This document describes three cases of patients with recurrent epidermoid cysts of the central nervous system that were treated with CyberKnife radiosurgery. In all three cases, the cysts had been difficult to resect completely through open surgery due to their locations near critical structures. The radiosurgery was able to stop or slow the growth of the cysts in all three cases, with follow up scans showing no additional growth over several years. The document concludes that stereotactic radiosurgery can be a safe and effective option for some recurrent or unresectable epidermoid cysts.
"INCIDENCE OF INCIDENTAL FINDINGS ON MRI SPINE AND PATIENT BENEFITS : SEE BE...Earthjournal Publisher
This document discusses a study of 300 patients undergoing MRI of the spine. The researchers found that around 50% of patients had incidental extra-spinal findings. The most common findings were renal cysts, ovarian/uterine cysts, and abnormalities of the kidneys and genitourinary system. Other frequent findings included lesions in the lungs, chest, liver, and brain. Reporting these incidental findings provides valuable clinical information for managing patients. Detecting conditions like kidney tumors early through incidental findings can help avoid long-term health risks. The study concludes it is important for radiologists to include and discuss any significant incidental extra-spinal findings in their reports.
An adolescent male football player presented with heel pain that had worsened over a year. Initial conservative treatment provided temporary relief but the pain intensified. Imaging revealed an osteoid osteoma, a benign bone tumor, in the calcaneus. Surgical excision of the tumor completely resolved the athlete's pain. Osteoid osteomas are rare in athletes but should be considered for persistent hindfoot pain atypical of common conditions like tendinitis.
This document provides information on Ewing sarcoma, a rare type of cancer that develops in bone or soft tissue. It discusses the epidemiology, pathology, clinical features, workup including imaging and staging, prognostic factors, management with chemotherapy, surgery and/or radiation therapy, and clinical trials. Ewing sarcoma is most common in children and young adults between ages 10-20. It is characterized by small, blue round cells and specific gene translocations. Treatment involves induction chemotherapy followed by local control with surgery or radiation and maintenance chemotherapy for at least 28-49 weeks. Prognostic factors and long term follow up care are also outlined.
gct distal radiusntrreated by extended curettage.newer modalities of treatment as per the literature.recent advsncses un ythe fiewld.bone c2wment,graft and ghelfoam were used to reconstruct the defect
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Tre...George S. Ferzli
This document discusses risk factors for chronic groin pain after hernia surgery and methods for treating post-surgical neuralgia. It identifies several risk factors including age, pre-operative pain, BMI, postoperative complications, recurrent hernias, day case surgery, and open versus laparoscopic technique. Treatment methods explored include identifying and protecting nerves during surgery, avoiding mesh where possible, and non-surgical approaches like neurolysis, medications, and physical therapy.
I. Real-time MR-guided stent placement is now feasible in coronary arteries of pigs. The presented real-time MR imaging sequence allows for high-quality coronary MR fluoroscopy without cardiac motion artifacts.
II. Passive visualization of the guidewire and stent during the procedure is sufficient for real-time monitoring.
III. While MR guidance has advantages over x-ray for interventional cardiology like reduced radiation and better imaging, challenges remain from respiratory and cardiac motion artifacts and the small, tortuous anatomy of coronary arteries.
I. Real-time MRI-guided stent placement is now feasible in coronary arteries of pigs. The presented real-time MRI sequence allows for high-quality coronary imaging without motion artifacts.
II. Passive visualization of guidewires and stents through MRI is sufficient for real-time monitoring of the procedure.
III. While MRI could provide advantages over x-ray for interventional cardiology, challenges include motion artifacts from breathing and heartbeat as well as the small, tortuous anatomy of coronary arteries.
An Atlas of Musculoskeletal Oncology: Volume 1Amber Caldwell
This document contains 53 cases of osteoid osteoma and osteoblastoma. Case 1-50 cover osteoid osteoma, with the typical presentation of a painful nidus most commonly in long bones visualized on CT or bone scan. Cases 51-94 cover osteoblastoma, a larger variant of osteoid osteoma most often in the spine. Later cases demonstrate recurrence, progression to aneurysmal bone cyst, and treatment with curettage or resection.
"INCIDENCE OF INCIDENTAL FINDINGS ON MRI SPINE AND PATIENT BENEFITS : SEE BE...Earthjournal Publisher
This document discusses a study of 300 patients undergoing MRI of the spine. The researchers found that around 50% of patients had incidental extra-spinal findings. The most common findings were renal cysts, ovarian/uterine cysts, and abnormalities of the kidneys and genitourinary system. Other frequent findings included lesions in the lungs, chest, liver, and brain. Reporting these incidental findings provides valuable clinical information for managing patients. Detecting conditions like kidney tumors early through incidental findings can help avoid long-term health risks. The study concludes it is important for radiologists to include and discuss any significant incidental extra-spinal findings in their reports.
An adolescent male football player presented with heel pain that had worsened over a year. Initial conservative treatment provided temporary relief but the pain intensified. Imaging revealed an osteoid osteoma, a benign bone tumor, in the calcaneus. Surgical excision of the tumor completely resolved the athlete's pain. Osteoid osteomas are rare in athletes but should be considered for persistent hindfoot pain atypical of common conditions like tendinitis.
This document provides information on Ewing sarcoma, a rare type of cancer that develops in bone or soft tissue. It discusses the epidemiology, pathology, clinical features, workup including imaging and staging, prognostic factors, management with chemotherapy, surgery and/or radiation therapy, and clinical trials. Ewing sarcoma is most common in children and young adults between ages 10-20. It is characterized by small, blue round cells and specific gene translocations. Treatment involves induction chemotherapy followed by local control with surgery or radiation and maintenance chemotherapy for at least 28-49 weeks. Prognostic factors and long term follow up care are also outlined.
gct distal radiusntrreated by extended curettage.newer modalities of treatment as per the literature.recent advsncses un ythe fiewld.bone c2wment,graft and ghelfoam were used to reconstruct the defect
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Tre...George S. Ferzli
This document discusses risk factors for chronic groin pain after hernia surgery and methods for treating post-surgical neuralgia. It identifies several risk factors including age, pre-operative pain, BMI, postoperative complications, recurrent hernias, day case surgery, and open versus laparoscopic technique. Treatment methods explored include identifying and protecting nerves during surgery, avoiding mesh where possible, and non-surgical approaches like neurolysis, medications, and physical therapy.
I. Real-time MR-guided stent placement is now feasible in coronary arteries of pigs. The presented real-time MR imaging sequence allows for high-quality coronary MR fluoroscopy without cardiac motion artifacts.
II. Passive visualization of the guidewire and stent during the procedure is sufficient for real-time monitoring.
III. While MR guidance has advantages over x-ray for interventional cardiology like reduced radiation and better imaging, challenges remain from respiratory and cardiac motion artifacts and the small, tortuous anatomy of coronary arteries.
I. Real-time MRI-guided stent placement is now feasible in coronary arteries of pigs. The presented real-time MRI sequence allows for high-quality coronary imaging without motion artifacts.
II. Passive visualization of guidewires and stents through MRI is sufficient for real-time monitoring of the procedure.
III. While MRI could provide advantages over x-ray for interventional cardiology, challenges include motion artifacts from breathing and heartbeat as well as the small, tortuous anatomy of coronary arteries.
