Acellular Dermal Matrix: Treating Periocular Melanoma in a Patient with Xeroderma Pigmentosa

We report a 7-year-old girl with xeroderma pigmentosum (XP), who presented in our clinic with a large melanoma (35 × 50 × 20 mm, Breslow depth 18 mm) in the zygomatic-malar area. Palliative surgery was performed to maintain her residual vision and to reduce the pain caused by the compression of local structures. Because of the limited access of autologous skin grafts in pediatric patients with XP who are severely affected, we opted to use an acellular dermal matrix. There was 100% graft uptake, and the pain due to compression by the tumor was alleviated. This case demonstrates that acellular dermal matrices can be safely and effectively used in oncological facial reconstruction, especially in patients with progressive conditions such as XP.

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Le statut MSI est un biomarqueur prédictif de la chimioradiothérapie néoadjuvante pour adénocarcinome du rectum

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): N. Meillan, D. Vernerey, G. Manceau, J. Lefèvre, J.-M. Simon, J.-B. Bachet, F. Huguet
Objectif de l'étudeLe phénotype MSS/MSI (MSS : absence d'instabilité des microsatellites ; MSI : instabilité des microsatellites) a un impact pronostique dans les cancers colorectaux de stade II–III avec un moindre risque métastatique pour le statut MSI. Son impact prédictif sur la réponse à la chimiothérapie et à l'immunothérapie est établi. Celui sur la réponse à la radiothérapie est inconnu. Cette étude avait pour objectif d'évaluer l'impact du statut MSI sur la réponse à la radiothérapie néoadjuvante des cancers du rectum localement évolués.Matériel et méthodeNous avons analysé rétrospectivement les dossiers de 17 patients avec le statut MSI et 338 patients avec celui MSS, atteints de cancer de stade T3–T4 et/ou avec atteinte ganglionnaire, pris en charge par chimioradiothérapie néoadjuvante de 45 à 50Gy en cinq semaines avec une chimiothérapie à base de fluoropyrimidines ou 25Gy en cinq fractions. Ces patients ont été appariés sur l'âge et le stade tumoral à l'aide d'un score de propension. Le critère de jugement principal était la réduction du stade T et/ou N sur la pièce opératoire après traitement néoadjuvant.RésultatsLe suivi médian était de 36,7 mois. Il y avait parmi les patients avec le statut MSI, deux tumeurs ypN+ (12 %), huit ypT1-2N0 (47 %) et sept ypT3-4N0 (41 %) contre respectivement 106 (31 %), 130 (38 %) et 102 (30 %) avec le statut MSS. Une réduction du stade tumoral a été observé chez 14 patients avec le statut MSI (93,3 %) contre 200 avec le statut MSS (59,2 %) (odds ratio [OR] : 0,10 ; intervalle de confiance à 95 % [IC 95 %] : 0,01–0,80, p=0,029). Le taux de rechute locale n'était pas significativement différent entre les deux populations, une patiente avec le statut MSI (7,7 %) contre 24 avec celui MSS (7,2 %) (OR=0,93 ; IC 95 % : 0,12–7,43, p=0,94), de même que la survie globale (hazard ratio [HR] : 0,39 ; IC 95 % : 0,05–2,87, p=0,35).ConclusionLe dysfonctionnement somatique du système de réparation des mésappariements de l'ADN semble entraîner une meilleure réponse à la radiothérapie néoadjuvante des cancers du rectum localement évolués. Cet impact ne se traduit pas significativement par un bénéfice en termes de rechute locale ni de survie globale avec un suivi médian relativement court.



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Issue Contents

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7





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Nouvelles techniques dans le cancer de la prostate localisé : chirurgie et radiothérapie

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): L. Cormier, G. Créhange
La prise en charge chirurgicale du cancer de la prostate localisé a été marquée ces dernières années par la place prépondérante de la surveillance active dans les formes de cancer à faible risque. En effet, le recul et la qualité des résultats sont maintenant suffisants pour proposer cette option à des patients relativement jeunes. En revanche, la question reste posée pour les formes intermédiaires. De plus, une extrême vigilance est indispensable pour la qualité de la sélection et du suivi des patients pour la surveillance active. Une autre évolution est l'importance prise par l'assistance robotique dans la prostatectomie totale. Même si le niveau de preuve en faveur du robot reste faible, son utilisation de plus en plus universelle est un fait indéniable qui répond vraisemblablement à la difficulté chirurgicale de cette intervention. Enfin, le concept du traitement focal du cancer de la prostate est en pleine évolution, sans doute lié à la qualité de l'IRM et la précision des biopsies de la prostate. Actuellement, le traitement focal du cancer de la prostate ne doit se faire que dans le cadre de la recherche clinique et/ou peut être par le biais de registres nationaux et validés par les différents acteurs intervenant dans la prise en charge des patients.The management of localized prostate cancer has been marked over these last years by the importance of Active Surveillance for low risk forms. Indeed, the long follow-up and the quality of the results are now sufficient to offer this option even in relatively young people. However, the question is still under investigation concerning intermediate risk of prostate cancer. Patients' selection and follow-up management are of very high importance. Another major evolution is the robotic assistance for radical prostatectomy. Even if the level of evidence is still low, the global utilization all over the world of robotic assistance is a major fact of these last years mostly explained by the difficulty to correctly perform manual laparoscopic surgical procedure. Lastly, the focal therapy of prostate cancer is a new concept. The development of this approach is authorized by the improvement of the quality of prostate MRI and the accuracy of prostate biopsy. Presently, the focal treatment has to be performed in clinical trials or maybe with the help of national database validated by all the actors concerned by the treatment of prostate cancer.



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Editorial Board

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7





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Radiothérapie adaptive des cancers ORL : bénéfice sur la couverture du volume tumoral

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): J. Castelli, A. Simon, B. Rigaud, C. Lafond, O. Henry, E. Chajon, F. Jégoux, E. Vauleon, R. de Crevoisier
Objectif de l'étudeDans le cadre d'une radiothérapie conformationnelle avec modulation d'intensité (RCMI) pour des cancers oropharyngés localement évolués, les objectifs de notre étude étaient d'évaluer la différence entre la dose planifiée et la dose délivrée au volume cible anatomoclinique, puis d'estimer le bénéfice dosimétrique d'une radiothérapie adaptative en termes de couverture du volume cible anatomoclinique.Matériel et méthodeVingt-quatre patients ont été pris en charge par RCMI (70Gy) et une chimiothérapie concomitante. Chaque patient a eu un scanographie de planification et cinq hebdomadaires. Deux situations ont été simulées : (1) évaluation de la dose délivrée sans replanification en replaçant la balistique initiale sur chaque scanographie hebdomadaire (2) évaluation de la dose avec replanification hebdomadaire. La moyenne des valeurs de la dose reçue par 98 % du volume cible anatomoclinique (D98-CTV) a été calculée pour chacune des deux situations et comparée par un test de comparaison des médianes (test de Wilcoxon) à la D98-CTV de la planification initiale.RésultatsEn l'absence de replanification, une diminution médiane de 0,9Gy de la D98-CTV a été observée (valeur médiane de 68,9Gy contre 68Gy, p=0,002). Une diminution de plus de 1Gy (allant jusqu'à 5Gy pour le patient n^o 11) a été observée pour dix patients. La replanification permettait de corriger ce « sous-dosage » du volume cible anatomoclinique, avec une D98-CTV identique à celle de la planification (68,9Gy, p=0,4). La différence entre la D98-CTV replanifiée et la D98-CTV initiale était comprise entre −0,8Gy et +0,8Gy pour tous les patients sauf un (persistance d'un « sous-dosage » de 4Gy pour le patient n^o 11).ConclusionUne diminution de plus de 1Gy de la dose délivrée au volume cible anatomoclinique a été observée pour environ 40 % des patients lors d'une RCMI pour des cancers ORL localement évolués. Une radiothérapie adaptative permet de corriger ce « sous-dosage » dans la quasi-totalité des cas avec le potentiel d'améliorer le taux de contrôle local de ces patients.



