The patient suffers an abrupt neurological deficit probably related to a vascular event, so first we will have to perform a cranial CT scan to rule out a hemorrhagic stroke. If the CT scan does not show bleeding, the patient has an acute ischemic stroke, probably cardioembolic due to his cardiac pathology, not anticoagulated. Given that his tumor process is under control, there are no contraindications for the administration of fibrinolysis in this case, since the patient is in a good baseline condition. Although the patient is 88 years old, age is no longer presented as an absolute exclusion criterion, but the general situation of the patient must be taken into account and in this case it is specified that he presents a good baseline situation.

A 33-year-old man, independent in all activities of daily living, with a history of well-controlled hypertension, antiplatelet atrial fibrillation and an adenocarcinoma of the prostate at 73 years of age, currently free of disease. He is brought to the emergency department for clinical aphasia and right hemiparesis of sudden onset, 45 minutes earlier. What is the most correct approach?

Perform a cranial CT scan and if there are no hemorrhagic lesions or other contraindications in the analysis, start immediate intravenous thrombolysis.

Perform urgent cranial CT scan and if there is no bleeding, start anticoagulation.

Perform cranial CT scan and admission to rehabilitation center, since their attitude will not differ regardless of whether the etiology is ischemic or hemorrhagic.

Cranial CT scan is not necessary, although I would withdraw the antiaggregation.

[Two cases of cerebral embolism showing global aphasia without hemiparesis].

We report two cases of typical global aphasia without hemiparesis due to cerebral embolism. Case 1 was a 65-year-old right-handed man with a history of old myocardial infarction. No spontaneous speech was noted by his family. Neurological examination upon admission revealed confusional state, global aphasia, conjugate deviation to the left and slight drift of the outstretched right limbs. The right hemiparesis rapidly recovered after admission. CT scan performed on the second hospital day showed discrete low density areas in the left posterior frontal lobe and left temporo-parietal regions. The extent and severity of his global aphasia were unchanged. The second case was an 82-year-old right-handed man with a history of atrial fibrillation. He was admitted to our hospital one hour after he was found unable to speak. Neurological examination upon admission revealed global aphasia, conjugate deviation to the left and suspected right homonymous hemianopia by confrontation. There was no sign of hemiparesis. CT scan showed extensive low density area in the left temporo-parietal regions. In both cases, cerebral angiography failed to demonstrate any occlusion of intra- and extra-cranial blood vessels. IMP-SPECT showed a depression of cerebral blood flow in the left anterior and posterior watershed areas in case 1 and 2. In the literature, there have been 20 cases of global aphasia without hemiparesis including our two cases. In many cases, the initial symptom was inability or difficulty in speaking.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolytic Therapy in the Oldest Old: Successful Alteplase Administration in a 105-Year-Old Female With Ischemic Stroke.

The elderly have a higher incidence of ischemic stroke along with higher mortality and morbidity compared to their younger counterparts. However, though studies have included people >85 or 90 years of age, there haven't been reports of many individuals above 100 years of age. Among the oldest old, the oldest age studied for alteplase administration is possibly 101 years. We present a case of a 105-year-old woman with a medical history of a cerebrovascular accident in 2018 for which she received thrombolytic therapy with residual slurred speech and mild dysphagia. She was brought in from her nursing facility for worsening of slurred speech and right facial droop that began two hours before presentation to the emergency department. She was found to have aphasia, left-sided gaze preference, and upper motor neuron dysfunction of her right arm associated with drift. Her National Institutes of Health Stroke Scale (NIHSS) score at presentation was 17. An urgent CT scan of the head was performed that did not show any evidence of acute bleeding. CT angiogram of brain and neck was unremarkable with no evidence of high-grade stenosis, aneurysm, occlusion, or dissection. With the negative CT findings, the patient received thrombolytic therapy with alteplase<i. </iShe was monitored in the intensive care unit for 24 hours after alteplase administration with neurological checks every one hour. The repeated CT head after 24 hours was negative for any hemorrhage. She was discharged after two days of hospital admission and her NIHSS score on the day of discharge was 4. Our patient was 105 years old, which is arguably one of the oldest ages to receive alteplase. Her NIHSS score improved considerably and she did not suffer from hemorrhagic complications.

Headache

One recommended diagnostic approach is as follows. If any urgent red flags are present such as visual loss, new seizures, new weakness, new confusion, further workup with imaging and possibly a lumbar puncture should be done (see red flags section for more details). If the headache is sudden onset (thunderclap headache), a computed tomography test to look for a brain bleed (subarachnoid hemorrhage) should be done. If the CT scan does not show a bleed, a lumbar puncture should be done to look for blood in the CSF, as the CT scan can be falsely negative and subarachnoid hemorrhages can be fatal. If there are signs of infection such as fever, rash, or stiff neck, a lumbar puncture to look for meningitis should be considered. If there is jaw claudication and scalp tenderness in an older person, a temporal artery biopsy to look for temporal arteritis should be performed and immediate treatment should be started. Neuroimaging

Intraparenchymal hemorrhage

Diagnosis Computed tomography (CT scan): A CT scan may be normal if it is done soon after the onset of symptoms. A CT scan is the best test to look for bleeding in or around your brain. In some hospitals, a perfusion CT scan may be done to see where the blood is flowing and not flowing in your brain. Magnetic resonance imaging (MRI scan): A special MRI technique (diffusion MRI) may show evidence of an ischemic stroke within minutes of symptom onset. In some hospitals, a perfusion MRI scan may be done to see where the blood is flowing and not flowing in your brain. Angiogram: a test that looks at the blood vessels that feed the brain. An angiogram will show whether the blood vessel is blocked by a clot, the blood vessel is narrowed, or if there is an abnormality of a blood vessel known as an aneurysm.

Vertebrobasilar Stroke -- Treatment / Management -- Ischemic Strokes

Treatment of ischemic strokes is time-dependent. If the onset of symptoms occurs before 4.5 hours without evidence of hemorrhage on a non-contrast CT scan, the patient is tissue plasminogen activator (TPA) eligible, the preferable agent being IV alteplase. The dose of alteplase is calculated as 0.9 mg/kg with a maximum dose of 90 mg. 10% of the total dose is given as a bolus over one minute, and the remainder is given over the next hour.  There is a set of inclusion criteria and contraindications that should be discussed with the patient to obtain informed consent before administering the medication. This is generally performed by a neurologist specializing in stroke; however, another physician can perform it with guidance. Most notable contraindications include recent intracranial surgery or trauma, active internal bleeding, intracranial hemorrhage, blood pressure greater than 180/90 mmHg. Inclusion criteria are stroke with a measurable neurological deficit occurring less than 4.5 hours. There are relative exclusion criteria for patients greater than 80 years old, NIHSS score greater than 25, and current anticoagulant use. [32]

Thrombolysis

Stroke Absolute contraindications: Uncertainty about time of stroke onset (e.g. patients awakening from sleep). Coma or severe obtundation with fixed eye deviation and complete hemiplegia. Hypertension: systolic blood pressure ≥ 185mmHg; or diastolic blood pressure >110mmHg on repeated measures prior to study. (if reversed, patient can be treated) Clinical presentation suggestive of subarachnoid haemorrhage even if the CT scan is normal. Presumed septic embolus. Patient having received a heparin medication within the last 48 hours and has an elevated Activated Prothrombin Time (APTT) or has a known hereditary or acquired haemorrhagic diathesis INR >1.7 Known advanced liver disease, advanced right heart failure, or anticoagulation, and INR > 1.5 (no need to wait for INR result in the absence of the former three conditions). Known platelet count <100,000 uL. Serum glucose is < 2.8 mmol/l or >22.0 mmol/l.

Stroke

Imaging For diagnosing ischemic (blockage) stroke in the emergency setting: CT scans (without contrast enhancements) sensitivity= 16% (less than 10% within first 3 hours of symptom onset) specificity= 96% MRI scan sensitivity= 83% specificity= 98% For diagnosing hemorrhagic stroke in the emergency setting: CT scans (without contrast enhancements) sensitivity= 89% specificity= 100% MRI scan sensitivity= 81% specificity= 100% For detecting chronic hemorrhages, MRI scan is more sensitive. For the assessment of stable stroke, nuclear medicine scans SPECT and PET/CT may be helpful. SPECT documents cerebral blood flow and PET with FDG isotope the metabolic activity of the neurons. CT scans may not detect an ischemic stroke, especially if it is small, of recent onset, or in the brainstem or cerebellum areas. A CT scan is more to rule out certain stroke mimics and detect bleeding. Underlying cause

[Follow-up brain imaging after strokes in internal medicine: frequently requested but rarely used for diagnosis or treatment].

To assess the interest of a second computed tomography (CT) scan of the brain during hospitalization of stroke patients in an internal medicine department and study the characteristics of these patients. This retrospective study included 110 patients diagnosed with stroke between January 1, 2002, and August 31, 2004 in an internal medicine department. All patients had a brain CT scan soon after admission - within three hours, on average, of arrival at the hospital; however, the mean delay between the onset of symptoms and hospital arrival was 40 hours. Mean hospital stay was 19 days. Eighty patients (73%) had at least one more scan. Indications for these scans were: no acute cerebral ischemia on the initial image (34%), routine follow-up or reason not specified (34%), worsening of neurologic status (15%), before oral anticoagulation (5%), to search a tumor (5%), to look for a cause (4%), and clinic-radiologic discordance (3%). Only 29% of the indications had any diagnostic or therapeutic reason. Among these 80 patients, the repeat brain scan resulted in a change in the initial diagnosis for 4 patients (5%) and in a change of therapy for 11 (14%). In our study, repeat CT imaging was frequently ordered in ischemic stroke, despite the not uncommon absence of any diagnostic or therapeutic reasons. To optimize the use of medical resources and avoid unnecessary imaging, it would be useful to identify subgroups of patients for whom repeat imaging might be of interest.