An Atlas of Musculoskeletal Oncology: Volume 1Amber Caldwell
This document contains 53 cases of osteoid osteoma and osteoblastoma. Case 1-50 cover osteoid osteoma, with the typical presentation of a painful nidus most commonly in long bones visualized on CT or bone scan. Cases 51-94 cover osteoblastoma, a larger variant of osteoid osteoma most often in the spine. Later cases demonstrate recurrence, progression to aneurysmal bone cyst, and treatment with curettage or resection.
1. The document discusses treatment options for giant cell tumor of the distal radius, including extended curettage with adjuvant therapies like phenol or bone cement for lower grade tumors, and en bloc resection with reconstruction using osteochondral allograft or arthrodesis for higher grade tumors.
2. Studies have found that extended curettage with cement has a high local control rate and good functional outcomes compared to wide resection.
3. Reconstruction options after tumor resection include osteoarticular allograft, vascularized fibular graft, or arthrodesis depending on the extent of bone loss and need to preserve wrist or forearm function.
Osteoid osteomas are benign bone tumors that typically occur in patients under age 25. They most commonly arise in the femur or tibia and cause pain that is often worse at night but relieved with aspirin. On imaging, osteoid osteomas appear as a small lucency known as a nidus surrounded by reactive bone thickening. Treatment involves surgically removing just the nidus tissue to relieve the pain.
This document summarizes a case report of a rare case of bilateral squamous cell carcinoma of the temporal bones in a 30-year-old male patient who presented with extensive late-stage disease. Imaging showed large lesions destroying bone structure in the right temporal bone and a smaller lesion in the left. Biopsy confirmed squamous cell carcinoma in both ears. The right-sided tumor was deemed unresectable and the patient received palliative radiotherapy, with a poor prognosis. Bilateral temporal bone cancer is exceptionally rare and this represents one of the few reported cases.
Identified in 1921 by James Ewing
2nd most common bone tumor in children
Ewing’s Sarcoma Family of tumors:
Ewing’s sarcoma (Bone –87%)
Extraosseous Ewing’s sarcoma (8%)
Peripheral PNET(5%)
Askin’s tumor
This document summarizes information about osteoid osteoma, a benign bone tumor. It describes the typical presentation as a painful lesion most common in younger males, often located in the femur or tibia. Diagnosis typically involves x-ray, CT scan or bone scan to locate the lesion. While traditionally treated with open surgical excision, minimally invasive techniques like CT-guided percutaneous excision have high success rates with less morbidity.
This document discusses intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) for head and neck cancers. It provides details on contouring targets and organs at risk for treatment planning. It summarizes evidence from trials on reducing xerostomia with IMRT. It also discusses the benefits of daily imaging with IGRT for accurate treatment delivery and potentially reducing planning target volume margins. Adaptive planning is mentioned as an area that continues to be explored to account for anatomical changes over the course of radiation treatment.
Giant cell tumor is a benign but locally aggressive bone tumor. It most commonly affects long bones like the distal femur and proximal tibia in skeletally mature patients aged 15-40. On imaging, it appears as an eccentric, epiphyseo-metaphyseal lesion that is lytic with thinning or destruction of the cortex. Biopsy is required for diagnosis. Treatment options include curettage with or without adjuvants, en bloc resection, embolization, or amputation depending on tumor size, location and involvement of surrounding tissues. The goal is to remove the tumor completely while reconstructing any bony defects to restore function.
This study evaluated the use of freehand 3D ultrasound imaging to measure muscle volume as an alternative to MRI. Nine subjects underwent ultrasound scans of the rectus femoris muscle, with image slices and position data reconstructed into 3D models. The results demonstrated the reliability and feasibility of this technique, with average errors of 2.4% for volume and 3.5% for distances compared to actual measurements. This suggests freehand 3D ultrasound could allow clinicians to conveniently evaluate muscle volume changes after ACL reconstruction surgery.
Carolina Amador has contributed significantly to research characterizing the viscoelastic properties of soft tissues using various acoustic methods such as Shearwave Dispersion Ultrasound Vibrometry (SDUV) and Acoustic Radiation Force Induced Creep (ARFIC). She has validated these methods on tissue mimicking phantoms and applied them to study properties of organs like the kidney and liver. Her work has also focused on developing techniques to characterize anisotropic and transverse isotropic materials, as well as factors that influence tissue properties such as blood flow.
BACKGROUND: The stimulating effect of low level laser phototherapy on bone healing has been shown in a number of in vitro and animal studies. However, the effect of LLLT on the bone healing in human has not been previously wide demonstrated. The article reports an accidentally injury pattern and reported as fractures of the mid third of the left tibia. OBJECTIVE: The purpose of this case study was to demonstrate the biological effects of low-level laser therapy (LLLT) on tibial fractures treated surgically using radiographic, examinations. CASE REPORT: The case hospitalized for conventional surgery and followed by applying Low Level Laser Therapy LLLT to enhance and accelerate the bone fracture healing of the left tibia using the effect of laser bio-stimulation. Radiological x-ray imaging evaluation follow up for our case showed a significant bone healing rate as result of exposure of Diode Laser 650 nm with energy density of 5 J/cm2 three times/week for one month. Radiographic findings revealed no significant fracture callus thickness difference before using LLLT however, the fractures showed significant callus formation after using LLLT. CONCLUSION: The study suggests that LLLT accelerates the process of fracture repair or cause increases in callus volume
Giant cell tumor of bone is a neoplasm arising from bone marrow tissue. It commonly affects people aged 20-40 years old and is more common in females. Common sites are the distal femur, proximal tibia, and distal radius. Treatment options include pharmacological therapies like bisphosphonates and denosumab, surgical curettage with or without adjuvants, and radiotherapy. Bisphosphonates and denosumab work to inhibit bone resorption by osteoclasts. Extended curettage with adjuvants provides a compromise treatment that is both oncologically safe and preserves function.
Bone is commonly affected by metastasis. Radiation therapy is effective for relieving bone pain from metastases. Shorter fractionation schedules like single 8 Gy fractions provide pain relief but have higher retreatment rates compared to longer schedules like 30 Gy in 10 fractions. Newer techniques like SBRT and hemibody irradiation also effectively palliate bone pain with acceptable toxicity. Bisphosphonates combined with radiation can further improve pain relief and increase bone density. Surgery to stabilize fractures is recommended for high risk or impending fractures to allow early mobility.
This document summarizes a study examining the prognostic value of MRI in detecting early-stage avascular necrosis of the femoral head. MRI images of 32 asymptomatic hips in 25 patients at risk were classified into four types based on the location and size of necrosis seen on the images. Hips classified as types B, C, or D, where necrosis extended further into the femoral head, were found to be most at risk of subsequent segmental collapse. None of the hips classified as type A, with more localized necrosis, went on to collapse. MRI can thus help predict which early-stage cases are likely to progress based on the initial extent and location of necrosis seen on imaging.
Presentation1.pptx, diffusion weighted imaging in brain tumour.Abdellah Nazeer
Diffusion-weighted MRI is useful for evaluating brain tumors by providing information about tumor cellularity and distinguishing different types of tumors. It can help differentiate high-grade from low-grade gliomas, as high-grade tumors tend to have lower apparent diffusion coefficients due to restricted diffusion from increased cellularity. Diffusion-weighted MRI is also helpful for distinguishing brain abscesses from cystic or necrotic tumors, and for differentiating tumor types like arachnoid cysts from epidermoid tumors. It may also provide information about tumor histology in cases of brain metastases.
