Dumbbell type jugular foramen meningioma extending both into the posterior cranial fossa and into the parapharyngeal space: report of 2 cases with vascular reconstruction

Two cases with huge dumbbell type jugular foramen meningioma with extension into the parapharyngeal space are reported. A well co-ordinated surgical strategy for total resection to this high risk tumour with neurosurgeons, otolaryngologists and plastic surgeons is mandatory to minimise operative complications. Both of our patients presented with a cervical mass and lower cranial nerve palsies, and had huge dumbbell type masses extending from the posterior cranial fossa through the jugular foramen to the parapharyngeal space, encasing the cervical internal carotid artery. Gross total resection of the tumours was successfully achieved by basically a 2-stage operation. In the first stage, posterior fossa tumours were removed by the transjugular approach, combined with the petrosal approach in one case. In the second stage, cervical tumours were removed along with the cervical carotid artery by the transcervical and/or transmandibular approach, followed by vascular reconstruction from the ipsilateral carotid artery to the middle cerebral artery using saphenous vein graft. From these experiences, we recommend this 2-stage operation for large dumbbell type meningiomas extending to the infratemporal/parapharyngeal space. The intracranial tumour is removed at the first operation. The extracranial portion is resected at the second, and if necessary, the involved cervical carotid artery is resected and simultaneous revascularisation using saphenous vein graft is performed with a vascularised free muscle graft. This strategy could maximise the functional preservation on the one hand, and minimise the surgical risk, such as postoperative infection, on the other.     

Giant cranial base tumours

Thirty-three patients with giant (diameter > or = 4.5 cm) cranial base tumours who underwent surgery at the Hadassah Hospital over the last ten years are described. Twenty-three of the patients had meningiomas, 4 neurinomas, one giant cell tumour, one haemangiopericytoma, and 4 had malignant meningiomas. Four tumours were at the cerebellopontine angle, 9 within the anterior cranial fossa, 8 petroclival, 8 on middle fossa floor, and 4 along the sphenoid ridge. The average pre-operative symptom duration was 31 months, range 3-180 months. Nineteen patients had a radical tumour resection, 10 subtotal, and 4 a partial resection on an average 1.7 operations per patient. The mean follow-up period from the first operation was 39 months (range 2-120). There was no mortality peri-operatively or during the follow-up period. The mean pre-operative Karnofsky score was 68 and at the last follow-up 76. There was no correlation between histology and degree of resection, complications, or status at last follow-up. The best resections (92% radical) and outcome (mean Karnofsky 92) with the least number of operations (mean 1.4) were in the anterior fossa and along the sphenoid wing. The patients requiring the most operations (mean 2.1), having the smallest percentage of radical resections (25%) and the least favourable outcomes (mean Karnofsky 52) were those with petroclival tumours. Patients with giant cranial base tumours have a good overall long-term prognosis, but especially those with petroclival tumours challenge us to improve our techniques.     

Reimplantation of autoclaved tumour bone in limb salvage surgery

This is a prospective clinical study of 7 patients with malignant bone tumours who were treated by resection of the tumour, followed with reconstruction by reimplantation of the resected autoclaved tumour bone. There were 3 male and 4 female patients between 10 and 36 years of age. All the tumours were Stage IIB. Five of the 7 were in the region of the knee joint. Histologically, 5 were osteosarcomas, 1 a recurrent chondrosarcoma and 1 a recurrent Ewing's sarcoma. All the patients were treated by en bloc resection of the tumour with wide margins. The resected length ranged from 13 cm to 28 cm. After removal of soft tissue and cartilage, the resected bone segment was autoclaved for 5 min at 132 degrees C and 29 pounds per square inch pressure (0.2 mega Pascal). This autoclaved segment of bone was then reimplanted and fixed with an appropriate implant. The average follow-up was 20 months with a range of 14 to 27 months. None of the tumours recurred and, at the most recent follow-up, all the patients were alive, 6 with no evidence of disease and one with a lung metastasis. Six of the 7 patients were available for radiological assessment. Solid bone union was seen in 4 patients, delayed union in 1 and nonunion in 1. This method of reconstruction using an autoclaved tumour bone graft is useful in countries where facilities for allograft or tumour prostheses are not available owing to financial, technical or sociocultural reasons.     

