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Palliation of recurrent Ewing sarcoma can be difficult to treat due to tumor resistance to chemotherapy and previously received maximum dose radiotherapy. We report the successful use of cryoablation for pain palliation in a patient with recurrent pelvic Ewing sarcoma. Tumor location necessitated use of somatosensory-evoked potentials to prevent nerve damage to the S1 nerve root. Clinical and imaging aspects of the case are discussed.

To evaluate the palliative benefits of image-guided thermal ablation for the treatment of painful tumors affecting the chest wall.Thirty-nine patients, median age 65 years, underwent percutaneous thermal ablation of 44 chest wall masses. Thirty-eight radiofrequency ablations (RFAs), 3 microwave ablations (MWAs), and 3 cryoablations were performed. Subjective pain reports at 1 week and 1 month postablation were scored from 0 to 4 based on a standard Likert pain relief scale, with 2 or higher representing clinically significant pain relief.Patients were followed for a median of 6 months. Overall, 31 of 44 procedures (70.5%) resulted in significant pain relief. Improvement followed 15 of 15 (100%) of ablations that were performed within 90 days of treatment with palliative external-beam radiation therapy (XRT), compared with 16 of 29 (55.2%) of the remaining procedures. Mean pain relief score at 1 month was 3.86 for the 15 combined procedures versus 1.96 for the 29 remaining procedures (P0.001). Local pain recurred after 5 of 31 positive responses (16.1%). Median survival was 11.2 +/- 2.3 months for patients with significant pain relief and 4.3 +/- 1.4 months for nonresponders (P0.001). Adverse events included a transient symptom "flare" (n = 5, 11.4%) and the exacerbation of a preexisting brachial plexopathy.Thermal ablation results in significant pain relief for the majority of patients and shows evidence of synergistic benefit when temporally combined with XRT. This minimally invasive technique appears to be a safe and durable alternative for the palliation of chest wall masses.

Thyroid cancer is the most common endocrine malignancy, accounting for an estimated 22,000 new cases in the United States in 2003 alone.1 Papillary carcinoma is the most common subtype of the well-differentiated thyroid carcinomas (WTC). It has a relative frequency ranging from 75% to 85% among all thyroid cancers, and frequently follows an indolent course, with overall 10-year survival rates reported at 90% to 98%.2–4 Treatment of WTC consists of total or subtotal thyroidectomy, with resection of suspicious lymph nodes in the central compartment. Modified neck dissection is the accepted treatment of patients with lymph node metastasis to the lateral compartments of the neck. Patients with only central compartment lymph node metastasis usually undergo central compartment node dissection only. The overall recurrence and mortality rates for WTC have been reported at 20.5% and 8.4%, respectively, at a mean follow-up of 11.3 years.5 Patients with thyroid cancer are routinely monitored for recurrence by ultrasound examination of the central and lateral compartments of the neck, along with serum thyroglobulin testing. When thyroid cancer recurs, it is typically found within the surgical bed or in lymph nodes of the central or lateral compartments.4 Factors that have been associated with recurrence include young age at diagnosis, large size of the primary tumor, extracapsular spread, and a known distant metastasis.6 The 2 most common sites for distant metastasis of papillary carcinoma of the thyroid are to the lungs and bone.2 Cases of distant metastatic spread have been reported to occur from 5 to 47 years after initial treatment.7,8 Reported 10-year survival rates for patients with lung and bone metastases are 53% and 15%, respectively.9–11 Following diagnosis of distant metastases, overall mortality rates at 5 and 10 years are 65% and 75%, respectively.12 Recurrence in the central compartment can be either in lymph nodes or in the thyroid bed. A recurrence in the thyroid bed results in increased rates of morbidity and mortality.13 Recurrence in the lateral compartment usually occurs as lymph node metastasis. Surgery is recommended for recurrence in the central or lateral compartments of the neck that can be identified by ultrasonography (US). Reoperative surgery in the central or lateral compartments of the neck in patients who have undergone a previous neck dissection is difficult, however, due to distortion of normal tissue planes by scar tissue formation within the surgical bed, and such operations are subsequently associated with a higher rate of complications.9 Percutaneous radiofrequency ablation (RFA) and percutaneous ethanol (EtOH) injection are relatively new, minimally-invasive techniques that have been widely used as alternatives to surgical treatment in patients with hepatocellular carcinoma or liver metastasis from other malignancies.14 RFA has also shown promise as an effective treatment of metastatic malignancies in bone, lung, and kidney.15–22 RFA and EtOH injection with local anesthesia have recently been reported as alternatives to surgery in patients with local recurrence of WTC.4,15,23,24 In this study, we present our experience with treatment of local WTC recurrence by RFA or EtOH at long-term follow-up. We also report our initial experience using RFA to treat focal distant metastases of WTC.