Journal club presentation on metastatic bone disesaseVenkat Vinay
This document summarizes the presentation on the diagnosis and management of metastatic bone disease. It discusses:
1. The clinical presentation of metastatic bone disease including musculoskeletal pain, pathological fractures, neurological complications, and hypercalcemia symptoms.
2. Diagnostic tests used including history, physical exam, imaging like CT, MRI, and biopsy.
3. Indications for treatment including pathological fractures and spinal instability.
4. Surgical and non-surgical management strategies for different areas of bone involvement including the extremities, pelvis, spine, and use of adjuvants like radiation and bisphosphonates.
The document discusses limb salvage surgery for both trauma and tumor cases. For traumatic injuries, it discusses the decision making process around whether to attempt limb salvage or perform amputation. It presents several scoring systems used to evaluate the likelihood of successful salvage. For tumors, it discusses options for reconstruction after limb salvaging resections, including allografts, endoprostheses, and allograft-prosthetic composites. It also outlines techniques for resections and reconstructions of various parts of the upper and lower extremities.
Open tibia fractures can range from minor soft tissue wounds to severe injuries with extensive soft tissue damage and bone loss. The goals of treatment are to prevent infection, achieve bone union, and restore function. Management involves thorough debridement and irrigation, temporary stabilization, soft tissue coverage within 7-10 days if possible, and definitive stabilization once the soft tissues have healed sufficiently. Complications include infection, malunion, nonunion, and compartment syndrome, which require additional treatment such as antibiotics, bone grafting, or surgery.
Gartner Healthcare Supply Chain Roundtable: October 14, Chicagocstoops
Please join Gartner Supply Chain Research Analysts Stephen Meyer and Eric O’Daffer for a discussion on some of Gartner’s most recent research in the Healthcare Life Science Supply Chain. Find out how organizations are transforming their supply chains, what supply chain leadership looks like, and how you can accelerate innovation at your organization.
1. The document discusses treatment options for giant cell tumor of the distal radius, including extended curettage with adjuvant therapies like phenol or bone cement for lower grade tumors, and en bloc resection with reconstruction using osteochondral allograft or arthrodesis for higher grade tumors.
2. Studies have found that extended curettage with cement has a high local control rate and good functional outcomes compared to wide resection.
3. Reconstruction options after tumor resection include osteoarticular allograft, vascularized fibular graft, or arthrodesis depending on the extent of bone loss and need to preserve wrist or forearm function.
Osteoid osteomas are benign bone tumors that typically occur in patients under age 25. They most commonly arise in the femur or tibia and cause pain that is often worse at night but relieved with aspirin. On imaging, osteoid osteomas appear as a small lucency known as a nidus surrounded by reactive bone thickening. Treatment involves surgically removing just the nidus tissue to relieve the pain.
This document summarizes a case report of a rare case of bilateral squamous cell carcinoma of the temporal bones in a 30-year-old male patient who presented with extensive late-stage disease. Imaging showed large lesions destroying bone structure in the right temporal bone and a smaller lesion in the left. Biopsy confirmed squamous cell carcinoma in both ears. The right-sided tumor was deemed unresectable and the patient received palliative radiotherapy, with a poor prognosis. Bilateral temporal bone cancer is exceptionally rare and this represents one of the few reported cases.
Identified in 1921 by James Ewing
2nd most common bone tumor in children
Ewing’s Sarcoma Family of tumors:
Ewing’s sarcoma (Bone –87%)
Extraosseous Ewing’s sarcoma (8%)
Peripheral PNET(5%)
Askin’s tumor
This document summarizes information about osteoid osteoma, a benign bone tumor. It describes the typical presentation as a painful lesion most common in younger males, often located in the femur or tibia. Diagnosis typically involves x-ray, CT scan or bone scan to locate the lesion. While traditionally treated with open surgical excision, minimally invasive techniques like CT-guided percutaneous excision have high success rates with less morbidity.
This document discusses intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) for head and neck cancers. It provides details on contouring targets and organs at risk for treatment planning. It summarizes evidence from trials on reducing xerostomia with IMRT. It also discusses the benefits of daily imaging with IGRT for accurate treatment delivery and potentially reducing planning target volume margins. Adaptive planning is mentioned as an area that continues to be explored to account for anatomical changes over the course of radiation treatment.
Giant cell tumor is a benign but locally aggressive bone tumor. It most commonly affects long bones like the distal femur and proximal tibia in skeletally mature patients aged 15-40. On imaging, it appears as an eccentric, epiphyseo-metaphyseal lesion that is lytic with thinning or destruction of the cortex. Biopsy is required for diagnosis. Treatment options include curettage with or without adjuvants, en bloc resection, embolization, or amputation depending on tumor size, location and involvement of surrounding tissues. The goal is to remove the tumor completely while reconstructing any bony defects to restore function.
This study evaluated the use of freehand 3D ultrasound imaging to measure muscle volume as an alternative to MRI. Nine subjects underwent ultrasound scans of the rectus femoris muscle, with image slices and position data reconstructed into 3D models. The results demonstrated the reliability and feasibility of this technique, with average errors of 2.4% for volume and 3.5% for distances compared to actual measurements. This suggests freehand 3D ultrasound could allow clinicians to conveniently evaluate muscle volume changes after ACL reconstruction surgery.
Carolina Amador has contributed significantly to research characterizing the viscoelastic properties of soft tissues using various acoustic methods such as Shearwave Dispersion Ultrasound Vibrometry (SDUV) and Acoustic Radiation Force Induced Creep (ARFIC). She has validated these methods on tissue mimicking phantoms and applied them to study properties of organs like the kidney and liver. Her work has also focused on developing techniques to characterize anisotropic and transverse isotropic materials, as well as factors that influence tissue properties such as blood flow.
BACKGROUND: The stimulating effect of low level laser phototherapy on bone healing has been shown in a number of in vitro and animal studies. However, the effect of LLLT on the bone healing in human has not been previously wide demonstrated. The article reports an accidentally injury pattern and reported as fractures of the mid third of the left tibia. OBJECTIVE: The purpose of this case study was to demonstrate the biological effects of low-level laser therapy (LLLT) on tibial fractures treated surgically using radiographic, examinations. CASE REPORT: The case hospitalized for conventional surgery and followed by applying Low Level Laser Therapy LLLT to enhance and accelerate the bone fracture healing of the left tibia using the effect of laser bio-stimulation. Radiological x-ray imaging evaluation follow up for our case showed a significant bone healing rate as result of exposure of Diode Laser 650 nm with energy density of 5 J/cm2 three times/week for one month. Radiographic findings revealed no significant fracture callus thickness difference before using LLLT however, the fractures showed significant callus formation after using LLLT. CONCLUSION: The study suggests that LLLT accelerates the process of fracture repair or cause increases in callus volume
Giant cell tumor of bone is a neoplasm arising from bone marrow tissue. It commonly affects people aged 20-40 years old and is more common in females. Common sites are the distal femur, proximal tibia, and distal radius. Treatment options include pharmacological therapies like bisphosphonates and denosumab, surgical curettage with or without adjuvants, and radiotherapy. Bisphosphonates and denosumab work to inhibit bone resorption by osteoclasts. Extended curettage with adjuvants provides a compromise treatment that is both oncologically safe and preserves function.
