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Metastatic disease Occasionally erectile dysfunction beta blockers order fildena online from canada, palliative radiotherapy may be considered for patients with metastatic disease who have a symptomatic primary stomach cancer that is either too large to resect or the patient is not considered appropriate for a palliative resection erectile dysfunction vitamin d buy 150mg fildena with visa. Radiotherapy could be considered although this is a rare indication for radiotherapy and is not considered in the decision tree as the incidence would be considered so small that it will have little impact on the overall radiotherapy utilisation erectile dysfunction 35 buy fildena 100mg. The proportion of patients with stage T1N0M0 who undergo distant relapse could not be identified impotence of organic origin meaning generic fildena 25mg with mastercard. However Kitamura et al reported a five-year survival rate for patients with Stage I gastric cancer of 95%; the main cause of death among the remaining 5% was metastatic disease (51). Therefore the proportion of T1N0M0 patients undergoing distant relapse was assumed to be 5%. Radiotherapy is also considered for palliation of bone or brain metastases that are symptomatic. In a randomised trial assessing chemotherapy for advanced or metastatic disease no mention was made of the presence of bone or brain metastases with the majority of metastases being in the abdomen (distant nodes, liver, peritoneum) as well as pulmonary. No data on the incidence of metastases to the brain or bone were identified and therefore values of 0 were chosen. Optimal radiotherapy utilisation rate and Sensitivity analysis There was uncertainty or variation concerning some of the epidemiological data. To assess the impact that this data uncertainty has on the overall estimate of radiotherapy utilisation, sensitivity analysis was performed. There was uncertainty regarding the incidence data for T1N0 stomach cancer, which varied between 0. Therefore, sensitivity analysis assessed the impact of this variation on the overall estimate. The graph below shows that the optimal proportion of stomach cancer patients who should receive radiotherapy based on evidence and the incidence of attributes for radiotherapy is 68% and could vary between 58% and 68% depending on the data used. As stomach cancer represents 2% of all cancers, the contribution to the overall radiotherapy utilisation rate is 1. Pancreatic carcinoma incidence the incidence of pancreatic carcinoma is approximately 1% of all cancers according to the Australian Health and Welfare statistics (12). Incidence of metastases at presentation the main decision regarding the management of pancreatic cancer is to determine whether the patient is operable. Patients with metastases (M1 disease) are usually not recommended for surgical resection although a palliative bypass procedure may be appropriate in selected patients (56). The proportion of patients with M1 disease at diagnosis is reported by Janes Jr et al (61). Proportion of M0 patients that undergo surgical excision Surgery is regarded as the mainstay of treatment in patients with localised operable disease who are considered fit for surgery. However, some patients are found to have localised but unresectable disease at diagnosis. Even though the resectability data varies widely between these 2 studies, sensitivity analysis was not performed because the variation in resection rate will have no impact on the decision tree. Patients with resectable disease are recommended to undergo post-operative radiotherapy (see explanatory note 4) and patients with unresectable tumours are also recommended to undergo radiotherapy if they have no evidence of metastatic disease (see explanatory note 5). The role of adjuvant radiotherapy the role of adjuvant radiotherapy remains controversial. This resulted in increased use of adjuvant therapy in the United States and Australia. Review articles and other non-randomised trials also support the use of adjuvant therapy with chemoradiation following resection of pancreatic cancer (65), (67) (68) (56) (69) (70) (58) (62). The European Study Group for Pancreatic Cancer trial showed no benefit for adjuvant radiotherapy (72). Currently a number of adjuvant and neoadjuvant trials are underway testing various chemotherapy/radiotherapy combinations. However, given that there is controversy, sensitivity analysis was also performed with no adjuvant radiotherapy being given as the alternative (see sensitivity analysis). Patients treated with chemoradiotherapy were better palliated and had longer median survival (55). Other studies and reviews have confirmed the