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Analyse de textures des cancers pancréatiques avant et après chimioradiothérapie : nouveau paramètre prédictif ?

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): C. Pouypoudat, C. Périer, O. Saut, E. Buscail, C. Cassinotto, E. Terrebonne, V. Vendrely
Objectif de l'étudeÉvaluation de l'apport de l'analyse des textures après chimioradiothérapie des adénocarcinomes pancréatiques borderline et localement évolués.Matériel et méthodeLes scanographies avant et après la chimioradiothérapie de patients pris en charge pour des cancers du pancréas borderline ou localement évolués entre 2010 et 2014 ont été analysées. Après détermination d'une région d'intérêt et délinéation de la tumeur par l'oncologue radiothérapeute sur les différentes scanographies, les données de textures de premier ordre (analyse de l'histogramme de la région d'intérêt) ou de deuxième ordre (analyse de la matrice de cooccurrence) ont été étudiées avec l'algorithme support vector machine (SVM). La relation entre ces paramètres et les données cliniques initiales et de suivi (progression versus non-progression) a été étudiée grâce à la technique de l'apprentissage statistique.RésultatsL'évolution des textures entre les scanographies avant et après la chimioradiothérapie de 50 patients a été analysée : le coefficient d'aplatissement ou kurtosis évoluait pour 100 % des patients de plus de 1 % et baissait pour 58 % des patients de plus de 5 % (augmentation de l'hétérogénéité). Au cours de leur suivi, 82 % des patients ont été atteints d'une récidive locale ou métastatique. L'analyse des données cliniques associée à l'évolution des textures par la méthode de l'apprentissage statistique conjoint permettait une prédiction au moins supérieure à ces 82 % contrairement aux données cliniques ou de textures seules.ConclusionLes textures scanographiques des cancers pancréatiques se modifient lors de la chimioradiothérapie et pourraient constituer de nouveaux paramètres prédictifs de l'évolution des patients.



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Place de la chimiothérapie d’induction dans le traitement des carcinomes épidermoïdes des voies aérodigestives supérieures : contre

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): F. Huguet, U. Schick, Y. Pointreau
Le traitement des carcinomes épidermoïdes des voies aérodigestives localement évolués repose sur la chimioradiothérapie concomitante. Un traitement séquentiel associant chimiothérapie d'induction par association de docétaxel, cisplatine et 5-fluoro-uracile (TPF), suivie d'une (chimio)radiothérapie, est utilisé fréquemment dans le cadre des stratégies de préservation laryngée. En dehors de cette situation particulière, le bénéfice en termes de survie d'une chimiothérapie d'induction a été beaucoup discuté ces dernières années. Dans cinq essais randomisés récents, une chimioradiothérapie a été comparée à une chimiothérapie d'induction par TPF, suivie d'une chimioradiothérapie. Parmi ces cinq essais, quatre concluent que ces traitements sont similaires. Un seul essai a montré un bénéfice de la chimiothérapie d'induction mais sa méthodologie est très discutable. Après la chimiothérapie par TPF, la chimioradiothérapie est moins bien tolérée. En cas d'envahissement ganglionnaire important (stade N2b-c-N3), la chimiothérapie d'induction permet de diminuer la survenue de métastases à distance. Le statut selon l'Human papilloma virus (HPV) ne doit pas influencer la décision thérapeutique.The treatment of locally advanced head and neck squamous cell carcinoma is based on concomitant chemoradiotherapy. A sequential treatment combining induction chemotherapy with docetaxel, cisplatin and 5-fluorouracil (TPF), followed by (chemo)radiotherapy is frequently used as part of laryngeal preservation strategies. Apart from this particular situation, the benefit in terms of survival of induction chemotherapy has been much discussed in recent years. In five recent randomized trials, chemoradiotherapy was compared with TPF induction chemotherapy followed by chemoradiotherapy. Of these five trials, four concluded that these treatments were similar. A single trial reports a benefit for induction chemotherapy but its methodology is highly debatable. After TPF chemotherapy, chemoradiotherapy is less well tolerated. In patients with significant lymph node invasion (N2b-c-N3), induction chemotherapy reduces the occurrence of distant metastasis. The HPV status should not influence the therapeutic decision.



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Doses aux organes à risque en radiothérapie conformationnelle et en radiothérapie stéréotaxique : le foie

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): K. Debbi, G. Janoray, N. Scher, É. Deutsch, F. Mornex
Le foie est un organe essentiel qui assure de très nombreuses fonctions vitales telles que : le métabolisme de la bilirubine, du glucose, des lipides, la synthèse des facteurs de coagulation, la destruction de nombreuses toxines, etc. Le parenchyme hépatique peut être irradié lors de la prise en charge de tumeurs digestives hautes, basithoraciques droite, de l'œsophage, de l'abdomen in toto ou TBI. De plus, la radiothérapie de l'aire hépatique, principalement stéréotaxique, occupe désormais une place centrale dans le cadre de la prise en charge des tumeurs hépatiques primitives ou secondaires. L'irradiation de la totalité du foie, ou d'une partie, peut se compliquer d'hépatite radio-induite. Il est donc nécessaire de respecter des contraintes dosimétriques strictes tant en stéréotaxie qu'en irradiation de conformation afin de limiter l'irradiation non souhaitée du parenchyme hépatique qui peut varier selon les techniques de traitement, la fonction hépatique de base ou la taille lésionnelle. Le foie est un organe dont l'architecture est parallèle, il faudra donc considérer la dose moyenne tolérable dans l'ensemble du foie sain plutôt que la dose maximale tolérable en un point. Cet article aura pour but de proposer une mise au point des recommandations de doses lors d'une radiothérapie de conformation ou stéréotaxique du foie.The liver is an essential organ that ensures many vital functions such as metabolism of bilirubin, glucose, lipids, synthesis of coagulation factors, destruction of many toxins, etc. The hepatic parenchyma can be irradiated during the management of digestive tumors, right basithoracic, esophagus, abdomen in toto or TBI. In addition, radiotherapy of the hepatic area, which is mainly stereotactic, now occupies a central place in the management of primary or secondary hepatic tumors. Irradiation of the whole liver, or part of it, may be complicated by radiation-induced hepatitis. It is therefore necessary to respect strict dosimetric constraints both in stereotactic and in conformational irradiation in order to limit the undesired irradiation of the hepatic parenchyma which may vary according to the treatment techniques, the basic hepatic function or the lesion size. The liver is an organ with a parallel architecture, so the average tolerable dose in the whole liver should be considered rather than the maximum tolerable dose at one point. The purpose of this article is to propose a development of dose recommendations during conformation or stereotactic radiotherapy of the liver.



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Contraintes de dose en radiothérapie conformationnelle fractionnée et en radiothérapie stéréotaxique dans les hippocampes, le tronc cérébral et l’encéphale : limites et perspectives

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): M. Gérard, R. Jumeau, B. Pichon, J. Biau, E. Blais, J. Horion, G. Noël
La toxicité cérébrale de la radiothérapie n'est pas rare. L'épargne de cet organe à risque constitue un enjeu pour la préservation cognitive, en particulier en cas de longue survie. Le diagnostic clinique, physiopathologique et radiologique de la radionécrose reste difficile. Les contraintes de doses utilisées en radiothérapie conformationnelle avec modulation d'intensité (RCMI), en radiochirurgie et en radiothérapie stéréotaxique sont critiquables. Elles ont été élaborées à partir d'études rétrospectives clinicodosimétriques anciennes. Le rapport α/β et l'architecture — en série ou en parallèle — des organes à risque sont discutables. Ils peuvent conduire à mésestimer les doses équivalentes (BED) par le modèle linéaire-quadratique ou la dose équivalente à une irradiation de 2Gy par fraction (EQD2), en particulier en cas d'hypofractionnement. Les modèles mathématiques se heurtent à l'hétérogénéité spatiale de la relation dose-réponse, aux différents fractionnements et étalements ainsi qu'à l'irradiation partielle des organes à risque induites par les forts gradients de doses. Ces limites doivent être connues en pratique clinique courante. À partir d'une revue de la littérature, notre article propose une mise au point sur le tronc cérébral, les hippocampes et l'encéphale. La pertinence des valeurs rapportées fait l'objet de discussions et de pistes de réflexions.Cerebral radiation-induced toxicities after radiotherapy (RT) of brain tumors are frequent. The protection of organs at risk (OAR) is crucial, especially for brain tumors, to preserve cognition in cancer survivors. Dose constraints of cerebral OAR used in conventional RT, radiosurgery (SRS) and stereotactic radiotherapy (SRT) are debated. In fact, they are based on historical cohorts or calculated with old mathematical models. Values of α/β ratio of cerebral OAR are also controversial leading to misestimate the equivalent dose in 2Gy fractions or the biological equivalent dose, especially during hypofractionated RT. Although recent progresses in medical imaging, the diagnosis of radionecrosis remains difficult. In this article, we propose a large review of dose constraints used for three major cerebral OAR: the brain stem, the hippocampus and the brain.



