Intraoperative ultrasonography for presumed brain metastases: a case series study

Brain metastases (BM) are one of the most common intracranial tumors and surgical treatment can improve both the functional outcomes and patient survival, particularly when systemic disease is controlled. Image-guided BM resection using intraoperative exams, such as intraoperative ultrasound (IOUS), can lead to better surgical results. Methods: To evaluate the use of IOUS for BM resection, 20 consecutives patients were operated using IOUS to locate tumors, identify their anatomical relationships and surgical cavity after resection. Technical difficulties, complications, recurrence and survival rates were noted. Results: IOUS proved effective for locating, determining borders and defining the anatomical relationships of BM, as well as to identify incomplete tumor resection. No complications related to IOUS were seen. Conclusion: IOUS is a practical supporting method for the resection of BM, but further studies comparing this method with other intraoperative exams are needed to evaluate its actual contribution and reliability.

A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access

Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach. A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection. The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient's recovery after the procedure was successful, without the need for further intervention. Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann's procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.

Should extragonadal germ cell tumors be included in studies of families with testicular germ cell tumors?

Abstract Background Family history is among the few established risk factors for testicular germ cell tumor (TGCT). Approximately 1.4% of newly diagnosed TGCT patients report a positive family history of TGCT. Sons and siblings of TGCT patients have four- to six fold and eight- to tenfold increase in TGCT risk, respectively. In twins of men with TGCT the relative risk of testicular cancer is 37.5 (12.3-115.6). Nevertheless, information about the occurrence of TGCT in relatives of patients with extragonadal germ cell tumor is limited. Case report A 24 year-old male patient was diagnosed with a mediastinum tumor and was submitted to image-guided biopsy, which revealed a seminoma. Two months later, his non-identical asymptomatic twin brother was submitted to an elective ultrasound of the testes, which showed a left testicular mass of 4.2 cm. This patient underwent orchiectomy revealing a seminoma of the left testis. There are no other cases of seminoma or other types of cancers reported in first-degree relatives in this family. Conclusions Although familial aggregations of TGCT have been well described, to the best of our knowledge, no data concerning the association of gonadal and extragonadal germ cell tumor in relatives has been previously reported. Further investigation on this association is warranted and may help in improving our knowledge of familial pattern inheritance.

Microendoscopic stereotactic-guided percutaneous radiofrequency trigeminal nucleotractotomy

Object. Over the past few decades, various authors have performed open or stereotactic trigeminal nucleotractotomy for the treatment of neuropathic facial pain resistant to medical treatment. Stereotactic procedures can be performed percutaneously under local anesthesia, allowing intraoperative neurological examination as a method for target refinement. However, blind percutaneous procedures in the region of the atlantooccipital transition carry a considerably high risk of vascular injuries that may bring prohibitive neurological deficit or even death. To avoid such complications, the authors present the first clinical use of microendoscopy to assist percutaneous radiofrequency trigeminal nucleotractotomy. The aim of this article is to demonstrate intradural microendoscopic visualization of the medulla oblongata through an atlantooccipital percutaneous approach. Methods. The authors present a case of severe postherpetic facial neuralgia in a patient who underwent the procedure and had satisfactory results. Stereotactic computational image planning for targeting the spinal trigeminal tract and nucleus in the posterolateral medulla was performed, allowing for an accurate percutaneous approach. immediately before radiofrequency electrode insertion, a tine endoscope was introduced to visualize the structures in the cisterna magna. Results. Microendoscopic visualization offered clear identification of the pial surface of the medulla oblongata and its blood vessels, the arachnoid membrane, cranial nerve rootlets and their entry zone, and larger vessels such as the vertebral arteries and the branches of the posterior inferior cerebellar artery. Conclusions. The initial application of this technique suggests that percutaneous microendoscopy may be useful for particular manipulation of the medulla oblongata, increasing the safety of the procedure and likely improving its effectiveness. (DOI: 10.3171/2011.8.JNS11618)

Clinical and image findings in bisphosphonate-related osteonecrosis of the jaws

Abstract: Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is characterized as exposed bone in the jaws for more than 8 weeks in patients with current or previous history of therapy with bisphosphonates (BPs) and no history of radiotherapy in the head and neck. We report a case series of 7 patients with BRONJ and analyze the variations of clinical and imaging signs, correlating them with the presence or absence of bone exposure. Among the patients, 6 were women and 1 was a man, aged 42–79 years. Five of the patients were using zoledronic acid and the other 2 alendronate. The use of BPs varied from 3 to 13 years. In 5 patients, tooth extraction was the triggering event of injuries. Panoramic radiographs and computed tomography (CT) were evaluated by a radiologist blinded to the cases. There were persistent unremodeled extraction socket even several months after tooth extraction in 3 of the cases that were consistent wit CT findings that also showed areas of osteosclerosis and osteolysis. Patients were treated according to the recommendations of the AAOMS, with surgical debridement and antibiotic coverage with amoxicillin in the symptomatic patients. The follow-up of these patients ranged from 8 to 34 months, with a good response to treatment. The image findings in this case series were not specific and showed no difference between each stages of BRONJ (AAOMS, 2009). The image features were similar in presence or absence of exposed bone.