Joshua De Leon, M.D.

• Assistant Professor of Medicine
• Mount Sinai School of Medicine
• New York, NY

Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage menstrual unusual bleeding purchase arimidex 1 mg on-line. Unilateral placement of metallic stents for malignany hilar obstruction: a prospective study menopause kit joke order 1 mg arimidex. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction: unilobar versus bilobar drainage women's health clinic ut austin buy 1 mg arimidex fast delivery. Hepatic iron overload induces hepatocellular carcinoma in transgenic mice expressing the hepatitis C virus polyprotein menstrual 6 days early 1 mg arimidex fast delivery. Opisthorchis felineus and Metorchis bilis are the main agents of liver fluke infection of humans in Russia menopause uk purchase arimidex with a mastercard. Ultrasonography women's health big book of 15 minute exercises purchase arimidex toronto, computed tomography and magnetic resonance imaging of hepatocellular carcinoma: toward improved treatment decisions. Diagnostic and therapeutic utility of single-operator peroral cholangioscopy for indeterminate biliary lesions and bile duct stones. Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study. Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis. European Association for the Study of the L, European Organisation for R, Treatment of C. Prognosis of hepatocellular carcinoma: comparison of 7 staging systems in an American cohort. Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis. Model for end-stage liver disease and Child-Turcotte-Pugh score as predictors of pretransplantation disease severity, posttransplantation outcome, and resource utilization in United Network for Organ Sharing status 2A patients. Elective liver transplant mortality: development of a United Kingdom end-stage liver disease score. Prognostic impact of hepatectomy for patients with non-hepatitis B, non-hepatitis C hepatocellular carcinoma. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report. A novel model measuring the harm of transplanting hepatocellular carcinoma exceeding Milan criteria. Transcatheter arterial chemoembolization combined with radiofrequency ablation for the treatment of hepatocellular carcinoma. Survival analysis of high-intensity focused ultrasound therapy versus radiofrequency ablation in the treatment of recurrent hepatocellular carcinoma. Irreversible electroporation therapy in the liver: longitudinal efficacy studies in a rat model of hepatocellular carcinoma. Contrast-enhanced ultrasound for the differentiation of benign and malignant focal liver lesions: a meta-analysis. Transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma: recent progression and perspective. A prospective randomized controlled trial of preoperative whole-liver chemolipiodolization for hepatocellular carcinoma. Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres. Chemosaturation with percutaneous hepatic perfusion for unresectable isolated hepatic metastases from sarcoma. Tivantinib, a new option for second-line treatment of advanced hepatocellular carcinoma Phase 2 study of erlotinib in patients with unresectable hepatocellular carcinoma. Phase I study investigating everolimus combined with sorafenib in patients with advanced hepatocellular carcinoma. Doxorubicin plus sorafenib vs doxorubicin alone in patients with advanced hepatocellular carcinoma: a randomized trial. Hepatitis B reactivation in patients with hepatocellular carcinoma undergoing systemic chemotherapy. Operative microwave ablation for hepatocellular carcinoma: complications, recurrence, and long-term outcomes. Ablation of perivascular hepatic malignant tumors with irreversible electroporation. Complete pathological remission is possible with systemic combination chemotherapy for inoperable hepatocellular carcinoma. Unresectable hepatocellular carcinoma: a prospective controlled trial with tamoxifen. Tamoxifen in treatment of hepatocellular carcinoma: a randomised controlled trial. Treatment of advanced hepatocellular carcinoma with tamoxifen and the correlation with expression of hormone receptors: a prospective randomized study. Lamivudine for the prevention of hepatitis B virus reactivation in hepatitis B s-antigen seropositive cancer patients undergoing cytotoxic chemotherapy. Jaundice predicts advanced disease and early mortality in patients with gallbladder cancer. Management of carcinoma of the gallbladder: a single-institution experience in 16 years. An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center. Treatment outcomes associated with surgery for gallbladder cancer: a 20-year experience. Impact of integrated positron emission tomography and computed tomography on staging and management of gallbladder cancer and cholangiocarcinoma. Positron-emission tomography with fluorine-18-fluoro-2-deoxy-D-glucose for gallbladder cancer diagnosis. Regional and para-aortic lymphadenectomy in radical surgery for advanced gallbladder carcinoma. Surgical treatment of primary carcinoma of the gallbladder based on the histologic analysis of 48 surgical specimens. Incidence of finding residual disease for incidental gallbladder carcinoma: implications for re-resection. Cholecystectomy, liver resection, and pylorus-preserving pancreaticoduodenectomy for gallbladder cancer: report of five cases. Combined pancreaticoduodenectomy and hepatectomy for patients with locally advanced gallbladder carcinoma: long term results. Prognostic significance of the number of positive lymph nodes in gallbladder cancer. What prognostic factors are important for resected intrahepatic cholangiocarcinoma Intrahepatic peripheral cholangiocarcinoma: mode of spread and choice of surgical treatment. Outpatient chemotherapy with gemcitabine and oxaliplatin in patients with biliary tract cancer. Gemcitabine and oxaliplatin combination chemotherapy in advanced biliary tract