Bone is commonly affected by metastasis. Radiation therapy is effective for relieving bone pain from metastases. Shorter fractionation schedules like single 8 Gy fractions provide pain relief but have higher retreatment rates compared to longer schedules like 30 Gy in 10 fractions. Newer techniques like SBRT and hemibody irradiation also effectively palliate bone pain with acceptable toxicity. Bisphosphonates combined with radiation can further improve pain relief and increase bone density. Surgery to stabilize fractures is recommended for high risk or impending fractures to allow early mobility.
This document summarizes a study examining the prognostic value of MRI in detecting early-stage avascular necrosis of the femoral head. MRI images of 32 asymptomatic hips in 25 patients at risk were classified into four types based on the location and size of necrosis seen on the images. Hips classified as types B, C, or D, where necrosis extended further into the femoral head, were found to be most at risk of subsequent segmental collapse. None of the hips classified as type A, with more localized necrosis, went on to collapse. MRI can thus help predict which early-stage cases are likely to progress based on the initial extent and location of necrosis seen on imaging.
Presentation1.pptx, diffusion weighted imaging in brain tumour.Abdellah Nazeer
Diffusion-weighted MRI is useful for evaluating brain tumors by providing information about tumor cellularity and distinguishing different types of tumors. It can help differentiate high-grade from low-grade gliomas, as high-grade tumors tend to have lower apparent diffusion coefficients due to restricted diffusion from increased cellularity. Diffusion-weighted MRI is also helpful for distinguishing brain abscesses from cystic or necrotic tumors, and for differentiating tumor types like arachnoid cysts from epidermoid tumors. It may also provide information about tumor histology in cases of brain metastases.
Journal club presentation on metastatic bone disesaseVenkat Vinay
This document summarizes the presentation on the diagnosis and management of metastatic bone disease. It discusses:
1. The clinical presentation of metastatic bone disease including musculoskeletal pain, pathological fractures, neurological complications, and hypercalcemia symptoms.
2. Diagnostic tests used including history, physical exam, imaging like CT, MRI, and biopsy.
3. Indications for treatment including pathological fractures and spinal instability.
4. Surgical and non-surgical management strategies for different areas of bone involvement including the extremities, pelvis, spine, and use of adjuvants like radiation and bisphosphonates.
The document discusses limb salvage surgery for both trauma and tumor cases. For traumatic injuries, it discusses the decision making process around whether to attempt limb salvage or perform amputation. It presents several scoring systems used to evaluate the likelihood of successful salvage. For tumors, it discusses options for reconstruction after limb salvaging resections, including allografts, endoprostheses, and allograft-prosthetic composites. It also outlines techniques for resections and reconstructions of various parts of the upper and lower extremities.
Open tibia fractures can range from minor soft tissue wounds to severe injuries with extensive soft tissue damage and bone loss. The goals of treatment are to prevent infection, achieve bone union, and restore function. Management involves thorough debridement and irrigation, temporary stabilization, soft tissue coverage within 7-10 days if possible, and definitive stabilization once the soft tissues have healed sufficiently. Complications include infection, malunion, nonunion, and compartment syndrome, which require additional treatment such as antibiotics, bone grafting, or surgery.
Gartner Healthcare Supply Chain Roundtable: October 14, Chicagocstoops
Please join Gartner Supply Chain Research Analysts Stephen Meyer and Eric O’Daffer for a discussion on some of Gartner’s most recent research in the Healthcare Life Science Supply Chain. Find out how organizations are transforming their supply chains, what supply chain leadership looks like, and how you can accelerate innovation at your organization.
O documento contém uma coleção de fotos de 13 anos de uma pessoa chamada Branca, incluindo uma foto dela cozinhando, cães e gatos, uma planta e duas menções a sinestesia.
Este documento presenta un curso de formación de auditores internos de calidad bajo la norma ISO 9001:2008 - NTC GP 1000:2009. El curso cubre generalidades sobre la norma, la estructura de la norma, introducción a las auditorías, gestión de un programa de auditorías, actividades de auditoría y competencia y evaluación de auditores. El objetivo del curso es que los participantes conozcan y puedan aplicar los requisitos de la norma para realizar auditorías internas.
This short document promotes creating Haiku Deck presentations on SlideShare and getting started making one. It encourages the reader to be inspired to make their own presentation using Haiku Deck on the SlideShare platform. A call to action is given to get started creating a Haiku Deck presentation.
El dubstep es un género de música electrónica de baile caracterizado por líneas de bajo abrumadoras, patrones rítmicos reverberantes y samples troceados. Se originó a finales de los 90 en el sur de Londres a partir de experimentos en el UK garage. Artistas como Skrillex y Knife Party ayudaron a popularizar el dubstep en la última década.
El poema describe la experiencia de una persona que usa morfina para escapar temporalmente del dolor emocional, pero luego la pena regresa con más fuerza. Al inyectarse la droga, siente calma y felicidad ilusoria, pero luego la realidad y el sufrimiento vuelven con más intensidad. El documento trata sobre Joana, cuya amiga Marta murió de una sobredosis. Joana empieza a escribirle cartas para entender lo sucedido y perdonarla, mientras lidia con la separación de sus padres y empieza a
Corbett Prep is a summer camp located at 12015 Orange Grove Dr, Tampa, FL 33618 that offers over 60 camps focused on outdoor athletics, performing and visual arts, drama, dance, music, art, science, technology, engineering, math, academic world languages, and field trips. Potential campers can view the online brochure and registration form by visiting www.corbettprep.com or contacting 813-961-3087 or CampIDS@corbettprep.com. The camp is located on Corbett Prep's beautiful lakeside campus covered in cypress trees.
Predicting March Madness with IBM Watson AnalyticsIan Balina
The document discusses using IBM Watson Analytics to predict the results of the 2016 March Madness college basketball tournament. It introduces Watson Analytics and describes how to prepare basketball tournament data by combining 15 seasons into a single data set. Predictive analysis is conducted on the data to identify the top predictors of teams that reach the Final Four and championship game. A comparison is shown of how accurately previous seasons were predicted. The analysis predicts that North Carolina will be the 2016 tournament winner.
The Witch is a 2016 horror film directed by Robert Eggers. It tells the story of a Puritan family in 17th century New England that is accused of witchcraft and banished from their plantation. Their baby son Samuel then mysteriously disappears in the woods, having been kidnapped by a witch. The film uses techniques like dim lighting, blood, and a dark color palette to create an eerie and frightening atmosphere for the horror genre. Cinematography techniques such as medium shots, close ups, and shot reverse shot are employed to advance the plot and build suspense for the audience.
The document provides an overview of various topics related to landing positions in private equity, including:
- Different types of positions in private equity like operating partner, principal, portfolio company CEO.
- How to market yourself effectively to private equity firms by highlighting relevant experience, skills, and track record of value creation rather than just tenure.
- An overview of the private equity industry including the top firms, typical funds and returns, and the investment process from sourcing deals to harvesting returns.
