Objective:To investigate the feasibility and adverse reactions of simultaneous integrated boost (SIB) in volumetric modulated arc therapy (VMAT) for early breast cancer after breast-conserving surgery.Methods:A total of 67 patients with early breast cancer after breast-conserving surgery at Zhongshan People's Hospital from September 2019 to May 2021 were enrolled. All patients received VMAT-SIB to the whole breast and tumor bed. The total breast dose and tumor bed dose were 40.5Gy/15 times every 3 weeks and 48 Gy/15 every 3 weeks respectively. The exposure dose of organs at risk and acute adverse reactions of radiotherapy were evaluated.Results:The average doses of planning target volume of the whole brease (PTV WB) and planning target volume of the boost(PTV BOOST) were (42.0±2.1) Gy and (49.9±0.8) Gy, respectively. The V 95% and V 105% of PTV WB and PTV BOOST were (98.8±1.2)% and (31.4±11.3)%, (99.8±0.6)% and (22.9±10.2)%, respectively. The V 5Gy, V 20Gy, V 30Gy and mean dose (D mean) of ipsilateral lung were (52.4±12.0)%, (15.3±4.5)%, (6.7±2.2)% and (11.0±2.4) Gy respectively. The V 18Gy, V 40Gy and D mean of heart were 3.80% (0.48%,9.60%), 0 (0,0.16%) and (6.7±2.1) Gy respectively. At the end of radiotherapy, 19 patients (29%) of all 67 patients had no acute skin toxicity, 41 patients (61%) showed radiation erythema, 5 patients (7%) had radioactive dry peeling and 2 patients (3%) had wet peeling mainly located in the nipple, areola area and breast folds. None of the patients had grade 3-4 acute skin reactions. Breast swelling and breast pain were found respectively in 9 patients (13%) and 7 patients (10%). No local recurrence or distant metastases were observed during the follow-up period. The 2-year disease-free survival rate was 100%. Conclusions:VMAT combined with SIB is feasible in the treatment of early breast cancer. The adverse reactions of radiotherapy are mild and well tolerated.

OBJECTIVETo investigate the value of magnetic resonance three dimensional sampling perfection with application optimized contrasts using different flip angle evolution (3D-SPACE) sequences in diagnosis and surgical strategy modification for obstructive hydrocephalus.

METHODSFrom March 2013 to July 2014, there were 152 cases admitted in People's Liberation Army General Hospital suffered from hydrocephalus, including 88 male patients and 64 female patients aging from 8 months to 79 years. All patients were performed magnetic resonance T2WI and 3D-SPACE sequence scanning before operation. Surgical strategy was made after evaluation of 3D-SPACE sequence. Non-communicating hydrocephalus was treated with endoscopic third ventriculostomy (ETV) and communicating hydrocephalus was treated with ventriculo-peritoneal shunt. According to MR images of direct observation to site of obstruction to determine the detection rate. MRI 3D-SPACE and cranial CT examination were performed in regular follow-up studies.

RESULTSThe relevance ratio of 3D-SPACE for the diagnosis of non-communicating hydrocephalus was 98.3% (114/116), while the relevance ratio of conventional T2-weighted MRI was 72.4% (84/116). Among the 152 patients, there were 36 cases with cerebral aqueduct film obstruction, 22 cases with space-occupying lesions in pineal region, posterior part of the third ventricle, or space-occupying lesions in quadrigeminal bodies area, 10 cases with Dandy-Walker symptom, 18 cases with cyst of the anterior pool of the bridge, 16 cases with cysticercosis, 4 cases with cyst of lateral ventricle, 2 cases with cyst of fourth ventricle, 2 cases with space-occupying lesion in foramen ofmonro, 2 cases with foramen ofmonro atresia, 4 cases with craniopharyngioma, 36 cases with communicating hydrocephalus. There were 112 hydrocephalus cases (73.7%) were treated with ETV, without shunt catheter insertion in follow-up study from 1 to 18 months (average (14±9) months).

CONCLUSIONSFor obstructive hydrocephalus, MRI 3D-SPACE sequence image has high diagnostic yield rate for providing more detailed anatomical information than conventional MRI. Hence, the advanced imaging methods are helpful for surgical treatment strategy decision making.

Adolescent ; Adult ; Aged ; Child ; Child, Preschool ; Craniopharyngioma ; pathology ; Cysts ; pathology ; Female ; Follow-Up Studies ; Humans ; Hydrocephalus ; diagnosis ; surgery ; Imaging, Three-Dimensional ; Infant ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Pineal Gland ; pathology ; Third Ventricle ; Ventriculostomy ; Young Adult

OBJECTIVETo summarize the clinical efficacy of ventriculo-peritoneal shunt (VPS) assisted by neuroendoscopy and laparoscopy for treatment of communicating hydrocephalus.