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Évaluation des différentes recommandations de délinéation de loge prostatique pour la radiothérapie de rattrapage après prostatectomie, par identification de récidives locales documentées par tomographie par émission de positons à la choline

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): O. El Kabbaj, P. Robin, R. Abgral, A. Valeri, D. Bouhris, P.-Y. Salaun, O. Pradier, J.-P. Malhaire, U. Schick
Objectif de l'étudeComparaison de trois recommandations différentes de délinéation de volume cible anatomoclinique d'irradiation postopératoire de loge de prostatectomie à partir de récidives locales identifiées sur tomographie par émission de positons (TEP) à la (¹⁸F)-fluorocholine dans une cohorte de patients opérés.Matériel et méthodeTrente-six patients atteints d'une ou plusieurs récidive(s) au sein de la loge de prostatectomie identifiée(s) sur la TEP à la (¹⁸F)-fluorocholine ont été inclus entre octobre 2011 et juin 2016. La concentration sérique médiane d'antigène spécifique de la prostate au moment de la réalisation de la TEP à la (¹⁸F)-fluorocholine était de 2,7ng/mL (0,76–9,35ng/mL) et son temps médian de doublement était de 11 mois (3–28 mois). Pour chaque patient, les volumes cible anatomocliniques selon le Radiation Therapy Oncology Group (RTOG), le Faculty of Radiation Oncology Genito-Urinary Group (FROGG) ou l'European Organisation for Research and Treatment of Cancer (EORTC) ont été délinéés selon les recommandations de chacun de ces groupes, puis comparés entre eux. Quarante et une récidives locales ont été identifiées, avec un volume médian de 1,64mL (0,02–18,17mL). Toutes les récidives locales ont été délinéées grâce à l'outil PET-Edge™ du logiciel MIM^® software (6.4.2) et fusionnées sur la scanographie d'un patient « référence » en utilisant l'outil de fusion élastique Atlas. Le pourcentage de récidives locales inclus dans chaque volume cible anatomoclinique a été évalué.RésultatsL'anastomose était le site de récidive le plus fréquent (52,8 %), suivie de la région rétro-vésicale (31,7 %) et du col de la vessie (7 %). La standard uptake value maximale (SUVmax) médiane était de 4,84 (2,31–16,14). Les valeurs médianes des volumes cible anatomocliniques selon le RTOG ou le FROGG étaient similaires (100cm³ et 100cm³, p=0,72). Le volume cible anatomoclinique médian selon le RTOG était significativement plus important que celui selon l'EORTC (100cm³ contre 50cm³, p<0,0001). Le pourcentage des récidives locales incluses dans le volume cible anatomoclinique selon le RTOG n'était pas significativement différent de celui inclus dans le volume cible anatomoclinique selon le FROGG (84 % contre 83 %, p=0,5). Davantage de récidives étaient en revanche incluses dans le volume cible anatomoclinique selon le RTOG par rapport à celui selon l'EORTC (84 % contre 68 %, p=0,0006).ConclusionDans notre étude, les volumes cible anatomocliniques selon le RTOG ou le FROGG assuraient la meilleure couverture des récidives locales identifiées sur TEP à la (¹⁸F)-fluorocholine. L'élargissement de la délinéation en arrière dans la région vésico-urétrale permettrait d'assurer une meilleure couverture de la maladie microscopique éventuelle.



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Préservation d’organe dans les cancers du rectum : résultats de l’essai randomisé de phase 3 Greccar 2

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): V. Vendrely, P. Rouanet, J.-J. Tuech, A. Valverde, B. Lelong, M. Rivoire, J.-L. Faucheron, M. Jafari, G. Portier, B. Meunier, A. Rullier, Q. Denost, J. Asselineau, A. Doussau, E. Rullier
Objectif de l'étudeComparaison de la tumorectomie et l'exérèse totale du mésorectum chez les patients en situation de bonne réponse à une chimioradiothérapie pour un cancer du rectum.Matériel et méthodeLes patients atteints de tumeur de stade T2 ou T3 (inférieure ou égale à 4cm) ont reçu une chimioradiothérapie (Cap50, capécitabine). Les patients en situation de bonne réponse clinique (tumeur résiduelle≤2cm) ont été randomisés entre une tumorectomie et l'exérèse totale du mésorectum. Le groupe qui a eu une tumorectomie, en cas de réponse ypT2-3 ou R1, a eu une exérèse totale du mésorectum complémentaire. L'objectif principal était de montrer la supériorité de la tumorectomie sur la l'exérèse totale du mésorectum par un critère composite incluant décès, récidive, morbidité et effets secondaires à 2 ans. Les objectifs secondaires incluaient la réponse tumorale, une survie sans récidive et globale à 3 ans.RésultatsDe mars 2007 à septembre 2012, 148 patientes en situation de bonne réponse (sur 186 patients pris en charge par chimioradiothérapie) ont été randomisés et les dossiers de 145 patients ont été analysés : 74 dans le groupe qui a eu une tumorectomie et 71 dans celui qui a eu une exérèse totale du mésorectum. Dans le groupe qui a eu une tumorectomie, 26 patients ont eu une l'exérèse totale du mésorectum complémentaire. En intention de traiter, il n'y avait pas de différence entre les deux groupes pour tous les composants du critère composite. Cependant, les analyses complémentaires sur la morbidité chirurgicale (12 % contre 22 % contre 46 %, p=0,003) et les effets secondaires (19 % contre 30 % contre 59 %, p=0,001) ont montré l'influence du type de chirurgie, tumorectomie contre l'exérèse totale du mésorectum contre l'exérèse totale du mésorectum complémentaire, respectivement. L'analyse des résultats histopathologiques a montré 61 % de bonnes réponses (ypT0-1) ainsi qu'une association entre les réponses ganglionnaire et tumorale avec 0, 0, 8 % et 40 % de tumeurs ypN1 pour respectivement les tumeurs ypT0, T1, T2 et T3. À 3 ans, il n'y avait pas de différence significative de taux de récidive locale (5,4 % contre 5,6 %) ni de probabilité de survie sans maladie (78,3 % contre 76,1 %).ConclusionL'étude n'a pas montré la supériorité de la tumorectomie par comparaison à la l'exérèse totale du mésorectum, en raison d'un taux élevé d'exérèse totale du mésorectum complémentaires, responsable d'une augmentation de la morbidité et des effets secondaires dans le groupe qui a eu une tumorectomie. Une meilleure sélection des patients, en évitant les exérèses totales du mésorectum non nécessaires, pourrait améliorer la stratégie.



