Spinal cord compression: an unusual presentation of malignant pleural mesothelioma. A case report and review of the literature
|
|
- Maximilian Bell
- 8 years ago
- Views:
Transcription
1 Tu mo ri, 98: e92-e97, 2012 Spinal cord compression: an unusual of malignant pleural mesothelioma. A case report and review of the literature Carolina Mensi 1,2, Lorenzo Termine 3, Anna Garberi 3, Stefano Meroni 4, Daniel Levi 5, Luca Balzarini 6, and Luciano Riboldi 1,2 1 Clinica del Lavoro Luigi Devoto, Department of Preventive Medicine, Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico, Milan; 2 Inhaled Dust Biological Effects Center (EBPI), Department of Occupational Health, Università degli Studi di Milano, Milan; 3 Postgraduate School of Occupational Medicine, Department of Occupational Health, Università degli Studi di Milano, Milan; 4 Postgraduate School of Radiodiagnostics, Università degli Studi di Milano, Milan; 5 Department of Neurosurgery, Humanitas Clinical Institute IRCCS, Rozzano, Milan; 6 Department of Radiology, Humanitas Clinical Institute IRCCS, Rozzano, Milan, Italy ABSTRACT Pleural malignant mesothelioma is a locally invasive tumor that tends to progress due to direct extension of the tumor into the pulmonary parenchyma, the chest wall, the mediastinum, or the abdominal cavity via the diaphragm. In the later stages of the disease, distant metastases can occur. Metastases to the nervous system are rare, and clinical signs of nervous system involvement typically appear between 2 months and 6 years after the primary diagnosis. However, the case presented here manifested as neurological impairment without any respiratory symptoms. Introduction Malignant mesothelioma (MM) is an aggressive tumor that develops at serosal surfaces such as the pleura, peritoneum, and tunica vaginalis of the testis. It has a strong etiological relationship to asbestos exposure 1. Although this tumor type was once rare, its incidence is increasing in several countries as a result of widespread exposure to asbestos 2,3. The symptoms of pleural MM usually involve progressive dyspnea and/or pain in the chest wall. These conditions may be accompanied by dry cough, weight loss, fever, fatigue, and night sweats. MM has a propensity to infiltrate underlying and neighboring structures, especially the lung, chest wall, mediastinum, and diaphragm. Accordingly, 50-67% of autopsies performed on patients with MM detect evidence of distant spread 4-6. The Lombardy Mesothelioma Registry (LMR) is a population-based registry that collects data on all MM cases associated with the pleura, peritoneum, pericardium, and tunica vaginalis of the testis reported for residents of the Lombardy Region of northern Italy (population, 9.8 million). Between 2000 and 2010, more than 3,400 cases were collected, and the regional age-standardized incidence rates of MM for this period were 5.2/100,000 (95% CI: ) and 2.0/100,000 (95% CI: ) per year, respectively, for males and females. The clinical records of each case were collected and reviewed, including radiological exams, histology reports, and disease history. Evaluations of asbestos exposure were also reviewed and included responses to a standardized questionnaire administered by trained interviewers to the patient or his/her next of kin: a detailed occupational history was collected that addressed the industrial sector of employment, the details of the patient s job and tasks, the jobs of the patient s coworkers, and a description of the workplace environment. Residential history, lifestyle habits, hobbies, and information regarding the job performed by all subjects that lived with the pa- Key words: mesothelioma, spinal cord compression, asbestos, occupational exposure. Conflict of interest: None of the authors have any conflicts of interest to report. Financial support: No financial support was provided for this work. Authorship: Mensi C, Termine L, Garberi A, Meroni S, Levi D, acquisition and interpretation of data, review of literature; Mensi C, Termine L, Garberi A, Meroni S, drafting the article; Mensi C, Balzarini L, Riboldi L, approval of final version of manuscript. Correspondence to: Carolina Mensi, Clinica del Lavoro Luigi Devoto, Fondazione IRCCS Ca Granda - Ospedale Maggiore Policlinico, Via San Barnaba 8, Milan, Italy. Tel ; fax ; carolina.mensi@unimi.it Received May 16, 2011; accepted January 3, 2012.
2 MALIGNT MESOTHELIOMA WITH SPIL CORD COMPRESSION e93 tient were also obtained. This information was then discussed with an industrial hygienist, occupational health physicians, and epidemiologists to evaluate the potential exposure to asbestos in the patient s workplace and non-workplace environment in accordance with the national guidelines of the Italian Mesothelioma Registry 7. As a result of this epidemiological surveillance, it became apparent that the case reported here is unique based on the patient s of neurological symptoms prior to the onset of respiratory symptoms. A C B D Case report History A 69-year-old non-smoking male previously treated for high blood pressure had suffered a myocardial infarction in In 2005, after a few months of recurrent back pain, the patient developed weakness in both legs, which developed further into paralysis of his left leg. Upon admission to a neurosurgery department, the patient s clinical condition rapidly deteriorated, with worsening of his urinary incontinence and inability to maintain an upright posture. The patient did not report any cardiorespiratory symptoms. Imaging studies Computed tomography (CT) imaging of the patient s chest was performed using a 16-slice CT scanner. Tissue in the left paravertebral region at the level of the aortic arch, with 4 cm of craniocaudal extension and 3 cm of anterior-posterior diameter, was characterized by intense and inhomogeneous contrast enhancement. This tissue area exhibited an infiltrative growth pattern that affected the left profile of T5 and the entire left T4-T5 vertebral foramen due to invasion of the medullary canal. Cranially, the affected tissue raised the proximal portion of the thoracic aorta in the absence of a definite cleavage plane, which was consistent with an infiltrative phenotype. Left pleural effusion was the only pathological finding in the thorax. Magnetic resonance (MR) scans (1.5 T system) of the entire cervical-dorsal spine were obtained using noncontrast sequences including T1W and T2W TSE fatsat. An intravenous bolus injection of gadobutrol was used to obtain the TSE multiplanar sequences. MR imaging confirmed the presence of the paraspinal mass detected on CT scans and also provided information regarding the relationship between the tumor and the spine. The mass was associated with a hypointense signal in T1 (Figure 1A) and a heterogeneous hyperintense signal in T2 (Figure 1B). Intense pathological enhancement characteristic of hypervascularized lesions was also observed (Figure 1C and 1D). The anatomic relationship of the solid mass, especially its spread into the vertebral foramen, and the invasion of the Figure 1 - Magnetic resonance scans of the entire cervical-dorsal spine of a 69-year-old non-smoking male. The left paraspinal tumor mass was associated with a hypointense signal in T1 (A) and a heterogeneous hyperintense signal in T2 (B). Intense pathological enhancement characteristic of hypervascularized lesions was also observed (C and D). medullary canal with spinal cord compression were also detected on the MR images. At the level of T4-T5, the spinal cord was displaced rightwards by the mass and was associated with a mildly hyperintense signal in all of the sequences collected using a craniocaudal extension of 2 cm. Histopathological diagnosis The patient underwent a medial dorsal incision from T3 to T5; skeletonization of the paravertebral channels bilaterally; flavectomy of T3, T4 and T4, T5 and laminotomy of T3 and T4; followed by spinectomy of T3, T4 and T5. After decompression, biopsy of the endocanalar mass collected specimens of extradural dorsal tissue, vertebral bone, and ectopic material from the dorsal spinal canal. Histopathological examination showed a malignant neoplasm composed of spindle-cells and fibrosclerosis-rich stroma. Immunohistochemical staining confirmed the presence of sarcomatous mesothelioma. Clinical evolution After surgery, the patient received palliative radiotherapy to the thoracic spine (T3-T5) at a dose of 20 Gy administered in 5 fractions. The patient showed marked atrophy and flaccid paralysis of the lower limbs, a midthoracic sensory level, and sphincter incontinence. He died after 2 months. Occupational history The patient s work history included employment as a flatiron assembly operator from age 14 to 17 (1949-
3 e94 C MENSI, L TERMINE, A GARBERI ET AL Table 1 - Spinal canal involvement of malignant mesothelioma: review of published cases Reference Age, gender Neurological symptoms 8 67, M Acute paraplegia occurred 10 days prior to sudden paralysis in right leg, followed by gradual paralysis in left leg; urine incontinence for 3 days 9 18, M Weakness and numbness of the lower extremities 10 54, M Right-sided Horner syndrome and Brown- Séquard syndrome with right-sided paralysis and left-sided sensory changes below the T1 level 11 57, M Radicular pain; paresthesia and loss of strength in lower limbs (T6-T10) Mechanism of spread Autopsy report: tumor extended along spinal nerve roots and spread over meningeal surfaces within the spinal canal (extradural spinal involvement) Left paraspinal mass with partial destruction of the vertebral body and transverse process of T12. Tumor tissue was also detected inside the spinal canal and encircling and compressing the spinal cord from the left side at T11-T12 Tumor invaded the lower trunk of the brachial plexus and spread along the T1 nerve root beneath the arachnoid onto the spinal cord Tumor on the left side of the spinal cord with paravertebral expansion at the level of T6- T9. Extradural invasion compressed the medulla at the metameric levels T7-T8 Diagnosis of mesothelioma Autopsy report performed 24 days after hospital admission detected alveolar cell lung carcinoma in addition to mesothelioma 2 years prior to neurological 3 years prior to neurological 5 months prior to Histological type Asbestos exposure The patient worked in the dockyards, although possible asbestos exposure could not be confirmed The patient did not recall any asbestos exposure The patient installed asbestos thermal insulation for 18 months The patient worked in a cement-asbestos factory for 28 years 12 Patient 1 56, F Progressive lower Masses present in the back pain radiating left intervertebral to the back of the legs foramina at L2-L3 and L3-L4, with thickening of the left psoas muscle. Tumor growth at the thoracic and cervical levels extending through the foramen magnum into the skull Pleural effusion was present 7 years prior to. Histological diagnosis concomitant with the onset of neurological symptoms (from a psoas muscle biopsy) confirmed the results of the autopsy report asbestos by the husband s working clothes Patient 2 46, M Pain in the lumbar spine radiating to the loin and loss of strength in the right leg Growth of the MM through the intervertebral foramina that extended into the epidural space and resulted in an epidural cuff reaching from T10 to L3. Tumor progression was observed up to the foramen magnum 6 years prior to neurological Patient 3 41, F Problems walking, weakness in both legs, and pin-prick sensory level below C6 Tumor extended from the right upper thorax into the neck and through the lower cervical foramina into the epidural space, causing cervical spinal cord compression 2 years prior to neurological Continued
4 MALIGNT MESOTHELIOMA WITH SPIL CORD COMPRESSION e95 (Continued) Table 1 - Spinal canal involvement of malignant mesothelioma: review of published cases Reference Age, gender Neurological symptoms Mechanism of spread Diagnosis of mesothelioma Histological type Asbestos exposure 12 Patient 4 53, M Severe back pain radiating to the right loin and abdomen A large paravertebral mass invaded multiple thoracic vertebrae and intervertebral foramina at the T10 level. An epidural cuff caused spinal cord compression 4 months prior to 13 55, F Progressive weakness in the left leg Tumor extended into the spinal canal through the neuroforamina of the T9 nerve root with spinal cord compression 18 months prior to 14 58, M Dorsal pain Tumor invaded the spine and spinal canal leading to cord compression 3 months prior to No asbestos exposure 15 62, M Back pain, decreased muscular strength, and incomplete paralysis below the T10 level Tumor masses penetrated through the neuroforamen into the spinal canal and resulted in spinal cord compression 2 weeks prior to Biphasic asbestos while working in a coal mine 16 61, M Horner syndrome, weakness, sensory loss Tumor extended into the spinal canal through the neuroforamina of C7-T1 and T1-T2 2 years prior to neurological asbestos while working in a chemical plant 17 50, M Acute 2-week history of progressive thoracic back pain, received radiation to the right chest. Progressive weakness and hypoesthesia of the right abdomen and right leg were experienced with slight sphincter disturbance Tumor spread across the dura into the spinal cord at T5 through the intervertebral foramen T4-T5 28 months prior to 18 61, M Progressive weakness of bilateral lower extremities, numbness in body and both legs, sensory deficit and paraplegia, dysfunction of bladder and bowel Tumor directly invaded the spinal cord along the T4 posterior nerve root 7 months prior to asbestos present in car brakes and clutches 19 64, M Low back pain at L2- L3 level, left flank pain, ileus Tumor directly invaded the spine at T11 2 months after intermittent discomfort and pain Poorly differentiated neoplastic cells The patient had no known history of asbestos exposure 20 67, M Weakness of the right leg and subsequent paralysis Tumor invaded the right T4 nerve root suggesting intramedullary involvement More than 6 months prior to neurological M, male; F, female;, not available.