cancers. Adjuvant external beam radiation therapy with concurrent chemotherapy in the management of gallbladder carcinoma. Intrahepatic biliary enteric bypass provides effective palliation in selected patients with malignant obstruction at the hepatic duct confluence. The role of chemotherapy and radiation in the management of biliary cancer: a review of the literature. Long-term survival and prognostic factors in the surgical treatment of mass-forming type cholangiocarcinoma. Indications for surgical treatment of intrahepatic cholangiocarcinoma with lymph node metastases. Number of lymph node metastases is a prognostic factor in intrahepatic cholangiocarcinoma. Mesothelioma may involve the pleura, less frequently the peritoneum, and rarely, the pericardium and tunica vaginalis testes. In the past, peritoneal mesothelioma was a rapidly fatal peritoneal surface malignancy with a median survival of less than one year [1, 2]. It represents about one-fifth to one-third of all forms of mesothelioma; there are approximately 400 new cases in the United States each year [3]. The initial clinical presentation of patients is usually non-specific with symptoms of abdominal pain and increasing abdominal girth being the most common [8]. Sixteen patients had no history of exposure to asbestos, 20 had a positive history, and no data are available on 15 patients. Nineteen patients had a family history of cancer in a parent or sibling and five had more than one first-degree relative with a malignancy; no data are available on nine patients [17]. This disease is mostly observed in countries with a higher socio-economic status due to the historical use of asbestos in the construction industry and the availability of current medical technology that allows its diagnosis [18]. In 2009, there were 2558 patients diagnosed with mesothelioma and this incidence has demonstrated an increasing trend since the 1970s with an exponential increase noted since year 2000 from 0. It is thought that inhaled asbestos may form expectorate that may subsequently be swallowed. Upon entry into the gastrointestinal tract, it penetrates the luminal surfaces of the intestinal mucosa to enter the lymphatic and splanchnic circulation [21]. This triggers a foreign body reaction resulting in a series of inflammatory responses. Discrepancies could depend on diverse experimental variables, including selection of the case series and the experimental assays used. Approximately 10% of patients with primary colon cancer will have peritoneal carcinomatosis. Up to 30% of patients with gastric cancer and pancreatic cancer have peritoneal seeding at the time of exploration for resection of the primary malignancy. A majority of patients with papillary serous ovarian cancer have peritoneal seeding. Also, the simultaneous occurrence of one of these common cancers coincidentally with a primary peritoneal mesothelioma can occur [17]. Interestingly, one patient in our series who was diagnosed with peritoneal carcinomatosis of colorectal origin presented two years later with peritoneal mesothelioma. Tumours arising from the mesothelial cells lining the abdominal cavity cover a wide spectrum of biological aggressiveness [37]. Adenomatoid tumour and solitary fibrous tumour are truly benign lesions that very unlikely recur after simple excision. The subsequent sections of this chapter centres on borderline and malignant peritoneal mesotheliomas, which attract more interest on the part of the medical community and pose substantial problems in clinical practice. As the disease progresses, the nodules become confluent to form plaques, masses, bowel encasement, or uniformly cover peritoneal surfaces. It consists of a mixture of small tubules and papillary structures with fibrovascular cores lined by bland flat, cuboidal, or polygonal cells. The solid pattern consists of nests, cords, or sheets of round, oval, or polygonal cells with abundant eosinophilic cytoplasm and is shown in Table 42. Adenomatoid tumour is a solitary asymptomatic lesion which most often involves the peritoneum of the genital region in women of reproductive age. Recent immunohistochemical and ultrastructural studies have suggested that this lesion Table 42. Demonstration of stromal invasion into visceral or parietal peritoneum (or beyond) is the key feature in the differential diagnosis with reactive mesothelial proliferations, and can be highlighted with pancytokeratin or calretinin immunostaining. Peritoneal (versus pleural) location, sex of the patient, and basic histological type affect the differential diagnosis. Since no immunohistochemical marker is entirely specific and sensitive for mesothelioma, the standard is to use panels of positive and negative markers. However, histomorphologic parameters can be used to help select treatment options and estimate survival. However, the low incidence of biphasic/sarcomatoid and borderline mesotheliomas restricts the clinical utility of this variable. For the same reason, rare secondary histological patterns that seem to have lower survival are of limited utility [42]. An exhaustive clinicopathological analysis of 62 patients undergoing comprehensive treatment at the Washington Cancer Institute revealed that nuclear and nucleolar size (rated by a four-tiered score) correlated with survival [48]. Clinical data from the Milan Peritoneal Malignancy Program demonstrated that both pathologically involved lymph nodes and inadequate nodal sampling correlate with poor prognosis. Accordingly, careful examination of lymph nodes that drain the visceral and parietal peritoneum is recommended, including bilateral iliac, right gastroepiploic, and ileocolic nodes [42]. Proliferative activity has been reported to be useful for prognostic stratification. It may be quantified either by means of mitotic count or immunohistochemical staining with Ki-67 antigen, an excellent marker of cellular proliferation.