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Essai de phase II randomisé de chimioradiothérapie exclusive avec ou sans escalade de dose chez des patients atteints de cancer de l’œsophage : concorde (Prodige 26)

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): G. Créhange, A. Bertaut, É. Le Prisé, P.L. Étienne, E. Rio, R. Pereira, G. Noêl, K. Bénézery, J.F. Seitz, F. Bonnetain, D. Peiffert
Objectif de l'étudeL'objectif de cette étude était d'évaluer la toxicité aiguë et la qualité de vie avec et sans escalade de dose chez des patients pris en charge par chimioradiothérapie exclusive avec irradiation prophylactique ganglionnaire pour un cancer de l'œsophage.Matériel et méthodeLes patients atteints d'un cancer de l'œsophage localement évolué ou non résécable et prouvé histologiquement ont été randomisés entre une irradiation prophylactique ganglionnaire de 40Gy et un complément de 10Gy dans la maladie macroscopique (bras A) et la même irradiation prophylactique ganglionnaire et un complément de 26Gy (bras B). Une chimiothérapie concomitante par folfox-4 (5-fluoro-uracile, oxalipaltine, acide folinique) a été délivrée dans les deux bras. L'objectif principal était d'évaluer la toxicité aiguë à 3 mois avec l'échelle du National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), v4.0. La qualité de vie a été évaluée par les questionnaires de l'European Organization for Research and Treatment of Cancer (EORTC) QLQ C30 et OES18. Les analyses ont été réalisées en intention de traitement.RésultatsCent-soixante patients ont été randomisés : 81 patients dans le bras A et 79 patients dans le bras B. Soixante-dix patients dans chaque bras étaient atteints d'un carcinome épidermoïde et 59 patients contre 58 d' une maladie de stade III. Les taux de toxicité non hématologique de grade 3 ou plus étaient de 76,5 % dans le bras A et 86 % dans le bras B. Les taux de toxicité hématologique de grade 3 ou plus étaient de 82,7 % et 88,6 %. Les scores moyens de santé globale au moment du diagnostic et à 3 mois étaient de 63,9 (standard deviation [sd] : 21,4) contre 69,6 (sd=23,1) dans le bras A et 65,3 (sd=19,5) contre 58,8 (sd=19,9) dans le bras B. La présence d'une dysphagie n'était significativement pas différente au moment du diagnostic entre le bras A (89,2 %) et le bras B (86,2 %) et à 3 mois (77,8 % contre 86,8 %).ConclusionUne escalade de dose sur la maladie macroscopique associée à une irradiation prophylactique ganglionnaire est faisable sans augmentation de la toxicité aiguë et sans modifications de la qualité de vie immédiate.



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Impact du trajet entre le domicile et l’hôpital sur la fatigue des patients pris en charge par radiothérapie

Publication date: October 2017
Source:Cancer/Radiothérapie, Volume 21, Issues 6–7
Author(s): C. Rancoule, M. Ben Mrad, A. El Meddheb Hamrouni, S. Ouni, A. Vallard, J.-B. Guy, N. Magné
Objectif de l'étudeLes patients pris en charge par radiothérapie rapportent fréquemment une fatigue gênante, le plus souvent sans qu'une cause spécifique ne puisse être identifiée. Nous nous sommes intéressés à l'impact des trajets quotidiens sur la fatigue des patients en cours de radiothérapie.Matériel et méthodeCinq cent patients pris en charge en intention curative par radiothérapie pour un cancer du sein (350 patientes) ou un cancer de la prostate (150 patients) à l'institut de cancérologie Lucien-Neuwirth (Saint-Étienne, Loire), ont été consécutivement inclus. Une échelle visuelle analogique (EVA) de fatigue (de 1 [absence de fatigue] à 10 [pire fatigue imaginable]) ainsi qu'un score de tolérance au traitement (de 1 [intolérance maximale au traitement] à 10 [meilleure tolérance imaginable]) ont été recueillis auprès du patient, en fin de traitement. La distance et la durée du trajet entre le domicile et le centre ont été colligées, ainsi que les données de toxicité aiguë. La recherche de corrélations a été réalisée au moyen du coefficient de Pearson.RésultatsLa distance moyenne d'un aller (du domicile à l'institut de cancérologie) était de 22,96km (±13,59) avec une distance maximale à 92km. La durée moyenne du trajet était de 27min (±12) avec un trajet maximum de 1h et 23min. L'EVA moyenne de la fatigue était de 4,01 (±2,57). Le score moyen de tolérance au traitement était de 7,43 (±1,34). Aucune corrélation significative n'a pu être mis en évidence entre distance et EVA de fatigue (r²=7·10^–4), durée et lEVA de fatigue (r²=9·10^–6), distance et tolérance (r²=4·10^–4), durée et tolérance (r²=19·10^–4). La fatigue n'était pas corrélée avec la sévérité de la toxicité aiguë radio-induite (r²=13·10³).ConclusionLa distance entre le domicile et le centre de radiothérapie ne semble pas corrélée avec la fatigue des patients en cours de traitement. Ces données questionnent sur la faisabilité de traiter les patients dans des centres référents de radiothérapie, même situés loin de leur domicile.



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Rare anatomic variation: true bifid inferior turbinate

Abstract

Nasal anatomic variations are relevant during nasal surgical and endoscopic procedures. The extent of imaging methods, such as the cone beam computed tomography (CBCT), allows a better characterization of such peculiar anatomic traits. The bifid inferior turbinate (BIT) is a rare finding, being previously reported less than ten times. It was found and described on CT scans of patients, being usually associated with the absence of the uncinate process (UP). We hereby report for the first time a bilateral true BIT which differs from the previously reported BITs by the fact that the UPs were present and the bifidity was oriented laterally. In the light of this new find, we consider that the variant resulted from UP displacement should be regarded as a false bifid, or double, inferior turbinate. Bifidity of the inferior turbinate was not previously evaluated in CBCT, as well as in three-dimensional volume renderizations. So, CBCT proves as an efficient tool to investigate prevalence of rare anatomical variants. Noteworthy, CT studies of patients on a case-by-case basis allows a better performance of surgical and endoscopic procedures.

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Contemporary Use of Interferon Therapy in the Myeloproliferative Neoplasms

Abstract

Purpose of Review

The purpose of this article is to review the current evidence behind interferon therapy in patients with myeloproliferative neoplasms.

Recent Findings

Preliminary analysis suggests that interferon may be non-inferior to hydroxyurea in patients with polycythemia vera and essential thrombocytosis. Responses have been observed regardless of JAK2 mutational status, but the presence of non-JAK2 somatic mutations may negatively influence response rates.

Summary

Pegylated interferon has proven efficacy for patients with myeloproliferative neoplasms. Both newly diagnosed and previously treated patients with polycythemia vera and essential thrombocytosis exhibit high hematologic response rates, and some of these patients achieve molecular responses as well. Interferon therapy leads to lower rates of hematologic response in MF patients, but patients earlier on in their disease course have a better chance of responding. There are ongoing trials comparing pegylated interferon to hydroxyurea in essential thrombocytosis (ET) and polycythemia vera (PV), and early analysis suggests non-inferiority. However, longer follow-up is needed before drawing any conclusions. Future research is needed to better define characteristics of the best responders and to determine whether novel forms of interferon therapy or combination therapy with interferon can enhance efficacy and tolerability.

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Chronic Myeloid Leukemia—the Promise of Tyrosine Kinase Inhibitor Discontinuation

Abstract

Some believe that tyrosine kinase inhibitor (TKI) therapy is as close to perfect as it gets in oncologic therapy. Patients diagnosed with chronic myeloid leukemia (CML) are treated with a daily oral therapy, through which most achieve remission. TKI therapy is not associated with classic chemotherapy side effects, and most patients are able to resume their normal activities of daily living. Moreover, recent data has demonstrated that CML does not affect the life expectancy of patients whose disease is well controlled with a TKI. However, TKI therapy is actually not that perfect. Patients need to stay on therapy forever. They have to remember to take their medications daily. TKIs are expensive, and the financial burden to patient and society cannot be overstated. Most patients' health-related quality of life is affected; common side effects include fatigue, muscle cramps, pain, edema, skin problems, and gastrointestinal symptoms. In addition, concerns about long-term side effects remain. Recently several studies have shown the feasibility and safety of discontinuation in a select group of patients. Herein, we will review the currently available data on stopping TKIs in CML.

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Molecular Pathogenesis of Myeloproliferative Neoplasms: Influence of Age and Gender

Abstract

The myeloproliferative neoplasms polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) display distinct clinical and pathologic features but are characterized by mutations in JAK2, MPL, and CALR leading to activation of the JAK-STAT pathway. This review addresses the pathogenesis and mechanisms of these mutant alleles and the unique interactions of both of age and gender.