5 e ). This job implied the use of asbestos elements to insulate electric resistance. Subsequently, the patient was employed as a barman (from age 17 to 22; ), a boiler conductor (from age 23 to 59; ), and a transformer maintenance man for the production of electric energy. The latter involved the maintenance of asbestos-caulked machinery and systems. Other sources of possible asbestos exposure including military service, hobbies, and residential history were excluded. Discussion Pleural MM is an aggressive neoplasm that initiates in the pleural layer of cells, then tends to invade locally into adjacent regions (lung, chest wall, mediastinum, and diaphragm). Involvement of the central nervous system is rare. However, when it occurs, it is usually mediated through the bloodstream, although there are some reports of direct infiltration of the spinal cord through the intervertebral foramina In Table 1, all published cases of pleural MM causing neurological compression since 1974 are presented. These cases are characterized by direct involvement of the spinal cord. The clinical onset of medullary invasion is usually associated with local pain that radiates to the limbs, progressive weakness, difficult movement up to the point of paralysis, and paresthesias with or without sensory level. Medullary localization was most often associated with a diagnosis of mesothelioma, independent of the time that had passed since the initial diagnosis (2 weeks to 6 years). In only 2 cases 8,19 were neurological symptoms manifest in the early stages, even prior to the diagnosis of a neoplasm. In 1 case, typical respiratory symptoms were exhibited 8. A second case was recently described involving a patient suffering from low back pain and ileus. In this patient, a CT scan showed a left paraspinal neoplasm over the T11 vertebra, which was associated with high levels of the tumor marker CA In addition, histological studies of the neoplasm revealed the presence of poorly differentiated neoplastic cells with punctuate cytoplasmic staining of mucin, suggesting metastasis of a gastrointestinal tract tumor. PET-CT scans further confirmed that a hypermetabolic nodular lesion was present in the left pleura, resulting in the diagnosis of pleural mesothelioma 19. Of the 16 mesotheliomas described in the literature, the histological types identified included 4 epithelial, 4 sarcomatous, and 1 biphasic. Six case reports did not include a histological diagnosis, and 1 case was associated with poorly differentiated neoplastic cells. In 10 cases, exposure to asbestos was investigated and, as a result, 4 subjects were excluded (no asbestos exposure) 8,9,14,19. However, it is not clear whether this investigation took into account the occupational history of the patients, and whether potential non-occupational sources of exposure were considered. In 5 cases, possible asbestos exposure was not addressed. While only a few cases described in the literature have been associated with medullary invasion by contiguity, the present case is further distinguished by its clinical onset where neurological symptoms, in the absence of respiratory symptoms or chest wall pain, were the first signs of the pleural mesothelioma. Furthermore, the presence of a neoplasm was unexpectedly detected by MR imaging that was intended to investigate the neurological symptoms. Therefore, the ability of MM to invade the intervertebral foramina and apply direct compression to the spinal cord indicates that there is the potential for a neurological component of MM to manifest in the early stages of the disease, although this is more of an exception than a primary characterization of MM. However, for all MM cases an appropriate diagnostic procedure is necessary to reach a definitive diagnosis and to exclude other potential primary tumor sites. Furthermore, histological examination of the neoplastic tissue involved needs to be performed. When a diagnosis of MM is confirmed, an investigation of possible asbestos exposure should be initiated, with considerations for the ethical and legal requirements involved. References C MENSI, L TERMINE, A GARBERI ET AL 1. Ismail-Khan R, Robinson LA, Williams CC Jr, Garrett CR, Bepler G, Simon GR: Malignant pleural mesothelioma: a comprehensive review. Cancer Control, 13: , Peto J, Decarli A, La Vecchia C, Levi F, Negri E: The European mesothelioma epidemic. Br J Cancer, 79: , Kazan-Allen L: Asbestos and mesothelioma: worldwide trends. Lung Cancer, 49 (suppl 1): S3-8, Hulks G, Thomas JS, Waclawski E: Malignant pleural mesothelioma in western Glasgow. Thorax, 44: , King JA, Tucker JA, Wong SW: Mesothelioma: a study of 22 cases. South Med J, 90: , Winfree CJ, Mack WJ, Sisti MB: Solitary cerebellar metastasis of malignant pleural mesothelioma: case report. Surg Neurol, 61: , Nesti M, Adamoli S, Ammirabile F, Ascoli V, Barbieri PG, Cacciarini V, Candela S, Cavone D, Cauzillo G, Chellini E, Chiappino G, Convertini L, Crosignani P, Gennaro V, Gioffrè F, Gorini G, Iavicoli S, Magnani C, Mangone L, Marinaccio A, Marras T, Menegozzo M, Mensi C, Merler E, Mirabelli D, Musti M, Montanaro F, Mosciatti P, Nicita C, Pannelli F, Pascucci C, Pezzarossi AM, Romanelli A, Scarselli A, Scondotto S, Silvestri S, Storchi C, Tosi S, Tumino S: National Guidelines of Malignant Mesothelioma Register, Second Edition. ISPESL (Istituto Superiore per la Prevenzione e la Sicurezza del Lavoro), Rome, Available (in Italian) at da.pdf. Accessed 18 January Cooper D: Malignant mesothelioma invading the spinal canal. Postgrad Med J, 50: , Mikhael MA, Paige ML, Thayer C: Computerized tomography of malignant pleural mesothelioma with spinal canal invasion. Comput Radiol, 6: 11-15, 1982.