Glial tumourettes (glial microtumours): their clinical and histopathological manifestations

This study represents our experience with eight cases (males: 4; females: 4; 13-47 years old, average age 28.5 years) of a "glial tumourette" (minute glioma), which measured less than 15 mm in diameter on an MRI. Four tumours were located in the frontal lobe, one in the rostrum of the corpus callosum, two in the midbrain, and one in the thalamus. The symptoms and signs lasted from two days to 15 months prior to diagnosis, and they consisted of epileptic seizures in five patients and increased intracranial pressure due to hydrocephalus resulting from aqueductal stenosis in three. All patients had a CT scan and an MRI as a part of their initial neuroimaging evaluations. While the CT findings failed to show the lesion in four patients, MRI demonstrated it in all cases. Five tumours were either totally or subtotally removed while the remaining three were biopsied. Histological examinations revealed six tumours to be low-grade gliomas (fibrillary astrocytoma: 4; oligoastrocytoma: 2) and two to be high-grade gliomas (anaplastic astrocytoma: 1; anaplastic oligodendroglioma: 1). Regarding adjuvant therapy, three patients received radiation and/or chemotherapy. One of the patients with midbrain fibrillary astrocytoma died of the disease 38 months after the operation, however, no evidence of progression in the remaining seven has been observed in the follow-up period ranging from five to 65 months after the operation (average: 25.4 months). The histogenesis of benign and malignant gliomas and the importance of surgical exploration in the management of such patients with minute intracerebral tumours are also discussed.     

Hypothalamic juvenile pilocytic astrocytoma presenting with intracerebral hemorrhage

Hemorrhage of juvenile pilocytic astrocytomas is very rare. However, it is clinically important because a high probability of a fatal outcome exists if hemorrhage occurs outside the optic nerve. Hemorrhage of a hypothalamic juvenile pilocytic astrocytoma has been reported only once, from an autopsy examination. We present a successfully managed case. The patient, a 34-year-old man, presented with sudden loss of consciousness. Computed tomography (CT) and magnetic resonance imaging demonstrated an exophytic hypothalamic tumor with a hemorrhage. Craniotomy with total removal of the tumor and the hematoma was performed. Histopathologic examination revealed that the tumor was a juvenile pilocytic astrocytoma. Brain CT examination 18 months later revealed no evidence of tumor recurrence. The patient was well, without neurologic deficit, and had a normal social life as of the last follow-up examination 22 months after craniotomy.     

Chemotherapy for spinal cord astrocytoma: can natural history be modified?

Standard treatment of spinal cord astrocytomas is based upon surgery, followed by radiotherapy when resection is incomplete or when histology is of high grade. Owing to the major consequences of radiotherapy on the spine in childhood, alternative therapies must be explored. The potential role of chemotherapy in the management of spinal cord astrocytoma remains to be defined. Two patients are described. The first was a 19-month-old child with an anaplastic astrocytoma of the cervical spinal cord that progressed rapidly after initial partial resection. Chemotherapy was begun according to the UKCCSG Baby Brain Protocol, with marked clinical improvement. Reassessment by MRI at 4 months showed improvement, and at the end of treatment no evaluable disease remained. The second was a 4-year-old child with a recurrent low-grade astrocytoma. Chemotherapy according to the SIOP Protocol for Low Grade Gliomas was administered for 3 months, after which marked tumour regression was seen, with neurological recovery. These patients demonstrate the potential value and low morbidity of chemotherapy in spinal cord astrocytoma. The management of this rare tumour is discussed.     

Medication control in hospitals: a practical approach to the problem of drug-drug interactions

We present 19 patients with tuberous sclerosis complex and subependymal giant cell astrocytoma. The mean age at the time of tumor diagnosis was 9.4 years (range, 1.5 to 21 years). Computed cranial tomography (CT) or cranial magnetic resonance imaging (MRI) identified the lesion which was resected in all cases. Seven patients had hydrocephalus and there was an interval increase in the tumor size or a large tumor without hydrocephalus in 12 patients. Surgical criteria included: (1) presence of hydrocephalus; (2) interval increase in tumor size; (3) new focal neurologic deficit attributable to the tumor; and/or (4) symptoms of increased intracranial pressure. Eight patients were identified through a surveillance program involving annual computed cranial tomography. All of these eight patients had their tumor removed prior to the development of symptoms, none had neurologic deficits which persisted after surgery, and none has so far developed recurrent subependymal giant cell astrocytoma. In contrast, of the 11 patients from the non-surveillance group 7 were symptomatic at tumor diagnosis, 1 had a complicated postoperative course, 2 developed recurrent giant cell astrocytoma, and 1 had an extensive lesion that could not be completely excised. Periodic cranial imaging may help to identify subependymal giant cell astrocytomas in tuberous sclerosis patients before they become symptomatic. Earlier diagnosis and treatment could reduce surgical morbidity and the risk of tumor recurrence.     