palliative benefits of radiotherapy in the management of locally advanced pancreatic cancer (65) (73) (58) (67) (74) (56). Therefore, locally advanced pancreatic cancer would reasonably be treated with palliative radiotherapy with concurrent chemotherapy. Alternative palliative procedures such as biliary bypass procedures, coeliac plexus blocks or chemotherapy have not been formally tested against radiotherapy to assess their better efficacy in terms of palliative benefit or prolongation of survival (67). The most common sites of metastases from pancreatic carcinoma are to the lymph nodes, liver, peritoneum and lung. Treatment of metastases with radiotherapy would be very rare and hence would have no significant effect on the overall radiotherapy utilisation rate. In most instances, if the patient is of reasonable performance status, they may receive palliative chemoradiotherapy for pain related to the pancreatic primary. Trying to determine the proportion of metastatic pancreatic cancer with symptoms warranting radiotherapy is very difficult as such specific data was not available. The chemotherapy treatment that appears to have reasonable activity in pancreatic cancer is Gemcitabine. It would be reasonable to consider patients for palliative radiotherapy if they have progressive pancreatic pain following a trial of Gemcitabine. It might be argued that some of these patients also may warrant radiotherapy, however in view of the poor prognosis of the patient group the conservative approach of considering radiotherapy only in those with worsening pain was taken for this decision tree. Optimal radiotherapy utilisation rate and Sensitivity analysis Based on the data and indications for radiotherapy discussed above, 57% of pancreatic cancer patients have clinical indications where radiotherapy may be considered appropriate at some time during their treatment course. There was some uncertainty about the recommendation that all pancreatic cancer patients who undergo resection should receive radiation, so the alternative of no patients receiving post-operative analysis was modelled in sensitivity analysis (see graph below). Tornado Diagram at Pancreas proportion of adjuvant radiotherapy for pancreatic cancer: 0 to 1. Pre operative radiotherapy (+/ chemotherapy) has been described in some anecdotal cases. In addition, recent reports have suggested external beam radiotherapy using modern conformal techniques to treat unresectable hepatocellular carcinoma. However, no defined role for radiotherapy has currently been established, according to the U. The majority of treatments are aimed at conservative palliation of symptoms or the use of chemotherapy or chemo embolisation. There are currently no indications to give radiotherapy in this setting outside of a clinical trial (75). Therefore, it is estimated that no patients with primary liver cancer receive radiotherapy. Th e incidence ofattributes used to define indications forradioth erapy K ey Populationor Attribute Proportionof Q ualityof R eferences E x planatory subpopulationof populationwith inform ation N otes interest thisattribute A Allregistrycancers G allBladder 0. Indications for Radiotherapy the guidelines make the following recommendations on cancer of the gall bladder. In these cases, isolated local recurrence is rare with either cure or development of distant disease the more likely outcome (82),(83), (80). Small series suggest tolerable toxicity and reasonable local control compared to historical controls (84),(85). In most instances radiotherapy is also of limited value as most metastases are hepatic, peritoneal or nodal. Therefore, based on these guidelines, radiotherapy is recommended for inoperable, non-metastatic disease in patients with good performance status. Proportion of patients with metastatic disease at presentation Patients with metastatic disease at diagnosis have a very short average life expectancy and therefore the vast majority would not have any indications for palliative radiotherapy. In a patterns of care study from Wessex, Carty and Johnson (78) reported that 62% of 95 patients with a diagnosis of gall bladder cancer had metastases or major liver involvement (Nevin stage V) at diagnosis. Proportion of gall bladder cancer patients who have poor performance status A survey of 73 institutions mainly in France as well as other European centres by Cubertafond et al (80) resulted in a database of 724 cases of histologically proven carcinoma of the gall bladder. They reported that 3% of cases were of such poor performance status that conservative palliation was the recommended treatment approach. They reported that 23% were fit and of a tumour stage that warranted radical surgery.