Cerebral embolism and hyperthyroidism.

Three different cases of cerebral embolism occurring in combination with hyperthyroidism are reported. Case 1; a healthy 37-year-old woman presented with sudden onset of left hemiparesis and left sided hypoesthesia of all modalities. Embolism in area of the right middle cerebral artery was confirmed by angiography and CT scan. Laboratory examination revealed hyperthyroidism and anemia. Antithyroid treatment brought about euthyroid function while slight hemiparesis remained present. Case 2; a 79-year-old woman who suffered from hypertension for one year had sudden onset of disorientation and left hemiparesis. Electrocardiogram showed atrial fibrillation. The CT scan indicated infarction in the right anterior and middle cerebral artery. The patient was diagnosed as having masked hyperthyroidism. Although antithyroid medication reduced it to euthyroid condition, the patient is now bedridden with hemiparesis. Case 3; a 45-year-old man who had partial thyroidectomy for Basedow's disease and had been treated with antithyroid and antiarrhythmic therapy for 10 years. Suddenly, he was in coma with dilated right pupil and left hemiplegia. Atrial fibrillation and hypothyroid function were observed. CT scan indicated hemorrhagic infarction in the territory of the middle cerebral artery with transtentorial herniation. He died on the 59th day of hospitalization following an episode of bronchopneumonia. On the basis of the cases presented here as well as on the basis of those described in the literature it appears that thyrotoxic patients with atrial fibrillation exhibit high incidence of cerebral embolism, and prophylactic anticoagulant therapy may be recommended.

[The early hemiparesis of stroke in evolution of basilar artery--case report].

In basilar artery thrombosis, hemiparesis without obvious brainstem signs may precede the tetraplegia with coma or a locked-in state. This premonitory hemiparesis was called as "herald hemiparesis" by Fisher (1988). Its early detection is important because immediate anticoagulant therapy may prevent its evolution. We reported two patients with such hemiparesis. The first case was a 71-year-old diabetic and hypertensive man who was admitted because of right hemiparesis, dysarthria and decreased spontaneous speech. Initially, his symptoms looked like those of a left cerebral lesion. CT scans revealed no fresh cerebrovascular lesion. A few hours later, a myoclonic movement appeared in his left lower limb, and right MLF syndrome developed. We thought he had basilar artery thrombosis and we started intravenous administration of heparin. But he developed tetraplegia with locked-in state. The second case was a 76-year-old diabetic and hypertensive man with a confusional state, right hemiparesis, dysarthria and conjugate gaze deviation to left. After admission, he rapidly became comatose and developed respiratory arrest. CT scans revealed low density areas in the brainstem, cerebellum and the occipital lobe. He died ten days later. Early detection of herald hemiparesis is by no means easy. However, severe dysarthria and myoclonic jerks in a patient with hemiparesis should be considered as warning signs to indicate the herald hemiparesis with subsequent severe brainstem infarction.

[A 81-year-old man with dementia, gait disturbance, hemiparesis, and sympathetic apraxia].

We present a 81-year old male who developed dementia, gait disturbance and right hemiparesis. He was well until the age of 74 when he developed a hemorrhagic infarction in the right occipital region, which left him left homonymous hemianopsia. One year later he had one TIA attack consisting of dizziness, headache, and some clouding of consciousness. At that time, atrial fibrillation was found. At age 79, he was attacked by right hemiparesis. Cranial CT scans revealed a lesion consistent with a hemorrhagic infarct in the left middle cerebral artery territory. Two months prior to his final admission, he had a gradual onset of forgetfulness, labile affect, nocturnal agitation and hallucination which were followed by gait disturbance and urinary incontinence. On admission, he was alert but moderately demented. In addition he showed difficulty in repetition, limb kinetic and ideomotor apraxia of the left hand indicative of sympathetic apraxia, and constructional apraxia bilaterally. Granial nerves appeared intact except for left homonymous hemianopsia. His gait was wide-based and small stepped. No weakness or ataxia was noted. Deep reflexes were diminished on the left side. Plantar reflex was equivocally extensor of the left. Light touch and pain was slightly diminished on the right side. Cranial CT scans revealed a large low density area in the left fronto-temporo-parietal region. Also ventricular dilatation, diffuse low density change in the subcortical white matter, and diffuse cortical atrophy were seen. His clinical course was complicated by melena, anemia, pneumonia, cardiac failure and renal failure. He expired 2 months after his admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery_Schwartz

followed rapidly by brain death. A patient exhibit-ing any of these symptoms needs an emergent neurosurgical evaluation for possible ventriculostomy or suboccipital crani-ectomy (removal of the bone covering the cerebellum). This situation is especially critical, as expeditious decompression can lead to significant functional recovery.StrokePatients presenting with acute focal neurologic deficits at a clearly defined time of onset (i.e., when the patient was last seen in a normal state of health) must be evaluated as rapidly as possible. An emergent head CT scan should be done. The study is often normal because CT changes from ischemic stroke may take up to 24 hours to appear (Fig. 42-6). A patient with a clinical diagnosis of acute stroke <4.5 hours old, without hemor-rhage on CT, may be a candidate for thrombolytic therapy with tissue plasminogen activator (tPA). When a proximal large-vessel obstruction is suspected, patients should be evaluated for endovascular mechanical

[Is very old age a prognostic factor for outcome after a first stroke?].

To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke. A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80. After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons. Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome. Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death.

Computed tomography of the head

Comparison with MRI Magnetic resonance imaging (MRI) of the head provides superior information as compared to CT scans when seeking information about headache to confirm a diagnosis of neoplasm, vascular disease, posterior cranial fossa lesions, cervicomedullary lesions, or intracranial pressure disorders. It also does not carry the risks of exposing the person to ionizing radiation. CT scans may be used to diagnose headaches when neuroimaging is indicated and MRI is not available, or in emergency settings when hemorrhage, stroke, or traumatic brain injury is suspected. MRI (magnetic resonance imaging) provides more sensitivity in the evaluation of the cavernous sinus and the orbital apex. One advantage over a brain MRI is in the evaluation of intracerebral calcifications.

[Understanding the reasons behind the low utilization of thrombolysis in hyperacute ischemic stroke].

The study aimed to analyze the influencing factors of thrombolysis therapy in acute ischemic stroke patients with onset time less than 4.5 hours. We consecutively prospectively screened acute ischemic stroke patients with onset time less than 4.5 hours from emergency department, outpatients and inpatients of neurology department, and image center in our hospital over a 31-month time period (April 2012-November 2014). The rate of thrombolysis and the reasons for not receiving thrombolysis were analyzed. A total of 538 patients who met the inclusion criteria were included (68.2% males, mean age 67±13 years old). Only 104 (19.3%) patients received thrombolysis. The main reasons for the patients not receiving thrombolysis included minor symptoms (172 cases, 39.6%), rapidly improving symptoms and high possibility of transient ischemic attack (TIA) (59 cases, 13.6%), patients or families refusing thrombolysis (44, 10.1%), in-hospital delay (38, 8.8%), elderly people with age over than 80 years old (38, 8.8%). The thrombolysis rate within time window of acute ischemic stroke is remarkably higher than that of several years ago in China. The main reasons for not receiving thrombolysis are minor and rapidly improving symptoms, patients or families' refusal, in-hospital delay, elderly people with age over than 80 years old.

Neurology_Adams

With the current focus on the cost-effective use of ancillary studies, criteria that justify obtaining a cranial CT following minor forms of head trauma have been developed as discussed in the next paragraph. We have generally advised a CT in cases of head injury that was associated with loss of consciousness (more than 1 min), severe and persisting headache, nausea and vomiting, a confusional state, and any new, objective neurologic signs, but these are admittedly arbitrary criteria. The CT scan may be particularly important in elderly patients with minor head trauma, in whom the presence of an intracranial lesion (mainly subdural hematoma) may not be predicted by clinical signs and, of course, imaging may be advisable if the patient is taking anticoagulants or antiplatelet agents of any type beyond small doses of aspirin. In children, it may be advisable to perform the scans more liberally. This is underscored by the results of a study of 215 children with minor head trauma

Successful intravenous thrombolysis for ischemic stroke after reversal of dabigatran anticoagulation with idarucizumab: a case report.

