The Journal of Craniofacial Surgery
Volume 26, Number 7, October 2015
FIGURE 1. A, The preoperative computed tomography scan of the patient. Features of external hydrocephalus, namely, subdural effusion and concurrent hydrocephalus, were found on the admission day. B, Postoperative magnetic resonance imaging scans demonstrated a noticeable improvement of hydrocephalus and subdural fluid collection after the placement of ventricularperitoneal shunt.
cause of the external hydrocephalus has been identified and hence it is categorized as idiopathic, numerous situations and conditions involve in its formation, such as meningitis,2 metabolic disorders,3 steroid therapy,4 chemotherapy,5 trauma,2 etc. Despite the fact that SDE usually runs a self-limiting course, surgical intervention is indicated when it exerts mass effect.6 As far as management is concerned, a variety of treatment modalities are available at present. Some researchers suggested that subdural-peritoneostomy represented the most effective and safest treatment modality for pediatric chronic subdural fluid collections. Additionally, a temporary subdural external drainage also benefited in all the cases, particularly in circumstances of postmeningitic or posttraumatic collections, as many patients could be treated by this simple procedure without a high risk of iatrogenic infection.7 However, others argued that for SDH, either subdural drainage or shunting treatment alone is suboptimal; ventricular shunting after subdural drainage or shunting is preferred in SDH with mass effects and enlarged ventricle.6 The clinical course of our present case suggested that VPS may be the appropriate choice for infants with symptomatic post-meningitic external hydrocephalus. To the best of our knowledge, this concept has not been widely accepted by clinicians when encountering similar clinical scenarios. Shuanglin Que, MD Zhenwen Gao, MD Jinliang Zheng, MD Jing Lu, MD Ping Qiu, MD Xiaolong Qi, MD Longyan First Hospital Fujian Medical University Fujian, China
Correspondence
3. Bhasker B, Raghupathy P, Nair TM, et al. External hydrocephalus in primary hypomagnesaemia: a new finding. Arch Dis Childhood 1999;81:505–507 4. Gordon N. Apparent cerebral atrophy in patients on treatment with steroids. Dev Med Child Neurol 1980;22:502–506 5. Enzmann DR, Lane B. Enlargement of subarachnoid spaces and lateral ventricles in pediatric patients undergoing chemotherapy. J Pediatr 1978;92:535–539 6. Tsuang FY, Huang AP, Tsai YH, et al. Treatment of patients with traumatic subdural effusion and concomitant hydrocephalus. J Neurosurg 2012;116:558–565 7. Caldarelli M, Di Rocco C, Romani R. Surgical treatment of chronic subdural hygromas in infants and children. Acta Neurochirurgica 2002;144:581–588; discussion 588
Evident Proptosis and Diplopia Due to Massive Orbital Ivory Osteoma To the Editor: Osteomas are slow-growing, encapsulated and benign tumors of bone and histologically classified into 3 groups as ivory, spongiosum, and mixed osteoma.1 Ivory osteoma also known as eburnated osteoma is composed of dense bone, deficient haversian system with minimal fibrous tissue and usually detected during the second to fifth decades of life.1,2 Osteomas predominantly arise from the paranasal sinuses and primary osteoma of the orbit is very rare.3,4 The etiology of lesion is still controversial and there are 3 hypotheses: the embryologic theory, which speculates that growing at the junction between the embryonic cartilaginous ethmoid and the membranous frontal bones; the traumatic theory which describes possible previous traumas and infective theory which relies on rhinosinusitis and osteoma association in 30% of patients.5 Majority
Xi Yang, MD The Department of Neurosurgery Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China [email protected]
REFERENCES 1. Yoshimoto Y, Wakai S, Hamano M. External hydrocephalus after aneurysm surgery: paradoxical response to ventricular shunting. J Neurosurg 1998;88:485–489 2. Kendall B, Holland I. Benign communicating hydrocephalus in children. Neuroradiology 1981;21:93–96 #
2015 Mutaz B. Habal, MD
FIGURE 1. Preoperative view and the evaluation of the mass by using computed tomography.