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The recommended initial fill volume of the replacement balloon is the same as the initial fill volume of the removed balloon. A Randomized, Multi-Center Study to Evaluate the Safety and Effectiveness of the Orbera Intragastric Balloon as an Adjunct to a Behavioral Modification Program, in Comparison with a Behavioral Modification Program Alone in the Weight Management of Obese Subjects. Only small particles can pass through it: Inside the Body Small Intestines Large particles (blood vessel) starch (starch) are left in starch the small intestines G starch and small particles G G (glucose) go through G G into the blood. Each of the different organ systems in the body is equally important in enabling us to function as complete organisms. All these systems work together so that the body stays in a steady state with enough oxygen and nutrients and the correct temperature and pH. There are lots of jobs connected with body systems, such as nursing, physiotherapy, cytology screening, technicians in pacemaker clinics, nutritionists, osteopathy, chiropractic and massage; as well as technicians in hospital biochemistry departments. Learning outcomes After completing this unit you should: 1 know the levels of organisation within the human body 2 be able to relate the structure of the circulatory system to its function in a multi-cellular organism 3 be able to relate the structure of the respiratory system to its function 4 be able to relate the structure of the digestive system to its function 5 understand the immunological function of the lymphatic system. To achieve a pass grade the To achieve a merit grade the To achieve a distinction grade evidence must show that you are evidence must show that, in the evidence must show that, in able to: addition to the pass criteria, you are addition to the pass and merit able to: criteria, you are able to: P1 describe the organisation of the M1 use diagrams or micrographs to D1 explain the relationship between eukaryotic cell in terms of the compare and contrast the four cells, tissues, organs and organ functions of the organelles tissue types systems in the organisation of the See Assessment activity 11. I especially enjoyed the section where we took measurements about blood pressure and pulse rate and saw how the readings change when we exercise. I have learnt about the different body systems and how they all work together to keep the body functioning properly. The assignments have helped me because I have done research and found things out for myself. We have had guest speakers who have told us about the jobs they do in the health service. All systems go Catalyst Match each system with the correct function System Function 1 Integumentary A Links outside air to the blood. Bones also store calcium and other minerals, which can be released into the blood to go to parts of the body as needed. In this section: P1 M1 D1 P2 In the mid-1600s Anton van Leeuwenhoek (pronounced lay van hook) used magnifying glasses to count threads in cloth. Small objects have a large surface area to lens volume ratio and the larger the object the smaller the surface specimen stage area to volume ratio. Its functions include binding and support, protection, insulation, movement, and Light microscope showing lenses transportation of substances within the body. Some have a light source underneath the stage and some use a lamp directed onto a mirror. The specimen is mounted on a small glass slide with a glass coverslip and placed on the stage so it is over a central hole. Light and electron Light passes through the condenser lens, through the microscopes specimen and is focused by the objective lens and the Humans have used lenses to magnify objects for about eyepiece lens. From There are three or four objective lenses and each the late seventeenth century scientists started to use magnifes the object by a different amount. The eyepiece lens magnifes the image again, so if a 10 eyepiece is in place then the total magnifcation with a 4 objective lens is 4 10 = 40. The electron beam is focused by magnets onto a screen, photographic paper, or a type of Activity 11. If you look at a specimen under the microscope with a 10 eyepiece and a 40 objective lens, what is the Scanning electron microscopes total magnifcation of the object A fne beam of electrons is scanned over the surface and If you now use a 15 eyepiece but the same objective, bounced off to make an image on a screen. However they can only magnify objects clearly up to about 1500 (higher if blue light is used). Also, if two small objects condenser lenses are closer together than 200nm then you would see them as one blurred object. The fner details of cell structure lens have only been seen since the 1930s when electron microscopes were developed. High voltage makes the electrons specimen travel fast so they have a wavelength of 0. For biological specimens the resolution is not as high as theoretically An electron microscope. This means you can see objects 1nm in diameter clearly when images are magnifed up to 200000 times. It divides into a ball of cells and then some become blood, bone, nerves, muscle, skin and internal organs. Each type of cell in these tissues is specialised to carry out particular functions. When biologists describe these features they talk about a generalised animal cell. This is just a way of describing the organelles that can be found in animal cells. Cells have a 3D structure When you look at cells through a microscope you see them cut into thin sections or fattened on the slide and they appear two-dimensional. False-colour scanning electron micrograph ribosome rough endoplasmic reticulum of blood cells. Note the red blood cells nuclear (red), the white blood cell (blue) and the mitochondrion envelope thrombocytes (yellow). Electron microscopes are very expensive and a lot of skill and training is needed in order to be able to use one. Specimens have to be stained with heavy metal salts, mounted on a copper grid and placed in a vacuum. Case study: Microscope technician Jasmine is a technician in a sixth form college. Part of one hand resting underneath) and how to clean the her job is to look after and service the microscopes. Each microscope is assigned to a She has to check that all the objective and eyepiece particular laboratory and each has a number.

