higher preT BMI, CSS, OS, and DM-free survival of patients with less BWL during radiation were statistically longer when compared with greater BWL. Conclusion: This study demonstrates that higher preT BMI positively influenced survival outcomes for patients with head-and-neck cancer. Patients with higher preT BMI who were able to maintain their weight during radiation hadmore » significantly better survival than patients with greater BWL.« less

Glioblastoma and astrocytoma are the most common brain tumors affecting adults 45-60 years of age. The poor prognosis for glioblastoma patients results from recurrence after treatment. There is therefore an urgent need to develop diagnostic and prognostic markers as well as new therapies.Microarray analyses of clinical specimens from glioblastoma patients were used to identify potential tumor markers. Expression of candidate genes was analyzed by real-time reverse transcription-polymerase chain reaction and by immunoblotting and immunohistochemistry.Five potential markers (CD44 antigen (CD44), growth arrest and DNA-damage-inducible, alpha (GADD45A), fibronectin 1 (FN1), CD63 antigen (CD63) and secreted phosphoprotein 1 (SPP1)) showed expression patterns that correlated significantly with malignant glioma. In particular, expression of the CD44 antigen was elevated in more severe tumor types, and higher in tumor cores than in peripheral regions. However, lower levels of CD44 expression surprisingly correlated with lower survival.The CD44 antigen is a promising candidate for further development as a prognostic and therapeutic tool.

Rathke's cleft cyst (RCC) is a rare sellar tumor that can extend to the retroclival region, resulting in brain stem compression. We report a male with short stature who experienced repeated syncope due to compression of the brain stem by a giant retroclival RCC. MRI revealed a large homogeneous sellar tumor with anterior displacement of the pituitary gland that extended to the left retroclival space. The tumor differed from ordinary RCCs because of its unusual clinical presentation, the direction of extension, and its imaging characteristics. The retromastoid surgical approach was used for cyst marsupialization. Intraoperative appearance and histological examination confirmed the diagnosis. A follow-up MRI, 2years after resection of the cyst, showed no recurrence.

The clinical features of pituitary hemorrhage vary from asymptomatic to catastrophic. Clinical symptomatic pituitary apoplexy is a well-described syndrome characterized by sudden headaches, visual impairment, hypopituitarism and, at times, impaired consciousness. Subclinical pituitary apoplexy is characterized by minimal atypical clinical manifestations and, as a result, may be misdiagnosed or inappropriately treated. The purpose of the study was to evaluate the clinical manifestations, surgical outcome and post-operative pituitary function in patients who had clinical or subclinical pituitary apoplexy. We retrospectively identified 65 patients (30 men, 35 women; age range 21-87 years, mean age 48.4 years) who underwent transsphenoidal surgery. Of these, 25 patients were diagnosed as having clinical apoplexy, while the remaining 40 patients were classified as having subclinical pituitary apoplexy. The follow-up period ranged from 21 to 73 months (mean 44 months). Vision improved in 14 of 22 patients with clinical apoplexy (64%) and in 26 of 28 patients with subclinical apoplexy (93%) (p=0.017); the total resection rate was 57% and 42%, respectively (p=0.285). After 2 years of follow-up, hormone replacement therapy was needed in only 26% and 36% of patients, respectively (p=0.149). Our findings suggest that the incidence of subclinical pituitary apoplexy is higher than that of clinical pituitary apoplexy. Both the tumor resection rate and mean age were higher in those with clinical pituitary apoplexy, while those who had subclinical pituitary apoplexy demonstrated better visual improvement. During long-term follow-up, the need for hormonal replacement decreased in both groups.

Rhinosinusitis/mucocele are rare complications of transsphenoidal surgery. We present a retrospective analysis of 323 patients who received transsphenoidal surgery for pituitary adenoma. Twenty of the 323 patients (6.2%) developed rhinosinusitis/mucocele after transsphenoidal surgery as shown by MRI. All 20 patients with rhinosinusitis/mucocele occurred in the group who received the small sphenoidotomy approach and simple postoperative nasal care. Medical management was successful in 13 of 20 cases (65%). The remaining seven patients received endoscopic sphenoidotomy. On re-operation, purulent pus was discovered in two, a necrotic fat graft in one, mucocele in one, a dropped tumor in two, and a bone chip in one. Sphenoid sinusitis resolved in all seven cases. The formation of sphenoid sinusitis/mucocele is related to the size of the sphenoidotomy, frequency of postoperative nasal care, and foreign body accumulation. Early surgical drainage is necessary in patients with rhinosinusitis/mucocele refractory to medical management to prevent ascending meningitis.