METHODSFrom January 2010 to January 2014, 209 cases (male 93, female 116) who suffered communicating hydrocephalus performed VPS with neuroendoscopy and laparoscopy in Department of Neurosurgery of People's Liberation Army General Hospital. The age of the patients were from 7 months to 79 years (mean 38.1 years), average duration were 20 days to 4 years (mean (2.4 ± 0.7) months). Neuroendoscopy and laparoscopy were used to help respectively to place shunt catheter to better position, both in the ventricle and peritoneal cavity. The effect of subsequent shunt system survival was analyzed with Kaplan-Meier survival analysis.

RESULTSThere were 209 patients received 255 times of VPS. All operations were successfully completed. No craniotomy or open operation were needed for technical-related complications. Forty-six revisions were performed in all patients. After the operation, 203 patients with hydrocephalus improved at different level after surgery. Thirteen cases occurred intracranial hypotension syndrome and improved after the pressure adjusted. All patients were followed up for 1 month to 4 years, with a median follow-up time of 2.1 years, while the shunt system efficiencies were 91.0%, 86.7%, 83.9% and 82.0% respectively from the end of the 1st year to the end of the 4th year.

CONCLUSIONSFor VPS, neuroendoscopy and laparoscopy can respectively help to place shunt catheter to better position, both in the ventricle and peritoneal cavity. Hence, the combination of these two modalities can reduce the failure rate of shunt catheter insertion and has significant impact on shunt system survival.

Adolescent ; Adult ; Aged ; Catheters ; Child ; Child, Preschool ; Female ; Humans ; Hydrocephalus ; surgery ; Infant ; Laparoscopes ; Laparoscopy ; Male ; Middle Aged ; Neuroendoscopes ; Neurosurgical Procedures ; Ventriculoperitoneal Shunt ; Young Adult

OBJECTIVETo investigate the clinical features, surgical transcranial approaches and outcomes of giant pituitary adenomas.

METHODSA series of 112 consecutive cases of giant pituitary adenomas underwent microsurgery through transcranial approaches at People' s Liberation Army General Hospital were retrospectively analyzed. Of the 112 patients, 58 were male and 54 were female, with age ranging from 3 to 72 years(mean age 44. 3 years). There were 91 non-functioning adenomas and 21 hormone-secreting adenomas. The maximum tumor diameter varied from 4. 0 to 7. 2 cm, with mean diameter of 4. 8 cm. Unilateral subfrontal approach was chosen in 16 cases, pterional approach in 41 cases, anterior interhemispheric approach in 34 cases, transcallosal-interforniceal approach in 6 cases, transcortical- transventricular approach in 5 cases, combined approach in 6 cases and other approaches in 4 cases. Postoperative MRI and endocrine function were re-examined routinely to evaluate the therapeutic efficacy. Staged operation through transsphenoidal approach or adjuvant treatments including medical and radiation therapies were administered in patients with hormone-secreting adenomas when hormonal excess persisted after surgery and in patients with non-functioning adenomas who had postoperative MRI evidence of residual tumor.

RESULTSTotal removal of the lesion was achieved in 57 cases (50. 9%) , 26 patients (23. 2%) underwent subtotal resection, and 29 patients (25. 9%) underwent partial removal. Postoperative mortality occurred in 3 patients (2. 7%). Major surgical morbidity occurred in 38 patients (33. 9%). Vision was preserved or improved in 98 patients (87. 5%). The postsurgical follow-up period varied from 3 to 64 months (mean 19. 5 months) . Nineteen of the 21 patients with hormone-secreting adenomas were considered to be in hormonal remission, and 87. 2% of the cases were capable of normal work and life and 8 patients suffered recurrence during the followed-up period.

CONCLUSIONSSelection of appropriate transcranial approaches is the key to successful microsurgery for giant pituitary adenomas according to the morphological characteristics presented in image examinations and clinical symptoms. Staged transsphenoidal operation and/or adjuvant therapies including medical and radiation therapies offer the best chances to control the residual tumors after the maximal surgical removal of giant adenomas through transcranial approaches.