Describe the process required to speak a word that is seen compared to one that is heard womens health np 1 mg arimidex free shipping. Name the three types of memory pregnancy kitty litter purchase generic arimidex on-line, and describe the processes that result in long-term memory pregnancy symptoms at 3 weeks purchase arimidex uk. Contrast the functions of the sympathetic and parasympathetic divisions of the autonomic nervous system 32 menstrual cycle purchase cheapest arimidex and arimidex. What kinds of neurons (sympathetic or parasympathetic breast cancer walk in chicago order arimidex 1 mg amex, preganglionic or postganglionic) are found in the following Given two series of neurons menstruation nutrition purchase arimidex 1 mg with amex, explain why action potentials could be propagated along one series more rapidly than along the other series. To reduce the empty space left in the thorax after the lung was removed, the diaphragm on the left side was paralyzed so that the abdominal viscera would push the diaphragm upward into the space. The elbow and wrist on one side are held in a flexed position and cannot be extended. The patient is unable to flex the right hip and extend the knee (as in kicking a ball). On the basis of what you know about cerebellar function, how could you determine that the cerebellum was involved Later, when he had regained consciousness, he was unable to remember any of the events that happened during the 10 minutes before the accident. He has several family members that are nearsighted, meaning they have problems seeing things at a distance, and require corrective lenses. The senses are the means by which the brain receives information about the environment and the body. Sensation is the process initiated by stimulating sensory receptors and perception is the conscious awareness of those stimuli. The brain constantly receives a wide variety of stimuli from both inside and outside the body, but stimulation of sensory receptors does not immediately result in perception. Sensory receptors respond to stimuli by generating action potentials that are propagated to the spinal cord and brain. Historically, five senses were recognized: smell, taste, sight, hearing, and touch. Today we recognize many more senses and divide them into two basic groups: general and special senses (figure 9. The somatic senses provide sensory information about the body and the environment. The visceral senses provide information about various internal organs, primarily involving pain and pressure. Module 7 Nervous System Special senses are more specialized in structure and are localized to specific parts of the body. Sensory receptors are sensory nerve endings or specialized cells capable of responding to stimuli by developing action potentials. Several types of receptors are associated with both the general and the special senses, and each responds to a different type of stimulus: Mechanoreceptors (mek a-no-re-sep torz) respond to mechanical stimuli, such as the bending or stretching of receptors. Nociceptors (no si-sep tors; noceo, to injure) respond to stimuli that result in the sensation of pain. The general senses have sensory receptors that are widely distributed throughout the body. The general senses include the senses of touch, pressure, pain, temperature, vibration, itch, and proprioception (pro-pre-o-sep shun), which is the sense of movement and position of the body and limbs. Many of the receptors for the general senses are associated with the skin (figure 9. Structurally, the simplest and most common receptors are free nerve endings, which are relatively unspecialized neuronal branches similar to dendrites. Some free nerve endings respond to painful stimuli, some to temperature, some to itch, and some to movement. Touch receptors are structurally more complex than free nerve endings, and many are enclosed by capsules. Merkel disks are small, superficial nerve endings involved in detecting light touch and superficial pressure. Hair follicle receptors, associated with hairs, are also involved in detecting light touch. Light touch receptors are very sensitive but not very discriminative, meaning that the point being touched cannot be precisely located. Receptors for fine, discriminative touch, called Meissner corpuscles, are located just deep to the epidermis. Deeper tactile receptors, called Ruffini corpuscles, play an important role in detecting continuous pressure in the skin. The deepest receptors are associated with tendons and joints and are called pacinian corpuscles. These receptors relay information concerning deep pressure, vibration, and position (proprioception). Pain Pain is characterized by a group of unpleasant perceptual and emotional experiences. There are two types of pain sensation: (1) localized, sharp, pricking, or cutting pain resulting from rapidly conducted action potentials, and (2) diffuse, burning, or aching pain resulting from action potentials that are propagated more slowly. Deep or visceral pain sensations are not highly localized because of the absence of tactile receptors in the deeper structures. Action potentials from pain receptors in local areas of the body can be suppressed by local anesthesia, a treatment where chemical anesthetics are injected near a sensory receptor or nerve, resulting in reduced pain sensation. This is usually accomplished by general anesthesia, a treatment where chemical anesthetics that affect the reticular formation are administered. Sensory axons from tactile receptors in the skin have collateral branches that synapse with neurons in the posterior horn of the spinal cord. Those neurons, in turn, synapse with and inhibit neurons that give rise to the spinothalamic tract, a sensory pathway that relays pain sensations to the brain (see table 8. For example, rubbing the skin in the area of an injury stimulates the tactile receptors, which send action potentials along the sensory axons to the spinal cord. According to the gate control theory, these action potentials "close the gate" and inhibit action potentials carried to the brain by the spinothalamic tract. The gate control theory may explain the physiological basis for several techniques that have been used to reduce the intensity of pain. Action potentials carried by the spinothalamic tract can be inhibited by action potentials carried by descending neurons of the dorsal column system (see chapter 8). These neurons are stimulated by mental or physical activity, especially involving movement of the limbs. The descending neurons synapse with and inhibit neurons in the posterior horn that give rise to the