6 MALIGNT MESOTHELIOMA WITH SPIL CORD COMPRESSION e Steel TR, Allibone J, Revesz T, D Arrigo C, Crockard HA: Intradural neurotropic spread of malignant mesothelioma. Case report and review of the literature. J Neurosurg, 88: , Rojas JL, Alfageme I, De la Cruz I, Reyes N, Munoz J: Radicular involvement and medullary invasion from a malignant mesothelioma. Respiration, 68: , Gijtenbeek JM, Brouwer HI, Boerman RH, Wiggenraad G, Vecht CJ, Sillevis Smitt PAE: Extensive epidural cufflike growth of malignant pleural mesothelioma causing spinal cord compression. J Thorac Cardiovasc Surg, 124: , Lee AW, Nikitins I, Pozza C, Koblar SA: Pleural mesothelioma with extension into the thoracic spinal cord. Intern Med J, 35: , Margery J, Grassin F, Le Moulec S, Ruffié P: Spinal cord compression from a malignant pleural mesothelioma. Rev Pneumol Clin, 61: , Heyer CM, Theile A, Weisser H, Reichert J, Horch C, Mueller KM, Bauer TT: Subarachnoid-pleural fistula as a complication of malignant pleural mesothelioma. Respirology, 11: , Hillard VH, Liu JK, Kwok A, Schmidt MH: Perineural spread of malignant mesothelioma resulting in an intradural spinal cord mass: case report. J Neurooncol, 81: , Payer M, von Briel T: Intradural pleural malignant mesothelioma. Acta Neurochir, 149: , Okura H, Suga Y, Akiyama O, Kudo K, Tsutsumi S, Abe Y, Yasumoto Y, Ito M, Izumi H, Shiomi K: Pleural malignant mesothelioma causing cord infiltration through the nerve root case report. Neurol Med Chir (Tokyo), 49: , Huang YC, Tu DG, Wu JD, Lee MY: Malignant pleural mesothelioma presenting as low back pain: diagnosed by bone scan coordinating with F-18 FDG PET/CT. Spine, 34: E , Chamberlain MC, Eaton KD, Fink JR, Tredway T: Intradural intramedullary spinal cord metastasis due to mesothelioma. J Neurooncol, 97: , 2010.
Management of spinal cord compression
Management of spinal cord compression (SUMMARY) Main points a) On diagnosis, all patients should receive dexamethasone 10mg IV one dose, then 4mg every 6h. then switched to oral dose and tapered as tolerated
More informationSarcomatoid Malignant Mesothelioma Presenting with Intramedullary Spinal Cord Metastasis: A Case Report and Literature Review
Global Spine Journal Case Report 115 Sarcomatoid Malignant Mesothelioma Presenting with Intramedullary Spinal Cord Metastasis: A Case Report and Literature Review Junkoh Yamamoto 1 Kunihiro Ueta 1 Masaru
More informationMesothelioma: Questions and Answers
CANCER FACTS N a t i o n a l C a n c e r I n s t i t u t e N a t i o n a l I n s t i t u t e s o f H e a l t h D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s Mesothelioma: Questions
More informationMALIGNANT SPINAL CORD COMPRESSION. Kate Hamilton Head of Medical Oncology Ballarat Health Services
MALIGNANT SPINAL CORD COMPRESSION Kate Hamilton Head of Medical Oncology Ballarat Health Services OVERVIEW Background Epidemiology Pathophysiology Diagnosis Investigation Differential Diagnosis Management
More informationPrimary -Benign - Malignant Secondary
TUMOURS OF THE LUNG Primary -Benign - Malignant Secondary The incidence of lung cancer has been increasing almost logarithmically and is now reaching epidemic levels. The overall cure rate is very low
More informationAdvanced Practice Provider Academy
(+)Dean T. Harrison, MPAS,PA C,DFAAPA Director of Mid Level Practitioners; Assistant Medical Director Clinical Evaluation Unit, Division of Emergency Medicine, Department of Surgery, Duke University Medical
More informationMalignant Mesothelioma
Malignant Malignant mesothelioma is a tumour originating from mesothelial cells. 85 95% of mesotheliomas are caused by asbestos exposure. It occurs much more commonly in the chest (malignant pleural mesothelioma)
More informationMalignant Mesothelioma
Malignant mesothelioma is a tumour originating from mesothelial cells. 85 95% of mesotheliomas are caused by asbestos exposure. It occurs much more commonly in the chest (malignant pleural mesothelioma)
More informationMesothelioma. 1995-2013, The Patient Education Institute, Inc. www.x-plain.com ocft0101 Last reviewed: 03/21/2013 1
Mesothelioma Introduction Mesothelioma is a type of cancer. It starts in the tissue that lines your lungs, stomach, heart, and other organs. This tissue is called mesothelium. Most people who get this
More informationIf you or a loved one have suffered because of a negligent error during spinal surgery, you will be going through a difficult time.
If you or a loved one have suffered because of a negligent error during spinal surgery, you will be going through a difficult time. You may be worried about your future, both in respect of finances and
More informationCase Report Pleural Mesothelioma Presenting as Periumbilical Metastasis: The First Clinical Documentation
Volume 2013, Article ID 198729, 4 pages http://dx.doi.org/10.1155/2013/198729 Case Report Pleural Mesothelioma Presenting as Periumbilical Metastasis: The First Clinical Documentation R. F. Falkenstern-Ge,
More informationSpine University s Guide to Cauda Equina Syndrome
Spine University s Guide to Cauda Equina Syndrome 2 Introduction Your spine is a very complicated part of your body. It s made up of the bones (vertebrae) that keep it aligned, nerves that channel down
More informationObjectives. Mylene T. Truong, MD. Malignant Pleural Mesothelioma Background
Imaging of Pleural Tumors Mylene T. Truong, MD Imaging of Pleural Tumours Mylene T. Truong, M. D. University of Texas M.D. Anderson Cancer Center, Houston, TX Objectives To review tumors involving the
More informationAsbestos Related Diseases
Asbestos Related Diseases Asbestosis Mesothelioma Lung Cancer Pleural Disease Asbestosis and Mesothelioma (LUNG CANCER) Support Group 1800 017 758 www.amsg.com.au ii Helping you and your family through
More informationSpine University s Guide to Vertebral Osteonecrosis (Kummel's Disease)
Spine University s Guide to Vertebral Osteonecrosis (Kummel's Disease) 2 Introduction Kummel's disease is a collapse of the vertebrae (the bones that make up the spine). It is also called vertebral osteonecrosis.