Background. The C-terminal activation region 2 (CTAR2) of Epstein-Barr virus latent membrane protein 1 is the major site that correlates with metastasis-related signaling path- way. The variation of CTAR2 sequence may affect the incidence of distant metastasis in patients with nasopharyngeal carcinoma (NPC). Methods. Two hundred forty-nine specimens from consecu- tive patients with nonmetastatic NPC were collected. Amplifica- tion by polymerase chain reaction and sequence analysis of CTAR2 were performed. DNA sequence identical to the Cao strain was grouped as Cao CTAR2, whereas sequences differ- ing from Cao made up non-Cao CTAR2. Clinical characteristics and CTAR2 status were subjected to statistical analysis for dis- tant metastasis. Results. Non-Cao CTAR2 was associated with a statistically significant lower distance metastasis and superior survival rate. A combination of clinical stage and CTAR2 expression provided an accurate method of identifying high risk of metastasis. Conclusion. NPC patients with non-Cao CTAR2 were less likely to have metastasis develop than those characterized by Cao CTAR2. V C 2006 Wiley Periodicals, Inc. Head Neck 29: 109-119

Objective: The specific 30-bp deletion of the Epstein-Barr virus (EBV)-derived latent membrane protein-1 gene has been suggested to be associated with the pathogenesis of nasopharyngeal carcinoma (NPC) and a more aggressive phenotype of some EBV-associated malignancies. Methods: The authors conducted a retrospective cohort study. Between 1995 and 2001, 542 patients who had received complete courses of radiotherapy followed by at least 3 years of follow up were enrolled. Patients were divided into two groups according to the presence or absence of the 30-bp deletion in their tumor samples. Results: A total of 446 (82.3%) patients were found to feature the 30-bp deletion, whereas 88 (16.2%) did not. Interestingly, dual infection was found in eight (1.5%) patients. No statistical significance was found in age, gender, NPC-presenting stage, radiosensitivity, and pathologic classification between the two groups. The actuarial 5-year overall survival rate and the distant metastasis-free rate for the 30-bp deletion and nondeletion group were not statistically different (61.3% vs. 65.4% and 68.1% vs. 73.1%; P = .132 and .135, respectively). In multivariate analysis, older age, nasopharyngeal recurrence, advanced tumor stage, and the development of distant metastasis were shown to be poorer prognosticators for overall survival, whereas the presence of 30-bp deletion was not. For distant metastasis, only advanced tumor stage was shown to be a poor prognosticator, whereas other variables, including the presence of 30-bp deletion, had no statistical significance. Conclusions: In this retrospective cohort, we have demonstrated that this specific 30-bp sequence deletion might be only the predominant variant rather than an NPC phenotype-associated polymorphism. Additionally, dual infection is a rare but possible phenomenon in the endemic NPC tumors.

Pituitary apoplexy is a rare neurovascular insult. Early surgical decompression is the most effective treatment, especially for rapid deterioration of visual acuity or for altered consciousness. The timing of rapidly expanded mass was strongly related to the treatment outcome.Thirteen patients who presented with severe visual defect after pituitary apoplexy were enrolled retrospectively. Six patients without severe underlying diseases were considered non-complicated and were treated early. Another seven patients who received delayed treatment after medical problems were stabilized and/or conservative management failed were considered to be complicated. The visual acuity of each individual eye was evaluated and organized into six grades based on visual acuity. Twelve patients received transsphenoidal surgery and one craniotomy was performed for tumor removal.The delay of surgical treatment was 3.5 days and 8.7 days in the two groups, respectively. Overall, 19 out of 26 eyes (73%) improved after surgery; 100% in non-complicated group and 50% in complicated group. The average grade of visual improvement was 2.66 vs. 0.71 by each individual eye, and the difference was statistically significant (P0.000). The ratio of regained useful vision was significant in non-complicated patients (P0.000). The incidence of requirement long-term hormone replacement was high in the complicated group (2/6 vs. 6/7). The resection rate was total in 8 patients, subtotal in 3, partial in 1, with one loss of image follow-up.Early decompression significantly improved visual outcomes and the need for hormone replacement was minimal. We postulated old age, underlying malignant diseases, and coagulation disorders played the predisposing factors of poor outcome in these cases.