spinothalamic tract. Vigorous mental or physical activity increases the rate of action potentials in neurons of the dorsal column and can reduce the sensation of pain. Exercise programs are important components in the clinical management of chronic pain. Acupuncture and acupressure procedures may also decrease the sensation of pain by stimulating descending dorsal column neurons, which inhibit action potentials in the spinothalamic tract neurons. Referred Pain Referred pain is perceived to originate in a region of the body that is not the source of the pain stimulus. Most commonly, we sense referred pain when deeper structures, such as internal organs, are damaged or inflamed (figure 9. This occurs because sensory neurons from the superficial area to which the pain is referred and the neurons from the deeper, visceral area where the pain stimulation originates converge onto the same ascending neurons in the spinal cord. The brain cannot distinguish between the two sources of pain stimuli, and the painful sensation is referred to the most superficial structures innervated, such as the skin. Referred pain is clinically useful in diagnosing the actual cause of the painful stimulus. For example, during a heart attack, pain receptors in the heart are stimulated when blood flow is blocked to some of the heart muscle. Heart attack victims, however, often may not feel the pain in the heart but instead perceive cutaneous pain radiating from the left shoulder down the arm (figure 9. Predict 2 A man has constipation that causes distention and painful cramping in the colon (part of the large intestine). What kind of pain does he experience (localized or diffuse), and where does he perceive it The dendrites of the olfactory neurons extend to the epithelial surface, and their ends are modified with long, specialized cilia that lie in a thin mucous film on the epithelial surface. The mucus keeps the nasal epithelium moist, traps and dissolves airborne molecules, and facilitates the removal of molecules and particles from the nasal epithelium. Airborne odorants become dissolved in the mucus on the surface of the epithelium and bind to receptor molecules on the membranes of the specialized cilia. The binding of the odorant to the receptor initiates action potentials, which are then conducted to the olfactory cortex of the cerebrum by sensory neurons. The senses of smell, taste, sight, hearing, and balance are associated with very specialized, localized sensory receptors. The sensations of smell and taste are closely related, both structurally and functionally, and both are initiated by the interaction of chemicals with sensory receptors. The sense of vision is initiated by the interaction of light with sensory receptors. Both hearing and balance function in response to the interaction of mechanical stimuli with sensory receptors. Hearing occurs in response to sound waves, and balance occurs in response to gravity or motion. Olfactory tract Olfactory epithelium Mucous layer on epithelial surface (b) Olfactory neuron Dendrite Cilia 9. Describe olfactory neurons, and explain how airborne molecules can stimulate action potentials in the olfactory nerves. Olfactory neurons are bipolar neurons within the olfactory (a) A sagittal section through the lateral wall of the nasal cavity shows the olfactory nerves, olfactory bulb, and olfactory tract. Unlike most other receptors in the body, each olfactory receptor can bind multiple types of odorants; conversely, each type of odorant can bind to multiple olfactory receptors. These multiple combinations of odorants and receptors allow us to detect an estimated 10,000 different smells. Once an odorant has bound to its receptor, that receptor is desensitized and does not respond to another odor molecule for some time, which helps with adaptation (described next) to a particular odor. The threshold for the detection of odors is extremely low, so very few odorants bound to an olfactory neuron can initiate an action potential. The olfactory range and sensitivity is even greater in some animals than in humans, due to a larger number and more types of olfactory receptors. For example, dogs are often used to detect small traces of explosives and other chemicals that people cannot detect. Root of tongue Epiglottis Palatine tonsil Papillae Nervous Neuronal Pathways for Olfaction Axons from olfactory neurons form the olfactory nerves (cranial nerve I), which pass through foramina of the cribriform plate and enter the olfactory bulb (figure 9. There they synapse with interneurons that relay action potentials to the brain through the olfactory tracts. Each olfactory tract terminates in an area of the brain called the olfactory cortex, located within the temporal and frontal lobes. Olfaction is the only major sensation that is relayed directly to the cerebral cortex without first passing through the thalamus. The olfactory cortex is involved with both the conscious perception of smell and the visceral and emotional reactions that are often linked to odors. Within the olfactory bulb and olfactory cortex are feedback loops that tend to inhibit transmission of action potentials resulting from prolonged exposure to a given odorant. This feedback, plus the temporary decreased sensitivity at the level of the receptors, results in adaptation to a given odor. For example, if you enter a room that has an odor, such as a movie theater that smells like popcorn, you adapt to the odor and cannot smell it as well after the first few minutes. If you leave the room for some time and then reenter the room, the odor again seems more intense. Taste buds are oval structures located on the surface of certain papillae (pa-pil e; nipples), which are enlargements on the surface of the tongue (figure 9. Taste buds are also distributed throughout other areas of the mouth and pharynx, such as on the palate, the root of the tongue, and the epiglottis. Specialized epithelial cells form the exterior supporting capsule of each taste bud, and the interior consists of about 40 taste cells. Each taste cell contains hairlike processes, called taste hairs, that extend into a tiny opening in the surrounding stratified epithelium, called a taste pore. Dissolved molecules or ions bind to receptors on the taste hairs and initiate action potentials, which sensory neurons carry to the insula of the cerebral cortex. Taste sensations are divided into five basic types: sour, salty, bitter, sweet, and umami (u-mame; savory). Although all taste buds are able to detect all five of the basic taste sensations, each taste bud is usually most sensitive to one class of taste stimuli.