- Strategies for positioning yourself for private equity roles, including marketing yourself proactively, optimizing your online presence, and starting with service firms to build relevant experience.
Microwave ablation was used to treat epiphyseal osteoid osteomas in 7 patients. All patients experienced complete pain relief within 1 week of the procedure and had no complications, except for 1 patient who experienced back pain for 2 months. MRI scans after treatment showed ablation areas averaging 21 x 12 x 14 mm. The study demonstrated that microwave ablation can safely and effectively treat epiphyseal osteoid osteomas with a single needle insertion and without complications. However, more research with larger patient groups is still needed to validate these promising initial results.
1. The document describes three cases of patients with giant aneurysmal bone cysts (ABCs) that were treated with en bloc resection and reconstruction with non-vascularized fibular bone grafts.
2. All patients achieved bony union following the procedure and had no recurrence of the cysts or limitations in range of motion.
3. Non-vascularized fibular grafts provided an effective reconstruction method for large bone defects left after resection of giant ABCs.
Leiomyoma is a benign tumor that originates from smooth
muscle cell. The most common sites are the uterus, gastrointestinal tract & skin. Leiomyoma is a relatively uncommon smooth muscle tumor rarely found in the head and neck. Enzinger and Weiss (1995), analyzed a total of 7748 leiomyomas, 95% of the tumors occurred in the female genitalia (uterus), 3% in the skin, 0.9% in the gastrointestinal tract and the remainder at various sites including skull base.
Abstract
Objective: To assess the outcome of arthroscopic release in patients with cronicalchronic lateral epicondylitis. Materials and methods: Arthroscopic release in three patients with lateral epicondylitis was performed. The Mayo Elbow Performance Index (or Mayo Elbow Performance score) was used pre and post surgical treatment. Sample: Two females and one male. The patients were principal labourers and not athletes. Patients had significant pain and pain was the principal symptom that affected the score of the performance index.
Results: Scores on the performance index improved after surgery. No neurological complications were reported and early return to normal daily activities was noted.
Conclusion: Arthroscopic treatment was an alternative safe and effective method for treating chronic lateral epicondiyitis in three cases. This method makes it possible to simultaneously scan the articulation to diagnostic and treatment associated diseases. It is necessary most wide assays and comparative studies for establish sure treatment protocols.
This document discusses the radiographic evaluation, classification, and management of acetabular and pelvic ring fractures. It covers common fracture classifications including Letournel-Judet, AO, Tile, and Young-Burgess. Indications for operative versus non-operative treatment are provided based on factors such as fracture pattern, displacement, and patient characteristics. Both open reduction with internal fixation techniques and non-operative management approaches are described. The importance of anatomic reduction and stability in achieving good long-term outcomes is emphasized.
This document summarizes the management of 13 acetabular fractures seen by the author between 2002-present. Most fractures were posterior wall or posterior column fractures resulting from motor vehicle accidents. Surgical treatment involved open reduction and internal fixation using plates and screws. Post-operatively, patients underwent rehabilitation and were evaluated using the Harris Hip Score, with most achieving excellent or good results. Complications included myositis ossificans and re-fracture in one case. The author concludes that pre-operative CT planning and specialized surgical techniques and implants like the hooked buttress plate facilitate anatomic reduction and fixation of these complex fractures.
A 35yrs young patient, presented to the hospital with lower extremities neurological deficit, radiological investigation showed bony lesion in the posterior elements of T10 causing severe compression on the cord, emergency surgery was performed to decompress the spinal cord, the microscopic examination revealed that lesion was “ aneurysmal bone cyst”.
Posttreatment imaging in head and neck cancer can help evaluate tumor response and recurrence but is complicated by changes from surgery, radiation, and reconstruction techniques. The summary describes:
1) Tumor recurrence typically appears as an infiltrative enhancing mass within 2 years, most commonly at surgical margins. Differentiating recurrence from fibrosis can be difficult.
2) Common surgery complications include fluid collections, fistulas, and flap necrosis appearing as fluid collections or thromboses. Late radiation effects involve surrounding tissues like skin thickening, bone necrosis, and vascular damage.
3) Imaging findings of recurrence, complications, and treatment effects can overlap, requiring correlation with clinical history and prior imaging for accurate interpretation.
Percutaneous fixation of bilateral anterior column acetabular fracturesApollo Hospitals
The treatment of displaced acetabular fractures with open
reduction and internal fixation has gained general acceptance. This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic ossification and neurovascular complications.
This document summarizes a study that evaluated the efficacy of ultrasonography and computed tomography in diagnosing palpable neck masses. 40 patients with neck masses were examined clinically and underwent ultrasound and CT scans. The results found that ultrasound was useful for characterizing masses as solid or cystic and identifying features like margins, calcifications and necrosis. CT provided additional information on tissue attenuation, extent of lesions, and involvement of surrounding structures or distant spread. The study concluded that ultrasound combined with CT provides valuable information to accurately diagnose neck masses and guide their management.
This document summarizes a study of 110 patients who underwent distal femur resection and endoprosthetic reconstruction between 1980-1998. The majority had malignant bone tumors. Reconstruction was performed with modular, custom-made, or expandable prostheses. At minimum 2-year follow up, function was good or excellent in 85% of patients. Complications included deep infection in 5%, aseptic loosening in 5%, and prosthetic failure in 5%. The limb salvage rate was 96%. Distal femur endoprosthetic reconstruction provided good function and local tumor control in most patients.
The document summarizes the results of using robotic surgery to resect benign and malignant chest masses in 5 pediatric patients. Key details include:
- Robotic surgery allowed for complete resection of chest masses in all 5 patients without need for open conversion. Articulating instruments facilitated dissection.
- Cases included ganglioneuroblastoma, germ cell tumor, inflammation, ganglioneuroma, and teratoma.
- On average, trocar placement time was 12.5 minutes, docking time was 3.4 minutes, robotic time was 98.4 minutes, and total procedure time was 113.2 minutes.
- Average length of hospital stay was 1.4 days and average
Squamous cell carcinoma in the native kidney of a renal transplant recipient ...Apollo Hospitals
A 54-year-old man who received a kidney transplant 3 years prior presented with flank pain. Imaging showed a large mass in his native left kidney. He underwent a nephrectomy and the mass was found to be a squamous cell carcinoma. He later developed a squamous cell carcinoma in his urethra, which was excised. The patient received adjuvant radiation therapy to the tumor bed to reduce the risk of recurrence, while avoiding damage to surrounding structures like the transplanted kidney. This case report discusses the rare occurrence of squamous cell carcinoma in the native kidney of a transplant recipient and the challenges of postoperative management.
This document discusses magnetic resonance imaging (MRI) for peripheral nerves. It begins by providing background on how MRI has become a standard imaging method for the central nervous system due to its soft tissue contrast. It then discusses some limitations of using MRI for peripheral nerves, including technical limitations of older scanners. The document outlines several clinical applications of peripheral nerve MRI, such as evaluating carpal tunnel syndrome, neural tumors, and traumatic nerve injuries. It describes the ability of MRI sequences like diffusion imaging to assess properties of neural tissue. The document concludes by discussing technical considerations for peripheral nerve MRI protocols and sequences.
- The study compared the diagnostic accuracy of conventional radiography and digital subtraction imaging in detecting simulated internal root resorption lesions of varying sizes created in cadaver teeth.