More informationFrancine Lortie-Monette, MD, MSc, CSPQ, MBA Department of Epidemiology and Biostatistics University of Western Ontario 2003
ASBESTOS Francine Lortie-Monette, MD, MSc, CSPQ, MBA Department of Epidemiology and Biostatistics University of Western Ontario 2003 Asbestosis Asbestosis is a model for other dust diseases as well as
More information1 REVISOR 5223.0070. (4) Pain associated with rigidity (loss of motion or postural abnormality) or
1 REVISOR 5223.0070 5223.0070 MUSCULOSKELETAL SCHEDULE; BACK. Subpart 1. Lumbar spine. The spine rating is inclusive of leg symptoms except for gross motor weakness, bladder or bowel dysfunction, or sexual
More informationKhaled s Radiology report
Khaled s Radiology report Patient Name: Khaled Adli Moustafa Date 06/15/2014 The patient is not present. And the following report is based upon what was in the MRI of the cervical and lumbar spine report
More informationAsbestos Related Diseases. Asbestosis Mesothelioma Lung Cancer Pleural Disease. connecting raising awareness supporting advocating
Asbestos Related Diseases Asbestosis Mesothelioma Lung Cancer Pleural Disease connecting raising awareness supporting advocating 1800 017 758 www.asbestosassociation.com.au Asbestos lagging was widely
More informationThe Lewin Group undertook the following steps to identify the guidelines relevant to the 11 targeted procedures:
Guidelines The following is a list of proposed medical specialty guidelines that have been found for the 11 targeted procedures to be included in the Medicare Imaging Demonstration. The list includes only
More informationMedullary Renal Cell Carcinoma Case Report
Bahrain Medical Bulletin, Vol. 27, No. 4, December 2005 Medullary Renal Cell Carcinoma Case Report Mohammed Abdulla Al-Tantawi MBBCH, CABS* Abdul Amir Issa MBBCH, CABS*** Mohammed Abdulla MBBCH, CABS**
More informationThe Anatomy of Spinal Cord Injury (SCI)
The Anatomy of Spinal Cord Injury (SCI) What is the Spinal Cord? The spinal cord is that part of your central nervous system that transmits messages between your brain and your body. The spinal cord has
More informationWORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 171/08
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 171/08 BEFORE: M.F. Keil : Vice-Chair M. Christie: Member Representative of Employers M. Ferrari: Member Representative of Workers HEARING:
More informationWhat is Mesothelioma?
What is Mesothelioma? Mesothelioma is a rare type of cancer that develops in the mesothelial cells found in one s body. These cells form membranous linings that surround and protect the body s organs and
More informationبسم هللا الرحمن الرحيم
بسم هللا الرحمن الرحيم Updates in Mesothelioma By Samieh Amer, MD Professor of Cardiothoracic Surgery Faculty of Medicine, Cairo University History Wagner and his colleagues (1960) 33 cases of mesothelioma
More informationAsbestos & Mesothelioma Cases. Presented by Sara Salger On behalf of Gori, Julian & Associates, P.C., Edwardsville, IL
Asbestos & Mesothelioma Cases Presented by Sara Salger On behalf of Gori, Julian & Associates, P.C., Edwardsville, IL What you know about Asbestos & Mesothelioma Insert Clip Here Definition of Asbestos
More informationRadiotherapy in locally advanced & metastatic NSC lung cancer
Radiotherapy in locally advanced & metastatic NSC lung cancer Dr Raj Hegde. MD. FRANZCR Consultant Radiation Oncologist. William Buckland Radiotherapy Centre. Latrobe Regional Hospital. Locally advanced
More informationIII./8.4.2: Spinal trauma. III./8.4.2.1 Injury of the spinal cord
III./8.4.2: Spinal trauma Introduction Causes: motor vehicle accidents, falls, sport injuries, industrial accidents The prevalence of spinal column trauma is 64/100,000, associated with neurological dysfunction
More informationKidney Cancer OVERVIEW
Kidney Cancer OVERVIEW Kidney cancer is the third most common genitourinary cancer in adults. There are approximately 54,000 new cancer cases each year in the United States, and the incidence of kidney
More informationSternotomy and removal of the tumor
Sternotomy and removal of the tumor All thymomas originate from epithelial thymic cells 4% of them consist of a pure population of epithelial cells Most have mixed populations of lymphoid cells to a
More informationAsbestos Disease: An Overview for Clinicians Asbestos Exposure
Asbestos Asbestos Disease: An Overview for Clinicians Asbestos Exposure Asbestos: A health hazard Exposure to asbestos was a major occupational health hazard in the United States. The first large-scale
More information.org. Fractures of the Thoracic and Lumbar Spine. Cause. Description
Fractures of the Thoracic and Lumbar Spine Page ( 1 ) Spinal fractures can vary widely in severity. While some fractures are very serious injuries that require emergency treatment, other fractures can
More informationTHE LUMBAR SPINE (BACK)
THE LUMBAR SPINE (BACK) At a glance Chronic back pain, especially in the area of the lumbar spine (lower back), is a widespread condition. It can be assumed that 75 % of all people have it sometimes or
More informationDisease/Illness GUIDE TO ASBESTOS LUNG CANCER. What Is Asbestos Lung Cancer? www.simpsonmillar.co.uk Telephone 0844 858 3200
GUIDE TO ASBESTOS LUNG CANCER What Is Asbestos Lung Cancer? Like tobacco smoking, exposure to asbestos can result in the development of lung cancer. Similarly, the risk of developing asbestos induced lung
More informationBrain Cancer. This reference summary will help you understand how brain tumors are diagnosed and what options are available to treat them.