Syringomyelia associated with posterior fossa cyst: a case report

We report a case of a 47-year-old woman with a posterior fossa cyst associated with syringomyelia and hydrocephalus. Her birth was traumatic and she had suffered a fractured skull. About 10 years prior to coming to our department she had occipitalgia and a pain had developed over a month from her right shoulder to hand. Shortly before presenting occasional electric-like shocks were felt in her right hand associated with coughing and hiccuping. Magnetic resonance imaging (MRI) revealed a large midline posterior fossa cyst, hydrocephalus and syrinx (C1-Th11). Cisternography could not demonstrate communication between the cyst and the subarachnoid space and the 4th ventricle was present but without communication with the cyst. The cyst was tentatively diagnosed as an arachnoid cyst. One week after placement of a cyst-peritoneal shunt, CT scans showed a decrease in cyst and ventricle size and 2 months later a follow-up MRI revealed resolution of the syringomyelia. We suspected that cyst-peritoneal shunt was effective for this patient who had syringomyelia associated with incommunicated posterior fossa cyst.     

Medullomyoblastoma. A rare cerebellar tumour in children

Seven patients between the ages of 3 and 24 years were admitted to our hospital in the last 28 years who had a histological diagnosis of medullomyoblastoma. These patients presented with classic symptoms of a posterior fossa midline mass associated with evidence of raised ICP. A CT scan in each patient revealed a uniformly high-attenuating tumour in the posterior fossa with gross hydrocephalus. In all seven patients a ventriculoperitoneal shunt was placed prior to definitive surgery. Radical tumour excision was carried out in all cases 3-5 days after CSF diversion. The histological diagnosis was made on H&E-stained slides. In two cases each, the tumour tissue was subjected to electron microscopy and immunohistochemical studies. Six of the seven patients survived the operation. One patient died 21 days after surgery as a result of shunt block and shunt infection. All surviving patients received cranial and spinal radiation 2-4 weeks after surgery, and also chemotherapy. The cranial radiation dose ranged from 4500 to 5000 rad, while the spinal radiation dose was limited to 1500 rad. Patients were followed up carefully. Three patients died within 6 months, and the remaining three between 2.5 and 3 years after surgery. None of the patients in our study survived longer than 3 years. One patient had developed paraplegia. This study highlights the details of an uncommon entity and reports the largest collection of such cases in the literature.     

Evaluation of drug concentration in tissues after percutaneous administration of non-steroidal antirheumatics]

Forty-two cases of medulloblastoma of posterior fossa in children are presented in this paper. Of the children, 28 were males and 14 females; their age ranged from 1.5 to 12 (mean 7.3) years. The foci found were in vermis (36) and cerebellar hemispheres (6). All of these children presented symptoms and signs of obviously increased intracranial pressure, and 31(77%) of them had the signs of cerebellar functional deficits. CT scan showed severe obstructive hydrocephalus in 39 cases. 42 children with posterior fossa medulloblastoma underwent surgical resection. Three died of postoperative prespiratory and circulatory failure, 39 made good recovery and received craniospinal radiotherapy and adjunct chemotherapy. Up to now, none died. Surgical intervention and operative procedures were emphasized particularly. Radiotherapy and chemotherapy were discussed also.     

The use of the Multi-Tabs vitamin and mineral complex to prevent influenza

Two cases of small bowel tumour, resected and considered as benign leiomyomas, are reported. Both developed late hepatic metastases, 6 and 8 years after surgery respectively, diagnosed as leiomyosarcoma. Emphasizing the difficulties in assessing malignancy of these tumours and considering local and far dissemination, a long-term follow-up is recommended after surgical resection.     