- Using conventional radiography, minimum detectable lesion size was medium (ISO size 010-012) for coronal lesions and large (ISO size 014-016) for apical lesions.
- Overall diagnostic accuracy was superior with subtraction imaging, though only significantly better for detecting coronal lesions according to statistical analysis comparing the two modalities.
This document describes a study evaluating the efficacy of using a dynamic hip screw (DHS) drill under image intensifier guidance to ablate osteoid osteoma of the lower extremities in children and adolescents. Eighteen patients between ages 4-16 were treated with this minimally invasive technique, with 16 achieving initial success from one drilling. Complications included one tibial fracture and two skin abrasions. At follow-up, all patients were classified as having a good clinical response. The combination of intraoperative localization using image intensifier guidance and ablation with a DHS drill provided an efficient, safe, and curative procedure with minimal bone loss for treating osteoid osteoma.
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This document provides an overview of traumatic thoracolumbar fractures. It discusses the themes of the lecture (three column injury, neurological deficit/ongoing compression, ligamentous injury involving 2-3 columns), biomechanics of spinal fractures, definitions of various fracture types, grading systems including Denis three-column model, and treatment considerations. The document covers the history, evaluation according to ATLS protocol, and classifications of thoracolumbar fractures in detail over several pages.
Chance fractures most frequently occur in front end collisions when only lap belts are used. The authors present a case of a 17-year old female who suffered a Chance fracture at L3 from a car accident while restrained only by a lap belt. She presented with paraplegia and was found to have a complete transection of the cauda equina at L3 as well as a large spinal epidural hematoma extending from L3 to T2. She underwent surgery to decompress the hematoma and stabilize the fracture with a pedicle screw construct from L1 to L5. Despite the surgery, she remained paraplegic due to the severity of her injuries from the Chance fracture and associated cauda equina transection and epid
This document summarizes spinal stereotactic radiosurgery (SRS) using the CyberKnife system. It describes the CyberKnife technology, treatment planning process, and indications for spinal SRS. Key points include:
- The CyberKnife allows very high radiation doses to be precisely delivered to small spinal tumors while sparing surrounding tissue.
- Treatment planning involves imaging the spine, contouring the tumor and sensitive structures, and optimizing beam placement to target the tumor.
- Common indications for spinal SRS include spinal metastases, benign tumors, postoperative residuals, and recurrent or inoperable tumors. SRS has shown efficacy in controlling tumor growth and providing pain relief.
This document summarizes the long-term results of using radiosurgery to treat paragangliomas. It found that radiosurgery provided near 100% local tumor control with few complications over follow-up periods of 5-10 years. Specifically, 97.7% local control was found in a review of 345 patients treated with radiosurgery across 18 centers. In comparison, surgical series showed 82.9% local control but around 48% of patients experienced complications like nerve damage. Therefore, the conclusion is that radiosurgery should be the primary treatment for paragangliomas due to its high effectiveness and low risk of complications compared to surgery.
This document presents 10 cases of patients treated with CyberKnife radiosurgery for intramedullary spinal cord metastases. Key details include that patients had various primary cancers, most commonly breast cancer, and multiple metastases elsewhere. Lesions ranged in size from 0.12 to 1.98 cc. Patients received radiosurgery doses from 1400 to 2700 cGy in 2 to 5 fractions. Five of five evaluable patients had stabilization or improvement of symptoms. No patients experienced radiation toxicity. CyberKnife radiosurgery appears to be a good treatment option for intramedullary spinal cord metastases that can preserve neurologic function with low morbidity.
This document provides guidance on MRI and CT scan protocols for various neurosurgical conditions including brain tumors, spine tumors, acoustic neuromas, trigeminal neuralgia, pituitary tumors, skull base tumors, nasopharyngeal carcinoma, AVMs, orbital tumors, paragangliomas, brachial plexus lesions, and pelvic conditions. It specifies the regions to cover, sequences, slice thickness, and other imaging parameters depending on the location and characteristics of the condition being imaged.
This document summarizes the use of stereotactic radiosurgery (SRS) to treat three patients with epidermoid tumors - one intracranial and two spinal. SRS was able to control the intracranial lesion long-term with no growth seen on follow-up MRI several years later. One spinal lesion required post-SRS aspiration but was then stable, while another grew after initial SRS treatment and required re-treatment with SRS. The authors conclude that SRS may be able to stop or delay re-growth of epidermoids and could be a primary treatment option for some lesions, though more studies are needed, especially for spinal versus intracranial epidermo
The document provides an overview of traumatic brain injury (TBI) for medical professionals. It discusses the demographics of TBI, including that over 2.5 million TBIs occur in the US each year from causes like falls, assaults, and motor vehicle accidents. It outlines the approach to evaluating a TBI patient, including performing a full neurological exam and Glasgow Coma Scale. Common injuries from TBI like contusions, hematomas, and shearing are also reviewed. The document then discusses various medical and surgical treatment options as well as factors that influence prognosis. The goal is to educate medical professionals on understanding and managing TBI.
This document summarizes the diagnosis and treatment of intramedullary spinal cord metastasis (ISCM). ISCM is rare, accounting for 0.9-2.1% of cancer metastases, with the most common primary sites being lung, breast, and colon cancers. MRI with gadolinium is the best diagnostic tool. While no randomized trials have been done, retrospective studies suggest that surgery combined with radiation therapy can improve neurologic function and survival compared to radiation alone. Stereotactic radiosurgery is a promising alternative to traditional radiation and has shown improved neurologic outcomes in some cases with fewer side effects. Overall prognosis remains poor, with 80% mortality within 3 months for most patients.
1. This document discusses various types of supratentorial and infratentorial herniations that can occur, as well as the anterior, middle, and posterior cerebral blood vessel circulations and areas susceptible to infarction.
2. Guidelines are provided for intracranial pressure (ICP) monitoring in severe traumatic brain injury patients based on Glasgow Coma Scale score and computed tomography results. Objectives and targets for ICP monitoring and cerebral perfusion pressure are also outlined.
3. Information is given about equipment and procedures for ICP monitoring, including ventricular catheters, Licox brain oxygen tension monitors, Camino ICP monitors, and locations of supplies in the hospital.
This document discusses carpal tunnel syndrome (CTS), providing:
- A brief history of CTS diagnosis and treatment.
- An overview of anatomy and physiology related to CTS, including compression of the median nerve.
- Common symptoms of CTS like numbness, pain worse at night, and dropping objects.
- Differential diagnosis and physical exam techniques to diagnose CTS.
- Details on electrodiagnostic studies and MRI to evaluate CTS severity and rule out other conditions.
- Conservative and surgical treatment options for managing CTS.
This document discusses Chiari malformations, which are abnormalities at the base of the brain. It begins by describing the history of discovery by Hans Chiari and Julius Arnold. It then defines the four main types of Chiari malformation: Type I involves herniation of the cerebellar tonsils with possible syringomyelia; Type II (Arnold-Chiari) involves herniation of the cerebellar vermis and is usually accompanied by a spinal defect; Type III involves an occipital encephalocele with other issues; Type IV lacks cerebellar development and is not compatible with life. The document provides details on features, symptoms, and potential surgeries for each type of Chiari mal
2. R. E. Lieberson et al.
2 Journal of Radiosurgery and SBRT Vol. 0 2011
progressivelysevere,intermittent,bilaterallowerextremity
numbness,weaknessandcrampingwithoutbowelorblad-
der complaints. The examination showed only 4/5 weak-
nessinthelefttibialisanteriorandextensorhallucislongus.