Objectives: To compare magnetic resonance imaging (MRI) with examination under anesthesia and with surgical findings in evaluating soft tissue injuries in acute traumatic knee dislocations in adults. Design: Retrospective analysis. Setting: Level I trauma center. Patients: For a single surgeon, all patients who underwent MRI before surgical treatment for knee dislocations (ten individuals). Intervention: Incompetent ligaments were repaired or reconstructed. Main Outcome Measurements: MRI of knee dislocations was compared with clinical examination under anesthesia and with intraoperative findings at arthrotomy in ten cases. Pertinent positive and negative findings were recorded, and accuracy, sensitivity, specificity, and positive and negative predictive values were calculated. Results: Two mid-grade sprains of the anterior cruciate ligament were erroneously read as complete tears. One rupture or avulsion of each the biceps tendon, the lateral collateral ligament, and the posterolateral and posteromedial corners were considered intact on MRI. The MRI studies erroneously identified tears of the lateral collateral ligament and medial meniscus in one case each. Otherwise, the study was highly accurate. Conclusions: MRI is useful for defining the presence of ligamentous injuries in knee dislocations; however, clinical examination under anesthesia is more accurate.

The standard therapy for multinodular goiter (MNG) has been surgery. Recently, there have been several reports of radioiodine (131I) being used successfully as treatment. In this report, we describe a case of a large, compressive, retrosternal-toxic MNG (thyroid volume 217 cc) that was treated with 131I with a dose of 105 mCi (88 μCi/g of thyroid tissue) with good response. Thyroid function tests normalized posttreatment, and the thyroid volume diminished to 125 cc by 6 months and 108 cc at 1 year (50% reduction in size). The volume of the thyroid was determined by spiral computed tomography of the neck with 3D assessment, using planimetry.

Traditionally computed axial tomography has had limitations in evaluating diseases that affect the tracheobronchial tree because of respiratory-induced artifacts, with the likelihood of missing lesions as a result of misregistration. Spiral computed tomography (CT) differs from conventional CT in that the entire thorax can be rapidly imaged in the axial plane after a single breath-hold. Five patients underwent non-contrast-enhanced volumetric CT, with emphasis on three-dimensional reconstruction, and endoscopic evaluation with pathologic confirmation. In all cases, there was complete corroboration between volumetric CT and endoscopic evaluation. The use of selective thresholds allowed the air within the tracheobronchial tree to be used as a negative contrast agent. Thus with the integration of selective windowing, detailed three-dimensional tracheobronchial anatomy may be elucidated. The absence of respiratory registration artifact due to the single breath-hold technique raises the confidence that three-dimensional and multiplanar images generated from such studies are accurate representations of the pathologic conditions at hand. By the integration of volumetric CT techniques and rapid three-dimensional display of tracheobronchial structures, volumetric CT bronchography becomes practical.

Twenty-two patients underwent surgical stabilization of thoracic and lumbar spine fractures. Twenty patients were operated on within 4 weeks of the injury and two patients more than 1 year following injury. Harrington rods were used in 21 and Dwyer instrumentation in one. The presenting neurological deficits were: four complete, five incomplete, and 13 intact. Clinical failure was noted in four patients, two of whom underwent posterior instrumentation more than 1 year following the initial injury. The most important contributing factor to failure was use of instrumentation in deviation from standard practice. The aim of operative treatment to maintain fracture reduction, decompress neural elements, promote fracture healing, and shorten hospitalization was achieved.