Adenoma ; surgery ; Adolescent ; Adult ; Aged ; Child ; Child, Preschool ; Combined Modality Therapy ; Female ; Humans ; Magnetic Resonance Imaging ; Male ; Microsurgery ; methods ; Middle Aged ; Neurosurgical Procedures ; methods ; Pituitary Neoplasms ; surgery ; Postoperative Period ; Retrospective Studies ; Young Adult

OBJECTIVETo summarize individualized surgical treatment strategies for complex middle cerebral artery (MCA) aneurysms.

METHODSTwenty patients with complex MCA aneurysms treated by microsurgery in Chinese People's Liberation Army General Hospital between December 2009 and November 2012 were retrospectively analyzed. There were 12 male and 8 female patients, with a mean age of 43 years (range: 14-58 years). Giant aneurysms (size > 2.5 cm) were found in 6 cases, wide-neck aneurysms in 7 cases and serpentine ones in 3 patients. Important perforators were involved in aneurysm neck in 2 cases. Important branches originated from aneurysms in 6 patients. Two patients harbored recurrent aneurysms after coiling. Individualized surgical strategies were planned according to preoperative imaging. A frontotemporal approach was routinely used. Intraoperative somatosensory evoked potential monitoring, indocyanine green videoangiography and microvascular Doppler ultrasonography were regularly used. A postoperative digital subtraction angiography (DSA) or computed tomography angiography (CTA) was performed to verify the efficacy of treatment and patency of bypass vessels.

RESULTSOf the 20 cases, 7 aneurysms were clipped with clipping and reconstruction of parent artery with multiple clips, 3 M1 segment aneurysms were proximally occluded with extra-intracranial high-flow revascularization, 2 aneurysms were treated with aneurysmectomy with superficial temporal artery to middle cerebral artery low-flow revascularization, 1 aneurysm was treated with aneurysmectomy with superficial temporal artery to middle cerebral artery low-flow revascularization and branch side-to-side anastomosis, 2 aneurysms were treated with aneurysmectomy and re-anastomosis of parent artery, 1 aneurysm was treated with aneurysmectomy and re-anastomosis of parent artery and reinplantation of lenticulostriate artery, 3 bilateral MCA aneurysms were clipped by unilateral approach, and 1 was trapped. Nineteen patients were favorable with Glasgow Outcome Scale score 4-5 at discharge, and 1 patient died of cardiac infarction one week after surgery. The mean clinical follow-up was 20 months (range: 6-39 months). During follow-up, no bleeding occurred. DSA or CTA confirmed absence of aneurysm in 14 cases and residual neck in 2 patients. The other 3 patients were lost to follow-up.

CONCLUSIONSIndividualized, multi-modality surgical treatment strategies are effective and safe solution for treatment of complex MCA aneurysms. Revascularization remains imperative surgical technique.

Adolescent ; Adult ; Cerebral Revascularization ; methods ; Female ; Follow-Up Studies ; Humans ; Intracranial Aneurysm ; surgery ; Male ; Middle Aged ; Retrospective Studies ; Young Adult

OBJECTIVETo study the techniques and efficacy of neuronavigation-guided puncture and drainage in the treatment of brain abscesses.

METHODSFrom February 2006 to December 2012, 31 patients with brain abscesses treated by the technique of neuronavigation-guided puncture and drainage were retrospectively analyzed. There were 27 male and 4 female patients, age ranged from 10 months to 69 years, average (34 ± 19) years.Single brain abscesses were found in 26 patients, multiple abscesses in 5 patients. The abscesses were located in eloquent regions in 19 patients. The mean diameter of the abscess was 4.1 cm (2.5-6.7 cm). The first follow-up visit was on the first month after surgery, and if residual was observed on enhanced MRI, then the patient was followed up every 3 months until the abscess disappeared completely. After residual absorbed, the patient was followed up every year.

RESULTSIncisions of all patients were healed well and no infection. The length of hospital stay after surgery was 6-42 days, mean (14 ± 9) days. Bacterial culture of pus was performed regularly including aerobic, anaerobic and fungal culture after surgery. Thirteen patients had positive culture whereas the other 18 patients had negative culture. The duration of antibiotic use was 18-42 days, mean (22 ± 5) days. All the patients were followed up for 3 months to 3 years. Twenty-nine patients recovered well postoperatively, 1 case died 2 months after operation.One case was performed the second drainage after 10 days from the first surgery.Eighteen patients showed the improvement of neurological status within the first day following surgery, 4 patients got improvement in the next day, 1 patient with hemiplegia showed improvement in 10 days postoperatively, 1 patient with aphasia recovered gradually after 1 month, 1 patient with hemiplegia showed deterioration temporarily after surgery, and recovered gradually after 15 days.

