Adequate Patient Selection Research Articles

Trastuzumab in combination with chemotherapy for HER2-positive metastatic gastric cancer patients underwent conversion therapy.

BackgroundConversion surgery is a treatment that aims for R0 resection of primary advanced gastric cancers (GCs) that have responded well to systemic chemotherapy. We investigated the role of conversion therapy in initially unresectable metastatic cancer with positive HER2 status that responded to chemotherapy plus trastuzumab.MethodsA total of 32 metastatic GC patients who underwent systemic chemotherapy plus trastuzumab sequenced by conversion surgery at Zhejiang Cancer Hospital between 2015 and 2020 were retrospectively reviewed.ResultsThe observed overall survival (OS) and progression-free survival (PFS) for all the patients were 30.2 and 25.1 months, respectively. The 1-year survival rate was 81.25%, and the 1-year PFS rate was 78.13%. Univariate and multivariate analyses demonstrated that liver metastasis (P=0.021), peritoneal metastasis (P=0.047), para-aortic lymph node metastasis (16a1/b2) (P=0.048), macroscopic type 4 (P=0.027), number of noncurative factors (P=0.011), Yoshida et al. category (P=0.021), and inductive chemotherapy cycles (P=0.025) were independent prognostic factors for OS.ConclusionsHER2-positive patients with potentially resectable disease had a remarkably good prognosis after conversion gastrectomy following trastuzumab treatment. Adequate selection of metastatic GC patients for conversion surgery is recommended.

Sympathetic and Vagal Nerve Activity in COPD: Pathophysiology, Presumed Determinants and Underappreciated Therapeutic Potential.

This article explains the comprehensive state of the art assessment of sympathetic (SNA) and vagal nerve activity recordings in humans and highlights the precise mechanisms mediating increased SNA and its corresponding presumed clinical determinants and therapeutic potential in the context of chronic obstructive pulmonary disease (COPD). It is known that patients with COPD exhibit increased muscle sympathetic nerve activity (MSNA), as measured directly using intraneural microelectrodes-the gold standard for evaluation of sympathetic outflow. However, the underlying physiological mechanisms responsible for the sympathoexcitation in COPD and its clinical relevance are less well understood. This may be related to the absence of a systematic approach to measure the increase in sympathetic activity and the lack of a comprehensive approach to assess the underlying mechanisms by which MSNA increases. The nature of sympathoexcitation can be dissected by distinguishing the heart rate increasing properties (heart rate and blood pressure variability) from the vasoconstrictive drive to the peripheral vasculature (measurement of catecholamines and MSNA) (Graphical Abstract Figure 1). Invasive assessment of MSNA to the point of single unit recordings with analysis of single postganglionic sympathetic firing, and hence SNA drive to the peripheral vasculature, is the gold standard for quantification of SNA in humans but is only available in a few centres worldwide because it is costly, time consuming and requires a high level of training. A broad picture of the underlying pathophysiological determinants of the increase in sympathetic outflow in COPD can only be determined if a combination of these tools are used. Various factors potentially determine SNA in COPD (Graphical Abstract Figure 1): Obstructive sleep apnoea (OSA) is highly prevalent in COPD, and leads to repeated bouts of upper airway obstructions with hypoxemia, causing repetitive arousals. This probably produces ongoing sympathoexcitation in the awake state, likely in the "blue bloater" phenotype, resulting in persistent vasoconstriction. Other variables likely describe a subset of COPD patients with increase of sympathetic drive to the heart, clinically likely in the "pink puffer" phenotype. Pharmacological treatment options of increased SNA in COPD could comprise beta blocker therapy. However, as opposed to systolic heart failure a similar beneficial effect of beta blocker therapy in COPD patients has not been shown. The point is made that although MSNA is undoubtedly increased in COPD (probably independently from concomitant cardiovascular disease), studies designed to determine clinical improvements during specific treatment will only be successful if they include adequate patient selection and translational state of the art assessment of SNA. This would ideally include intraneural recordings of MSNA and-as a future perspective-vagal nerve activity all of which should ideally be assessed both in the upright and in the supine position to also determine baroreflex function.