Surgical treatment of 32 patients with peripheral intrahepatic cholangiocarcinoma

BACKGROUND: Peripheral intrahepatic cholangiocarcinoma (PIC) is an intrahepatic primary liver neoplasm which is clinicopathologically distinct from hepatocellular carcinoma and major duct cholangiocarcinoma. The clinical outcome after resection of these rare tumours is not well documented. METHODS: Review of the hepatic database and tumour registry at Memorial Sloan-Kettering Cancer Center identified 32 cases of PIC resected for cure over a 23-year period. Intrahepatic cholangiocarcinomas with major bile duct involvement were excluded from this analysis. Demographics, pathological features, biochemical markers, operative results and survival were analysed. RESULTS: The majority of patients presented with abdominal pain (n=19). Only two patients had pathological evidence of hepatic cirrhosis. Serum marker levels included 7-fetoprotein (AFP; median 3.7 (range 0-225) ng/ml) and carcinoembryonic antigen (CEA; median 1-6 (range 0-30) ng/ ml). Type of hepatic resection included: wedge (n=2), lobectomy (n=14) and extended lobectomy (n=16). There was one postoperative death. Median follow-up time was 27 months. Median survival was 59 months with an actuarial 5-year survival of 42 per cent. Vascular invasion and intrahepatic satellite lesions were predictors of worse survival (P < 0.05). CONCLUSION: PIC is a rare hepatic primary tumour, which usually presents in non-cirrhotic livers with a normal serum AFP and CEA level. In selected patients, complete surgical resection can be performed safely and is associated with long-term survival.     

Endoscopic neurosurgery and endoscope-assisted microneurosurgery for the treatment of intracranial cysts

OBJECTIVE: Different endoscopic techniques have been introduced into neurosurgery, but accepted terminology and definitions are still missing. We propose a terminology based on whether the endoscope is used alone or in conjunction with an operating microscope and on whether the route of surgical manipulations is through or outside the endoscope. Accordingly, procedures are categorized into endoscopic neurosurgery (EN), endoscope-assisted microneurosurgery (EAM), and endoscope-controlled microneurosurgery (ECM). METHODS: We treated 36 patients with intracranial arachnoid cysts (ACs) and intraventricular cysts endoscopically. The patients ranged in age from 4 months to 69 years (mean age, 31 yr). The follow-up period ranged from 6 to 44 months (mean follow-up duration, 14 mo). The indications were hydrocephalus in 17 patients, focal neurological deficits in 4 patients, progressive nonlocalizing symptomatology in 13 patients, and space occupation in 2 asymptomatic patients. EN was used in 14 cases, EAM in 15 cases, and ECM in 7 cases. RESULTS: The overall success rate was 70%. Nine patients (25%) had unchanged symptomatology, and the condition of two patients (5%) deteriorated. The best success rates were achieved in patients with intraventricular cysts (89%) and posterior fossa ACs (78%). Symptomatic improvement was best achieved in patients with hydrocephalus or focal neurological deficits (81%). CONCLUSION: Different endoscopic techniques (i.e., EN, EAM, and ECM) provide sufficient treatment of selected intracranial cysts. Our data suggest that intraventricular cysts and suprasellar ACs should be approached using EN whereas posterior fossa and sylvian ACs may be more effectively treated using a combined technique (EAM or ECM).     

Sacrococcygeal germ-cell tumours--the Red Cross War Memorial Children's Hospital experience, 1980-1996

OBJECTIVE: To document the experience of Red Cross War Memorial Children's Hospital in the treatment of sacrococcygeal germ-cell tumours. PATIENTS: Twenty-seven patients with sacrococcygeal germ-cell tumours were treated in our hospital from 1980 to 1996. DESIGN: A retrospective review of these patients' records was undertaken. RESULTS: There were 19 female and 8 male patients. Seventeen (63%) presented in the neonatal period, 13 on the first day of life. Complete surgical resection of the tumour was achieved in all patients with mature or immature teratomas (20 patients) and in 2 neonates with malignant tumours. The first of these 2 neonates, with a malignant teratoma, was not given chemotherapy and remains well 10 years later. The second, with a yolk-sac tumour, also received no initial chemotherapy. He relapsed at the age of 9 months and was successfully treated with repeat excision and chemotherapy. All 5 patients first diagnosed after the age of 1 year had malignant tumours. These patients had incomplete surgical resection (3) or biopsy only (2), and 3 were successfully treated with chemotherapy. One patient relapsed with yolksac tumour after initial complete resection of a mature teratoma. She was successfully treated with repeat surgery and chemotherapy.     