CONCLUSIONThe technique of puncture and drainage guided by neuronavigation has many advantages to treat brain abscesses, such as small trauma, short operation time, high accuracy and safety, simple surgical procedures and good prognosis.

Adolescent ; Adult ; Aged ; Brain Abscess ; therapy ; Child ; Child, Preschool ; Drainage ; methods ; Female ; Humans ; Infant ; Male ; Middle Aged ; Neuronavigation ; Retrospective Studies ; Young Adult

OBJECTIVETo study the clinical characteristics, surgical principles and treatment options of blood-blister-like cerebral aneurysms in supra-clinoid segment of internal carotid artery.

METHODSTwelve blood-blister-like aneurysms were retrospectively studied including 4 open-surgery cases and 8 endovascular-treated cases from November 2008 to December 2012. Patients comprised 8 female and 4 male patients, whose mean age was 46.6 (range 38-56) years. Eleven patients presented with severe headache as the primary symptom, and 1 patient was found with aneurysm incidentally. Preoperative Hunt-Hess graded 0 in 1 patient, graded I in 5 patients, graded II in 4 patients, and graded III in 2 patients. By DSA examinations, 4 blood-blister-like aneurysms located in anterior wall and 8 in medial-anterior wall of supra-clinoid segment of internal carotid artery. Open surgical treatment included direct clipping, trapping, or wrapping and interventional treatment included stent-assisted coiling or simple stent placement. Intra-operative electroencephalogram and somatosensory evoked potentials monitoring was regularly used. Microvascular Doppler ultrasonography and indocyanine green videoangiography were used to assess blood flow in parent and branch vessels. The patients were followed up at 6 months by CT angiography (CTA) examination in outpatient clinic.

RESULTSFor 4 open surgeries, 2 aneurysms were directly clipped, 1 was trapped and 1 was wrapped. The patient underwent trapping paralyzed postoperatively. For endovascular treatment, 6 patients were coiled assisted with stents and 2 patients were treated with simple stent placement. All the patients were followed with a mean follow-up time of 16 months (range, 6-61 months). At 6 months follow-up, 3 out of 4 surgical treated patients had good outcome and 1 was moderately severe disabled by modified Rankin scale; 1 patient underwent wrapping recurred and was transferred to endovascular treatment. Of the 6 patients treated with stent-assisted coiling, 4 patients were recurrent and coil replacements were performed. Two patients with simple stent placement had no recurrences.

CONCLUSIONSBlood-blister-like aneurysm is a special type of complex cerebral aneurysm. Comprehensive understanding of blood-blister-like aneurysm is the key to successful treatment.Open surgery is difficult procedure with high risk and complications while stent-assisted coiling has a high recurrent rate. To date, neither is the safe and effective treatment option.

Adult ; Carotid Artery, Internal ; pathology ; surgery ; Female ; Humans ; Intracranial Aneurysm ; diagnosis ; surgery ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome

The data of 30 patients simulated before surgery were analyzed using Dextroscope operation planning system in Department of Neuresurgery,General Hospital of Chinese PLA between August 2004 and September 2005,including 2 patients with basilar artery aneurysm,1 with posterior cerebral artery aneurysm,3 with ophthalmic aneurysm,2 with middle cerebral artery aneurysms,1 with anterior cerebral artery aneurysm,7 atlas-occipital malformation,4 meningioma,5 schwannomas,and 5 deep gliomas. The primary CT and MRI data of 30 patients were input to the workstation of Dextroscope system for 3D reconstruction,reunion,segmentation and simulation the entire process of the operation. The relationship of the cranial nerves,vessels and skull base bone with lesions during operations were similar with that of the preoperative simulation on the workstation. The time of clipping aneurysms was reduced from (37.60±13.43) minutes to (23.51±7.62) minutes following application of Dextroscope system,and time of resections of odontoid processes was shortened from 81 minutes to 50 minutes. The ratios of complications were decreased and the patients' Karnofsky scales were 88.7 scores 3 months after operation. Dextroscope operation planning system can help doctors to analyze the patients' image data on a 3-D view and video outlook. The system can raise a precise and detailed operation plan before operation based on the simulation of the operation process,to well know the difficulty and shorten operation duration.