A magnetic resonance image (MRI) scan demonstrated an
intramedullary lesion of the conus, 3.9 centimeters (cm)
in greatest extent. In October 1999, patient 1 underwent
a T12
to L2
laminectomy, gross total resection of the epi-
dermoid. Within a year, her symptoms returned. In Octo-
ber 2000, we performed a second open resection a for a
3.8 cm recurrence seen on MRI. The surgeon reported
that it was impossible to develop a plane between the cyst
wall and the cord and a gross total resection could not
be completed. Painful recurrences in July and August of
2001, which were both associated with increased numb-
ness, worsened weakness, and incontinence of bowel and
bladder. Two MRI-guided-aspirations of prominent cystic
components were completed, removing 4 cubic centim-
eters (cc) and then 2 cc of keratinized material from
the lesion, reducing its volume by approximately 30%
by MRI. An MRI in May 2002 (Figure 1A) showed a
3.8 cm recurrence and, consequently, the patient received
SRS. In a single session, we delivered a marginal dose
of 18 Gray (Gy) to the 81% isodose line. The patient’s
pain, numbness, weakness, and incontinence improved
within weeks. Three months following SRS, an additional
aspiration procedure was required. Because of recurrent
symptoms, in January 2003, the lesion was re-explored
and the 2.3 × 1.4 × 1.2 cm recurrence was removed with
intraoperative monitoring. During surgery, there was a
well-developed cleft around the lesion and it was possible
to easily separate and remove at least 80% of the cyst wall
from the cord. Only the most cranial and caudal compo-
nents could not be resected due to changes in monitor-
ing potentials with manipulation of those portions. At her
most recent neurosurgical follow-up visit in June 2009,
she was clinically stable, complaining only of residual
bladder incontinence and hypalgesia of the right foot.
Although two small areas of cyst wall were not removed,
the most recent, post-operative MRI showed no evidence
of any residual (Figure 1B).
Patient 2
Patient 2, a 62-year-old man at the time, was first
seen at Stanford in February 2004. He had undergone-
four separate L3
to S1
laminectomies for pain, numb-
ness, and weakness (1991, 1995, 1999, and 2002). MRI
scans in 2003 showed a residual lesion extending from
L3
to S1
. In February 2004, the fifth was completed. At
surgery, it was felt that the entire contents of the cyst
and most of the cyst wall had been removed. Because of
his history of multiple prior recurrences, elective SRS
to the resection cavity followed the open procedure. A
total of 22Gy prescribed to the 81% isodose line was
delivered in two sessions to the 39.6 cc resection bed.
Symptoms of pain, a unilateral foot drop, and numbness
remained stable. In January 2011, increasing urinary
symptoms led to an MRI, which showed a cystic recur-
rence, with a cavity measuring 7.1 cm in greatest extent.
We felt that an open surgery would unlikely be effec-
tive and recommended an additional course of SRS. In
March 2011 we delivered 22Gy prescribed to the 75%
isodose line in two sessions (Figure 2). In the brief time
Figure 1. Patient 1.The image on the left (A), shows
a T2 weighted MRI obtained prior to radiosurgery in
2002. A 3.8 cm cystic recurrence is seen within the
conusmedullaris at the L1-2 level.The image on the right
(B), shows a similar T2 weighted MRI taken following
both radiosurgery and the open resection. There is no
evidence of residual tumor within the conus.
Figure 2. Patient 2. This image shows the most recent
radiosurgical plan as delivered in 2011. The black
outline surrounds the cystic, epidermoid lesion. The
white outline surrounds the nerve roots, anterior and to
the right of the mass.
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3. Radiosurgery for recurrent epidermoids (revised)
Journal of Radiosurgery and SBRT Vol. 0 2011 3
that has elapsed following treatment, there have been
no changes in complaints or findings.
Patient 3
Patient 3, a 48-year-old man, was referred to Stan-
ford in November 2007. The patient related a his-
tory of headaches and seizures which began in the
early 1990s. Computerized tomography (CT) scans
at that time were reportedly unremarkable. By 2000,
increasingly symptoms prompted a re-evaluation, and
an MRI showed a 3.7 cm diameter lesion occupying
right anterior middle fossa. Aftera first craniotomy
and reported gross total resection in October 2000, an
MRI showed no residual. Serial MRI scans showed
a recurrence that by July 2006, was 3 cm in greatest
diameter. A second right temporal craniotomy was
completed and it was felt that a gross total resection
had been achieved. Although the immediate post-op-
erative scans reportedly showed no residual, only one
year later, a follow-up MRI showed a 2.3 cm diam-
eter recurrence in the sylvian fissure and suprasellar
cistern. He was referred to Stanford for SRS. At the
time, the patient reported increased headache and
five to six seizures per day, but the physical examination
was unremarkable. In November 2007, we delivered
a marginal dose of 24Gy prescribed to the 75%
isodose line, in three sessions, for a lesion measuring
2.3 cm in maximum diameter and 4.5 cc in volume
(Figure 3A). The most recent scan of August 2010
showed that the lesion remained unchanged by MRI
(Figure 3B). When last examined, in November 2010,
the patient was seizure free and denied significant
headaches.
DISCUSSION
Epidermoid cysts are also known as cholesteoto-
mas or “pearly tumors.” Verattus is credited with the
first description of an epidermoid in 1745 and in 1807,
Pinson, an artist working with Dupuytren at the Hotel
Dieu, constructed a wax model of one of these lesions.
[10] Cruveilhier, a French pathologist, characterized
them more completely in 1829 and described them as
having a “mother-of-pearl” appearance. [11] In 1839,
Mueller coined the term “cholesteotoma” because of the
abundant choldesterol crystals seen in some specimens
and, since then, any masses containing cholesterin have
been referred with this moniker. Von Remakfirst identi-
fied their epithelial cell origin in 1854. [12] It was not
until 1920 that the first successful surgical treatment of
an epidural was described by Bailey. [13]
Epidermoids of the CNS originate from embryo-
nal cell rests or from fragments of epithelial tissue left
behind following surgery, lumbar puncture, or other
trauma. [3, 4] They are composed of squamous epithe-
lial cells and connective tissues components surround-
ing degenerated, desquamated skin. Epidermoids do
not contain skin appendages, such as hair. [14] They
grow slowly along natural cleavage planes, and may
be clinically apparent only after years of growth. [5]
Malignant transformation is uncommon. [15] They are
more common in women (54%) and, although most
are congenital, they often do not present until the fifth
decade. [14] Headache, seizures, intracranial hyperten-
sion, and focal deficits related to lesion location are the
most common presenting symptoms and signs. Epider-
moids are usually homogeneously hypodense on CT,
and may have an enhancing rim or irregular calcified
inclusions. On magnetic resonance imaging (MRI),
they are hypointense on T1-weighted sequences and
hyperintense on T2-weighted images. [5] The differ-
ential diagnosis may include arachnoid cysts and less
commonly glioma, metastasis, lymphoma, or infection,
and MRI diffusion studies may be helpful in differenti-
ating epidermoids from other cystic lesions of the CNS.