Magnetic resonance imaging features of pituitary yttrium-90 rod implantation

Intersellar implantation of yttrium-90 rods was a common treatment for a variety of pituitary tumours in the 1960s and 1970s. The magnetic resonance (MR) imaging features in three patients with implants (two for growth hormone-secreting and one for prolactin-secreting pituitary adenomas) are presented: the implants appeared as low signal cylinders with no image distortion, in contradistinction to CT where the implants generate beam hardening and back projection artefacts. Confident evaluation of the pituitary fossa for residential tumour and sequelae of therapy could be made on MR. It is the imaging technique of choice in the follow-up of patients treated with yttrium-90 implants.     

Extralobar pulmonary sequestration presenting as a mediastinal malignancy

OBJECTIVE: We intended to characterize the CT patterns of hemorrhage associated with ruptured posterior inferior cerebellar artery (PICA) aneurysms. MATERIALS AND METHODS: CT scans of 44 cases of angiographically confirmed ruptured saccular PICA aneurysms (4) aneurysms at the junction of the vertebral artery and the PICA and three distal PICA aneurysms) were retrospectively reviewed. All scans had been obtained within 2 days of the subarachnoid hemorrhage (SAH) (day 0 [less than 24 hr], 35 patients; day 1, eight patients; day 2, one patient). Presence or absence of hemorrhage in specific subarachnoid, intraventricular, and intraparenchymal locations was noted, as were the presence and degree of hydrocephalus. RESULTS: Posterior fossa SAH was present in 95% of cases. Isolated posterior fossa SAH was present in 30% of cases, but in no case was isolated supratentorial SAH present. Supratentorial SAH was present in 70% of cases. SAH involving the sylvian fissure or the interhemispheric region was present in 25% and 23% of cases, respectively. SAH along the convexity was present in 2% of cases. Intraventricular hemorrhage (IVH) with or without associated SAH was seen in 95% of cases, whereas isolated IVH was seen in 5% of cases. Hydrocephalus was present in 95% of cases and was moderate to marked in 70%. Both IVH and hydrocephalus were present in 93% of cases. CONCLUSION: Ruptured PICA aneurysms almost always coexist with hydrocephalus and IVH, as seen in 93% of cases, and almost never coexist with SAH along the convexity. The most common pattern of hemorrhage associated with such aneurysms includes IVH and posterior fossa hemorrhage. Extensive supratentorial SAH, in conjunction with posterior fossa SAH, is a common finding in patients with ruptured PICA aneurysms. SAH isolated to the posterior fossa is present in a sizeable minority of cases.     

Posterior cranial fossa surgery in 454 children. Comparison of results obtained in pre-CT and CT era and after various types of management of dura mater

At the Department of Neurosurgery, Hradec Kralové, 454 children (aged under 18 years) were operated on for posterior cranial fossa lesions in a period of 49 years (1948-1996). The majority (402) had tumours: cerebellar astrocytomas 149 (37.1%), medulloblastomas 139 (34.6%), brain stem gliomas 46 (11.4%), ependymomas 28 (7.0%), and others 40 (9.9%). Postoperative mortality was compared for the pre-CT era (1948-1977) and the CT era (1978-1996): astrocytomas (8.6%:4.7%), medulloblastomas (14.9%:2.9%), brain stem gliomas (21.7%:19.0%), ependymomas (18.2%:6.3%), and others (40.0%:7.4%). The initially high mortality was due to insufficient intracranial decompression, brain oedema and disturbances of cerebrospinal fluid circulation. Obstructive hydrocephalus was treated in 53 children with tumours and 25 with aqueduct stenoses, by Torkildsen's drainage in 5.5%, and/or by catheterisation of aqueduct in 12.3%. The main postoperative complications of medial posterior fossa surgery in 429 children operated on were: pseudomeningocele (12.3%), active hydrocephalus (6.2%) and CSF leakage (4.6%). Only 8.2% had shunts placed for these complications. We presume that this low percentage of shunts used results from a frequent use of duraplasties and drains installed at the primary operation. The dura mater was initially (1948-1954) left open (50 cases), and later (1955-1958) also sutured (37 cases), and from 1958, onward, and especially from 1961, reconstructed by a medial approach by means of various grafts (377 cases). In all, duraplasty was performed in 81.6% of cases. The grafts used for dura mater reconstruction were prepared from autogeneic (1.6%), allogeneic (72.3%), xenogeneic (24.8%), or synthetic (1.3%) material. They were successful in 99.2% of cases (all materials). Our own suture technique for posterior fossa duraplasty is presented.     