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Patients with stable spines women's health clinic indooroopilly cheap 1 mg arimidex with amex, who are able to walk women's health center dickson tn buy cheap arimidex online, could be considered for chemotherapy for very chemosensitive tumours (teratoma or lymphoma); radiotherapy alone if the tumour is very radiosensitive (small cell carcinoma pregnancy forums order arimidex 1 mg without prescription, germ cell tumour women's health issues heart disease cheap 1mg arimidex free shipping, lymphoma menstruation smells bad buy arimidex 1 mg without a prescription, leukaemia breast cancer 5k columbia sc buy cheap arimidex 1mg online, and multiple myeloma); or, for the majority of patients, surgical decompression followed by radiotherapy (30Gy in ten fractions). Surgical decompression is done through either an anterior approach or a posterior laminectomy. Most cases require a metallic instrumented fixation and fusion to maintain spinal stability. When an anterior approach is employed, an anterior plate spanning one level above and one level below the vertebrectomy defect is generally used to support the cage or cement reconstruction in the vertebral body. In posterior decompression, posterolateral lateral mass or pedicle instrumentation is usually employed, spanning at least two levels above and below the tumour. Chemotherapy Systemic chemotherapy administered to patients with brain metastases of chemosensitive tumours, such as lymphoma, teratoma, small cell lung cancer, and breast cancer, can induce clinical responses, particularly in previously untreated patients. More recent evidence has become available on the use of targeted agents crossing the blood brain barrier for brain metastases. Lapatinib is an oral small molecule tyrosine kinase inhibitor also crossing the blood brain barrier that interrupts Her-2 receptor pathways. Its use resulted in prolonged median survival for Her-2 positive breast cancer patients with brain metastases (19 months) compared with trastuzumab (12 months), a monoclonal antibody inhibitor of Her-2 receptor [283]. Metastatic spinal tumours Although uncommon, spinal tumours may present with symptoms mimicking many benign disorders, frequently delaying diagnosis. These include back pain, sometimes radiating to other parts of the body; loss of sensation, especially in the arms or legs; difficulty in walking; decreased sensitivity; loss of bowel or bladder function; and muscle weakness depending on which nerve or part of the spinal cord is compressed. In general, cancerous spinal tumours grow more quickly, and noncancerous spinal tumours tend to develop very slowly. Metastatic tumours to the spine are usually extradural, arising from bony or surrounding soft tissue metastatic masses. The neurological deficit is the result of the combination of local cord oedema, ischaemia, and direct pressure. Spinal cord compression by a tumour of unknown primary site or progression of signs despite radiotherapy are also indications for surgery. Laminectomy alone has been shown to be no better than radiotherapy and should not be used. Patients without the good prognostic features outlined above should be considered for treatment with palliative radiotherapy. This is more likely for patients whose symptoms develop slowly (>2 weeks), treatment is started <12 hours after loss of ambulation, and bladder and bowel function are retained [292]. An optimal radiotherapy regimen has not been defined; in patients with a limited prognosis a dose of 20 Gy in five fractions by direct field is usually adequate. In addition, the low-dose radiation to normal tissues beyond the target volume is significantly lower with protons, and the rate of second malignancy following proton therapy appears to be half that of conventional radiotherapy (6. Published case series of 416 patients with chordoma treated with proton therapy has shown five-year local control and overall survival rates of 69% and 80%, respectively [295]. The results for chondrosarcoma are higher with ten-year local control and survival rates over 98% following 72 Cobalt Gy-equivalent proton therapy [296]. Randomized trials comparing photon therapy and proton treatment for indications such as skull base chordoma and chondrosarcoma should be conducted [297]. They arise from the vestibular nerve within the internal auditory meatus and commonly present with unilateral progressive deafness. However, symptoms may not occur until the tumour has expanded into the cerebello-pontine angle, causing ataxia and involvement of the trigeminal and facial nerves. Large tumours may also involve the adjacent seventh or fifth (trigeminal) nerves with associated clinical signs. Schwannomas may rarely involve the trigeminal, glossopharyngeal, vagus, or hypoglossal nerves and these may also affect the cerebello-pontine angle. They are well-circumscribed, avidly-enhancing solid tumours, but larger lesions can have areas of non-enhancing cystic degeneration. Histologically, they are highly cellular with interlacing bundles of spindle cells whose nuclei are often in parallel arrays, alternating with lesser-textured, often partially cystic areas. Skull base tumours Clinical features the most frequent site of primary bone tumours of the skull is the base of the cranium, with rare involvement of other regions. The most common tumours are chordomas and chondrosarcomas, with occasional osteomas, giant cell tumours of the bone, and osteosarcomas. Base of skull (clivus) tumours present with symptoms of local bone destruction (usually pain) and gradually progressive features of cranial nerve, brainstem, or mid-brain compression. Tumours may also invade other surrounding structures, such as the sphenoid sinus, pituitary fossa, orbits, and nasopharynx, with attendant focal clinical features. Surgery Surgery is the primary treatment but the tumour site and extensive invasion of surrounding structures make complete excision difficult. High-energy charged-particle radiation (protons and helium ions) has been employed in the treatment of skull-base chordomas and low-grade chondrosarcomas. Due to the sharp dose gradient fall off, a higher dose (70 Cobalt-Gy equivalent) can be delivered to the skull-base tumour with reduced risk of normal tissue Surgery Tumours may be resected by retrosigmoid, subtemporal, or translabyrinthine routes. Patients with recurrence are offered further surgery rather than radiation therapy [314, 315]. Following incomplete excision, radiotherapy has been employed with variable results [316]. Treatment with craniospinal axis irradiation resulted in better outcomes than focal irradiation [317]. A recent large meta-analysis (>11,000 patients) showed 90% facial nerve preservation with tumour <2 cm vs 67% with >2 cm [306]; therefore, most surgeons now accept a subtotal resection with preservation of facial nerve function [307, 308] or follow it with planned radiosurgery [309]. Radiotherapy Radiotherapy has been employed in the treatment of inaccessible or incompletely excised schwannomas of the eighth and other cranial nerves. The likelihood of hearing preservation following treatment should also be considered in the choice of treatment. Targeting brain cancer: advances in the molecular pathology of malignant glioma and medulloblastoma. International Society of Neuropathology-Haarlem Consensus Guidelines for Nervous System Tumor Classification and Grading. Treatment is indicated when there is brainstem compression, deterioration in hearing, and/or facial nerve dysfunction. Surgery is usually carried out; however, hearing preservation is problematic with bilateral disease. In one study, 55% of 31 patients showed a response in terms of initial tumour reduction and hearing improvement. This improvement was durable; 61% had stable or improved hearing and 54% had stable or reduced tumour size at three years [312, 313]. The tumours have an irregular frond-like outline and usually enhance avidly but heterogeneously. International Society of Neuropathology-Haarlem consensus guidelines for nervous system tumor classification and grading. Mutational analysis reveals the origin and therapy-driven evolution of recurrent glioma. Practice parameter: anticonvulsant prophylaxisin patients with newly diagnosed brain tumours: report of the Quality Standards Subcommittee of the American Academy of Neurology. Management of venous thromboembolism in patients with primary and metastatic brain tumors. Depression in patients with high-grade glioma: results of the Glioma Outcomes Project. A systematic review of functional magnetic resonance imaging and diffusion tensor imaging modalities used in presurgical planning of brain tumour resection. Ultrasound imaging in neurosurgery: approaches to minimize surgically induced image artefacts for improved resection control. Stupp R, Mason W, Van der Bent M et al Radiotherapy plus concomitant and adjuvant temozolamide for glioblastoma. The probability of correct target dosage: dose-population histograms for deriving treatment margins in radiotherapy. Dosimetric comparison of different treatment modalities for stereotactic radiosurgery of arteriovenous malformations and acoustic neuroma. Effects of X-radiation of the spinal cord: an experimental study of the morphological changes in central nerve fibres. Cognitive and radiological effects of radiotherapy in patients with low-grade glioma: long-term follow up. Endocrine function in long-term survivors of low-grade supratentorial glioma treated with radiation therapy. Malignant transformation and new primary tumours after therapeutic radiation for benign disease: substantial risks in certain tumour prone syndromes. Resection of malignant brain tumors in eloquent cortical areas: a new multimodal approach combining 5-aminolevulinic acid and intraoperative monitoring. Intraoperative fluorescence-guided resection of high-grade gliomas: a comparison of the present techniques and evolution of future strategies. Magnetic resonance diffusion tensor imaging with fluorescein sodium dyeing for surgery of gliomas in brain motor functional areas. Impact of extent of resection for recurrent glioblastoma on overall survival: clinical article. Gliadel wafer in initial surgery for malignant glioma: long-term follow-up of a multicenter controlled trial. Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. Retrospective comparison of chemoradiotherapy followed by adjuvant chemotherapy, with or without prior gliadel implantation (carmustine) after initial surgery in patients with newly diagnosed high-grade gliomas. Confirmation of the value of postoperative irradiation and lack of potentiation of bleomycin on survival time. Complications in 622 cases of frame-based stereotactic biopsy, a decreasing procedure. Failure pattern following complete resection plus radiotherapy and temozolomide is at the resection margin in patients with glioblastoma. Establishing percent resection and residual volume thresholds affecting survival and recurrence for patients with newly diagnosed intracranial glioblastoma. Impact of intraoperative high-field magnetic resonance imaging guidance on glioma surgery: a prospective volumetric analysis. Intraoperative visualization for resection of gliomas: the role of functional neuronavigation and intraoperative 1. Glioma resection in a shared-resource magnetic resonance operating room after optimal image-guided frameless stereotactic resection. Counterbalancing risks and gains from extended resections in malignant glioma surgery: a supplemental analysis from the randomized 5-aminolevulinic acid glioma resection study. Impact of the combination of 5-aminolevulinic acid-induced fluorescence with intraoperative magnetic resonance imaging-guided surgery for glioma. Malignant glioma: patterns of failure following individually tailored limited volume irradiation. Patterns of failure and comparison of different target volume delineations in patients with glioblastoma treated with conformal radiotherapy plus concomitant and adjuvant temozolomide. Pattern of failure after limited margin radiotherapy and temozolamide for glioblastoma. Stereotactic histologic correlations of computed tomography and magnetic resonance imaging defined abnormalities in patients with glial neoplasms. Management of patients aged over 60 years with supratentorial glioma: lessons from an audit. Management of patients aged >60 years with malignant glioma: good clinical status and radiotherapy determine outcome. Postoperative treatment of primary glioblastoma multiforme with radiation and concomitant temozolomide in elderly patients. Aggressive treatment is appropriate for glioblastoma multiforme patients 70 years old or older: a retrospective review of 206 cases. Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: a prospective 101. Temozolamide versus standard 6 week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised phase 3 trial. Early necrosis following concurrent Temodar and radiotherapy in patients with glioblastoma. Brada M, Stenning S, Gabe R et al Temozolamide versus procarbazine, lomustine and vincristine in recurrent high-grade glioma. Low-grade gliomas: six-month tumor growth predicts patient outcome better than admission tumor volume, relative cerebral blood volume, and apparent diffusion coefficientt.

