The authors report a novel technique of balloon-assisted embolization of a skull base meningioma supplied by a branch of the cavernous segment of the internal carotid artery using liquid embolic agent. A temporarily inflated balloon distal to the meningioma's feeding vessel may improve the access to this small branch and may reduce the chances of unintended reflux during delivery of the liquid embolic agent.
Background
Differentiation between benign and malignant superficial lymph nodes (LNs) presents clinical dilemma. No specific criteria are established with conventional ultrasound to make a distinction. We aimed to study the added value of shear wave velocity (SWV) measurement with acoustic radiation force impulse (ARFI) and strain elastography (SE) to identify benign superficial LNs. The study included 115 superficial LNs subjected to conventional ultrasonography, 4-scale strain elastography and shear wave velocity measurement using ARFI. Histopathological analysis was obtained for all examined nodes.
Results
SE correctly diagnosed 89.3% of the reactive and 92.2% of the metastatic LNs and erroneously diagnosed 72.7% of the lymphoma LNs as being benign. Overall sensitivity, specificity, PPV, NPV and accuracy were 74.4%, 73%, 85.3%, 57.4% and 73.9%, respectively. The receiver operating curve analysis of SWV measurement using ARFI revealed a cut-off value of ≥ 2.70 m/sec to recognize malignant LNs and to obtain best sensitivity (88.5%) and specificity (89.2%) (Area under the curve: 0.819, 95% confidence interval (CI): 0.744 and 0.894). The PPV, NPV and accuracy were 94.5%, 78.6% and 88.7%, respectively. As compared to SE, ARFI boosted the diagnostic accuracy of lymphoma LNs from 27.3 to 68.2% and showed better specificity and NPV to identify benign LN as contrasted to SE.
Conclusions
SE could be adequate to differentiate reactive from metastatic LN but not from Lymphomas. Shear wave elastography is a reasonable imaging modality to identify benign lymph nodes. ARFI at a cut-off value of < 2.7 m/sec was superior to SE and the best B-mode features.
INTRODUCTION
1/3 of Ependymoma patients will develop recurrence with only 25% are long term survivors. Treatment is usually between surgery, radiotherapy or combinations.
PATIENTS AND METHODS
Retrospective review of children with recurrent Ependymoma in northwest of Egypt between 2005 and 2019 in Alexandria School of medicine records.
RESULTS
27 patients were identified 19 of them after 2010. The median age is 9.7 years (1.5–19), with 16 males and 11 females. Pathology were 11 grade II Ependymoma and 16 anaplastic Ependymoma. 16 had gross residual disease after 1st surgery and 22 received radiotherapy initially at median dose of 53.5 Gy, 4 patients received suboptimal radiotherapy. The initial site was14 supratentorial tumors and 13 infratentorial. Median time to recurrence is 27.6 months(3–84), and recurrences were 17 local and 9 CSF disseminated, and one patient had recurrence at the scar with lung metastasis. At a median follow up of 56.6 months 14(51.8%) are still alive. Treatment was surgery only in 6(4 alive) radiotherapy alone in 2(1alive), combined in 15(9 alive) and 4 patients received neither. The best outcome were in patients with late local relapse treated with complete resection and CSI after 2010. Radiotherapy dose was between 54 to 57.3 Gy and one patient developed reirradiation injury at brain stem. 5 of the 14 living patients is having toxicity in form of hearing aids (4) and low TSH(1).
CONCLUSION
Aggressive treatment of recurrent Ependymoma with surgery and radiotherapy is feasible and about half of the patients are salvageable.
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