Non-vitamin K antagonist oral anticoagulants, including dabigatran, are currently widely used for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. Recently, idarucizumab, a monoclonal antibody fragment for immediate reversal of dabigatran-induced anticoagulation, has been introduced into the market to be used in life-threatening bleeding or urgent surgery, allowing for rapid normalization of clotting parameters. The use of idarucizumab is not yet well established in patients presenting with acute ischemic stroke on dabigatran who are candidates for thrombolytic therapy. We report the case of a 71-year-old hypertensive Caucasian woman with non-valvular atrial fibrillation treated with dabigatran 150 mg twice daily, who presented with acute ischemic stroke causing right-sided hemiparesis and aphasia. Two hours after presentation to the emergency department, a decision was made to administer idarucizumab for achieving complete reversal of any potential anticoagulant effect of dabigatran and, in the absence of any contraindications, our patient underwent successful thrombolysis. At discharge, our patient was able to walk unassisted and had only residual aphasia. Twenty days later, she had completely recovered motor function of her right side, with further progressive improvement of aphasia. Repeat cranial computed tomography confirmed the absence of hemorrhage, and anticoagulant therapy with dabigatran 150 mg twice daily was resumed. Our case report adds to the evidence that idarucizumab administration is safe in the setting of patients with atrial fibrillation treated with dabigatran who develop acute ischemic stroke requiring thrombolysis.

Evolution of changes in the computed tomography scans of the brain of a patient with left middle cerebral artery infarction: a case report.

Stroke is a common and important condition in medicine. Effective early management of acute stroke can reduce morbidity and mortality. A 63-year-old man presented to the Accident and Emergency department with a history of collapse and progressive right-sided weakness. Clinically this was a cerebrovascular accident affecting the left hemisphere of the brain causing right hemiplegia. Computed tomography scans, performed 3 days apart, showed the evolution of infarction in the brain caused by the thrombus in the left middle cerebral artery. This is one of the early signs for stroke seen on computed tomography imaging and it is called the hyperdense middle cerebral artery sign. Patients admitted with a stroke, undergo CT brain within 24 hours. The scan usually takes place at admission into the hospital and is done to rule out a bleed or a space occupying lesion within the brain. A normal CT brain does not confirm a stroke has not taken place. When scanned early, the changes seen on the CT due to an infarction from a thrombus may not have taken place yet. This paper highlights the early changes that can be seen on the CT brain following a stroke caused by infarction due to a thrombus in the middle cerebral artery.

Is intravenous thrombolysis safe for acute ischemic stroke patients taking warfarin with INR 1.9?: A case report.

Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR > 1.7 or PT > 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9. A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92. Acute ischemic stroke. The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered. The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life. The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients.

Stroke

The main risk factor for stroke is high blood pressure. Other risk factors include high blood cholesterol, tobacco smoking, obesity, diabetes mellitus, a previous TIA, end-stage kidney disease, and atrial fibrillation. An ischemic stroke is typically caused by blockage of a blood vessel, though there are also less common causes. A hemorrhagic stroke is caused by either bleeding directly into the brain or into the space between the brain's membranes. Bleeding may occur due to a ruptured brain aneurysm. Diagnosis is typically based on a physical exam and supported by medical imaging such as a CT scan or MRI scan. A CT scan can rule out bleeding, but may not necessarily rule out ischemia, which early on typically does not show up on a CT scan. Other tests such as an electrocardiogram (ECG) and blood tests are done to determine risk factors and rule out other possible causes. Low blood sugar may cause similar symptoms.

[Really drunk?].

We report about a 42-year-old patient who was admitted to the emergency department because of suspected alcohol abuse. He declared himself to be drunk. He stated in his case history that he had suffered from right sided neck and facial pain for several days. The clinical examination revealed a left sided hemiparesis. Together with the demonstrated right hemispherical brain ischemia by computed tomography, a presumptive diagnosis of a dissection of the right internal carotid artery was made. This diagnosis was finally confirmed by ultrasound and magnetic resonance imaging. A therapy with full dose heparin was begun and oral anticoagulation was subsequently initiated. After two weeks of follow-up, the neurological deficiencies were partially regredient.

[Early surgery of subarachnoid hemorrhage from cerebral aneurysms. A material from health care region 5].

During the period 1986 to 1993, 94 patients were admitted consecutively to the neurosurgical department of Tromsø university hospital following subarachnoid haemorrhage. Nine-three patients were operated on. Five patients were in extremely poor condition and three were operated on as emergency cases after computerized tomography without previous angiography. They are included in the total management outcome and also in the outcomes after early surgery. Of all the patients, 63.8% returned to their previous activities, 12.8% experienced moderate invalidity, and 9.6% had serious invalidities. The total management mortality was 13.8%. Fifty-four patients were operated on within three days, and 64.8% of these returned to their previous activities. Of these 14.8% ended up with moderate invalidity; mortality was 11.1%. Of eight patients above 70 years of age, five underwent early surgery. In six of these older patients the final outcome was good, one became disabled and one died. We consider early surgery to be by far the most important factor for achieving optimal results from surgery.

Acute Ischemic Stroke.

A 77-year-old woman with a history of hypertension developed acute onset of aphasia and right hemiplegia and hemisensory loss. She was urgently referred to emergency department. Cerebral multidetector computed tomographic angiography (MD-CTA) revealed an acute ischemic stroke due to the occlusion of the left middle cerebral artery (Figure 1). Since the symptoms started three hours previously, the patient was candidate for mechanical thrombectomy. The patient then performed a selective digital subtraction angiography (DSA) of the left internal carotid artery that confirmed occlusion of the ipsilateral middle cerebral artery (Figure 2) and subsequently successfully performed the endovascular mechanical thrombectomy (Figure 2). Her clinical course has shown neurological symptoms improvement over time. Acute ischemic stroke can be caused by several factors, but the main ones are arterial and cardiac embolism, arterial wall disease or variants(1-4). The National Institutes of Health Stroke Scale (NIHSS) score, is widely used as clinical assessment for neurological deficits related to ischemic stroke(1). MDCTA and Magnetic Resonance Imaging are the two gold standard methods for diagnosis in acute ischemic stroke patients(1-5). Thrombolytic therapy of this pathological state began in the fifties, while the endovascular mechanical thrombectomy was defined as a new standard of care in 2015(1,5,6). This recent technique have added tissue window" to the existing "time window" (5,6). So, nowadays patients with small ischemic core, large penumbra, and good collaterals vessel may benefit from endovascular mechanical thrombectomy(1,5,6); even if they arrive within 6-24 h of stroke onset(5.

[Four cases of cerebral venous angioma--with special reference to its surgical indication and CT diagnosis].

Four cases of venous angioma, one cerebral and three in the cerebellum, are reported. Case 1. A 50-year-old woman who had a sudden attack of headache and disorientation was admitted to the Mitsui Memorial Hospital. Neurological examination revealed slight disorientation, mild motor aphasis and right hemiparesis. Plain CT scan on admission showed a left frontal hematoma. Left cerebral angiomas demonstrated a caput-Medusae-like lesion which consisted of numerous small veins and drained into one single enlarged vein. Enhanced CT scan taken 12 days after the attack demonstrated a linear enhancement next ot the hematoma. Left frontal craniotomy was performed, and the hematoma was evacuated. In the next step, coagulation and resection of the major part of the angioma was attempted. However, this caused significant swelling of the adjacent brain and the angioma had to be resected totally including intervening normal cerebral tissue. Postoperatively, the patient became worse with significant hemiparesis and severe motor aphasia. After intensive rehabilitation treatment, she recovered gradually and was discharged on foot with moderate speech disturbances. Histological examination revealed a typical venous angioma with hyalinization of vessel wall. Case 2. A 55-year-old woman with a 9 year history of vertigo and headache was admitted to our hospital because of sudden onset of numbness in her right lower limb. Enhanced CT scan revealed a small nodular high density lesion and an old hematoma in the right cerebellar hemisphere. Vertebral angiograms demonstrated a single abnormal vein with some small veins in the right cerebellum. Right suboccipital craniectomy was performed and the blood clot was removed. The abnormal veins were electro-coagulated. The postoperative course was uneventful and the patient was discharged with no neurological deficit. Case 3. A 31-year-old man was admitted to our department with 9 month history of nausea and vertigo attack. Enhanced CT scan demonstrated a large nodular high density lesion in the left cerebellar hemisphere. Vertebral angiograms showed a typical caput-Medusae-like venous angioma. The patient had no evidence of hemorrhage and was discharged without surgery. Case 4. A 36-year-old man who had two attacks of nausea and headache was admitted to the Mitsui Memorial Hospital. Enhanced CT scan showed a linear high density lesion in the right cerebellar hemisphere. Vertebral angiograms disclosed a typical venous angioma in the right cerebellum. This patient also had no attack of bleeding and was discharged without operation.(ABSTRACT TRUNCATED AT 250 WORDS)

[First experience with intravenous thrombolysis in ischemic stroke in Serbia].

Systemic thrombolytic therapy in the first three hours of acute ischemic stroke (IS) significantly improves its outcome. This therapy was approved for treatment in USA in 1997, and in most European countries in 2002. First intravenous thrombolysis of 15 in Serbia was carried out in February 2006. We present our preliminary experience with intravenous thrombolysis in treating patients with acute IS and compare it with the results of other clinical studies. All patients with IS treated with intravenous thrombolysis in our department were included in the study. The time of stroke onset, first neurological exam, time of CT exam and beginning of therapy were recorded. The early CT signs of ischemia were graded by the ASPECTS score. Neurological deficit was assessed with NIHSS score and functional outcome with modified Rankin Scale (mRS). During the eight-month period intravenous thrombolysis was given to 12 patients with acute IS, aged 18 to 66 years, of whom 75% were younger than 55 years. Median time from symptom onset to hospital door was 57.5 minutes, median time door-to-CT was 32.5 minutes, and the time from symptom onset to treatment was 155 minutes. Early CT signs of ischemia were present in 10 patients with median ASPECTS score 9. Median initial NIHSS score was 16.5 with its decline during the first 24 hours for at least 5 points in 58% of patients. Symptomatic intracerebral haemorrhage was present in one patient. After 30 days of follow-up 42% of patients had favourable outcome (mRS<1). In only 2 patients the outcome was poor (mRS 4-5). One patient died with signs of cardiac failure. Despite a small number of patients with short time of follow up, these results with thrombolysis in acute IS were found to be consistent with other authors' reports. Uniqueness of our series of patients who received thrombolysis as compared to other studies was their very young age.