[3, 16, 17] Epidermoids occur in the cerebellopontine
angle (37.3%), theparasellar cisterns (30%), the middle
cranial fossa (18%), within the diploë (16%), or in the
spinal canal (5%). [18-20] Although most epidermoids
are in the intradural-extramedullary space, they can
be extradural, or transdural, and they will rarely occur
within the substance of the spinal cord and intramedul-
lary epidermoids of the brain have been reported. [3, 6,
21] Epidermoids exhibit linear, rather than logarithmic
growth, explaining their slower expansion compared to
some CNS tumors. [22] Surgical gross total resection
remains the goal for most treatment, but there remains
controversy regarding the appropriateness of subtotal
Figure 3. Patient 3. The image on the left (A), shows
the most recent radiosurgical plan, completed in 2007.
The image on the right (B), is the most recent MRI,
obtained following the radiosurgicaltreatmentof 2010.
There has been no interval change or increase in the
size of the lesion.
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4. R. E. Lieberson et al.
4 Journal of Radiosurgery and SBRT Vol. 0 2011
resection when the risk of post-operative deficits might
be increased. [5]
Although radiotherapy has been described as inef-
fective for epidermoid cysts, [3, 5, 11] its successful use
has been described. [7, 8] Parikh et al reported that 50Gy
delivered in 25 daily sessions yielded radiographic and
symptomatic control of a previously resected, recurrent
cerebello-pontine angle epidermoid after a two-year
period of follow-up. [7] Bretz et al treated a recurrent
intraspinal C6-T2 epidermoid, causing sensory and
motor deficits, with 46 Gray in 23 daily fractions. [8]
The patient, followed radiographically for two years
and clinically for six years, remained stable without
increased symptoms or evidence of re-growth.
Kida et al [9] first reported the use of stereotactic
radiosurgery (SRS) for intracranial epidermoids. They
treated seven patients with trigeminal neuralgia or hemi-
facial spasm secondary to posterior fossa cysts. The
pain or spasms resolved in five of their seven patients
after Gamma Knife therapy. They achieved local control
in all of their patients, and in two patients, the lesions
reportedly decreased in size after a mean follow-up of
52.7 months. We were unable to find any other reports
describing the use of radiosurgery for intracranial epi-
dermoid cysts. We are aware of no prior reports describ-
ing the use of SRS for spinal epidermoids.
In our three patients, SRS was safe, we saw no
radiation related complications, and SRS appeared to
prevent or delay recurrence. Patient 3, who had a mid-
dle fossa lesion, had radiographic recurrences within a
year following each of two craniotomies. MRI scans
show him to be disease free three years after radio-
surgery. Patient 2 had required five open resections in
a period of 13 years; an average of one operation every
2 ½ years. Following the last open surgery, we delivered
SRS to the resection cavity and patient 2 did not require
any additional intervention for seven years. Patient 1
had undergone two open and two percutaneous proce-
dures in the 2 ½ years before SRS. Although ongoing
symptoms forced us to re-resect the epidermoid shortly
after the SRS treatment, patient 1 now remains without
radiographic or clinical evidence of a recurrence after
eight years. We believe that, without SRS, the time to
the next recurrence for each of our patients would have
been similar to that observed before SRS. Although
we are confident that we delayed the recurrence of the
lesion, we cannot assume that we have achieved any
cures. Epidermoids are slow growing and the time to
recurrence can be a decade or more. [22]
We have used SRS in a variety of situations. For
patient 3, SRS was used to treat a recurrence following
surgery. Repeat courses of radiosurgery for recurrences
have previously been reported as safe for a variety of
other conditions, including arteriovenous malforma-
tions, [23] acoustic neuromas, [24] ependymomas,
[25] chordomas, [26] and nasopharyngeal carcinomas.
[27] Radiosurgery to the resection bed of a metastasis
improves local control. [28] Patient 2 received SRS
both to treat a post-operative resection cavity and also
as a salvage procedure for a recurrence after SRS. SRS
has been employed to decrease vascularity prior to
planned resections for hemangioblastomas, [29] renal
cell metastases, [30] and arteriovenous malformations.
[31] SRS may create an improved capsule or a more
defined plane around some lesions. Kamitani et al,
reported that a capsule around the radiated hemangiob-
lastoma, “made resection easy.” [29] Sanchez-Mejia
et al reported that following SRS, the tissue planes of
separation around the AVMs were more “distinct.” [31]
Patient 1 was treated with SRS prior to an unplanned
open resection. At surgery, we found a clear plane that
separated most of the lesion from surrounding cord,
facilitating a near total resection.
Patient 1’s care was particularly interesting for two
reasons. First, we believe that the lesion was more eas-
ily resected as a result of the SRS treatment. Patient 1
had undergone four procedures before the SRS treat-
ment. During each operation, the intramedullary conus
lesion could not be separated from the surrounding
cord. Shortly following SRS, and because of increasing
symptoms, we were forced to operate. Whereas before
SRS we were unable to develop a plane around the lesion
before SRS, after SRS it was possible to remove the
lesion almost entirely because of a well developed cleft
that had not been present at the time of the earlier oper-
ations. Second, patient 1’s unplanned surgery following
SRS might have been predicted. Since the expansion of
the cavity in other cystic lesions, such as hemangiob-
lastomas, does not stop for some time after SRS, we
believe that this may also be true for epidermoids.
Patients with multiply recurrent epidermoids have
a high-risk of complication. Given the location of the
lesions in our patients, had additional open surger-
ies been required, there would probably have been
injury to the involved structures of the cavernous sinus
(patient 3) or to the conus and caudaequina (patient 2 and
patient 1). Others have argued that a gross total resection is
not always the best approach and, alternatively, a debulk-
ing with planned subsequent surgeries over the course of
a patient’s lifetime may be safer. [3, 5, 32, 33] Instead,
consideration of planned post-operative radiosurgery for
those patients where a gross total resection is not possible,
or is excessively risky, might be appropriate.
Although we have not seen evidence of any radia-
tion related complications in our patient population,
potential risks could include radiation necrosis or mye-
lopathy. Epidermoids can also spontaneously undergo
malignant degeneration. [15] Although the mechanism
is not well understood and is thought to involve chronic
inflammation, cyst rupture, and subtotal resection of the
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5. Radiosurgery for recurrent epidermoids (revised)
Journal of Radiosurgery and SBRT Vol. 0 2011 5
cyst wall, [34] SRS could theoretically increase the risk
of a malignant conversion.
CONCLUSION
Others have discussed radiation therapy and SRS
as possible treatments for epidermoids of the central
nervous system, however, we describe the first use of
SRS for spinal epidermoid cysts. Our patients all had
multiply recurrent lesions and we believe that the use
of SRSprevented or significantly delayed subsequent
recurrences. We believe that SRS should be considered
for some epidermoids that are difficult or impossible
to resect, or for epidermoids in patients who would
not tolerate or might not accept an open procedure.
For those patients who must have surgery because
of mass effect, but for whom a gross total resection
might be excessively risky, a planned subtotal resec-
tion followed by radiosurgery might be an appropriate
consideration. Our recommendations are preliminary.
The study of a larger cohort, followed for a much
longer period, would be required to perfect treatment
recommendations.
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