2237
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
The Journal of Craniofacial Surgery
Volume 26, Number 7, October 2015
REFERENCES 1. Fu YS, Perzin KH. Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. A clinicopathologic study. II. Osseous and fibro-osseous lesions, including osteoma, fibrous dysplasia, ossifying fibroma, osteoblastoma, giant cell tumor, and osteosarcoma. Cancer 1974;33:1289–1305 2. de Chalain T, Tan B. Ivory osteoma of the craniofacial skeleton. J Craniofac Surg 2003;14:729–735 3. Henderson JW. Orbital Tumors. 3rd ed. New York: Raven Press;1994: 161–164 4. Alper M, Gurler T, Totan S, et al. Intraorbital osteoma and surgical strategy. J Craniofac Surg 1998;9:464–467 5. Namdar I, Edelstein DR, Huo J, et al. Management of osteomas of the paranasal sinuses. Am J Rhinol 1998;12:393–398 6. Atallah N, Jay MM. Osteomas of the paranasal sinuses. J Laryngol Otol 1981;95:291–304
Second Cancer in a Patient With Breast Cancer FIGURE 2. Postoperative view of the patient and computed tomography.
of the cases occur sporadically and less common form of osteoma can arise with Gardner syndrome.6 We present a patient with evident proptosis and diplopia due to massive orbital ivory osteoma. A 42 year-old man who had been diagnosed with ivory osteoma was admitted to our clinic. There was a palpable, smooth, and dense mass on right lateral orbital wall (Fig. 1). Proptosis and diplopia were observed during opthalmologic examination. Eye movement restriction, pupillary edema, and optic nerve compression were not observed; fundus examination and pupillary reflexes were normal. A 5 3 cm hyperdense, pedunculated lesion was detected on the right lateral orbital wall by using computed tomography (Fig. 1). Bicoronal incision was performed while patient was under general anesthesia. Subgaleal plane was dissected gently. Temporal muscle was incised and subperiostal dissection was performed toward the lateral orbital wall. Pedinculated mass and partial lateral orbital wall were excised. Incision was closed properly. There were no complications on postoperative 2-year period (Fig. 2). Proptosis and diplopia complaints regressed totally. Although the orbital ivory osteomas are rare, they may cause serious complaints such as proptosis and diplopia. The craniofacial surgeon should give importance to the management of these tumors. Salih Onur Basat, MD Fatih Ceran, MD Funda Akoz Saydam, MD Bagcilar Training and Research Hospital Istanbul, Turkey Ilker Uscetin, MD Okmeydani Training and Research Hospital Istanbul, Turkey Samet Vasfi Kuvat, MD Department of Plastic Reconstructive and Aesthetic Surgery Istanbul University Faculty of Medicine Istanbul, Turkey [email protected]
2238
To the Editor: Breast cancer (BC) is one of the most common origins of the intracranial metastatic lesion(s), and approximately 10% to 15% of BC patients experience intracranial metastatic lesion(s) throughout the course of treatment.1 Many BC patients with subsequent intracranial lesion(s) were diagnosed as intracranial metastatic lesion(s), based exclusively on image findings without further histopathologic verification.1,2 Thus, secondary intracranial tumor(s) in BC patients should be thoroughly evaluated and not always presumed to be of metastatic origin. Furthermore, it is of great importance and clinical interest to differentiate the metastatic intracranial tumor(s) from the primary intracranial tumor(s), as the treatment and prognosis of these two lesions are considerably different with respect to adjuvant radiotherapy and chemotherapy. Although extremely rare, glioblastoma multiforme (GBM), which is the most malignant primary brain tumor, may occur in BC patients.3 –6 Herein, we report 2 cases of GBM patients with prior BC, to mention the importance of histopathologic examination and the association between GBM and prior BC. A 65-year-old woman was diagnosed with left-sided invasive ductal carcinoma (T2N0M0) without family history of BC. After a modified radical mastectomy of the left breast, the tumor was confirmed as adenocarcinoma with positive stained for estrogen receptor, but negative for progesterone receptor and human epidermal growth factor receptor-2. The patient was further treated with local radiotherapy and chemotherapy, without notable adverse effects; however, 3 years later, the patient was admitted with severe headache, vomiting, and two episodes of seizures. Physical examinations were unremarkable. Emergent cranial computed tomography and magnetic resonance (MR) scans revealed a large infiltrative lesion involving the right temporal lobe with inhomogenous contrast (Fig. 1A-F). An intracranial metastatic lesion was first considered, but systemic bone scans of the patient were performed and found to be normal (Fig. 2). The pathologic and immunohistochemical examinations of the tumor with total removal confirmed it to be a GBM, with plenty of cells having hyperchromatic, pleomorphic nuclei, and necrosis and vascular proliferation. (Fig. 3A-C) Further immunohistochemical examinations showed the tumor was strongly positive for glial fibrillary acidic protein (Fig. 3D). The patient then received external radiotherapy up to 60 Gy with concurrent daily temozolomide treatment (75 mg/kg), followed by standard temozolomide chemotherapy (150 mg/kg) for the #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Volume 26, Number 7, October 2015
FIGURE 1. A, The preoperative computed tomography scan of the patient. Features of external hydrocephalus, namely, subdural effusion and concurrent hydrocephalus, were found on the admission day. B, Postoperative magnetic resonance imaging scans demonstrated a noticeable improvement of hydrocephalus and subdural fluid collection after the placement of ventricularperitoneal shunt.