Brain Cancer Introduction Brain tumors are not rare. Thousands of people are diagnosed every year with tumors of the brain and the rest of the nervous system. The diagnosis and treatment of brain tumors
More informationMesothelioma. 1. Introduction. 1.1 General Information and Aetiology
Mesothelioma 1. Introduction 1.1 General Information and Aetiology Mesotheliomas are tumours that arise from the mesothelial cells of the pleura, peritoneum, pericardium or tunica vaginalis [1]. Most are
More informationMeasure Title X RAY PRIOR TO MRI OR CAT SCAN IN THE EVAULATION OF LOWER BACK PAIN Disease State Back pain Indicator Classification Utilization
Client HMSA: PQSR 2009 Measure Title X RAY PRIOR TO MRI OR CAT SCAN IN THE EVAULATION OF LOWER BACK PAIN Disease State Back pain Indicator Classification Utilization Strength of Recommendation Organizations
More informationSurvey of Mesothelioma Associated with Asbestos Exposure in Japan
The research and development and the dissemination projects related to the 13 fields of occupational injuries and illnesses Survey of Mesothelioma Associated with Asbestos Exposure in Japan Clinical characteristics
More informationRecommendations for cross-sectional imaging in cancer management, Second edition
www.rcr.ac.uk Recommendations for cross-sectional imaging in cancer management, Second edition Breast cancer Faculty of Clinical Radiology www.rcr.ac.uk Contents Breast cancer 2 Clinical background 2 Who
More informationMalignant Spinal Cord Compression: Highlights on Specific Management Aspects
Palliative Medicine Doctors Meeting HKSPM Newsletter 2008 Apr Issue 1 p 21 Malignant Spinal Cord Compression: Highlights on Specific Management Aspects Dr. KH Wong Department of Clinical Oncology, Queen
More informationA Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH)
A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH) Introduction Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a phenomenon that more commonly affects older males. It is associated
More informationWORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1557/14
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1557/14 BEFORE: M. Crystal: Vice-Chair HEARING: August 20, 2014 at Toronto Written DATE OF DECISION: December 4, 2014 NEUTRAL CITATION: 2014
More informationCERVICAL DISC HERNIATION
CERVICAL DISC HERNIATION Most frequent at C 5/6 level but also occur at C 6 7 & to a lesser extent at C4 5 & other levels In relatively younger persons soft disk protrusion is more common than hard disk
More informationEpidemiology, Staging and Treatment of Lung Cancer. Mark A. Socinski, MD
Epidemiology, Staging and Treatment of Lung Cancer Mark A. Socinski, MD Associate Professor of Medicine Multidisciplinary Thoracic Oncology Program Lineberger Comprehensive Cancer Center University of
More informationInternational Journal of Case Reports in Medicine
International Journal of Case Reports in Medicine Vol. 2013 (2013), Article ID 409830, 15 minipages. DOI:10.5171/2013.409830 www.ibimapublishing.com Copyright 2013 Andrew Thomas Low, Iain Smith and Simon
More informationGeneral Information About Non-Small Cell Lung Cancer
General Information About Non-Small Cell Lung Cancer Non-small cell lung cancer is a disease in which malignant (cancer) cells form in the tissues of the lung. The lungs are a pair of cone-shaped breathing
More informationSmoking and misuse of certain pain medicines can affect the risk of developing renal cell cancer.
Renal cell cancer Renal cell cancer is a disease in which malignant (cancer) cells form in tubules of the kidney. Renal cell cancer (also called kidney cancer or renal adenocarcinoma) is a disease in which
More information.org. Herniated Disk in the Lower Back. Anatomy. Description
Herniated Disk in the Lower Back Page ( 1 ) Sometimes called a slipped or ruptured disk, a herniated disk most often occurs in your lower back. It is one of the most common causes of low back pain, as
More informationClinical cases in Malignant Pleural Mesothelioma: Adherence to the ESMO Clinical Practice Guidelines
Clinical cases in Malignant Pleural Mesothelioma: Adherence to the ESMO Clinical Practice Guidelines Wieneke Buikhuisen The Netherlands Cancer Institute Amsterdam The Netherlands Case (1) Male, 56 year
More informationLinfoma maligno pulmonar tratado com Nerium oleander. http://www.drozel.org/eng/diagnosis_malignant_mg.htm CASE REPORT
Linfoma maligno pulmonar tratado com Nerium oleander http://www.drozel.org/eng/diagnosis_malignant_mg.htm CASE REPORT Diagnosis: Malignant lymphoma, lung cancer A 60-year-old woman experienced pain in
More informationLow Back Injury in the Industrial Athlete: An Anatomic Approach
Low Back Injury in the Industrial Athlete: An Anatomic Approach Earl J. Craig, M.D. Assistant Professor Indiana University School of Medicine Department of Physical Medicine and Rehabilitation Epidemiology
More informationCase Number: RT2009-124(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor
Renal Cell Carcinoma of the Left Kidney Post Radical Surgery with pt4 Classification with Multiple Lung and Single Brain Metastases: the Role and Treatment Consideration of Radiotherapy Case Number: RT2009-124(M)
More informationLumbar Disc Herniation/Bulge Protocol
Lumbar Disc Herniation/Bulge Protocol Anatomy and Biomechanics The lumbar spine is made up of 5 load transferring bones called vertebrae. They are stacked in a column with an intervertebral disc sandwiched
More informationHerniated Disk. This reference summary explains herniated disks. It discusses symptoms and causes of the condition, as well as treatment options.
Herniated Disk Introduction Your backbone, or spine, has 24 moveable vertebrae made of bone. Between the bones are soft disks filled with a jelly-like substance. These disks cushion the vertebrae and keep
More informationFAQ About Prostate Cancer Treatment and SpaceOAR System
FAQ About Prostate Cancer Treatment and SpaceOAR System P. 4 Prostate Cancer Background SpaceOAR Frequently Asked Questions (FAQ) 1. What is prostate cancer? The vast majority of prostate cancers develop
More informationLung Cancer: Diagnosis, Staging and Treatment
PATIENT EDUCATION patienteducation.osumc.edu Lung Cancer: Diagnosis, Staging and Treatment Cancer begins in our cells. Cells are the building blocks of our tissues. Tissues make up the organs of the body.