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Risk Factors for and Management of MPN-Associated Bleeding and Thrombosis

Abstract

Purpose of the Review

The Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) are characterized by both thrombotic and bleeding complications. The purpose of this review is to describe the risk factors associated with bleeding and thrombosis in MPN, as well as to review prevention strategies and management of these complications.

Recent Findings

Well-described risk factors for thrombotic complications include older age and history of prior thrombosis, along with traditional cardiovascular and venous thromboembolic risk factors. More recently, JAK2 V617F mutation has been found to carry an increased risk of thrombotic complications, whereas CALR has a lower risk than JAK2 mutation. Factors associated with an increased risk of bleeding in MPN include a prior history of bleeding, acquired von Willebrand syndrome, and primary myelofibrosis. Recent findings suggest that thrombocytosis carries a higher risk of bleeding than thrombosis in MPN, and aspirin may exacerbate this risk of bleeding, particularly in CALR-mutated ET.

Summary

Much of the management of MPN focuses on predicting risk of bleeding and thrombosis and initiating prophylaxis to prevent complications in those at high risk of thrombosis. Emerging evidence suggests that sub-populations may have bleeding risk that outweighs thrombotic risk, particularly in setting of antiplatelet therapy. Future work is needed to better characterize this balance. At present, a thorough assessment of the risks of bleeding and thrombosis should be undertaken for each patient, and herein, we review risk factors for and management of these complications.

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Prognostication in Philadelphia Chromosome Negative Myeloproliferative Neoplasms: a Review of the Recent Literature

Abstract

Purpose of Review

The prognosis for patients with Philadelphia chromosome (Ph)-negative myeloproliferative neoplasms (MPNs) is highly variable. All Ph-negative MPNs carry an increased risk for thrombotic complications, bleeding, and leukemic transformation. Several clinical, biological, and molecular prognostic factors have been identified in recent years, which provide important information in guiding management of patients with Ph-negative MPNs. In this review, we critically evaluate the recent published literature and discuss important new developments in clinical and molecular factors that impact survival, disease transformation, and thrombosis in patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis.

Recent Findings

Recent studies have identified several clinical factors and non-driver mutations to have prognostic impact on Ph-negative MPNs independent of conventional risk stratification and prognostic models. In polycythemia vera (PV), leukocytosis, abnormal karyotype, phlebotomy requirement on hydroxyurea, increased bone marrow fibrosis, and mutations in ASXL1, SRSF2, and IDH2 were identified as additional adverse prognostic factors. In essential thrombocythemia (ET), JAK2 V617F mutation, splenomegaly, and mutations in SH2B3, SF3B1, U2AF1, TP53, IDH2, and EZH2 were found to be additional negative prognostic factors. Bone marrow fibrosis and mutations in ASXL1, SRSF2, EZH2, and IDH1/2 have been found to be additional prognostic factors in primary myelofibrosis (PMF). CALR mutations appear to be a favorable prognostic factor in PMF, which has not been clearly demonstrated in ET.

Summary

The prognosis for patients with PV, ET, and PMF is dependent upon the presence or absence of several clinical, biological, and molecular risk factors. The significance of additional risk factors identified in these recent studies will need further validation in prospective studies to determine how they may be best utilized in the management of these disorders.

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Serotonin reuptake inhibitors and mortality in epilepsy: A linked primary-care cohort study

Summary

Objective

Preliminary evidence suggests that serotonin reuptake inhibitor (SRI) use may increase postictal respiratory drive and prevent death. We sought to determine whether SRIs are associated with improved all-cause and possible seizure-specific mortality in patients with epilepsy.

Methods

Patients with epilepsy and a random 10:1 sample without epilepsy were extracted from The ClinicAl research using LInked Bespoke studies and Electronic health Records (CALIBER) resource. The hazard ratio (HR) of all-cause and possible seizure-specific mortality, treating SRI use as a time-varying covariate, was determined using the date of a second SRI prescription as exposure and in discrete 6-month periods over the entire duration of follow-up. We used Cox regression and competing risk models with Firth correction to calculate the HR. We controlled for age, sex, depression, comorbidity, (Charlson comorbidity index) and socioeconomic status (Index of Multiple Deprivation).

Results

We identified 2,718,952 eligible patients in CALIBER, of whom 16,379 (0.60%) had epilepsy. Median age and follow-up were 44 (interquartile range [IQR] 29–61]) and 6.4 years (IQR 2.4–10.4 years), respectively, and 53% were female. A total of 2,178 patients (13%) had at least two SRI prescriptions. Hazard of all-cause mortality was significantly elevated following a second prescription for an SRI (HR 1.64 95% confidence interval [95% CI] 1.44–1.86; p < 0.001). The HR was similar in 163,778 age, sex, and general practitioner (GP) practice-matched controls without epilepsy. Exposure to an SRI was not associated with seizure-related death (HR 1.08, 95% CI 0.59–1.97; 0.796).

Significance

There is no evidence in this large population-based cohort that SRIs protect against all-cause mortality or seizure-specific mortality. Rather, SRI use was associated with increased mortality, irrespective of epilepsy, which is probably due to various factors associated with the use of antidepressants. Larger studies with systematically collected clinical data are needed to shed further light on these findings.

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Movement disorders with neuronal antibodies: syndromic approach, genetic parallels and pathophysiology

Abstract

Movement disorders are a prominent and common feature in many autoantibody-associated neurological diseases, a group of potentially treatable conditions that can mimic infectious, metabolic or neurodegenerative disease. Certain movement disorders are likely to associate with certain autoantibodies; for example, the characteristic dyskinesias, chorea and dystonia associated with NMDAR antibodies, stiff person spectrum disorders with GAD, glycine receptor, amphiphysin or DPPX antibodies, specific paroxysmal dystonias with LGI1 antibodies, and cerebellar ataxia with various anti-neuronal antibodies. There are also less-recognized movement disorder presentations of antibody-related disease, and a considerable overlap between the clinical phenotypes and the associated antibody spectra. In this review, we first describe the antibodies associated with each syndrome, highlight distinctive clinical or radiological 'red flags', and suggest a syndromic approach based on the predominant movement disorder presentation, age, and associated features. We then examine the underlying immunopathophysiology, which may guide treatment decisions in these neuroimmunological disorders, and highlight the exceptional interface between neuronal antibodies and neurodegeneration, such as the tauopathy associated with IgLON5 antibodies. Moreover, we elaborate the emerging pathophysiological parallels between genetic movement disorders and immunological conditions, with proteins being either affected by mutations or targeted by autoantibodies. Hereditary hyperekplexia, for example, is caused by mutations of the alpha subunit of the glycine receptor leading to an infantile-onset disorder with exaggerated startle and stiffness, whereas antibodies targeting glycine receptors can induce acquired hyperekplexia. The spectrum of such immunological and genetic analogies also includes cerebellar ataxias and some encephalopathies. Lastly, we discuss how these pathophysiological considerations could reflect on possible future directions regarding antigen-specific immunotherapies or targeting the pathophysiological cascades downstream of the antibody effects.

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TOR1A variants cause a severe arthrogryposis with developmental delay, strabismus and tremor

Abstract

Autosomal dominant torsion dystonia-1 is a disease with incomplete penetrance most often caused by an in-frame GAG deletion (p.Glu303del) in the endoplasmic reticulum luminal protein torsinA encoded by TOR1A. We report an association of the homozygous dominant disease-causing TOR1A p.Glu303del mutation, and a novel homozygous missense variant (p.Gly318Ser) with a severe arthrogryposis phenotype with developmental delay, strabismus and tremor in three unrelated Iranian families. All parents who were carriers of the TOR1A variant showed no evidence of neurological symptoms or signs, indicating decreased penetrance similar to families with autosomal dominant torsion dystonia-1. The results from cell assays demonstrate that the p.Gly318Ser substitution causes a redistribution of torsinA from the endoplasmic reticulum to the nuclear envelope, similar to the hallmark of the p.Glu303del mutation. Our study highlights that TOR1A mutations should be considered in patients with severe arthrogryposis and further expands the phenotypic spectrum associated with TOR1A mutations.