Multi-institutional trials are in progress to better define optimal adjuvant treatment for subsets of patients [151] breast cancer 9mm pistol cheap arimidex 1 mg free shipping. For patients able to tolerate aggressive therapy menstrual 2 weeks early order 1 mg arimidex with visa, multiagent chemotherapy produces higher response rates than single-agent therapy breast cancer 2nd time around order arimidex amex. A significant 5-year survival increase of 13% for patients was present for patients who got chemotherapy relative to the radiotherapy arm [152] breast cancer pink ribbon order 1 mg arimidex with mastercard. Meta-analysis of nine prospective 6teen menstrual cycle arimidex 1mg otc, randomized trials with 2197 patients showed that adjuvant chemotherapy in high-risk endometrial carcinoma can decrease lethality by 25% [153] menstruation 101 arimidex 1 mg otc. The most favourable benefit/risk profile seems to have carboplatin/paclitaxel, but platinum/anthracycline and platinum/anthracycline/taxane combinations are effective also [154]. Hormonal therapy is standard treatment in metastatic hormonal receptor positive endometrial cancers, but not in the adjuvant setting. Hormonal therapy, primarily with progestins, is less toxic than chemotherapy and 20% response rates are seen in properly selected patients [155]. Control hysteroscopy and curettage is necessary and recommendation of hysterectomy and oophorectomy after childbearing [157]. For distant metastases chemotherapy schedules similar to cervical cancer are applicable. These data provide robust evidence for the important role of bevacizumab in ovarian cancer treatment. Data from European clinical trials of dose-dense regimen with paclitaxel weekly could not confirm a survival benefit in comparison to standard treatment [170]. Neoadjuvant platinum/taxane-based chemotherapy in ovarian cancer is recommended only within clinical trials. Despite higher complete resection rates after neoadjuvant treatment, no improved survival was present and the documented extent of surgical management within this trial was very questionable [98]. If neoadjuvant chemotherapy was initiated because of contraindication for immediate radical surgery, interval debulking surgery should be performed after a maximum of two to three cycles because of the development of resistance mechanisms in case of later surgery [171]. A very mild toxicity profile was documented for maintenance therapy with olaparib [172]. The management of the very rare, but very aggressive small-cell carcinomas of the gynaecologic tract (cervix, ovary, uterus, vulva, and vagina) requires systemic chemotherapy with cisplatin and etoposide, both in the setting of early and advanced stage disease [173]. General and surgical management A biopsy was performed and histology showed invasive squamous cell carcinoma, grade 2. Cystoscopy showed an intact urinary bladder mucosa and thus did not confirm bladder wall invasion. After laparoscopic lymph node staging, 0 of 23 removed lymph nodes (12 pelvic, 11 para-aortic) showed malignant cells indicating a pN0 status. Radiotherapy management the patient was referred to the Department of Radiotherapy for initiation of primary radiochemotherapy consisting of external beam radiotherapy, concomitant chemotherapy, and image-guided adaptive brachytherapy. The clinical tumour-related target volume included the whole uterus, the upper third of the vagina, the whole parametria and the (regional) lymph node areas up to the aortic bifurcation, internal/external/common iliac areas, para-rectal, and pre-sacral areas. The fifth cycle of chemotherapy had to be delivered in reduced dosage due to impaired renal function. In week six, the first brachytherapy application was performed in an operation theatre under spinal anaesthesia. Case report 1 A 45-year-old patient presented at the Department of Gynaecology with dyspareunia, vaginal bleeding, and persisting vaginal discharge for approximately three months. C, D: At the time of brachytherapy after 45 Gy of external beam radiotherapy and five cycles of chemotherapy: 5. The surrounding organs at risk (rectum, urinary bladder, sigmoid colon, and bowel) were delineated. Follow-up the patient achieved complete remission as assessed three months after completion of radiochemotherapy. Gynaecologic examination shows no evidence of disease and some vaginal shortening and narrowing in the upper third (G2). Rectosigmoidoscopy shows telangiectasia in the proximal anterior rectal wall but without any sign for bleeding. Discussion According to international and institutional guidelines based on clinical level 1 evidence this patient was treated with primary radiochemotherapy. Before initiation of radiochemotherapy laparoscopic lymph node staging was performed. However, precise assessment of lymph node status is crucial for the definition of the lymph node target volume (pelvic vs pelvic + para-aortic). Furthermore, in lymph node positive patients, removal of bulky lymph nodes is assumed to be associated with a survival benefit. Cisplatin-based chemotherapy was added to radiotherapy due to the significant overall survival benefit shown in randomized controlled trials. The use of interstitial needles allows for significant dose escalation and increase of target dose coverage, if required by the individual tumour situation. Studies investigating the impact of additional adjuvant and/or intensified chemotherapy are currently ongoing. Vaginal ultrasound reveals a normal sized uterus and the endometrium is hyperplastic with a maximum thickness of 11 mm. Hysteroscopy showed a suspicious mass in the uterine cavity (fundus) with a diameter of approximately 2. The cervical canal was visualized without suspicious findings and curettage was performed. Endometrial sampling revealed moderately differentiated (G2) endometrioid adenocarcinoma of the uterus. Surgical management Total laparoscopic hysterectomy with bilateral salpingooophorectomy with pelvic lymphadenectomy was performed. Frozen section analysis revealed a moderately-differentiated endometrioid adenocarcinoma and a myometrial tumour invasion of the outer half of the myometrium. Because of the deep myometrial tumour invasion, the moderate tumour differentiation, and tumour size, peri-aortic lymph node dissection was performed. The histologic results were confirmed in the paraffin sections and all resected lymph nodes (n = 42) were found negative. Adjuvant therapy Based on clinical-pathological findings adjuvant radiotherapy was recommended. Post-treatment surveillance the patient was followed in our outpatient clinic with physical examination, vaginal vault cytology, abdominal