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Esses S erectile dysfunction treatment options natural order on line fildena, Botsford D diabetic erectile dysfunction icd 9 code 25 mg fildena visa, Kostuik J (1989) the role of external spinal skeletal fixation in the assessment of low-back disorders erectile dysfunction causes in early 20s generic fildena 50mg online. Fernstrom U (1966) Arthroplasty with intercorporal endoprothesis in herniated disc and in painful disc impotence word meaning order genuine fildena on line. Fritzell P, Hagg O, Jonsson D, Nordwall A (2004) Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a mul ticenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group. Fritzell P, Hagg O, Wessberg P, Nordwall A (2001) 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multi center randomized controlled trial from the Swedish Lumbar Spine Study Group. With special reference to the articular facets, with presentation of an operative procedure. Gorbach C, Schmid M, Elfering E, Hodler J, Boos N (2006) Therapeutic efficacy of facet joint blocks. Gotfried Y, Bradford D, Oegema T (1986) Facet joint changes after chemonucleolysis induced disc space narrowing. Grob D, Humke T (1998) Translaminar screw fixation in the lumbar spine: technique, indi cations, results. Gunzburg R, Szpalski M, Passuti N, Aebi M (2001) Biomaterials: the new frontiers in spine surgery. Hackenberg L, Halm H, Bullmann V, Vieth V, Schneider M, Liljenqvist U (2005) Transfo raminal lumbar interbody fusion: a safe technique with satisfactory three to five year results. Hahn F, Kissling R, Weishaupt D, Boos N (2006) the extremes of spinal motion: a kine matic study of a contortionist in an open-configuration magnetic resonance scanner: case report. Humke T, Grob D, Dvorak J, Messikommer A (1998) Translaminar screw fixation of the lumbar and lumbosacral spine. Igarashi A, Kikuchi S, Konno S, Olmarker K (2004) Inflammatory cytokines released from the facet joint tissue in degenerative lumbar spinal disorders. Indahl A, Velund L, Reikeraas O (1995) Good prognosis for low back pain when left untam pered. Jacobs R, Montesano P, Jackson R (1989) Enhancement of lumbar spine fusion by use of translaminar facet joint screws. Kanayama M, Hashimoto T, Shigenobu K, Togawa D, Oha F (2007) A minimum 10-year fol low-up of posterior dynamic stabilization using Graf artificial ligament. Con tributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Kawaguchi Y, Matsui H, Gejo R, Tsuji H (1998) Preventive measures of back muscle injury after posterior lumbar spine surgery in rats. Kawaguchi Y, Matsui H, Tsuji H (1994) Back muscle injury after posterior lumbar spine surgery. Kawaguchi Y, Matsui H, Tsuji H (1996) Back muscle injury after posterior lumbar spine surgery. History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial. Louis R (1986) Fusion of the lumbar and sacral spine by internal fixation with screw plates. Louis R, Maresca C (1976) Les arthrod`ese stables de la charni`ere lombo-sacree (70 cas). Macnab I, Dall D (1971) the blood supply of the lumbar spine and its application to the technique of intertransverse lumbar fusion. Magerl F (1982) External skeletal fixation of the lower thoracic and the lumbar spine. Magora A, Schwartz A (1976) Relation between the low back pain syndrome and x-ray findings. Malinsky J (1959) the ontogenetic development of nerve terminations in the interverte bral discs of man. Okawa A, Shinomiya K, Komori H, Muneta T, Arai Y, Nakai O (1998) Dynamic motion study of the whole lumbar spine by videofluoroscopy. Pellise F, Hernandez A, Vidal X, Minguell J, Martinez C, Villanueva C (2007) Radiologic assessment of all unfused lumbar segments 7. A critical appraisal of clinical-radiological flexion-extension studies in lumbar disc degeneration. Pruss A, Kao M, Gohs U, Koscielny J, von Versen R, Pauli G (2002) Effect of gamma irradia tion on human cortical bone transplants contaminated with enveloped and non-enveloped viruses. Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost H, Wilson-MacDonald J (2005) Sur gical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. Roy-Camille R, Saillant G, Mazel C (1986) Internal fixation of the lumbar spine with pedi cle screw plating. Schmorl G, Junghanns H (1968) Die gesunde und die kranke Wirbelsaule in Rontgenbild und Klinik. A new internal fixation device for disorders of the lumbar and thoracolumbar spine. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospec tive, randomized clinical study. Tiusanen H, Seitsalo S, Osterman K, Soini J (1995) Retrograde ejaculation after anterior interbody lumbar fusion. Vernon-Roberts B (1992) Age-related and degenerative pathology of intervertebral discs and apophyseal joints. Wiltse L, Bateman J, Hutchinson R, Nelson W (1968) the paraspinal sacrospinalis-splitting approach to the lumbar spine. Approx imately 10% of individuals report having had back pain within the previous year, and 6. However, the recur care provider rencerateishighandhasbeendescribedasbetween25%and70%indifferent populations [2, 38, 77]. Coincidental with a change of workplace his pain was progressively getting worse (blue flag). Initially employed as an unskilled worker helping out on different projects, he hadtoshifttoworkinglongshiftsas a bricklayer. The newjobwas associ atedwith working longer hoursand a b under hightimepressure(blue flag). Convinced that movement would harm him (yellow flag), he remained as inactive as possible while waiting for another consultation with his doctor. The patient was referred to a physical therapist who administered heat, massage and electrical stimulation. After a few weeks, he felt a little better regarding his pain but did complain of a burning sensation over his whole leg. Resuming work was still not possible and by this time he had a compensation case pending at work and was required to obtain an independent medical evaluation (black flag). However, the patient was upset because he felt accused of simulating and stressed that he was in severe pain (black flag). His family recommended quitting his job to avoid further damage to his back (yellow flag). He was immediately relieved but still sceptical as he could not completely understand what was causing his pain (yellow flag). The physical therapist again gave him the advice that there was no serious damage to justify physical inactivity. He began a physical therapy regi men skeptically, but with increasing activity his motivation and compliance improved. The program consisted of general conditioning with an emphasis on tasks he was afraid to perform. Three weeks after the program start he was almost pain free but still unwilling to return to work because he felt discomfort in certain positions and when lifting heavy objects. He still believed that pain indicated damage and returning to work would injure his back (yellow flag).

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Ace t a zo la m id e sh o u ld b e avoided because of teratogenicity 2nd &3rd trimester: acetazolamide has been used safely, but involvement of high-risk obstetrician specialist is advised 6. Sim p le sh u n t in g for h yd r o ce p h a lu s r u n s t h e r isk o f p r o d u cin g t e n s io n p n e u m o ce p h a lu s fr om a ir drawn in through the former leak site. This may necessitate transsphenoidal repair with simul taneous external lumbar drainage, to be converted to a permanent shunt shortly thereafter. Visu a l d e t e r io r a t io n m ay b e t r e a t e d w it h ch ia s m a p e x y (p r o p p in g u p t h e ch ia s m) u su a lly b y t r a n s sphenoidal approach and packing the sella with fat, muscle or cartilage. Ap p e a r s t o b e b e t t e r fo r im p r ov in g vis u a l fie ld d e ficit s t h a n lo s s o f visu a l a cu it y. Cerebrospinal fluid pressure Ve n t r ic le in Be n ig n In t r a c r a n ia l Hy p e r t e n s io n. Co m p u t e d To m o gr a p h y Ve n t r icu la r Size h a s n o Pr e Ar ch Op h t h a lm ol. Endon asal en doscopic t ran ssph enoi [18] Johnston I, Hawke S, Halmagyi M, Teo C. The Pseu dal chiasmapexy using a clival cranial base cranio dotumor Syndrome: Disorders of Cerebrospinal Flu plasty for visual loss from massive empty sella id Circulation Causing Intracranial Hypertension follow in g m acroprolactin om a treatm en t w ith bro Without Ventriculomegaly. Alexandria Journal of Medi Ce r eb r i d u e t o Pa r t ia l Ob st r u ct ion of t h e Sigm oid cine. Common ones include: prostate breast lung kidney thyroid lymphom a multiple myeloma/plasmacytoma (p. Th ey are ben ign, slow -grow in g lesions, that occur com m only in the cranial vault, m astoid and paranasal air sinuses, and the m andi ble. Se e Localize d in cr e ase d d e n sit y or h yp e rost osis of t h e calvar ia (p. Pathology Co n s is t s o f o s t e o id t is s u e w it h in o s t e o b la s t ic t is s u e, s u r r o u n d e d b y r e a ct ive b o n. Ra d io g r a p h ic e v a lu a t io n Sku ll x r a y: round, sclerotic, well demarcated, homogeneous dense projection. Su r ge r y m ay b e co n sid e r e d fo r co sm et ic r e a so n s, o r if pressure on adjacent tissues produces discom fort. Lesions involving only the outer table m ay be removed leaving the inner table intact. Th