cause of the external hydrocephalus has been identified and hence it is categorized as idiopathic, numerous situations and conditions involve in its formation, such as meningitis,2 metabolic disorders,3 steroid therapy,4 chemotherapy,5 trauma,2 etc. Despite the fact that SDE usually runs a self-limiting course, surgical intervention is indicated when it exerts mass effect.6 As far as management is concerned, a variety of treatment modalities are available at present. Some researchers suggested that subdural-peritoneostomy represented the most effective and safest treatment modality for pediatric chronic subdural fluid collections. Additionally, a temporary subdural external drainage also benefited in all the cases, particularly in circumstances of postmeningitic or posttraumatic collections, as many patients could be treated by this simple procedure without a high risk of iatrogenic infection.7 However, others argued that for SDH, either subdural drainage or shunting treatment alone is suboptimal; ventricular shunting after subdural drainage or shunting is preferred in SDH with mass effects and enlarged ventricle.6 The clinical course of our present case suggested that VPS may be the appropriate choice for infants with symptomatic post-meningitic external hydrocephalus. To the best of our knowledge, this concept has not been widely accepted by clinicians when encountering similar clinical scenarios. Shuanglin Que, MD Zhenwen Gao, MD Jinliang Zheng, MD Jing Lu, MD Ping Qiu, MD Xiaolong Qi, MD Longyan First Hospital Fujian Medical University Fujian, China
Correspondence
3. Bhasker B, Raghupathy P, Nair TM, et al. External hydrocephalus in primary hypomagnesaemia: a new finding. Arch Dis Childhood 1999;81:505–507 4. Gordon N. Apparent cerebral atrophy in patients on treatment with steroids. Dev Med Child Neurol 1980;22:502–506 5. Enzmann DR, Lane B. Enlargement of subarachnoid spaces and lateral ventricles in pediatric patients undergoing chemotherapy. J Pediatr 1978;92:535–539 6. Tsuang FY, Huang AP, Tsai YH, et al. Treatment of patients with traumatic subdural effusion and concomitant hydrocephalus. J Neurosurg 2012;116:558–565 7. Caldarelli M, Di Rocco C, Romani R. Surgical treatment of chronic subdural hygromas in infants and children. Acta Neurochirurgica 2002;144:581–588; discussion 588
Evident Proptosis and Diplopia Due to Massive Orbital Ivory Osteoma To the Editor: Osteomas are slow-growing, encapsulated and benign tumors of bone and histologically classified into 3 groups as ivory, spongiosum, and mixed osteoma.1 Ivory osteoma also known as eburnated osteoma is composed of dense bone, deficient haversian system with minimal fibrous tissue and usually detected during the second to fifth decades of life.1,2 Osteomas predominantly arise from the paranasal sinuses and primary osteoma of the orbit is very rare.3,4 The etiology of lesion is still controversial and there are 3 hypotheses: the embryologic theory, which speculates that growing at the junction between the embryonic cartilaginous ethmoid and the membranous frontal bones; the traumatic theory which describes possible previous traumas and infective theory which relies on rhinosinusitis and osteoma association in 30% of patients.5 Majority
Xi Yang, MD The Department of Neurosurgery Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China [email protected]
REFERENCES 1. Yoshimoto Y, Wakai S, Hamano M. External hydrocephalus after aneurysm surgery: paradoxical response to ventricular shunting. J Neurosurg 1998;88:485–489 2. Kendall B, Holland I. Benign communicating hydrocephalus in children. Neuroradiology 1981;21:93–96 #
2015 Mutaz B. Habal, MD
FIGURE 1. Preoperative view and the evaluation of the mass by using computed tomography.