201Tl single photon emission tomography in the evaluation of residual and recurrent astrocytoma

Twenty-five patients with malignant astrocytoma, either postoperatively (15 cases) or with recurrent tumour versus gliosis (10 cases) were included in this study. 201Tl single photon emission computed tomography (SPECT) was performed with the calculation of early and delayed uptake values and retention index. A high mean value of early and delayed uptake correlated with a low retention index in patients with high-grade astrocytoma in both postoperative residual and recurrent groups, versus a lower mean value of early and delayed uptake with a high retention index in patients with low-grade tumours. All postoperative cases with high-grade astrocytoma had high 201Tl uptake > 1.5, whereas 66.6% of cases with low-grade astrocytoma had low 201Tl uptake < 1.5. There was a correlation between retention index of 201Tl and tumour grade with r = 0.47. Also, recurrent cases showed remarkable differences in early and delayed 201Tl uptake (P < 0.05) and retention index (P < 0.001) compared with postradiation gliosis. There was a higher sensitivity in detection of tumour viability by 201Tl SPECT of 100% versus 80% using computed tomographic scanning and in the differentiation between recurrent tumour and postradiation gliosis.     

Possible involvement of endothelial leukotrienes in acetylcholine-induced contraction in rabbit coronary artery

OBJECTIVE: To evaluate the symptoms, diagnostic procedures, and treatment by transduodenal excision, of tumours in the ampulla of Vater. DESIGN: Open study of consecutive patients. SETTING: University hospital, Denmark. SUBJECTS: Six patients with tumours in the ampulla of Vater. INTERVENTIONS: Ultrasonography, duodenoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic biopsy if tumour was visible at the papilla. Transduodenal excision of the ampulla and anastomoses of the common duct and pancreatic duct to the duodenum. MAIN OUTCOME MEASURES: Postoperative complications and survival. RESULTS: None of the tumours could be seen on ultrasonography. All the tumours were diagnosed on duodenoscopy with ERCP. The histopathological diagnoses of the endoscopic biopsy specimens were adenoma (n = 3), suspicion of adenocarcinoma (n = 2), and adenocarcinoma (n = 1). Curative resection by transduodenal excision of the ampulla of Vater was possible in all cases. Pathological examination of the surgical specimens showed three adenomas and three adenocarcinomas. One patient had a recurrence after 2.5 years and had a further resection. Three patients died after one, three, and nine years, respectively; two had no recurrence and one was suspected of having one. The other three patients were alive 8-20 months after the operation. CONCLUSION: The procedure is recommended for small and probably benign tumours and, when technically possible, in malignant tumours in patients at high operative risk. Close postoperative follow-up with duodenoscopy and ERCP is recommended.     

Preoperative and postoperative follow-up in high-grade gliomas: comparison of transcranial color-coded real-time sonography and computed tomography findings

Twenty patients with high-grade gliomas were prospectively studied by pre- and postoperative transcranial color-coded real-time sonography (TCCS) and CT, to determine the sensitivity of TCCS in the identification of residual tumor and tumor regrowth. Each patient was subjected to preoperative and early postoperative CT (postoperative day 1) and TCCS examinations (postoperative days 6 to 8) and subsequent CT and TCCS follow-up examinations within a time interval of 6 weeks to 3 months. In eight patients, a total of 15 biopsy specimens were intraoperatively obtained from the wall of the resection cavity. Histological findings of intraoperative biopsy specimens showed that hyperechogenic areas adjacent to the resection cavity always contained residual tumor tissue. Early postoperative TCCS identified these hyperechogenic areas in 19 of 20 patients. In 12 patients, postoperative CT revealed contrast enhancement at the resection margin, indicating residual tumor. In these patients the extension of these hyperechogenic areas on TCCS exceeded the contrast-enhancing areas on CT by a mean of 58%. In eight patients, postoperative CT displayed no contrast enhancement along the border of resection. TCCS and histological findings indicated residual tumor in seven of these eight patients. The size of the hyperechogenic lesions identified by postoperative TCCS increased in time and follow-up examinations revealed that tumor regrowth arose from these hyperechogenic areas in all patients. In four patients, tumor regrowth was identified, on average 0.7 months earlier by TCCS than by CT. From these data we conclude that the sensitivity of TCCS in detection of residual tumor and tumor regrowth seems to be superior to CT. The value of TCCS requires further clarification by comparative studies including histology and MRI.