UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)

UvA-DARE (Digital Academic Repository)

AMORE (Ablative surgery, MOulage technique brachytherapy and REconstruction) forchildhood head and neck rhabdomyosarcoma

Buwalda, J.

Link to publication

Citation for published version (APA):Buwalda, J. (2004). AMORE (Ablative surgery, MOulage technique brachytherapy and REconstruction) forchildhood head and neck rhabdomyosarcoma.

General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).

Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.

Download date: 15 Mar 2020

Addendum

A d d e n d u m

Chapter 1

a %•+, •

• » *

•

; . ' •

<% ê *

Figure 1 . Embryonal rhabdomyosan oma. Hematoxylin-Eosin staining. Myxoid background in which loosely textured small cells and primitive spindle-cells with an ec< cntric ally pla< ed nucleus and unipolar cytoplasmic extensions, varying in size. (Courtesy: Dr. |. Bras, Dept. of Pathology, Ac ademic Medical Center)

4

Figure 2. Embryonal rhabdomyosarcoma, botryoid subtype. Hematoxylin-Eosin staining. Polypoid ,\nd myxoid appearance wi th a subepithelial 'cambium layer' , def ined as a condensat ion of tumor cells separated from an intac t epithelial surface In a zone of loose stroma. (Courtesy: Dr. |. Bras, Dept. of Pathology, Ac ademic Medic al Center)

Figure 3.1 mbryonal rhabdomyosarcoma, spindle-» ell type, at low (A) and high (B) magnification. I lematoxylin-Eosin staining. Relatively uni form long, spindle shaped < ells w i th a slender to ovo id nucleus, arranged in an irregular fascicular, sometimes storiform pattern. (Courtesy: Dr. I. Bras, Dept. of Pathology, Academic Medic ,il ( e n t e n

;

m

%**

Figure 4. Alveolar rhabdomyosarcoma at low (A) and high (B) magnif icat ion. Hematoxylin-Eosin staining. Small cel l aggregates wi th loss of cellular cohesion, resulting in an alveolar pattern. High manif icat ion shows del icate f ibrous septa, l ined by a single row of undifferentiated cells wi th a small unipolar cytoplasmatic extension. (Courtesy: Dr. ). Bras, Dept. of Pathology, Academic Medical Center)

170

Color i l lustrat ions

Figure 6. Rhabdomyosarcoma. Cytology, showing small cells w i th an eccentrically placed nucleus and unipolar cytoplasmatic extensions (A, Giemsa staining). The tumor cells express desmin (B, Desmin staining).

F igure 8. Patient (18 yrs) after external beam irradiation (at age 2 yrs) of a RMS in the left parot id region, (published wi th permission of the patient!

171

A d d e n d u m

Chapter 2

m

Figure 2. Submandibular approa( h lor a RMS of the right parapharyngeal spa( e. Alter posterior retraction of the sternocleidomastoid muse le and elevation oftheskin/plastysma flap, the posterior belly of the digastric muscle, nn. X, XI, XII and internal jugulary vein c an be identified. By pul l ing the mandible anteriorly, the tumor (arrow) in the parapharyngeal spa( e c an be reac hed medial to the digastric muscle and the great vessels.

Figure 3. Parotidectomy-approach to a RMS in the right infratemporal fossa. In this patient a total < on-servative parotidectomy and partial m a n d i b u l e c t o m y (because ol destruction of cortical bone have been per fo rmed. The two major branches of the facial nerve have been identified and the parotid gland is pu l l ed anter ior ly to reach the infratemporal fossa.

Figure 4. Trans-antral approach for a RMS in the right pterygopalatine fossa. The mu( osa and periostium are incised in the buccogingival fo ld and ,K (ess is gained to the a n t r u m of the m a x i l l a r y s inus (above the level of the permanent teeth). After removal of the posterior sinus wal l , the pterygopalatine fossa is reached.

Figure 1 1 . CT scan image at PDR brachytherapy treatment planning. The residual tumor mass in the parapharyngeal space- has been removed and the Gutta Percha m o u l d is in s i tu. The m o u l d is loaded w i th dummies and close distribution is c all ulated. Referein e isodose lines (cGy/h) around the moulage are dep ic ted in co lor : green line 80 cGy/h, outer yel low line 100 cGy/h, inner yel low line 125 cGy/h, light blue line 1 56 cGy/

172

Color i l lustrat ions

Figure 5. Moulds ' in situ'. The composition of the several parts exactly tits the surgical defect, ensuring an adequate dose distribution to the target area.

Figure 6. The separate parts wh ich together constitute the mou ld . Ho l low flexible polyethi lene cathethers are 'sandwiched' between two layers of Gutta Percha. The catheters are either bent together towards the top of the mould or protrude from the mould to ensure an adequate dose (arrows'.

Figure 7. Si tuat ion alter c losure of an ex tended Figure 10. Patient (8 years of age) at the radiotherapy parotidectomy incision. The catheters protrude from w a r d , c o n n e c t e d to the m ic rose lec t ron -LDR for the wound and can be afterloaded with Ir idium'"- ' wire afterloading low close rate bra< hytherapy.

sources.

Figure 9A Figure 9B

Computer-aided two-dimensional calculation of the distribution of the radiation dose. Isodose curves (in cG) h)

are drawn around the sources.

173

A d d e n d u m

Chapter 3

Figure 2 . Computed tomography (CT) scan image at brachytherapy treatment planning. The residual t u m o r mass is r emoved and the gutta percha moulage is in situ. The moulage is loaded wi th dummies and the dose distr ibution is calf ulated. Reference isodose lines (cGy/h) around the moulage are depicted in color: green l ine 80 cGy/h , outer yellow line 100 cGy/h, inner yel low l ine 125 cGy/ h, light blue line 156 cGy/h, dark blue lines 250 ( Gy/h.

Chapter 4

Figure 2. Computed tomography (CT) scan image in the axial plane. The moulage has been introduced into the surgical cavitv (patient r>i. The sources have been identified and dose distribution is calculated. Reference isodose lines (cGy/h) are depic ted in color. Each c olor corresponds with a different doserate, ranging from 200 c G y / h (inner green line) to 50 cGy/h (outer green line).

174

Color i l lustrat ions

Chapter 5

Figure 1 . G r a p h i c rep resen ta t i on of the 14 measurements used for quantification ofthecraniofa< ial skeleton (patient 5). Five measurements were performed on axial CT slices at the level of the orbit dig. la , b) and midface (fig. 1c). Nine measurements were carried out on three dimensional reconstructions of the orbit and midface in anteroposterior view (fig. Id), the midfa< e in inferior view (fig. 1e) and the mandible in lateral (fig. 1f, g), obl ique (fig. 1h) and anteroposterior view (tig. I i). See Table 1 for description of the 14 measurement',.

175

Addendum

Figure 3. Patient with an asymmetric appearand of the < raniofacial skeleton at clinical assessment. In this patient (patient 7), a hemimaxillectomy was performed as a part of the AMORE procedure at 1.2 years of age. Clinical assessment after 9 years ol follow-up revealed an interior position of the left eye and auricle, a deviation of the bony and ( artilaginous nasal pyramid, growth retardation of the midface and mandible and maldevelopment of the teeth, (published with permission of the patient)

176