Canadian CT head rule

The Canadian CT head rule (abbreviated CCTHR or CCHR; also sometimes referred to as the Canadian Computed Tomography Head Rule) is a medical scale used to decide whether patients with minor head injuries should undergo cranial CT scans. It was originally described by Stiell et al. in a paper published in the Lancet in 2001, in which they initially used it only on patients with Glasgow Coma Scale scores of between 13 and 15. Since then, the CCTHR has become the most widely researched and extensively validated rule of its kind, though a 2011 systematic review noted that "its exclusion criteria make it difficult to apply universally." Criteria The CCTHR excludes patients who: did not experience a traumatic brain injury have a Glasgow Coma Scale score of lower than 13, are under the age of 16, has a bleeding disorder or is using warfarin, and/or has a visible open skull fracture.

Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review.

Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis. A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient's muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty. Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.

Therapeutic route of patients at the acute phase of their stroke in Burkina Faso.

The advent of the neurovascular units and thrombolysis has improved support for stroke in developed countries. Our objective was to study the therapeutic route of stroke patients in Burkina Faso, a country with limited resources. It was a prospective cohort study over a period of 4months, from February 02, 2014 to June 05, 2014, in medical emergencies and Neurology department of the teaching hospital Yalgado Ouedraogo. The study focused on patients diagnosed with stroke through brain imaging when they first entered hospital or during hospitalization. Variables of the study included socio-demographic data of the patients, route of the patients, nature of the stroke, treatment and clinical course. The time between the onset of clinical signs and the first contact with a peripheral public health unit extended from 30min to 24h with an average of 6h and 56min. The minimum time between the first contact with a peripheral public health unit and medical emergencies of the Teaching Hospital Yalgado Ouédraogo was 15min, and the maximum, two weeks. After their arrival in medical emergencies, patients spent on average 21h and 18min to achieve the cerebral CT scan. Concerning the treatment, the thrombolysis, which was not available yet, had never been prescribed, while 19% of patients were eligible according to the 4h30mn period criteria. Our study shows that the long delay in the access of neurological expertise is, in most cases, related to the therapeutic route of patients. Thus, the setting-up of a stroke sector would improve the management and the prognosis of cases in Burkina Faso.

Subarachnoid hemorrhage

Angiography After a subarachnoid hemorrhage is confirmed, its origin needs to be determined. If the bleeding is likely to have originated from an aneurysm (as determined by the CT scan appearance), the choice is between cerebral angiography (injecting radiocontrast through a catheter to the brain arteries) and CT angiography (visualizing blood vessels with radiocontrast on a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm (see below). In emergency department patients complaining of acute-onset headache without significant risk factors for SAH, evidence suggests that CT scanning of the head followed by CT angiography can reliably exclude SAH without the need for a lumbar puncture. The risk of missing an aneurysmal bleed as the cause of SAH with this approach is less than 1%. Lumbar puncture

Assessment of Cost-Effectiveness of Computerized Cranial Tomography in Children with Mild Head Trauma.

Pediatric head traumas constitute the majority of admissions to emergency departments (ED) due to trauma. This study aims to draw attention to the use of cranial computerized tomography (CT) scans in the evaluation of children with head trauma under the age of 18, and to determine CT scans' usefulness in terms of cost-effectiveness. Age, gender, mechanism of trauma and Glasgow Coma Scale (GCS), diagnosis, time of admission to hospital, hospitalization and operation, cranial computerized tomography and hospitalization costs of all cases were retrospectively analyzed. A total of 26,412 patients younger than 18 years old who were admitted to the emergency department due to head trauma and who had a cranial tomography were analyzed. They had a mean age of 7.74 ± 5.66 years. In total, 26,363 (99.8%) of these patients had a GCS greater than 14. Out of these patients, only 402 (1.5%) had brain injury revealed by cranial CT, 41 (0.2%) of these patients were operated and 3 of the patients lost their lives. The total cost of patients admitted to the emergency department with a head injury amounts to USD 583,317. Furthermore, 75.78% of this cost comes from negative cranial CTs. A cost analysis according to different age groups did not show a meaningful difference between 0-2 years and 3-5 years (<ip</i = 1.000), but there was a meaningful difference for all the other age groups. Our findings show that applying algorithms to predict traumatic brain injury in children with mild head injury rather than scanning all patients with cranial CT will enable more reliable and cost-effective patient care. Current practices should be reviewed to avoid unnecessary radiation exposure and expense in the ED. It is also necessary to inform and educate parents about the risk/benefit ratio of cranial CT scans.

[Migratory hyperdense posterior cerebral artery sign following intravenous thrombolysis].

Computed tomography (CT) scanning of the brain continues to be the basic imaging mode in the acute phase of stroke. The hyperdense posterior cerebral artery sign is an early and infrequent radiological finding with topographic and prognostic value that must be taken into account in the initial CT scans. We report the case of a 79-year-old woman who suddenly presented with severe left homonymous hemianopsia, mild lower left facial paresis, 3/5 left hemiparesis and severe left hypaesthesia. In the initial brain CT scan, calcium hyper-density of the P1 segment is observed in the right posterior cerebral artery. Intravenous fibrinolytic therapy is administered. The patient shows clinical improvement, and in the follow-up brain CT scan at 24 hours after fibrinolysis, hyperdensity of the P3 segment is observed in the right posterior cerebral artery. Evidence of posterior cerebral artery hyperdensity is a rare radiological finding associated with an increased volume of ischaemic stroke. A computed tomography scan of the head in the acute phase is essential to try to clarify its causation. Calcium emboli are an under-diagnosed cause of stroke and occur spontaneously in a large proportion of cases. If calcium embolism is suspected, a study must be conducted in search of a carotid, valvular or aortic arch pathology. Migration of the arterial hyperdensity towards distal is associated with a better prognosis. This case presented good progress in contrast to the poor prognosis described in the literature in cases of arterial hyperdensity as an early marker of stroke in the acute phase.

Multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome: case study.

Intracerebral hemorrhage is the most feared complication of intravenous thrombolysis for acute ischemic stroke. Such hemorrhage usually occurs within or at the margin of ischemic or manifestly infarcted brain tissue. A patient with Trousseau syndrome who developed multiple extra-ischemic hemorrhages following intravenous thrombolysis is described. An 80-year-old Japanese man with no other underlying disease was diagnosed with unresectable advanced lung cancer (stage IV) without brain metastasis and had not yet been treated. The patient suddenly presented with disturbance of consciousness, right hemiplegia, and total aphasia, and was admitted to our hospital. Magnetic resonance imaging revealed acute cerebral infarction extending from the basal ganglia to the corona radiata of the left cerebrum and multiple small areas of bilateral cerebral cortices. Cardiogenic cerebral embolism was considered among the differential diagnoses, but the brain natriuretic peptide level was within the normal range, and no arrhythmias such as atrial fibrillation were observed. With no other causes, the patient was diagnosed with Trousseau syndrome due to hypercoagulability associated with the advanced lung cancer. The patient received intravenous tissue plasminogen activator (t-PA) at 96 minutes after onset of symptoms. His symptoms partially improved, but they suddenly deteriorated at 84 minutes after the thrombolysis. A computed tomography (CT) scan immediately after the neurological deterioration revealed a subcortical hemorrhage in the left occipital lobe. A repeat CT scan the day after onset showed enlargement of the left occipital hemorrhage and two new subcortical hemorrhages in the right frontal and right temporal lobes. These hemorrhages were located in areas remote from the acute ischemic lesions. To the best of our knowledge, this is the first reported case of multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome. The course of this case suggests that intravenous t-PA administration for acute ischemic stroke with Trousseau syndrome may be associated with a higher risk of intracranial hemorrhage.


Very typical too. In the ED it can be diagnosed with a pregnancy test (in males), because it detects that beta HCG in urine. Hepatocarcinoma can elevate (alone) alpha-fetus, seminoma LDH, lymphoma also LDH.

40-year-old patient, with normal physical examination, in whom a mediastinal mass and a hepatic nodule have been evidenced in the CT scan, and in the CBC a serum elevation of lactic dehydrogenase (LDH), human chorionic betagonadotropin (beta-HCG) and alpha-fetoprotein.What is your diagnostic suspicion. What is your diagnostic suspicion:

Metastatic extragonadal nonseminomatous germ cell cancer.

Germ cell tumor causing pleural effusion: A diagnostic dilemma.