More informationICD-9-CM coding for patients with Spinal Cord Injury*
ICD-9-CM coding for patients with Spinal Cord Injury* indicates intervening codes have been left out of this list. OTHER DISORDERS OF THE CENTRAL NERVOUS SYSTEM (340-349) 344 Other paralytic syndromes
More informationSmall Cell Lung Cancer
Small Cell Lung Cancer Types of Lung Cancer Non-small cell carcinoma (NSCC) (87%) Adenocarcinoma (38%) Squamous cell (20%) Large cell (5%) Small cell carcinoma (13%) Small cell lung cancer is virtually
More informationSUNY DOWNSTATE MEDICAL CENTER SURGERY GRAND ROUNDS February 28, 2013 VERENA LIU, MD ROSEANNA LEE, MD
SUNY DOWNSTATE MEDICAL CENTER SURGERY GRAND ROUNDS February 28, 2013 VERENA LIU, MD ROSEANNA LEE, MD Case Presentation 35 year old male referred from PMD with an asymptomatic palpable right neck mass PMH/PSH:
More informationComputed Tomography, Head Or Brain; Without Contrast Material, Followed By Contrast Material(S) And Further Sections
1199SEIU BENEFIT AND PENSION FUNDS High Tech Diagnostic Radiology and s # 1 70336 Magnetic Resonance (Eg, Proton) Imaging, Temporomandibular Joint(S) 2 70450 Computed Tomography, Head Or Brain; Without
More informationOpen Discectomy. North American Spine Society Public Education Series
Open Discectomy North American Spine Society Public Education Series What Is Open Discectomy? Open discectomy is the most common surgical treatment for ruptured or herniated discs of the lumbar spine.
More informationSurgery for cervical disc prolapse or cervical osteophyte
Mr Paul S. D Urso MBBS(Hons), PhD, FRACS Neurosurgeon Provider Nº: 081161DY Epworth Centre Suite 6.1 32 Erin Street Richmond 3121 Tel: 03 9421 5844 Fax: 03 9421 4186 AH: 03 9483 4040 email: paul@pauldurso.com
More informationSpine University s Guide to Kinetic MRIs Detect Disc Herniations
Spine University s Guide to Kinetic MRIs Detect Disc Herniations 2 Introduction Traditionally, doctors use a procedure called magnetic resonance imaging (MRI) to diagnose disc injuries. Kinetic magnetic
More informationInnovative RT SBRT. The variables with REQ in superscript are required.
The variables with REQ in superscript are required. The variables with a are single-select variables; only one answer can be selected. The variables with a are multi-select variables; multiple answers
More informationSummary of treatment benefits
Risk Management Plan PEMETREXED Powder for concentrate for Solution for infusion Pemetrexed is also indicated as monotherapy for the maintenance treatment of locally advanced or metastatic non small cell
More informationAUTHOR QUERY FORM. Please e-mail or fax your responses and any corrections to:
Our reference: IJHEH 12438 P-authorquery-v8 AUTHOR QUERY FORM Journal: IJHEH Please e-mail or fax your responses and any corrections to: Article Number: 12438 Fax: +353 6170 9272 E-mail: corrections.esil@elsevier.thomsondigital.com
More informationThe Furcal nerve. Ronald L L Collins,MB,BS(UWI),FRCS(Edin.),FICS (Fort Lee Surgical Center, Fort Lee,NJ)
The Furcal nerve. Ronald L L Collins,MB,BS(UWI),FRCS(Edin.),FICS (Fort Lee Surgical Center, Fort Lee,NJ) The furcal nerve is regarded as an anomalous nerve root, and has been found with significant frequency
More informationCommon Regional Nerve Blocks Quick Guide developed by UWHC Acute Pain Service Jan 2011
Common Regional Nerve Blocks Quick Guide developed by UWHC Acute Pain Service Jan 2011 A single shot nerve block is the injection of local anesthetic to block a specific nerve distribution. It can be placed
More informationNeoplasms of the LUNG and PLEURA
Neoplasms of the LUNG and PLEURA 2015-2016 FCDS Educational Webcast Series Steven Peace, BS, CTR September 19, 2015 2015 Focus o Anatomy o SSS 2000 o MPH Rules o AJCC TNM 1 Case 1 Case Vignette HISTORY:
More informationWhiplash injuries can be visible by functional magnetic resonance imaging. Pain Research and Management Autumn 2006; Vol. 11, No. 3, pp.
Whiplash injuries can be visible by functional magnetic resonance imaging 1 Bengt H Johansson, MD FROM ABSTRACT: Pain Research and Management Autumn 2006; Vol. 11, No. 3, pp. 197-199 Whiplash trauma can
More informationRadiologic Diagnosis of Spinal Metastases
September 2002 Radiologic Diagnosis of Spinal Metastases Natalie J. M. Dailey, Harvard Medical Student Year III Our Patient s Presenting Story 70 year old male Presents to the hospital for laparascopic
More informationSpine Injury and Back Pain in Sports
Spine Injury and Back Pain in Sports DAVID W. GRAY, MD 1 Back Pain Increases with Age Girls>Boys in Teenage years Anywhere from 15 to 80% of children and adolescents have back pain depending on the studies
More informationNISG Asbestos. Caroline Kirton
NISG Asbestos Caroline Kirton 1 The Control of Asbestos Regulations 2012, Regulation 10 requires every employer to ensure that adequate information, instruction and training is given to their employees
More informationJ of Evidence Based Med & Hlthcare, pissn- 2349-2562, eissn- 2349-2570/ Vol. 2/Issue 33/Aug. 17, 2015 Page 5063
PERITONEAL MALIGNANT MESOTHELIOMA: A RARE S. R. Dhamotharan 1, S. Shanthi Nirmala 2, F. Celine Foustina Mary 3, M. Arul Raj Kumar 4, R. Vinothprabhu 5 HOW TO CITE THIS ARTICLE: S. R. Dhamotharan, S. Shanthi
More informationTHYROID CANCER. I. Introduction
THYROID CANCER I. Introduction There are over 11,000 new cases of thyroid cancer each year in the US. Females are more likely to have thyroid cancer than men by a ratio of 3:1, and it is more common in
More informationInformation for the Patient About Surgical
Information for the Patient About Surgical Decompression and Stabilization of the Spine Aging and the Spine Daily wear and tear, along with disc degeneration due to aging and injury, are common causes
More informationClosed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario
Page 1 Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario Injury Descriptions Developed from Newfoundland claim study injury definitions No injury Death Psychological
More informationMale. Female. Death rates from lung cancer in USA
Male Female Death rates from lung cancer in USA Smoking represents an interesting combination of an entrenched industry and a clearly drug-induced cancer Tobacco Use in the US, 1900-2000 5000 100 Per Capita
More informationReport series: General cancer information
Fighting cancer with information Report series: General cancer information Eastern Cancer Registration and Information Centre ECRIC report series: General cancer information Cancer is a general term for
More informationBrown-Sequard Syndrome Caused by Cervical Disc Herniation
62 CASE REPORT Brown-Sequard Syndrome Caused by Cervical Disc Herniation Chih-Hsiu Wang, Chun-Chung Chen, Der-Yang Cho Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan, R.O.C.