The role and impact of immunotherapy in multiple malignancies in the Mexican population.

e14570 Background: Cancer in Mexico represents the third cause of death nationally. Immunotherapy agents have changed management and prognosis of cancer patients. Immune-checkpoint agents are now being used as both first- and second-line treatment improving cancer patient prognosis, nevertheless it is not always accessible. Methods: Retrospective review of patients diagnosed with any type of cancer that received immunotherapy during their disease course from the last 5-years. We present the most common malignancies, immunotherapeutic regimens received, population characteristics and survival analysis. Results: 130 records of patients ≥18 years that received immunotherapy were included. 52.3% female with mean age of 59 years (range, 22-89 years), 48.5% former smokers (average pack/year of 22.5) and 31.5% asbestos exposure. 53.1% were ECOG 0 and 82.3% clinical stage IV. 62.3% of cases were lung adenocarcinoma, followed by lung epidermoid carcinoma (13.1%) and 10% small-cell lung carcinoma. Immunotherapeutic agents used included nivolumab in 63.1%, pembrolizumab 12.3%, nivolumab + ipilimumab 8.5%, durvalumab 6.2%, pembrolizumab + ipilimumab 4.6%. 36.2% of patients received immunotherapy as second line treatment, 30.0% as third and 23.8% as first line treatment. The best Response Evaluation Criteria in Solid Tumors (RECIST) was RECIST 3 in 46.2% followed by RECIST 0 with 25.4%. Median progression-free survival (PFS) was 5 months (95% CI; 3.883-6.117) and median OS of 13 months (95% CI; 10.210-15.790). Analysis per immunotherapy on PFS (p = 0.0414) and OS (p = 0.0046) demonstrated pembrolizumab had the longest median PFS with 19-months and OS with 22-months. Analysis between tumor types was significant for both PFS (p = 0.0018) and OS (p = 0.0090) with melanoma having the longest median PFS (42-months) and OS (46-months). Conclusions: Immunotherapy has changed cancer management; however, its use depends on specific biomarkers and adequate patient selection. Not all patients benefit from immunotherapy, in a country like ours where resources are limited, it is of vital importance to properly select candidates for immunotherapy. Even though, all patients had an FDA-approved indication at the time of receiving immunotherapy, PFS and OS are not as significant as Phase 3 studies demonstrate, this may be due to late stages, advanced ECOG, correct biomarkers availability and adequate patient selection. It is important to mention that about 40-60% of patients with immunotherapy do not respond adequately. In our study, because there is more evidence with pembrolizumab, the patients who received it were better chosen and therefore there was an impact in PFS and OS. Immunotherapy selection also depends on physician experience to the different immunotherapy regimens.

"Zooming" in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé?

SUMMARYOBJECTIVE:Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days.METHODS:This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy.RESULTS:The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected.CONCLUSIONS:Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment.

Comparison of Surgical Outcomes of Hysterectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) versus Single-Port Access (SPA) Surgery.

Single-port access (SPA) laparoscopic surgery and vaginal natural orifice transluminal endoscopic surgery (vNOTES) have many advantages. The objective of the present study is to compare patient characteristics, operative details, and postoperative outcomes between the two surgical methods. Patients who were planned to undergo vNOTES or SPA laparoscopic surgery between April 2020 and June 2021 were prospectively enrolled. The surgical method was determined by a single surgeon after imaging results evaluation and a physical exam. Those who had favorable pelvic conditions without any evidence of adhesion were scheduled for vNOTES. A total of 33 patients underwent a vNOTES hysterectomy while 40 patients received a SPA laparoscopic hysterectomy. All surgeries were performed by one surgeon. The proportion of the patients who had a history of vaginal delivery was significantly higher in the vNOTES group. The operative time for port installation was significantly longer in the vNOTES group, but the total operative time was shorter compared to the SPA group. The postoperative pain scores 12 h after the operations were also significantly lower in the vNOTES group. Other surgical outcomes were comparable between the two groups. The present study demonstrated that the early operative outcomes of vNOTES hysterectomy were comparable to those of SPA hysterectomy. It also highlights the importance of adequate patient selection when determining surgical methods based on imaging results and physical examinations.