2237
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
The Journal of Craniofacial Surgery
Volume 26, Number 7, October 2015
REFERENCES 1. Fu YS, Perzin KH. Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. A clinicopathologic study. II. Osseous and fibro-osseous lesions, including osteoma, fibrous dysplasia, ossifying fibroma, osteoblastoma, giant cell tumor, and osteosarcoma. Cancer 1974;33:1289–1305 2. de Chalain T, Tan B. Ivory osteoma of the craniofacial skeleton. J Craniofac Surg 2003;14:729–735 3. Henderson JW. Orbital Tumors. 3rd ed. New York: Raven Press;1994: 161–164 4. Alper M, Gurler T, Totan S, et al. Intraorbital osteoma and surgical strategy. J Craniofac Surg 1998;9:464–467 5. Namdar I, Edelstein DR, Huo J, et al. Management of osteomas of the paranasal sinuses. Am J Rhinol 1998;12:393–398 6. Atallah N, Jay MM. Osteomas of the paranasal sinuses. J Laryngol Otol 1981;95:291–304
Second Cancer in a Patient With Breast Cancer FIGURE 2. Postoperative view of the patient and computed tomography.
of the cases occur sporadically and less common form of osteoma can arise with Gardner syndrome.6 We present a patient with evident proptosis and diplopia due to massive orbital ivory osteoma. A 42 year-old man who had been diagnosed with ivory osteoma was admitted to our clinic. There was a palpable, smooth, and dense mass on right lateral orbital wall (Fig. 1). Proptosis and diplopia were observed during opthalmologic examination. Eye movement restriction, pupillary edema, and optic nerve compression were not observed; fundus examination and pupillary reflexes were normal. A 5 3 cm hyperdense, pedunculated lesion was detected on the right lateral orbital wall by using computed tomography (Fig. 1). Bicoronal incision was performed while patient was under general anesthesia. Subgaleal plane was dissected gently. Temporal muscle was incised and subperiostal dissection was performed toward the lateral orbital wall. Pedinculated mass and partial lateral orbital wall were excised. Incision was closed properly. There were no complications on postoperative 2-year period (Fig. 2). Proptosis and diplopia complaints regressed totally. Although the orbital ivory osteomas are rare, they may cause serious complaints such as proptosis and diplopia. The craniofacial surgeon should give importance to the management of these tumors. Salih Onur Basat, MD Fatih Ceran, MD Funda Akoz Saydam, MD Bagcilar Training and Research Hospital Istanbul, Turkey Ilker Uscetin, MD Okmeydani Training and Research Hospital Istanbul, Turkey Samet Vasfi Kuvat, MD Department of Plastic Reconstructive and Aesthetic Surgery Istanbul University Faculty of Medicine Istanbul, Turkey [email protected]
2238
To the Editor: Breast cancer (BC) is one of the most common origins of the intracranial metastatic lesion(s), and approximately 10% to 15% of BC patients experience intracranial metastatic lesion(s) throughout the course of treatment.1 Many BC patients with subsequent intracranial lesion(s) were diagnosed as intracranial metastatic lesion(s), based exclusively on image findings without further histopathologic verification.1,2 Thus, secondary intracranial tumor(s) in BC patients should be thoroughly evaluated and not always presumed to be of metastatic origin. Furthermore, it is of great importance and clinical interest to differentiate the metastatic intracranial tumor(s) from the primary intracranial tumor(s), as the treatment and prognosis of these two lesions are considerably different with respect to adjuvant radiotherapy and chemotherapy. Although extremely rare, glioblastoma multiforme (GBM), which is the most malignant primary brain tumor, may occur in BC patients.3 –6 Herein, we report 2 cases of GBM patients with prior BC, to mention the importance of histopathologic examination and the association between GBM and prior BC. A 65-year-old woman was diagnosed with left-sided invasive ductal carcinoma (T2N0M0) without family history of BC. After a modified radical mastectomy of the left breast, the tumor was confirmed as adenocarcinoma with positive stained for estrogen receptor, but negative for progesterone receptor and human epidermal growth factor receptor-2. The patient was further treated with local radiotherapy and chemotherapy, without notable adverse effects; however, 3 years later, the patient was admitted with severe headache, vomiting, and two episodes of seizures. Physical examinations were unremarkable. Emergent cranial computed tomography and magnetic resonance (MR) scans revealed a large infiltrative lesion involving the right temporal lobe with inhomogenous contrast (Fig. 1A-F). An intracranial metastatic lesion was first considered, but systemic bone scans of the patient were performed and found to be normal (Fig. 2). The pathologic and immunohistochemical examinations of the tumor with total removal confirmed it to be a GBM, with plenty of cells having hyperchromatic, pleomorphic nuclei, and necrosis and vascular proliferation. (Fig. 3A-C) Further immunohistochemical examinations showed the tumor was strongly positive for glial fibrillary acidic protein (Fig. 3D). The patient then received external radiotherapy up to 60 Gy with concurrent daily temozolomide treatment (75 mg/kg), followed by standard temozolomide chemotherapy (150 mg/kg) for the #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