More informationManagement of Neurologically Intact Patient with Cervical Epidural Abscess
Management of Neurologically Intact Patient with Cervical Epidural Abscess Jason C. Eck, DO, MS Center for Sports Medicine & Orthopaedics Chattanooga, TN Overview Pathophysiology and epidemiology of epidural
More informationFrequently Asked Questions About Ovarian Cancer
Media Contact: Gerri Gomez Howard Cell: 303-748-3933 gerri@gomezhowardgroup.com Frequently Asked Questions About Ovarian Cancer What is ovarian cancer? Ovarian cancer is a cancer that forms in tissues
More informationUniversity College Hospital. Metastatic spinal cord compression (MSCC) information for patients at risk of developing MSCC.
University College Hospital Metastatic spinal cord compression (MSCC) information for patients at risk of developing MSCC Cancer Services 2 If you would like this document in another language or format,
More informationPET POSITIVE PLEURAL PLAQUES DECADES AFTER PLEURODESIS: MESOLTHELIOMA? Ellen A. Middleton 1. Jonathan C. Daniel 2. Kenneth S.
PET POSITIVE PLEURAL PLAQUES DECADES AFTER PLEURODESIS: MESOLTHELIOMA? Ellen A. Middleton 1 Jonathan C. Daniel 2 Kenneth S. Knox 1 Kathleen Williams 1 Departments of Medicine 1 and Surgery 2, University
More informationTranscript for Asbestos Information for the Community
Welcome to the lecture on asbestos and its health effects for the community. My name is Dr. Vik Kapil and I come to you from the Centers for Disease Control and Prevention, Agency for Toxic Substances
More informationCervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury. Canadian Family Physician
Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury 1 Canadian Family Physician Volume 32, September 1986 Arthur Ameis, MD Dr. Ames practices physical medicine and rehabilitation,
More informationPosterior Cervical Decompression
Posterior Cervical Decompression Spinal Unit Tel: 01473 702032 or 702097 Issue 2: January 2009 Following your recent MRI scan and consultation with your spinal surgeon, you have been diagnosed with a
More informationClinical Guideline. Low Back Pain Orthopaedics. Princess Alexandra Hospital Emergency Department. 1 Purpose. 2 Background
Princess Alexandra Hospital Emergency Department Clinical Guideline Orthopaedics Review Officer: Katherine Isoardi Version no: 1 Approval date: 18/03/2015 Review date: 18/03/2017 Approving Officer Dr James
More informationMalignant Pleural Diseases Advances Clinicians Should Know F Gleeson
Malignant Pleural Diseases Advances Clinicians Should Know F Gleeson The following relevant disclosures, conflicts of interest and/ or financial relationships exist related to this presentation: Consultant
More informationUnderstanding Pleural Mesothelioma
Understanding Pleural Mesothelioma UHN Information for patients and families Read this booklet to learn about: What is pleural mesothelioma? What causes it? What are the symptoms? What tests are done to
More informationImage. 3.11.3 SW Review the anatomy of the EAC and how this plays a role in the spread of tumors.
Neoplasms of the Ear and Lateral Skull Base Image 3.11.1 SW What are the three most common neoplasms of the auricle? 3.11.2 SW What are the four most common neoplasms of the external auditory canal (EAC)
More informationMesothelioma. Malignant Pleural Mesothelioma
Mesothelioma William G. Richards, PhD Brigham and Women s Hospital Malignant Pleural Mesothelioma 2,000-3,000 cases per year (USA) Increasing incidence Asbestos (50-80%, decreasing) 30-40 year latency
More informationThoracic Region Pain. ICD-9-CM: 724.4 Thoracic or Lumbosacral neuritis or radiculitis, unspecified
Thoracic Region Pain ICD-9-CM: 724.4 Thoracic or Lumbosacral neuritis or radiculitis, unspecified ICF codes: Activities and Participation Domain code: d4108 Changing basic body position, other specified
More informationDiagnosis and Treatment of Lumbar Spinal Canal Stenosis
Low Back Pains Diagnosis and Treatment of Lumbar Spinal Canal Stenosis JMAJ 46(10): 439 444, 2003 Katsuro TOMITA Department of Orthopedic Surgery, Kanazawa University Abstract: Lumbar spinal canal stenosis
More informationExploring the Role of Vitamins in Achieving a Healthy Heart
Exploring the Role of Vitamins in Achieving a Healthy Heart There are many avenues you can take to keep your heart healthy. The first step you should take is to have a medical professional evaluate the
More informationX Stop Spinal Stenosis Decompression
X Stop Spinal Stenosis Decompression Am I a candidate for X Stop spinal surgery? You may be a candidate for the X Stop spinal surgery if you have primarily leg pain rather than mostly back pain and your
More informationCPT Radiology Codes Requiring Review by AIM Effective 01/01/2016
CPT Radiology Codes Requiring Review by AIM Effective 01/01/2016 When a service is authorized only one test per group is payable. *Secondary codes or add-on codes do not require preauthorization or separate
More informationExtrapleural Pneumonectomy for Malignant Mesothelioma: Pro. Joon H. Lee 9/17/2012
Extrapleural Pneumonectomy for Malignant Mesothelioma: Pro Joon H. Lee 9/17/2012 Malignant Pleural Mesothelioma (Epidemiology) Incidence: 7/mil (Japan) to 40/mil (Australia) Attributed secondary to asbestos
More informationTable 16a Multiple Myeloma Average Annual Number of Cancer Cases and Age-Adjusted Incidence Rates* for 2002-2006
Multiple Myeloma Figure 16 Definition: Multiple myeloma forms in plasma cells that are normally found in the bone marrow. 1 The plasma cells grow out of control and form tumors (plasmacytoma) or crowd
More informationWORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1894/06
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1894/06 BEFORE: R. Nairn : Vice-Chair HEARING: September 25, 2006 at Windsor Oral DATE OF DECISION: October 16, 2006 NEUTRAL CITATION: 2006
More information