Case Report A 60-year-old man presented with slow decreasing visual acuity for 3 months. Sudden deterioration in the right side vision, accompanied by severe headache and vomiting, was noted 1 day prior to admission. Physical examination revealed mild fever, neck stiffness and blunting of consciousness. Emergent brain CT showed a bright mass within the sella which was thought compatible with pituitary apoplexy. The mass extended into the right cavernous sinus with bony destruction. A brain MRI was arranged before emergent optic nerve decompression via the transsphenoidal route. The MRI of the brain revealed an intracavernous carotid aneurysm with a signal void embedded in pituitary macroadenoma. The tumor was located in the sellar region with marked suprasellar extension ( fi g. 1 ). High-dose glucocorticoids were administered after diagnosis, and cerebral angiography for embolization of the aneurysm was performed. Due to diffi culties in identifying the neck of the aneurysm, we checked the collateral circulation by the balloon occlusion test. An angiogram showed good collateral blood supply through both the anterior and posterior communicating arteries. The patient tolerated the occlusion test well. Trapping was not done, but proximal occlusion of the right ICA was performed with detachable Cerebrovasc Dis 2006;21:142–144 DOI: 10.1159/000090450

Purpose: The presence of Epstein-Barr virus latent membrane protein-1 (LMP-1) gene in nasopharyngeal swabs indicates the presence of nasopharyngeal carcinoma (NPC) mucosal tumor cells. This study was undertaken to investigate whether the time taken for LMP-1 to disappear after initiation of primary radiotherapy (RT) was inversely associated with NPC local control. Methods and Materials: During July 1999 and October 2002, there were 127 nondisseminated NPC patients receiving serial examinations of nasopharyngeal swabbing with detection of LMP-1 during the RT course. The time for LMP-1 regression was defined as the number of days after initiation of RT for LMP-1 results to turn negative. The primary outcome was local control, which was represented by freedom from local recurrence. Results: The time for LMP-1 regression showed a statistically significant influence on NPC local control both univariately ( p p = 0.004). In multivariate analysis, the administration of chemotherapy conferred a significantly more favorable local control ( p = 0.03). Advanced T status (≥ T2b), overall treatment time of external photon radiotherapy longer than 55 days, and older age showed trends toward being poor prognosticators. The time for LMP-1 regression was very heterogeneous. According to the quartiles of the time for LMP-1 regression, we defined the pattern of LMP-1 regression as late regression if it required 40 days or more. Kaplan-Meier plots indicated that the patients with late regression had a significantly worse local control than those with intermediate or early regression ( p = 0.0129). Conclusion: Among the potential prognostic factors examined in this study, the time for LMP-1 regression was the most independently significant factor that was inversely associated with NPC local control.

From May 1994 to December 1999, 43 patients with meningiomas in the base of the skull underwent linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) at Chung Gung Memorial Hospital. SRS was performed as a primary treatment in 14 patients, and after resection in 29 patients. The mean tumor volume was 5.68 cc, and the mean target surface dose was 16 Gy, delivered with an average of three isocenters. The median follow-up was 74.5 months. The 7-year local control rate and 7-year overall survival rate were 89.7% and 80.2%, respectively. The 7-year local control was 100% and 84.4% in SRS alone group and surgical excision with SRS group (p = 0.21), respectively. A stationary tumor following SRS was seen in 23 (53.5%) patients, partial shrinkage was seen in 16 (37.2%) patients, and complete disappearance in one patient was seen (2.3%). Furthermore, disease progression was noted in three (7%) patients, one of whom died of disease. The median time to tumor response was 15.4 months (range 5.8-52.8 months). Cases remained stable or had improved neurological statuses without any deterioration in 37.9% and 78.7% of the groups treated with surgery and SRS and SRS alone, retrospectively. In summary, LINAC-based SRS is an effective and safe modality of treating unresectable or partially resected meningiomas in the base of the skull. For tumors with diameters of 3 cm or less, particularly in patients without or with minimal clinical neurological symptom, SRS alone can provide a good local control without causing cranial neuropathy.

Background/PurposeRadiotherapy is a crucial treatment for acromegalic patients with growth hormone (GH)-secreting pituitary tumors. However, its effect takes time. We retrospectively reviewed the long-term outcome of linear accelerator stereotactic radiosurgery (LINAC SRS) for patients with acromegaly from the perspective of biochemical remission and associated factors.MethodsTwenty-two patients presenting with residual or recurrent (GH)-secreting functional pituitary tumor between 1994 and 2004 who received LINAC SRS were enrolled and followed up for at least 3 years. Residual or recurrent tumor was defined as persistent elevated GH or insulin-like growth factor-1 (IGF-1) level and image-confirmed tumor after previous surgical treatment. Biochemical remission was defined as fasting GH less than 2.5 ng/mL with normal sex-and-age adjusted IGF-1.ResultsThe mean follow-up period was 94.7 months (range 36–161 months). Overall mean biochemical remission time was 53 months (median 30 months). Biochemical control was achieved in 15 patients (68.2%) over the follow up period. One patient experienced recurrence after SRS and underwent another operation. Initial GH at diagnosis and pre-SRS GH correlated with biochemical control (p = 0.005 and p