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Neuroinflammation and its relationship to changes in brain volume and white matter lesions in multiple sclerosis

Abstract

Brain magnetic resonance imaging is an important tool in the diagnosis and monitoring of multiple sclerosis patients. However, magnetic resonance imaging alone provides limited information for predicting an individual patient's disability progression. In part, this is because magnetic resonance imaging lacks sensitivity and specificity for detecting chronic diffuse and multi-focal inflammation mediated by activated microglia/macrophages. The aim of this study was to test for an association between 18 kDa translocator protein brain positron emission tomography signal, which arises largely from microglial activation, and measures of subsequent disease progression in multiple sclerosis patients. Twenty-one patients with multiple sclerosis (seven with secondary progressive disease and 14 with a relapsing remitting disease course) underwent T₁- and T₂-weighted and magnetization transfer magnetic resonance imaging at baseline and after 1 year. Positron emission tomography scanning with the translocator protein radioligand ¹¹C-PBR28 was performed at baseline. Brain tissue and lesion volumes were segmented from the T₁- and T₂-weighted magnetic resonance imaging and relative ¹¹C-PBR28 uptake in the normal-appearing white matter was estimated as a distribution volume ratio with respect to a caudate pseudo-reference region. Normal-appearing white matter distribution volume ratio at baseline was correlated with enlarging T₂-hyperintense lesion volumes over the subsequent year (ρ = 0.59, P = 0.01). A post hoc analysis showed that this association reflected behaviour in the subgroup of relapsing remitting patients (ρ = 0.74, P = 0.008). By contrast, in the subgroup of secondary progressive patients, microglial activation at baseline was correlated with later progression of brain atrophy (ρ = 0.86, P = 0.04). A regression model including the baseline normal-appearing white matter distribution volume ratio, T₂ lesion volume and normal-appearing white matter magnetization transfer ratio for all of the patients combined explained over 90% of the variance in enlarging lesion volume over the subsequent 1 year. Glial activation in white matter assessed by translocator protein PET significantly improves predictions of white matter lesion enlargement in relapsing remitting patients and is associated with greater brain atrophy in secondary progressive disease over a period of short term follow-up.

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Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use

BACKGROUND

Cannabis is purported to alleviate symptoms related to cancer treatment, although the patterns of use among cancer patients are not well known. This study was designed to determine the prevalence and methods of use among cancer patients, the perceived benefits, and the sources of information in a state with legalized cannabis.

METHODS

A cross-sectional, anonymous survey of adult cancer patients was performed at a National Cancer Institute–designated cancer center in Washington State. Random urine samples for tetrahydrocannabinol provided survey validation.

RESULTS

Nine hundred twenty-six of 2737 eligible patients (34%) completed the survey, and the median age was 58 years (interquartile range [IQR], 46-66 years). Most had a strong interest in learning about cannabis during treatment (6 on a 1-10 scale; IQR, 3-10) and wanted information from cancer providers (677 of 911 [74%]). Previous use was common (607 of 926 [66%]); 24% (222 of 926) used cannabis in the last year, and 21% (192 of 926) used cannabis in the last month. Random urine samples found similar percentages of users who reported weekly use (27 of 193 [14%] vs 164 of 926 [18%]). Active users inhaled (153 of 220 [70%]) or consumed edibles (154 of 220 [70%]); 89 (40%) used both modalities. Cannabis was used primarily for physical (165 of 219 [75%]) and neuropsychiatric symptoms (139 of 219 [63%]). Legalization significantly increased the likelihood of use in more than half of the respondents.

CONCLUSIONS

This study of cancer patients in a state with legalized cannabis found high rates of active use across broad subgroups, and legalization was reported to be important in patients' decision to use. Cancer patients desire but are not receiving information about cannabis use during their treatment from oncology providers. Cancer 2017. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

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Hypoglossal nerve stimulation for treatment of obstructive sleep apnea (OSA): a primer for oral and maxillofacial surgeons

Abstract

The prevalence of obstructive sleep apnea (OSA) is estimated to be 1–5% of the adult population world-wide, and in Korea, it is reported at 4.5% of men and 3.2% of women (Age 40 to 69 years old). Active treatment of OSA is associated with decrease in insulin resistance, cardiovascular disease, psychosocial problems, and mortality. Surgical treatment of OSA has evolved in the era of neuromodulation with the advent of hypoglossal nerve stimulation (HGNS). We share this review of HGNS with our maxillofacial surgical colleagues to expand the scope of surgical care for OSA.

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Endoscopic enucleation of large jaw cysts: Promising outcomes

To describe the endoscopic approach for management of large jaw cysts and assess the feasibility of endoscopic enucleation as well as analyze its outcome on a wide scale at Mansoura University Hospital MUH.

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Indications and Controversies for Complete and Implant-Enhanced Latissimus Dorsi Breast Reconstructions

Publication date: Available online 23 September 2017
Source:Clinics in Plastic Surgery
Author(s): Oren P. Mushin, Paige L. Myers, Howard N. Langstein

Teaser

This article describes the use of implant-enhanced and total-autologous latissimus dorsi myocutaneous flaps in breast reconstruction. It addresses the indications for use of this reconstruction alternative, which have recently been expanded thanks to the advent of high-volume fat grafting. Given its straightforward dissection, reliable vascular pedicle, variety of approaches, and potential for excellent aesthetic results, use of latissimus dorsi flaps may be considered among first-line options in selected patients.


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Indications and Controversies for Nonabdominally-Based Complete Autologous Tissue Breast Reconstruction

Publication date: Available online 23 September 2017
Source:Clinics in Plastic Surgery
Author(s): Dries Opsomer, Koenraad van Landuyt

Teaser

Autologous breast reconstruction can be challenging in mastectomy patients who are not eligible for a deep inferior epigastric artery perforator flap reconstruction. Depending on body habitus, alternative donor sites for free flap transfer can be found on the back, the thighs, and in the gluteal area. These alternative flaps can demand a higher level of expertise, which should be mastered by the modern day reconstructive microsurgeon. The flap choice should be tailored individually to each patient and should not be limited by the difficulty of the surgery.


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The Quantitative and Functional Changes of Postoperative Peripheral Blood Immune Cell Subsets Relate to Prognosis of Patients with Subarachnoid Hemorrhage: A Preliminary Study

Publication date: December 2017
Source:World Neurosurgery, Volume 108
Author(s): Yugang Jiang, Yu Zhou, Yong Peng, Mingming Zhang
ObjectiveIt has been suggested that the preoperative (PRE) and postoperative (POST) immune system alteration triggered by aneurysmal subarachnoid hemorrhage (SAH) and surgical treatment itself may affect patients' prognosis and contribute to POST complications. The mechanisms may be attributed to immune suppression–triggered infection or immune overreaction–triggered aseptic inflammation. In this study, we investigated the dynamic changes in peripheral immune cell subsets as well as the alterations of inflammatory cytokines in patients with aneurysmal SAH who received craniotomy and clipping surgery. In addition, we studied the association of those changes with POST complications and clinical prognosis.MethodsWe investigated 27 patients who received craniotomy and clipping surgery for aneurysmal SAH. The operations were all performed within 24 hours after the occurrence of aneurysm rupture. Detailed immune monitoring (peripheral blood leukocytes and lymphocyte subsets and inflammatory cytokines) was performed on PRE (on admission), day 1, day 3, and day 6 after operation.ResultsOur data showed that the percentage of CD3+, CD8+, natural killer T (NKT), CD4+, and regulatory T (Treg) cells significantly decreased and the level of interleukin 4 (IL-4), interferon γ, and IL-2 significantly increased 1 day after surgery compared with the data in PRE. On the contrary, natural killer (NK), NK group 2 (NKG2D), and B cells increased and the level of IL-10 in plasma decreased. In study of the relationship between POST fever and the change in immune cell subgroups, the fever group had a lower percentage of CD3+, CD4+, NKT, Tregs, and B cells on day 1, day 3, and day 6 after surgery compared with the patients who did not have fever, whereas the CD8+, NK, and NKG2D subsets showed the opposite trend. Furthermore, we analyzed the association between immune profile changes and the prognosis of those patients. The patients were divided into those with an unfavorable prognosis (n = 6) and those with a favorable prognosis (n = 21) according to Glasgow Outcome Scale score and postoperation (POST) coma. Our results showed that except for B cells, patients with a favorable prognosis had a relatively higher percentage of CD3+, CD4+, CD8+, NK, NKT, NKG2D, and Treg cells compared with the unfavorable prognosis group from PRE to day 6 POST.ConclusionsOur results indicated that patients with aneurysmal SAH undergoing craniotomy and clipping surgery had a profound transient deterioration in immune function. In addition, the changes in immune cell subgroups had a strong association with POST fever. The changes in immune cell subgroups were also directly associated with clinical prognosis of the patients. These association findings might be attributable to a better biomarker to predict patient diagnosis.