Objective To investigate the effect of several types of cervical braces used for external immobilization on craniovertebral junction malformation. Methods 48 patients with craniovertebral junction malformation applied several types of cervical braces, including Philadelphia collar, sterno-occipito-mandibular immobilizer (SOMI) and Halo-vest, for the surgical treatment were retrospectively analyzed. Results The primary applications of external cervical brace after posterior internal craniovertebral fixation in this series were 20 cases of Philadelphia collar, 16 cases of SOMI and 12 cases of Halo-vest, with excellent or good results in 80%, 87.5% and 91.7%. The applications of external brace for post-hospital recovery were 16 cases of collar, 15 cases of SOMI and 17 cases of Halo-vest. 35 (72.9%) patients were followed-up for at least 4 months, with satisfying immobilization and duration which fulfilled the requirements for post-operative recovery. Conclusion The applications of the all of 3 kinds of external brace, including collar, SOMI and Halo-vest, have their important clinical value for peri-operational and post-operational recovery in the treatment of patients with craniovertebral junction malformation. To have a reasonable choice of these brace in different patients, the characteristics of pathology as well as the surgical stages should be taken into account.

BACKGROUND: The anatomical position of facial nerve is often abnormal because of the acoustical neuroma growth, so sometimes, the facial nerve injury is inevitable in the surgery treatment for acoustic neuroma.OBJECTIVE: To investigate the technology, veracity and practicality as well as the relationship between intraoperative monitorning and prognosis of facial nerve, and the clinical experiment was summed up of facial nerve function monitoring in 120 cases of acoustic neuroma surgery.DESIGN: Self-control observation.SETTING: Department of Neurosurgery, General Hospital of Chinese PLA.PARTICIPANTS: Totally 120 patients with acoustic neuroma who received treatment in the Department of Neurosurgery, General Hospital of Chinese PLA from May 1996 to February 2000 were recruited. Among them, 3 cases suffered from small-type acoustic neuroma (＜ 2 cm in diameter), 9 cases from middle-type acoustic neuroma (＞ 2 cm in diameter) and 108 from large-type acoustic neuroma (＞ 3 cm in diameter), including 1 case of bilateral acoustic neuroma and 1 cases of recrudescent acoustic neuroma; Suboccipital retromastoid approach was used in 119 cases and transretrolabyrinthine approach in 1 case.METHODS: American Viking-Ⅳ type monitor was used to monitor facial nervous function. When facial nervous function was monitored, recording electrode was put on orbicular muscle of eye, orbicular muscle of mouth or quadrate muscle of upper lip. When trigeminal motor branch was monitored, recording electrode was put on masseter muscle; When accessory nerve was monitored, recording electrode was put on trapezius muscle.Measurement of evoked auditory brainstem potential: recording electrode was positive electrode and was put at the midline in the frontal region (electroencephalogram 10-20 classification system). The recorded waveshape presented upward deflection. Reference electrode A1 or A2 and ground electrode were put in the midline of frontal pole (relevant to root of nose); Recording electrodes were all needle electrodes and were fixed with adhesive tape. Common stimulus intensity was 80 to 90 nHL, and 40 nHL noise was used in contralateral ear. Facial nerve was reserved following intraoperative monitoring. CT (enhancement scanning was necessary) or MRI was rechecked after operation to investigate the cutting degree of tumor; Facial nerve function was evaluated by H-B scoring (at 2 weeks, or 6 to 9 months following operation).MAIN OUTCOME MEASURES: Facial nerve function by H-B scoring before and after acoustic neuroma surgery.RESULTS: Totally 120 patients were enrolled, and no one dropped out.① Facial nerve anatomy was reserved in 117 cases; One case was failure to reserve facial nerve anatomy because pinnate facial nerve lay behind of acoustic neuroma, and electrical stimulation was not given at the beginning of neuroma resecting, then he received anastomosis of hypoglossal and facial nerve. Nerve of 2 cases was pulled and broken carelessly, and its two stumps were long enough that end-to-end anastomosis of facial nerve was performed with 7-0 absorbable suture following trimming. H-B score was Ⅳ to Ⅴ in the 6th month after surgery. ②Grade Ⅰ of facial nervous function at postoperative 2 weeks was found in 10 cases, grade Ⅱ in 57 cases,grade Ⅲ in 44 eases, grade Ⅳ in 4 cases, grade Ⅴ in 2 cases and gradeⅥ in 3 cases. ③Grade Ⅰ of facial nervous function at postoperative 9 weeks was found in 94 cases, grade Ⅱ in 18 cases, grade Ⅲ in 4 cases,grade Ⅳ in 1 case and grade Ⅵ in 2 cases.CONCLUSION: Spontaneous and evoked facial muscle electromyogram may be helpful to make sure the facial nervous position exactly and estimate the prognosis of facial nerve.