Straw colored pleural fluid with raised adenosine deaminase (ADA) levels in young healthy adults usually raises suspicion of tuberculosis, sometimes leading to laxity in carrying thorough physical examination and missing out some important clues with potential disastrous consequences. A 35-year-old male was diagnosed to have left pleural effusion and anti-tubercular treatment was started on the basis of straw colored, lymphocyte-predominant pleural fluid with significantly raised ADA levels. When there was no improvement after 1 month of treatment he was investigated further and found to have a mediastinal mass along with hydro-pneumothorax. Fine needle aspiration cytology (FNAC) of the mass was done twice at different centers with different reports followed by biopsy from the mass to settle the diagnosis. Histopathological examination revealed yolk sac tumor. Testicular ultrasound showed a mass with ill-defined hypoechoic areas and lobulated margins in left testis, which was missed on clinical examination. Serum lactate dehydrogenase (LDH) and alpha fetoprotein (AFP) levels were found to be elevated. Beta-human chorionic gonadotropin (β-hCG) was normal. The final diagnosis of nonseminomatous germ cell tumor with mediastinal metastasis was made. The present case underlines the importance of good clinical examination, an art which is diminishing with availability of sophisticated investigations and a thin line of difference between potentially curable and fatal diagnosis, especially in young population, where malignancy is overlooked as a differential diagnosis. Furthermore, despite all its advantages, too much reliance on FNAC may be responsible for misdiagnosis in certain cases.

Late testicular relapse two decades after primary extragonadal germ cell tumor with uncommon metastases: a case report.

Extragonadal germ cell tumor (EGCT) is a relatively rare condition, reportedly representing 3-7% of all germ cell tumors. We report a patient who had metachronous testicular tumor with uncommon metastases 20 years after primary retroperitoneal EGCT treatment, along with a corresponding literature review. A 49-year-old Japanese man visited our department in November 2017 with chief complaints of indolent right scrotum enlargement and a right inguinal mass. History showed that the patient visited our department of gastroenterology with chief complaints of blackish feces and ill complexion in February 1997. Computed tomography (CT) showed a right retroperitoneal tumor, which was removed in the same month. Histopathological examination showed a teratoma and yolk sac tumor. He was diagnosed with primary retroperitoneal EGCT and received three courses of chemotherapy (bleomycin/etoposide/cisplatin; BEP). Periodic imaging and the determination of tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [HCG], and lactate dehydrogenase [LDH]) showed no recurrence or metastasis during the 5 years postoperatively. Subsequently, he did not visit the outpatient ward. In August 1999, he underwent surgery of right hydrocele. Contrast-enhanced CT showed a 35-mm contrast effect with uneven content in the right testicle and enlarged nodes that raised suspicion for metastases in the right inguinal and right external iliac lymph nodes. All tumor markers were within normal ranges. He underwent right high orchiectomy and resection of the right inguinal lymph nodes in the same month. Histopathological findings revealed seminoma (pT1, pN2, M0, S0, and TNM stage IIB). He received postoperative chemotherapy, one course of BEP therapy, and three courses of etoposide and cisplatin therapy. Post-chemotherapy CT confirmed a complete clinical response at the right external iliac lymph nodes, and this response continued 12 months later. No recurrence or metastasis has been found so far. We report a patient in whom a testicular tumor with uncommon metastases occurred 20 years after primary retroperitoneal EGCT treatment. After EGCT treatment, testicular relapses tend to occur after relatively long-term follow-up. After EGCT treatment, such patients must be closely monitored for testicular recurrences and onset of testicular tumor.

Primary retroperitoneal seminoma - embryology, histopathology and treatment particularities.

Retroperitoneal seminoma is a very rare form of cancer, with embryological origin represented by primordial germ cells from the urogenital ridges left behind during the fetal development. Extragenital germ cell tumors can also occur in the mediastinum or the pineal gland. The aim of this paper is to outline the particularities and draw embryological, histopatological and treatment conclusions regarding extragonadal germ cell tumors. A 43-year-old patient without any additional pathology was admitted for anemia of unknown etiology. The clinical examination revealed through deep abdominal palpation a mass in the left flank, and normal testes. Thoraco-abdomino-pelvic computed tomography (CT) scan showed a large retroperitoneal tumor adjacent to the great vessels in the left lumbo-iliac region. The blood work revealed just a low hemoglobin and hematocrit. With the established diagnosis of retroperitoneal tumor, radical surgical removal was decided. During the surgery, we were required to dissect a large solid encapsulated tumor mass from the aorta and the common iliac artery, starting at the renal pedicle all the way to the left iliac bifurcation. The surgical access was obtained through a transperitoneal left subcostal incision prolonged pararectally. Histopathological and immunohistochemical studies revealed a seminoma of the usual type. After the histological findings, the patient's tumor markers were investigated (LDH - lactate dehydrogenase, βHCG - beta-human chorionic gonadotropin, αFP - alpha-fetoprotein), all values being within normal ranges. In addition, the left testicle was thoroughly reexamined, clinically, through ultrasound and magnetic resonance imaging (MRI) scans, and no abnormalities were observed. After the surgery, the patient followed three courses of chemotherapy (BEP - Bleomycin, Etoposide and Cisplatin). The CT scan done 24 months after surgery found no signs of local or distant tumor recurrence. The patient entered a follow-up schedule consisting of periodical clinical, serological and imagistic evaluations. Primary retroperitoneal seminoma is a rare entity that must be taken into account when treating a retroperitoneal tumor. It develops out of the urogenital ridge, while the testes are normal. Thorough testicular evaluation (clinical, ultrasound and serum markers) is mandatory in all retroperitoneal tumors. The histopathological analysis is crucial for an accurate diagnosis and a proper management strategy. Through radical surgery and chemotherapy, the patients that are diagnosed prior to massive visceral metastatic dissemination can be cured.

A presumed extragonadal germ cell tumor that turned out to be a gastric cancer-a case report.

A solely retroperitoneal mass in males in combination with elevated serum Alpha-Fetoprotein (AFP) and beta-human choriogonadotropin (β-HCG) levels is highly indicative of a metastatic testicular cancer. Although testicular cancers are rare, they represent the most common diagnosed cancer in males between 14 and 40 years. However, in cases without evidence of a primary testicular tumor, the rare diagnosis of a retroperitoneal extragonadal germ cell tumor (EGCT) must be assumed. Here, we describe the first published case of a 66-year-old man presenting with this typical clinical picture and the diagnosis of an AFP and β-HCG producing advanced gastric cancer with retroperitoneal lymph node metastases mimicking a primary retroperitoneal EGCT. The final diagnosis was only made by gastroscopy performed after a CT-guided retroperitoneal lymph node biopsy revealed an adenocarcinoma, suggesting an upper gastrointestinal tract primary origin. However, a specific initial anamnesis and also in the primary staging, including a full-body CT-scan there was no hint for another primary tumor. Only the slightly unusual extension of the retroperitoneal mass up to the ligamentum hepatoduodenale and the pylorus, as well as the atypical age made us question our initial diagnosis. This extraordinary case is of special clinical interest to all practising physicians and once again highlights the importance of keeping rare differential diagnosis such as AFP-producing gastrointestinal tumors in mind.

Mediastinal Germ Cell Tumors -- Evaluation

A thorough physical examination is necessary to evaluate a patient with suspicion of mediastinal germ cell tumors, paying particular attention to the gonads. Testicular ultrasound should be a part of the standard work-up to identify co-existing germ cell tumors. Further imaging, histological, and biochemical analysis are necessary to make a diagnosis. Patients usually present after an incidental anterior mediastinal mass is found on a chest X-ray or may present with symptoms related to a large anterior mediastinal mass. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) can assist in better defining the tumor size, location, and borders. Biochemical markers, alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (B-hCG), and lactate dehydrogenase (LDH) can be elevated and should be checked. Similar to germ cell tumor diagnostic pathways, a significant elevation in serum B-hCG of >1,000 U/L with or without elevation in AFP is supportive of diagnosing mediastinal germ cell tumors in the appropriate clinical setting. [1]

[A case of metachronal testicular tumor eight years after medical treatment of extragonadal germ cell tumor].

A 22-year-old man was admitted to our hospital complaining of a left cervical mass. Computed tomography (CT) showed multiple enlarged lymph nodes at the left cervical vein and para-aortic areas. Histological examination of a biopsy indicated an embryonal carcinoma. The levels of human β-chorionic gonadotropin (β-HCG) and lactic dehydrogenase (LDH) were both elevated. Ultrasonography revealed testicular calcification, but there were no findings on magnetic resonance imaging (MRI). The patient was diagnosed as having an extragonadal germ cell tumor. After four courses of chemotherapy with BEP protocol (bleomycin, etoposide and cisplatin), retroperineal lymph node dissection (RPLND) was performed and there was no involvement of the viable cells in the resected lymph nodes. Eight years after chemotherapy, he noticed an enlargement of his left scrotum without pain. β-HCG was again elevated. A unilateral high orchiectomy was performed, and histology revealed a seminoma. He was staged as pT1N0M0S0. Six months later he remains disease-free.

[A non-seminomatous extra-gonadal germ cell tumor responding to intensive treatment: a case report].