e se b e n ign t u m o r s co m m o n ly o ccu r in t h e sk u ll (d is cu sse d h e r e) and spine (p. Ra d io g r a p h ic e v a lu a t io n Sku ll x-r ay: ch a ract er ist ically sh ow s a circu lar lu cen cy w it h h on e ycom b or t rab e cu lar p at t e r n (se e n 1 in 50%of cases) or radial trabeculations producing a sunburst pattern (seen in 11%of cases). Tr e a t m e n t Acce s s ib le le s io n s m a y b e cu r e d b y e n b lo c e x cis io n o r cu r e t t a ge. Th e g r o s s a p p e a r a n ce is o f a hard, blue-domed mass beneath the pericranium. Derm oids an d epiderm oids are ben ign in clusion cysts of ectoderm th at m ay involve skull an d underlying dural venous structures or brain. Primary skull involvement 50 is rare and occurs w hen ectoderm al rests are entrapped in the developing skull w hich causes these tumors to arise within the diploe and expand both inner and outer tables. Because they are not neo plastic, they grow at a linear rate (instead of exponential). Ep id e r m o id t u m or s co n t a in o n ly t h e ou t e r layer o f skin, a n d a r e t h e r efo r e lin e d w it h st r a t ifie d squamous epithelium and the resultant byproduct, keratin. Derm oid t um ors con tain all elem en ts of skin in cludin g h air follicles (w h ich m ay produce h air in the tumor) sweat glands (sebaceous glands (apocrine) and sweat glands (eccrine)). Present at ion Th e se le sio n s m ay p r e se n t a s a r e su lt o f m a ss e ect from continued growth. Th e y m a y r u p t u r e (m o r e co m m o n w it h d e r m o id s t h a n e p id e r m o id s), a n d ca n ca u se ch e m ica l meningitis (from the irritating properties of fat and or keratin), or, if infected, bacterial meningitis. When possible, the goal is to avoid rupture during removal in order to avoid chemical and/or bac terial meningitis. Se a r ch m u s t b e m a d e fo r a t r a ct le a d in g t o t h e in t r a cr a n ia l ca v it y which must be followed if found. Preparation for dural sinus repair must be made for lesions over lying the sagittal sinus (including torcular Herophili). En d o scop ic su r ge r y m ay b e a n o p t io n for so m e sku ll b a se le sio n s. Fever, bone &skin lesions c) multifocal multisystem: nee Letterer-Siwe disease (a fulminant, m alignant lym phoma of 3 infancy). Clin ic a l Gen erally a con d it ion of you t h, 70%of p at ien t s are < 20 yrs age. May be asym ptom at ic and incidentally discovered on skull x-ray obtained for other reasons. Pathology Gross: p in kish gray t o p u rp le lesion exten d in g ou t of bon e an d involvin g p ericran iu m. Du ral involve ment occurs in only 1 of26 patients,but with no dural penetration. Microscopic: numerous histiocytes, eosinophils, and multinucleated cells in a reticulin fiber net work. Tr e a t m e n t The n d e n cy t ow a r d sp o n t a n e o u s r e gr e s sio n, h ow e ve r, m o s t s in gle le sio n s a r e t r e a t e d b y cu r e t t a ge. Multiple lesions are usually associated with extracalvarial bony involvement and are often treated with chemotherapy and/or low dose radiation therapy. Recurrences were local in one case, and in others involved other bones (includ ing the skull, fem ur, lum bar spine) or brain (including the hypothalam us, presenting w ith diabetes insipidus and grow th delay). Can arise anywhere along the neuraxis where there is remnant of notochord, however, cases tend to cluster at the two 5 5 ends of the primitive notochord: 35%cranially in the spheno-occipital region (clivus), and 53% in 6 the spine at the sacrococcygeal region. Le s s c o m m o n l y, t h e y m a y o c c u r i n t h e s p i n e a b o v e t h e s a c 7 8 rum. Th e y r e p r e s e n t le ss t h a n 1 %o f in t r a cr a n ia l t u m o r s a n d 3 %o f p r im a r y s p in e t u m o r s. However, their behavior is m ore malignant because ofthe di culty of total removal, a high recurrence rate, and the fact that they can 50 metastasize (usually late). Metasta ses occur in about 10%of sacral tumors, usually late and after multiple resections, and most often to lung, liver and bone. Malignant transform ation into fibrosarcom a or m alignant fibrous histiocytom a is rare. Physaliphorous cells are distinctive, vacuolated cells on histology that probably represent cytoplasmic mucus vacuoles seen ultrastructurally. Ra d io g r a p h ic a p p e a r a n c e Usually lytic w ith frequen t calcificat ion s. Di erential diagnosis: Prim arily between other cartilaginous tum ors of the skull base; see di er ential diagnosis of other foramen magnum region tumors (p.

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