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Transfer of Learning from Practicing Microvascular Anastomosis on Silastic Tubes to Rat Abdominal Aorta

Publication date: December 2017
Source:World Neurosurgery, Volume 108
Author(s): Pooneh Mokhtari, Ali Tayebi Meybodi, Michael T. Lawton, Andre Payman, Arnau Benet
ObjectiveLearning to perform microvascular anastomosis is difficult. Laboratory practice models using artificial vessels are frequently used for this purpose. However, the efficacy of such practice models has not been objectively assessed for the performance of microvascular anastomosis during live surgical settings. This study was conducted to assess the transfer of learning from practicing microvascular anastomosis on tubes to anastomosing rat abdominal aorta.MethodsTen surgeons without any experience in microvascular anastomosis were randomly assigned to an experimental or a control group. Both groups received didactic and visual training on end-to-end microvascular anastomosis. The experimental group received 24 sessions of hands-on training on microanastomosis using Silastic tubes. Next, both groups underwent recall tests on weeks 1, 2, and 8 after training. The recall test consisted of completing an end-to-end anastomosis on the rat's abdominal aorta. Anastomosis score, the time to complete the anastomosis, and the average time to place 1 stitch on the vessel perimeter were compared between the 2 groups.ResultsCompared with the control group, the experimental group did significantly better in terms of anastomosis score, total time, and per-stitch time. The measured variables showed stability and did not change significantly between the 3 recall tests.ConclusionThe skill of microvascular anastomosis is transferred from practicing on Silastic tubes to rat's abdominal aorta. Considering the relative advantages of Silastic tubes to live rodent surgeries, such as lower cost and absence of ethical issues, our results support the widespread use of Silastic tubes in training programs for microvascular anastomosis.



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Quantitative Analysis of Intracranial Vertebrobasilar Dissecting Aneurysm with Intramural Hematoma After Endovascular Treatment Using 3-T High-Resolution Magnetic Resonance Imaging

Publication date: December 2017
Source:World Neurosurgery, Volume 108
Author(s): Zhongbin Tian, Junfan Chen, Yisen Zhang, Jian Liu, Yang Wang, Binbin Sui, Xinjian Yang
ObjectiveQuantitative measurements of intracranial vessel walls are reliable in 3-T high-resolution magnetic resonance imaging (HR-MRI). However, few reports have assessed the arterial wall after endovascular treatment (EVT) by 3-T HR-MRI. This study aimed to quantitatively analyze vessel walls in vertebrobasilar artery dissecting aneurysms after EVT.MethodsFrom May 2012 to December 2015, a total of 21 patients with 21 intracranial vertebrobasilar dissecting aneurysms (VBDAs) were enrolled in this consecutive study. All the VBDAs were characterized by intramural hematomas (IMHs ≥5 mm) and treated with reconstructive EVT. Images of preoperative and follow-up 3-T HR-MRI were used to evaluate the arterial wall. The relative signal intensity (RSI) of IMHs was quantified on T1-weighted imaging (T1WI) and magnetization-prepared rapid acquisition gradient-echo (MPRAGE).ResultsAngiographic follow-up was performed for a mean of 9.19 ± 3.22 months. According to angiographic results at follow-up, 21 patients were divided into 2 groups (progressive group, n = 6; stable group, n = 15). In the progressive group, RSI of IMHs was significantly increased on MPRAGE of follow-up 3-T HR-MRI compared with that before treatment (P < 0.05), and the difference was not significant on T1WI. However, in the stable group, RSI of IMHs was significantly reduced after treatment (P < 0.05).ConclusionsPersistent high signal intensity of IMHs in VBDAs after reconstructive EVT may be associated with the progression of VBDAs. It may also indicate an unsteady state of the aneurysm, which suggests that reconstruction of the parent artery is not satisfactory.



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Single-Step Resection of an Intraosseous Meningioma and Cranial Reconstruction: Technical Note

Publication date: December 2017
Source:World Neurosurgery, Volume 108
Author(s): Charlotte-Elise Broeckx, Thomas J.J. Maal, Rinaldo D. Vreeken, Ruud R.M. Bos, Mark ter Laan
ObjectiveSimultaneous tumor resection and cranial reconstruction can be a challenging task. Surgical navigation is an indispensable tool in making this single-step procedure possible. In this technical note, we describe a new technique for this procedure to ensure a precise resection and optimal fit of the implant in a patient with an intraosseous meningioma.MethodsWe generated a 3-dimensional (3D) model of the patient's skull based on a computed tomography scan and created a digital "resection line" object using 3D Studio Max 2016 software. Based on this object, the patient-specific implant was generated and printed with a 3D printer. Before surgery, the digital object was transferred to the neuronavigation system to enable a navigated resection of the lesion to ensure maximum precision. During surgery, the craniotomy was performed, and the custom-made implant was fitted in a single step.ResultsThe planned resection was achieved, and the implant could be fitted without need for further adjustments to the resection border.ConclusionsWe provide a simple technique to digitally define a planned resection site and create a custom-made implant using specialized software and 3D printing to enable single-step resection of a skull lesion and cranial reconstruction, thereby reducing surgical time and costs and ensuring a good cosmetic result.



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Synchronous Ganglioneuroma and Schwannoma Mistaken for Carotid Body Tumor

Ganglioneuromas are a very rare benign neural tumor, commonly derived from the ganglia of the sympathetic system, and are composed of mature Schwann cells, ganglion cells, and nerve fibres. They may arise anywhere from the base of the skull to the pelvis along the paravertebral sympathetic plexus. We report a rare case of synchronous ganglioneuroma and schwannoma, mistaken for carotid body tumor. The coexistence of these two entities in head and neck region is very rare.

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Soft obturator prosthesis for postoperative soft palate carcinoma: A clinical report

Publication date: Available online 23 September 2017
Source:The Journal of Prosthetic Dentistry
Author(s): Tomohisa Ohno, Kyoko Hojo, Ichiro Fujishima
An intraoral prosthesis with a soft flexible obturator was provided for a patient with a soft palate perforation after surgical and chemoradiotherapy treatments of a soft palate tumor. An obturator composed of movable and flexible silicone was attached to a structure similar to a palatal lift; it was therefore able to move according to the movement of the soft palate, which was confirmed by endoscopic examination. The application of this prosthesis resulted in complete disappearance of hypernasality and food reflux, and the patient was able to eat without particular limitation during daytime wearing. This type of prosthesis represents a potential prosthetic approach to a soft palate nasal-oral fistula.



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Endoscopic enucleation of large jaw cysts: Promising outcomes

Publication date: Available online 24 September 2017
Source:Auris Nasus Larynx
Author(s): Mohamed Abdelwahab, Ahmed Musaad Abd Elfattah, Yasser W. Khafagy, Ahmed El-Degwi
ObjectiveTo describe the endoscopic approach for management of large jaw cysts and assess the feasibility of endoscopic enucleation as well as analyze its outcome on a wide scale at Mansoura University Hospital MUH.MethodsThis prospective cohort study was done on 23 consecutive cases presenting with different types of large jaw cysts in the period from January 2013 to July 2016 at ENT Department, Mansoura University Hospital. All patients, (16 maxillary & 7 mandibular) cysts, were managed endoscopically. Follow up ranged from 6 to 48 months.ResultsAll patients showed complete resolution of their symptoms postoperatively except for 2 maxillary case who didn't undergo an antrostomy and 1 mandibular indicated a second look.ConclusionLarge jaw cysts lie at the border line of management options. Resection of the affected segment is a radical option but the most deforming. On the other hand, conservative procedures are prolonged and not definitive. To our knowledge this is the first case series of endoscopic enucleation of large maxillary and mandibular cysts, highlighting its advantages in variable types.