ultrasound, and monitoring for symptoms. Discussion Treatment recommendations for endometrial cancer depend upon disease stage and additional factors that influence the risk of disease recurrence. Surgery performed as total hysterectomy with bilateral salpingo-oophorectomy, with or without lymphadenectomy, is usually curative for women who are at a low risk of disease recurrence. In patients with highly and moderately-differentiated endometrioid tumours that are confined to the endometrium or the inner half of the myometrium and a tumour size <2cm the risk of lymph node metastasis is less than 1% and lymphadenectomy is therefore not recommended. Case report 2 A seventy-one-year-old woman was referred by her gynaecologist because of recurrent vaginal bleeding since three months. The gynaecologist described a distinct endometrial hyperplasia diagnosed by vaginal ultrasound. The definitive histology described a high-grade serous papillary adenocarcinoma of the ovary in all described tumour locations. Patients who are at intermediate or high risk for disease recurrence are candidates for adjuvant therapy. Based on clinical-pathological findings such as age (71 years), deep myometrial invasion, moderate tumour differentiation (G2), and large tumour size (>2. Randomized controlled trials showed that vaginal brachytherapy is an adequate therapy for patients at intermediate risk of recurrence. Vaginal brachytherapy is associated with a more favourable toxicity profile (such as a lower rate of diarrhoea and other bowel symptoms) when compared with external beam radiation, resulting in equivalent loco-regional control rates. In addition, external beam radiation therapy seems to reduce long-term survival of patients less than 60 years of age at the time of treatment because of an increased risk of rectal and bladder malignancies. Patients with endometrial cancer at intermediate risk show five-year survival rates of more than 80% and a reduced risk of loco regional recurrences when vaginal brachytherapy is applied. External beam radiation should only be used in cases with lymph node metastasis or in advanced stage disease. Pain episodes during intraperitoneal therapy were successfully managed by reducing the intraperitoneal infusion amount to 1500 ml and the prophylactic use of paracetamol. Case report 3 A fifty-eight-year-old patient was referred with increasing abdominal pain and abdominal diameter. She had three children, no cases of malignant disease in her family and had been healthy. Management of recurrent disease the patient underwent re-laparotomy and a complete tumour resection with segmental resection of the descending colon. The patient is well and still on treatment with bevacizumab and there is no evidence of disease. Discussion Complete surgical tumour resection is still one of the most important prognostic factors in the therapy of advanced stage ovarian cancer. In centres capable of performing such complex surgical procedures 60 to 70% of patients with advanced stage disease can be debulked to no residual tumour rest. Complete cytoreduction may provide the patient with a median survival of 50 to 100 months, whereas interval cytoreduction after neoadjuvant chemotherapy is consistently associated with a median survival of only 30 to 36 months even if complete resection is attained in this setting. In addition to optimal (R0) cytoreduction the application of platinum and taxane based chemotherapy is considered as gold standard in the therapy of advanced epithelial ovarian cancer. However, there are three randomized controlled trials showing an advantage of ip chemotherapy in progression free and overall survival. Bevacizumab has been shown to be effective in the adjuvant treatment, as well as in the treatment of platinum sensitive and resistant disease. Proof of principle was demonstrated in four randomized controlled trials showing a significant improvement in progression-free survival. We found two litres of ascites, large bilateral adnexal masses, involving the complete pelvic peritoneum, uterus, and recto-sigmoid. Peritoneal carcinosis was present in both para-colic gutters, the right diaphragm, and in parts on the mesenterium of the small bowel. There was a solid tumour infiltration of the ileo-coecal region and an omental cake up to the transverse colon. Because of the good medical condition of the patient the tumour was assumed to be completely resectable. Frozen section revealed a high-grade serous papillary adenocarcinoma of the ovary. We performed an en bloc resection with a complete pelvic peritoneumectomy and a recto-sigmoidal anastomosis, extensive peritoneumectomy in the described areas of tumour involvement, infra- and supra-colic omentectomy, and an ileo-coecal resection. Because there was no macroscopic intra-abdominal tumour left a systematic pelvic and peri-aortic lymphadenectomy was added. This trial will probably define the role of secondary cytoreduction in this setting. Pelvic lymphadenectomy for cervical carcinoma: laparotomy extraperitoneal, transperitoneal or laparoscopic approach Accuracy of 18-fluoro-2-deoxy-D-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Pelvic lymphadenectomy in cervical cancer-surgical anatomy and proposal for a new classification system. Audit of preoperative and early complications of laparoscopic lymph node dissection in 1000 gynecologic cancer patients. Cervical carcinoma metastatic to para-aortic nodes: extended field radiation therapy with concomitant 5-fluorouracil and cisplatin chemotherapy: a Gynecologic Oncology 22. Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer. Randomized trial of surgical staging (extraperitoneal or laparoscopic) versus clinical staging in locally advanced cervical cancer. Therapeutic value of pretherapeutic extraperitoneal laparoscopic staging in locally advanced cervical carcinoma. New classification system of radical hysterectomy: emphasis on a three-dimensional anatomic template for parametrial resection. Laparoscopic vaginal radical trachelectomy: a treatment to preserve the fertility of cervical carcinoma patients. Anatomic identification of nerve-sparing radical hysterectomy: a step-by-step procedure. Reconstruction of the pelvic floor with human acellular dermal matrix and omental flap following anterior pelvic exenteration. Pelvic exenteration: surgical aspects and analysis of early and late morbidity in a series of 106 patients. Ovarian transposition for patients with cervical carcinoma treated by radiosurgical combination. Prevention of complications following pelvic exenteration with the use of mammary implants in the pelvic cavity: technique and results of 28 cases.