A 23-year-old man presented with lumbago as a chief complaint. Computed tomographic (CT) scan revealed multiple lung tumors, multiple liver tumors, bulky retroperitoneal tumors with marked elevation of serum lactic dehydrogenase (LDH), alpha-fetoprotein, and beta subunit of human chorionic gonadotropin (HCG-beta). The patient was referred to our hospital for treatment. Scrotal ultrasonography and physical examination revealed bilateral normal testes. Because of bulky retroperitoneal masses with elevated specific tumor markers as well as bilateral normal testes, our diagnosis led to extra-gonadal germ cell tumor. Because the pulmonary lesion had increased rapidly, chemotherapy was performed without the tumor biopsy. After multiple chemotherapy regimens including BEP (bleomycin, etoposide, cisplatin), high-dose chemotherapy, and TIN (paclitaxel, ifosfamide, nedaplatin), all tumor marker levels fell into within the normal range. The tumor size was decreased remarkably on CT. Then, retroperitoneal lymphadenectomy were performed to confirm whether they still contained viable tumor cells. They contained only necrotic tissues without viable cancer cells by pathological examination. Consequently, the patient has been free of recurrence for 18 months after intensive treatment.

Mediastinal germ cell tumor

Cause Some investigators suggest that this distribution arises as a consequence of abnormal migration of germ cells during embryogenesis. Others hypothesize a widespread distribution of germ cells to multiple sites during normal embryogenesis, with these cells conveying genetic information or providing regulatory functions at somatic sites. Diagnosis The diagnosis of a mediastinal germ cell tumor should be considered in all young males with a mediastinal mass. In addition to physical examination and routine laboratory studies, initial evaluation should include CT of the chest and abdomen, and determination of serum levels of HCG and alpha-fetoprotein.

[A case of extragonadal germ cell tumor with inferior vena caval tumor thrombus].

We report a case of retroperitoneal extragonadal germ cell tumor with tumor thrombus in the inferior vena cava. The patient referred to our hospital with lumbago. Computed tomography (CT) showed a bulky mass in the retroperitoneum. The levels of alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) in the serum were elevated. Histological examinations indicated embryonal cell carcinoma. Bilateral testicles did not contain any palpable mass upon careful palpation. No tumor mass was detected in the bilateral testicles on ultrasonography. Clinically, the diagnosis was a retroperitoneal extragonadal germ cell tumor associated with para-aortic lymph-node involvement. After the combination chemotherapy (BEP 1 course and EP 3 courses), the tumor mass was reduced in size and the tumor marker was normalized. Retroperitoneal lymph node dissection (RPLND) was performed and tumor thrombus in the inferior vena cava was resected. There was no involvement of the viable cells in the resected tumor. The patient has been in good condition with no evidence of disease.

Seminoma

Diagnosis Blood tests may detect the presence of placental alkaline phosphatase (ALP, ALKP, ALPase, Alk Phos) in fifty percent of cases. However, Alk Phos cannot usefully stand alone as a marker for seminoma and contributes little to follow-up, due to its rise with smoking. Human chorionic gonadotropin (hCG) may be elevated in some cases, but this correlates more to the presence of trophoblast cells within the tumour than to the stage of the tumour. A classical or pure seminoma by definition do not cause an elevated serum alpha fetoprotein . Lactate dehydrogenase (LDH) may be the only marker that is elevated in some seminomas. The degree of elevation in the serum LDH has prognostic value in advanced seminoma.

Mediastinal Nonseminoma -- Evaluation

A complete physical exam including a genital exam is crucial. Alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (b-HCG), and lactate dehydrogenase (LDH) are the tumor markers that can be elevated in these patients [5] . Patients with benign teratomas do not have elevated b-HCG or AFP. Levels of AFP and HCG are elevated in the majority of patients with mediastinal non-seminomas. Cytogenticstudents are often done to rule out Klinefelter syndrome

InternalMed_Harrison

Careful monitoring of the serum tumor markers AFP and hCG is essential in the management of patients with GCT, because these markers are important for diagnosis, as prognostic indicators, in monitoring treatment response, and in the early detection of relapse. Approximately 70% of patients presenting with disseminated nonseminomatous GCT have increased serum concentrations of AFP and/or hCG. Although hCG concentrations may be increased in patients with either nonseminoma or seminoma histology, the AFP concentration is increased only in patients with nonseminoma. The presence of an increased AFP level in a patient whose tumor shows only seminoma indicates that an occult nonseminomatous component exists, and the patient should be treated for nonseminomatous GCT. LDH levels are less specific than AFP or hCG but are increased in 50–60% patients with metastatic nonseminoma and in up to 80% of patients with advanced seminoma.

Management of Residual Disease After First-line Chemotherapy in a Patient With a Nonseminomatous Germ Cell Tumor.

The case An 18-year-old male presented with a one-month history of a nonpainful right testicular enlargement. He had no family history of neoplasia, nor any relevant past medical history. The physical examination was only remarkable for an enlarged right testicle. A testicular ultrasound revealed a 2.5-cm tumor, and serum tumor markers revealed an elevated β-human chorionic gonadotropin (β-HCG), 22 mUI/L (normal, < 0.06 mUI/L); elevated alpha-fetoprotein (AFP), 329 ng/mL (normal, 0-9 ng/mL); and normal lactate dehydrogenase (LDH), 135 /L (normal, 179 U/L). A right radical inguinal orchiectomy was performed. Pathological examination revealed a 2.4 cm by 2 cm embryonal carcinoma with tumor invasion into the tunica albuginea. Postsurgical tumor markers obtained 3 weeks after orchiectomy were β-hCG, 100.5 mUI/L (normal, < 0.06 mUI/L); AFP, 1075 ng/mL (normal, 0-9 ng/mL); and LDH, 180 U/L (normal, 179 U/L). A chest, abdomen, and pelvis CT scan showed a 2.7-cm retroperitoneal lymph node enlargement, without visceral metastasis. Given the presence of node-positive disease with S2 serum markers, the diagnosis of a stage IIIB intermediate risk nonseminomatous germ cell tumor (NSGCT) was determined, and the patient underwent sperm banking. The patient was started on chemotherapy with 4 cycles of BEP (bleomycin, etoposide, and cisplatin), with a favorable tumor marker decline according to the Gustave-Roussy nomogram. After completion of the fourth chemotherapy cycle, serum tumor markers were negative, and 8 weeks after chemotherapy, the follow-up CT showed a 1.6-cm residual retroperitoneal lymph node conglomerate.

Mediastinal Cancer -- Evaluation -- Laboratory Studies

Basic Laboratory tests such as complete blood count (CBC) and basic metabolic panel (BMP) can help in the differential diagnosis of lymphomas. In the instances of mediastinal masses, tumor markers can help support a presumptive diagnosis. These include: Beta-hCG (associated with germ cell tumors and seminoma) LDH (may be elevated in patients with lymphoma) AFP (associated with malignant germ cell tumors): Mediastinal non-seminomatous germ cell tumors are more likely to result in distinct elevations of serum AFP and less likely in elevations of beta-hCG compared to gonadal or retroperitoneal non-seminomatous germ cell tumors. Malignant germ cell tumors are closely related to serum tumor markers, especially AFP and beta-hCG. The measurement of these serum tumor markers is important in the diagnosis, management, and follow-up of these patients.

Extragonadal malignant germ cell tumors: a clinicopathological and immunohistochemical analysis of 48 cases at a single Chinese institution.

Primary extragonadal malignant germ cell tumors (EMGCTs) are rare and characterized by the location in the midline of the body, including mediastinum, CNS, retroperitoneum and coccyx. EMGCTs present with different clinical and biologic characteristics in different tumor locations. Accurately diagnosing MEGCTs would be very difficult by performing on HE staining alone, and requires immunohistochemical verification. This study was to investigate the biological feature of EMGCTs and diagnostic value of immunohistochemical markers OCT3/4, CD117, PLAP, AFP, β-HCG and CD30 in EMGCTs. A retrospective study was performed on 48 patients with EMGCTs. EMGCTs were found to occur predominantly in males, especially for mediastinal MGCTs. The tumor locations included mediastinum, CNS and retroperitoneum. The mediastinum and CNS were the most common sites of EMGCTs. Seminoma/germinomas (64.6%) was the most common histological subtypes of EMGCTs. Chest pain, dyspnea, cough and fever were the most common clinical presentations in mediastinal MGCTs. Headache, visual disturbances, endocrine abnormalities, and signs of increased intracranial pressure were common clinical symptoms in CNS MGCTs. Abdominal mass with or without pain, backache and weight loss were common clinical presentations in retroperitoneal MGCTs. PLAP, CD117 and OCT3/4 were highly expressed in seminomas/gernimomas. CD30, EMA and CK AE1/3 staining were positive in embryonal carcinoma. AFP and β-HCG positive staining are characteristic in yolk sac tumors and choriocarcinoma, respectively. Patients with seminomas/germinomas had a better prognosis than those with NS/G-GCTs. Our finding suggests that the accurate diagnosis of EMGCTs is critical not only for predicting the tumor progression but also for patient management. Immunohistochemical markers have become an important tool in the diagnosis and differential diagnosis of EMGCTs.

[Retroperitoneal germ cell tumors with high level of serum and urine hCG in an adult: a case report].