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Comparison of the accuracy of maxillary position between conventional model surgery and virtual surgical planning

Publication date: Available online 23 September 2017
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): F.G. Ritto, A.R.M. Schimtt, T. Pimentel, J.V. Canellas, P.J. Medeiros
The aim of this study was to determine whether virtual surgical planning (VSP) is an accurate method for positioning the maxilla when compared to conventional articulator model surgery (CMS), through the superimposition of computed tomography (CT) images. This retrospective study included the records of 30 adult patients submitted to bimaxillary orthognathic surgery. Two groups were created according to the treatment planning performed: CMS and VSP. The treatment planning protocol was the same for all patients. Pre- and postoperative CT images were superimposed and the linear distances between upper jaw reference points were measured. Measurements were then compared to the treatment planning, and the difference in accuracy between CMS and VSP was determined using the t-test for independent samples. The success criterion adopted was a mean linear difference of <2mm. The mean linear difference between planned and obtained movements for CMS was 1.27±1.05mm, and for VSP was 1.20±1.08mm. With CMS, 80% of overlapping reference points had a difference of <2mm, while for VSP this value was 83.6%. There was no statistically significant difference between the two techniques regarding accuracy (P>0.05).



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Clinicopathologic significance of in vivo antinuclear autoantibodies in oral mucosal biopsies.

Clinicopathologic significance of in vivo antinuclear autoantibodies in oral mucosal biopsies.

Oral Surg Oral Med Oral Pathol Oral Radiol. 2017 Aug 24;:

Authors: Alshagroud R, Neiders M, Kramer JM, Suresh L

Abstract
OBJECTIVE: Although antinuclear autoantibody (ANA) staining of oral biopsy specimens is indicative of chronic ulcerative stomatitis, it is not known whether this staining is characteristic of other autoimmune diseases. Our study was undertaken to characterize the various in vivo ANA patterns detected in the oral mucosa by direct immunofluorescence to describe the associated hematoxylin and eosin findings, and determine whether patients with these findings had a coexisting systemic connective tissue disease.
STUDY DESIGN: This was a retrospective analysis of oral biopsy specimens submitted from 2013 to 2016.
RESULTS: In vivo ANA staining was present in 72 of the 2019 cases examined. Immunoglobulin G was the most common immunoreactant (71 of 72 cases), and speckled nuclear staining was the most frequent in vivo ANA pattern (52 of 72). In most cases, hematoxylin and eosin staining of biopsy specimens showed mucositis (24 of 34). Detailed clinical information was available for 10 patients, and all of them had an autoimmune disease.
CONCLUSIONS: We found similar prevalence of ANA staining with direct immunofluorescence in oral epithelial biopsy specimens as reported for those of skin. In vivo ANA in the oral epithelium may indicate the presence of an immune-mediated disease. Patients who show ANA deposits in oral mucosal biopsy specimens should be investigated for systemic connective tissue disease as well as for chronic ulcerative stomatitis.

PMID: 28939244 [PubMed - as supplied by publisher]

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Laryngotracheal reconstruction and swallowing: A review

Publication date: November 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 102
Author(s): Jennifer F. Ha, Lynn Driver, David A. Zopf
ObjectivesSignificant advances in laryngotracheal reconstruction over the last few decades have revolutionised the management of paediatric patients with complex congenital or acquired airway stenosis. The primary aim of laryngotracheal reconstruction has focused primarily on airway and surgery specific outcomes, often at the expense of voice, as well as swallowing function, which are all intricately related. There is currently a paucity of data on swallowing outcome. The goal of this paper is to review and discuss the existing research on the impact of laryngotracheal on swallowing.MethodsNarrative review.ResultsSuccessful and safe oral feeding in children requires a highly complex and integrated sensorimotor system for proper timing and coordination, beginning with a well-coordinated suck-swallow-breathe sequence in infancy. Factors to consider include the normal laryngeal anatomy, nutrition as a stimulus and the development of feeding skills on swallowing, the underlying aetiology and other risk factors, LTR procedures and their adjuncts. All these impact on the children's growth. Swallow assessments and rehabilitation is therefore an important part of the post-operative care.ConclusionsAs airway reconstructive surgeries have improved in airway and surgery specific outcomes, swallowing function is an important secondary outcome that impacts on the children's and their families' life. Management in a multi-disciplinary manner will optimise the outcome and improve their quality of life.



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Evaluating the sinus and Nasal Quality of Life Survey in the pediatric cystic fibrosis patient population

Publication date: November 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 102
Author(s): Deborah X. Xie, Jeffanie Wu, Katherine Kelly, Rebekah F. Brown, Chevis Shannon, Frank W. Virgin
IntroductionThe Sinus and Nasal Quality of Life Survey (SN-5) is a validated quality of life (QOL) questionnaire for chronic rhinosinusitis in patients age 2–12. Its utility in the cystic fibrosis (CF) has been studied, but not yet validated. The purpose of this study is to determine the effectiveness of the SN-5 for evaluation of sinonasal symptoms in the pediatric CF population.MethodsThis retrospective study analyzed SN-5 surveys completed between 2012 and 2015 by pediatric CF patients and caregivers. Baseline and follow-up overall QOL scores and specific symptom scores were obtained from surveys completed in the three-year span. Non-parametric statistics were conducted to identify differences in survey data.ResultsA total of 165 patients completed baseline and follow-up surveys. The overall QOL of the patient cohort did not change over the duration of the study (p = 0.660). Thirty-seven patients indicated higher overall QOL, with all five symptom scores showing significant improvement. Analysis by age group showed that QOL was significantly correlated with all five symptoms for children ages 0–4. In patients 5–12 years, overall QOL was only correlated with sinus infection (r = −0.3090, p = 0.01). QOL was significantly correlated with sinus infection (r = −0.2903, p = 0.04) and allergy symptoms (r = −0.5644, p < 0.01) in patients >12 years of age.ConclusionThere remains a need for a validated CRS QOL tool for children with CF. Though the SN-5 has previously been described as a potential instrument, our data suggest that it may be more valuable in children ages 0–4.



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Towards reporting standards for neuropsychological study results: A proposal to minimize communication errors with standardized qualitative descriptors for normalized test scores

Publication date: November 2017
Source:Clinical Neurology and Neurosurgery, Volume 162
Author(s): Mike R. Schoenberg, Ruba S. Rum
ObjectiveRapid, clear and efficient communication of neuropsychological results is essential to benefit patient care. Errors in communication are a lead cause of medical errors; nevertheless, there remains a lack of consistency in how neuropsychological scores are communicated. A major limitation in the communication of neuropsychological results is the inconsistent use of qualitative descriptors for standardized test scores and the use of vague terminology.Patients and methodsPubMed search from 1 Jan 2007 to 1 Aug 2016 to identify guidelines or consensus statements for the description and reporting of qualitative terms to communicate neuropsychological test scores was conducted. The review found the use of confusing and overlapping terms to describe various ranges of percentile standardized test scores.ResultsIn response, we propose a simplified set of qualitative descriptors for normalized test scores (Q-Simple) as a means to reduce errors in communicating test results. The Q-Simple qualitative terms are: 'very superior', 'superior', 'high average', 'average', 'low average', 'borderline' and 'abnormal/impaired'. A case example illustrates the proposed Q-Simple qualitative classification system to communicate neuropsychological results for neurosurgical planning.ConclusionsThe Q-Simple qualitative descriptor system is aimed as a means to improve and standardize communication of standardized neuropsychological test scores. Research are needed to further evaluate neuropsychological communication errors. Conveying the clinical implications of neuropsychological results in a manner that minimizes risk for communication errors is a quintessential component of evidence-based practice.



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