A case of retroperitoneal germ cell tumors in a 32-year-old male is reported. He was admitted to our hospital with complaints of lumbago and abdominal mass. He was diagnosed with primary retroperitoneal malignant tumor and underwent resection of the tumor with retroperitoneal lymphadenectomy. The final pathological diagnosis revealed germ cell tumors of more than one histological type in the retroperitoneal space. Serum human chorionic gonadotropin (hCG) and hCG-beta levels were very high preoperatively (4,8000 mIU/ml, 57 ng/ml, respectively) and they decreased to normal after vinblastine-bleomycin cisplatin combination chemotherapy three times postoperatively. The patient later developed a solitary lung metastasis and died in another hospital 7 months after the operation. Retroperitoneal germ cell tumors in adults are rare. One question continually arises: are they extragonadal occurrences or germ cell tumors or do they represent metastatic lesions from occult testicular tumors?

An Unusual Case of Primary Retroperitoneal Germ Cell Tumour in a Young Man.

Some 2-5% of germ cell tumours are of extragonadal origin, with a retroperitoneal location being very rare. The majority of retroperitoneal germ cell tumours have metastasized from a testicular tumour. These tumours are diagnosed incidentally or symptomatically and nearly all present with high alpha-fetoprotein and lactate dehydrogenase levels. We describe the unusual case of a 31-year-old man with a yolk-sac, retroperitoneal germ cell tumour, with normal serum alpha-fetoprotein and lactate dehydrogenase levels, which has not previously been described. A testicular tumour was excluded by physical examination and additional tests. Our diagnosis was based on a high level of suspicion and histopathological results. As far as we know, this is the first case described with these characteristics. Extragonadal germ cell tumours are rare but can have fatal consequences if undiagnosed.The usual laboratory markers of the disease were absent in our patient.A high level of suspicion is required for diagnosis and close follow-up is required.

Testicle Cancer -- Evaluation

All patients with testicular germ cell tumors should undergo abdominopelvic imaging with computed tomography (CT). Patients with elevated serum tumor markers (AFP, α-fetoprotein; β-hCG, β-subunit of human chorionic gonadotropin; LDH, lactate dehydrogenase) should be evaluated further with computed tomography (CT) of the chest, abdomen, and pelvis for staging. [39] If testicular tumor markers are within the normal range, the rate of metastasis almost outside of the retroperitoneum is very low; therefore, the addition of a chest CT-scan to cross-sectional imaging of the abdomen and pelvis is highly unlikely to alter the treatment plan, and a chest radiograph suffices when combined with abdominopelvic CT imaging.  Choriocarcinoma has been shown to spread via hematogenous routes, and patients with high levels of β-hCG should undergo cross-sectional imaging of the brain to identify metastatic lesions due to choriocarcinoma hematogenously spreading to the brain.

Surgery_Schwartz

PET is useful for distinguishing malignant from benign tumors and may help detect distant metastases in some patients. However, the role of routine PET imaging for staging surgically resectable lesions of the mediastinum has not been established.The use of serum markers to evaluate a mediastinal mass can be invaluable in some patients. For example, nonsemino-matous and seminomatous germ cell tumors can frequently be diagnosed and often distinguished from one another by the lev-els of α-fetoprotein (AFP) and human chorionic gonadotropin (hCG). In over 90% of nonseminomatous germ cell tumors, either the AFP or the hCG level will be elevated. Results are close to 100% specific if the level of either AFP or hCG is greater than 500 ng/mL. Some centers institute chemotherapy based on this result alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than

Extracranial germ cell tumor

Diagnosis Professionals use a combination of testaments to diagnose the type or stage of EGCT is present. Common testaments for EGCTs are a physical examination, tumor marker test, immunohistochemistry, cytogenetic analysis, MRI, chest x-ray, CT scan (CAT scan), ultrasound exam, and biopsy. Explanations for each testament are below. Physical examination: a body check to look for signs of disease, such as a lump in the testicle in males or abnormal virginal bleeding in females. Tumor marker test: two tumor markers are tested, alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-hCG), to detect and diagnose the EGCTs. Immunohistochemistry: the use of antibodies to detect the reaction of antigens in the human body. Cytogenetic analysis: a method to discover abnormal arrangement of chromosomes in the tumor cells. MRI: an instrument that uses magnetic field, radio waves, and a computer to investigate the condition inside the human body through a series of pictures.

Testicular Seminoma -- Evaluation

Several laboratory values may be useful in following tumor burdens. These include AFP, B-HCG, and LDH. Alpha-fetoprotein (AFP) elevation indicates at least some nonseminomatous disease, and those patients are then treated as nonseminomas, germ cell patients. LDH may be used to follow the overall seminomatous tumor burden. Beta-human chorionic gonadotropin (HCG) is present in 5% to 10% of seminoma patients; these usually demonstrate the syncytial cytotrophoblastic subtype. Such elevations tend to be associated with metastatic disease, but the beta-HCG elevation by itself has no connection with overall survival.

The role of 18F-FDG-PET/CT in evaluating retroperitoneal masses -Keeping your eye on the ball!

Testicular germ cell tumour is the commonest malignancy affecting males aged between 15 and 35, with an increased relative risk amongst those with a history of cryptorchidism. In patients presenting with locoregional metastatic disease, retroperitoneal and pelvic soft tissue masses are common findings on ultrasound and computed tomography, which has several differential diagnoses within this demographic cohort. On staging <sup18</supF-FDG-PET/CT, understanding the typical testicular lymphatic drainage pathway facilitates prompt recognition of the pathognomonic constellation of unilateral absence of testicular scrotal activity, and FDG-avid nodal masses along the drainage pathway. We describe the cases of three young males presenting with abdominopelvic masses, in whom FDG-PET/CT was helpful in formulating a unifying diagnosis of metastatic seminoma, retrospectively corroborated by a history of testicular maldescent. In all three cases, the patients were males aged in their 30s and 40s who were brought to medical attention for back and lower abdominal pain of varying duration. Initial imaging evaluation with computed tomography and/or ultrasound revealed large abdominopelvic soft tissue masses, with lymphoproliferative disorders or soft tissue sarcomas being high on the list of differential diagnoses. As such, they were referred for staging FDG-PET/CT, all of whom demonstrated the pathognomonic constellation of, 1) unilateral absence of scrotal testicular activity, and 2) FDG-avid nodal masses along the typical testicular lymphatic drainage pathway. These characteristic patterns were corroborated by a targeted clinical history and examination which revealed a history of cryptorchidism, and elevated β-hCG in two of three patients. All were subsequently confirmed as metastatic seminoma on biopsy and open resection. These cases highlight the importance of clinical history and examination for the clinician, as well as a sound knowledge of the typical testicular lymphatic drainage pathway for the PET physician, which would assist with prompt recognition of the characteristic imaging patterns on FDG-PET/CT. It further anecdotally supports the utility of FDG-PET/CT in evaluating undiagnosed abdominopelvic masses, as well as a potential role in the initial staging of germ cell tumours in appropriately selected patients.

Nonseminomatous Testicular Tumors -- Evaluation

Alpha-fetoprotein is elevated in 50% to 70% of all patients with NSGCT.  Pure seminomas do not make alpha-fetoprotein, so if it's elevated in a patient diagnosed only with seminoma, it means that NSGCT elements were missed. The patient should be treated as having a mixed germ cell malignancy. Syncytiotrophoblasts manufacture human chorionic gonadotropins in seminomas and a few non-seminomatous germ cell tumors such as choriocarcinoma and embryonal carcinomas. LDH is generally a nonspecific tumor marker that is elevated in 20% to 60% of patients with NSGCT and is generally considered an indicator of bulky disease. Alpha-fetoprotein has a half-life of about 6 days, while the half-life of HCG is 24 to 48 hours.  In practical terms, HCG should begin to return to normal about 1 week after orchiectomy, while alpha-fetoprotein will take a minimum of 5 weeks. AFP and β-hCG are also elevated in various lung, liver, gut, bone, and live tumors. [47] [48] There are new markers to diagnose and evaluate germ cell tumors, like levels of circulating microRNAs, especially miR-371a-3p. However, their precise role in the management of testicular tumors is yet to be determined. [49]

Mediastinal germ cell tumor

Treatment Pure mediastinal seminomas are curable in the large majority of patients, even when metastatic at the time of diagnosis. These tumors are highly sensitive to radiation therapy and to combination chemotherapy. However, the cardiotoxicity of mediastinal radiation is substantial and the standard treatment of mediastinal seminomas is with chemotherapy using bleomycin, etoposide and cisplatin for either three or four 21-day treatment cycles depending on the location of any metastatic disease. Patients with small tumors (usually asymptomatic) that appear resectable usually undergo thoracotomy and attempted complete resection followed by chemotherapy. The treatment for mediastinal nonseminomatous germ cell tumors should follow guidelines for poor-prognosis testicular cancer. Initial treatment with four courses of bleomycin, etoposide, and cisplatin, followed by surgical resection of any residual disease, is considered standard therapy.

Mixed germ cells tumour primarily located in the thyroid -- a case report.

Germ cells tumours most frequently occur in the gonads. Extragonadal localisation is rare and concerns mainly the mediastinum, retroperitoneum and pineal. We present the first description of a patient with a mixed germ cells tumour located primarily in the thyroid. A 35-year-old man in a good clinical condition was admitted to diagnose metastasis revealed in an X-ray of his lungs. Abnormal laboratory tests showed high concentrations of beta-HCG and LDH. Ultrasound examination revealed: hypoechogenic area 8 × 4 × 5 mm in the left testicle, and enlarged left thyroid lobe with echogenically heterogenous mass. In cytological examination of the thyroid, carcinomatous cells were found, which suggested metastasis. A diagnosis of cancerous spread of testicular cancer to the lungs and thyroid was made. The left testicle, with spermatic cord, was removed, yet in the histopathological examination no carcinomatous cells were found. Rescue chemotherapy, according to the BEP scheme (bleomycin, etoposide, cisplatin) was started, but during its course the patient died. Histopathology disclosed primary mixed germ cells tumour in the thyroid, predominantly with carcinoma embryonale and focuses of choriocarcinoma. Extragonadal germ cells tumours rarely occur in the thyroid. In medical literature, some cases of teratomas and a single case of yolk sac tumour in the thyroid have been described. The presence of choriocarcinoma was responsible for the high serum concentration of beta-HCG. Surgery of germ cells tumours proves insufficient. The conventional chemotherapy is based on cisplatin. In conclusion, extragonadal germ cells tumours are rare, but should be considered while co-existing with elevated markers such as: AFP, beta-HCG and lack of abnormalities in the gonads.

InternalMed_Harrison

Role of Serum Tumor Markers and Cytogenetics Most tumor markers, including CEA, CA-125, CA 19-9, and CA 15-3, when elevated, are nonspecific and not helpful in determining the primary tumor site. Men who present with adenocarcinoma and osteoblastic metastasis should undergo a prostate-specific antigen (PSA) test. In patients with undifferentiated or poorly differentiated carcinoma (especially with a midline tumor), elevated β-human chorionic gonadotropin (β-hCG) and α fetoprotein (AFP) levels suggest the possibility of an extragonadal germ cell (testicular) tumor. With the availability of IHC, cytogenetic studies are rarely needed.

Chemotherapy of extragonadal germ cell tumors.

Forty-nine patients with histologically proven germ cell tumors arising in extragonadal sites were retrospectively reviewed. Included in the review were an additional seven patients with undifferentiated tumors with a pathologic appearance compatible with that of a germ cell tumor and elevated levels of serum biomarkers (beta subunit of human chorionic gonadotropin [beta-HCG] +/- alpha-fetoprotein [AFP]. Nineteen patients had a pure seminoma arising in an extragonadal site, whereas 30 patients had nonseminomatous germ cell tumors. Seven patients had primary undifferentiated tumors with elevated levels of serum biomarkers. Sixteen (84%) of the 19 patients with pure extragonadal seminomas with normal levels of serum AFP are alive and free of disease. Eighteen of these 19 patients received platinum-containing regimens and four had received prior chemotherapy that failed. Of the patients with nonseminomatous germ cell tumors, 12 (40%) of the 30 are alive and free of disease with vinblastine/bleomycin +/- cisplatin (13 patients) or CISCAII (cisplatin, cyclophosphamide, and doxorubicin) (nine patients) alternating CISCAII/VBIV (eight patients) chemotherapy. None of the seven patients with undifferentiated germ cell tumors are alive and free of disease. Three of the five patients with pure anterior mediastinal endodermal sinus tumors treated with chemotherapy remain alive and free of disease. Of the seven patients with choriocarcinomas arising in extragonadal sites, three are alive and free of disease. A classification for patients with extragonadal germ cell tumors incorporating site of origin, histology, and likelihood of being truly extragonadal is proposed. The implications of this classification are discussed.

Extracranial germ cell tumor

Extragonadal GCT Under the classification of the biology GCT, there is a more detailed classification contains specific types of extracranial extragonadal germ cell tumor. There are two types, teratomas, and malignant GCTs. Lists of these two categories and its subtypes are shown below. Teratomas Mature teratomas Immature teratomas Malignant GCTs Seminomatous GCTs: seminoma, dysgerminoma, germinoma Non-seminomatous GCTs: yolk sac tumor (endodermal sinus tumor), choriocarcinoma, embryonal carcinoma, gonadoblastoma, teratoma & yolk sac tumor Mixed GCTs: a combination of EGCTs. Common combinations include teratoma & embryonal carcinoma & yolk sac tumor (11%), seminoma & embryonal carcinoma (16%), and teratoma & embryonal carcinoma (26%). The yolk sac tumor produce the AFP hormone, and the germinomas, choriocarcinomas, and seminoma are tumors that produce the β-hCG hormone. The hormones that are produced by the tumors can be detected while proceeding testaments.

Second-line chemotherapy in patients with relapsed extragonadal nonseminomatous germ cell tumors: results of an international multicenter analysis.

Relapsed extragonadal germ cell tumors patients (EGGCT) are treated with identical salvage chemotherapy regimens, as are patients with metastatic testicular cancer. This investigation evaluates the results of second-line chemotherapy in nonseminomatous EGGCT and tries to identify prognostic factors for survival. We conducted a retrospective review of 142 patients treated at eleven European and American centers between 1975 and 1996. All had received cisplatin-containing regimens as induction treatment. Twenty-seven of 142 patients (19%) were long-term disease-free, 11% with primary mediastinal and 30% of patients with primary retroperitoneal disease. Median follow-up since start of salvage treatment was 11 months (range, 1 to 157) for all patients and 45 months (range, 6 to 157) for surviving patients. Forty-eight patients (34%) received high dose chemotherapy with autologous bone marrow transplant at relapse, and 10 of these patients (21%) are continuously disease-free. Primary mediastinal location (P =.003), sensitivity to cisplatin (P =.003), elevated beta-HCG at relapse (P: =.04), and normal LDH at diagnosis (P =.01) were shown to be significant negative prognostic factors for overall survival in univariate; mediastinal location [relative risk ratios (HR) = 1.9; 95% confidence intervals (CI), 1.2 to 3.0] and sensitivity to cisplatin [HR = 2.4; 95% CI, 1.1 to 5.2] were significant negative prognostic factors in multivariate analysis. Although current salvage strategies will cure between 20% and 50% of recurrent metastatic testicular cancer, relapsed nonseminomatous EGGCT patients appear to have an inferior survival rate, in particular in case of primary mediastinal location. Mediastinal primary tumor and inadequate response to cisplatin-based induction chemotherapy have been identified as independent negative prognostic factors, both associated with an approximately two-fold higher risk for failure of salvage treatment.

InternalMed_Harrison

Neuroimaging is the only test necessary to diagnose a brain tumor. Laboratory tests are rarely useful, although patients with metastatic disease may have elevation of a tumor marker in their serum that reflects the presence of brain metastases (e.g., β human chorionic gonadotropin [β-hCG] from testicular cancer). Additional testing such as cerebral angiogram, electroencephalogram (EEG), or lumbar puncture is rarely indicated or helpful.

The Second Medical Research Council study of prognostic factors in nonseminomatous germ cell tumors. Medical Research Council Testicular Tumour Working Party.

To assess prognostic factors in a large population of patients with metastatic nonseminomatous germ cell tumors (NSGCT) arising in gonadal or extragonadal sites. Data from 795 patients treated with chemotherapy between 1982 and 1986 in 13 centers were analyzed. Particular emphasis was placed on exact tumor measurements (eg, size of nodal masses, number of lung metastases), and the diagnostic pathology was also reviewed. Cox regression analysis was performed on these data. The patients were treated with a variety of cisplatin-containing chemotherapy regimens, 86% of which included etoposide. With median follow-up of 45 months, overall 3-year survival is 85%. The independently adverse features proved to be (1) the presence of liver, bone, or brain metastases; (2) raised marker levels (alpha-fetoprotein [AFP] level greater than 1,000 kU/L or beta subunit of human chorionic gonadotropin [HCG] greater than 10,000 IU/L [corrected]); (3) the presence of a mediastinal mass greater than 5 cm in diameter; (4) the presence of 20 or more lung metastases; (5) increasing age; and (6) absence of undifferentiated teratoma (embryonal carcinoma) or fibrous tissue from the primary tumor. The first four factors were used to define a simple prognostic classification. A good-prognosis group having none of these features comprised 67% of our patient population and had a 3-year survival of 93%. The remaining 33% of patients having at least one of these features had a 3-year survival rate of 68%. These patient groups are currently the subjects of international randomized clinical trials.

[Metastases of germ cell tumors to the ENT area--a rare differential diagnosis of lymph node metastases in unknown primary tumor].

Germ cell tumors of the testis usually metastasize to retroperitoneal lymph nodes, lungs, and liver. Other lymphatic or organ metastases especially in the head and neck are rare. The cases of two men, ages 21 and 35, are presented. In both cases, the histologic examination of cervical lymph node specimen lead to the correct tumor diagnosis of testicular cancer. Multimodal urooncologic therapy led to long-lasting complete remissions in both cases. In young men between 20 and 35 years of age with cervical metastases of tumors of unknown primary site, germ cell tumors must be suspected. Histologic findings of non-squamous epithelial metastases (seminoma, embryonal carcinoma, chorionic carcinoma, teratoma, yolk sack tumor, and their combined forms) with or without retroperitoneal, mediastinal, or lung metastases; elevated tumor markers (human-chorionic gonadotropin, alpha-feto-protein, placental alkaline phosphatase, lactate dehydrogenase); and palpable intratesticular mass lead to the correct tumor diagnosis. Early detection of the disease is essential for successful therapy and long-term remission.