Umbilical hernia repair in patients with cirrhosis: who, when and how to treat.

Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.

Deep brain stimulation in Parkinson's disease: state of the art and future perspectives.

For more than 30 years, Deep Brain Stimulation (DBS) has been a therapeutic option for Parkinson's disease (PD) treatment. However, this therapy is still underutilized mainly due to misinformation regarding risks and clinical outcomes. DBS can ameliorate several motor and non-motor symptoms, improving patients' quality of life. Furthermore, most of the improvement after DBS is long-lasting and present even in advanced PD. Adequate patient selection, precise electric leads placement, and correct DBS programming are paramount for good surgical outcomes. Nonetheless, DBS still has many limitations: axial symptoms and signs, such as speech, balance and gait, do not improve to the same extent as appendicular symptoms and can even be worsened as a direct or indirect consequence of surgery and stimulation. In addition, there are still unanswered questions regarding patient's selection, surgical planning and programming techniques, such as the role of surgicogenomics, more precise imaging-based lead placement, new brain targets, advanced programming strategies and hardware features. The net effect of these innovations should not only be to refine the beneficial effect we currently observe on selected symptoms and signs but also to improve treatment resistant facets of PD, such as axial and non-motor features. In this review, we discuss the current state of the art regarding DBS selection, implant, and programming, and explore new advances in the DBS field.

Normal pressure hydrocephalus: an update.

Normal pressure hydrocephalus (NPH) has been a topic of debate since its introduction in publications. More frequent in the elderly population, it is characterized by gait disturbance, urinary urge incontinence and cognitive decline. Therefore, it is a clinical-radiological entity with relatively common findings for the age group, which together may have greater specificity. Therefore, its diagnosis must be careful for an adequate selection of patients for treatment with ventricular shunt, since the symptoms are potentially reversible. The tap test has a high positive predictive value as a predictor of therapeutic response, but a negative test does not exclude the possibility of treatment. Scientific efforts in recent years have been directed towards a better understanding of NPH and this narrative review aims to compile recent data from the literature in a didactic way for clinical practice.

Stellenwert der Chirurgie bei fernmetastasierten neuroendokrinen Neoplasien des Pankreas

The majority of patients with pancreatic neuroendocrine neoplasms (pNEN) already present with distant metastases at diagnosis. The heterogeneity of pNEN and the broad spectrum of treatment options make adequate patient selection and an evidence-based strategy essential. In metastatic pNEN both primary resection and resection of liver metastases have been shown to improve overall survival. Surgical treatment of liver metastases can also be carried out with palliative intent, especially for symptomatic pNEN and can have apositive effect on disease-free survival and overall survival. Classical hepatectomy techniques and innovative techniques (two-stage resections, liver transplantation) are available to the surgeon. In complex growth types of liver metastases, there is increasing evidence for acombination of surgery and ablative methods. Due to arelevant risk of recurrence following liver resection, pNEN patients need to be included in multimodal treatment concepts. Current areas of interest in the treatment of metastatic pNEN are the use of adjuvant/neoadjuvant chemotherapy and surgery in G3-NEN and G3-NEC patients. The aim of this review is to give an overview on the impact of surgery in the situation of distant metastatic NEN of the pancreas.

Surgical and focal treatment for metastatic renal cell carcinoma: A literature review.

Accompanied by the development of systemic therapy for metastatic renal cell carcinoma, the concept of focal treatment, including surgical treatment, has been changing. Although immediate cytoreductive nephrectomy was essentially considered for synchronous metastatic renal cell carcinoma patients, the CARMENA trial and SURTIME trial revealed the negative impact of immediate cytoreductive nephrectomy. Therefore, immediate cytoreductive nephrectomy is currently considered only for a limited number of patients. Besides, deferred cytoreductive nephrectomy seems to have efficacy for overall survival in prior retrospective studies. Two randomized controlled trials, the PROBE trial (NCT04510597) and the NORDIC-SUN trial (NCT03977571), are underway to elucidate deferred cytoreductive nephrectomy. Metastasectomy is also considered in metastatic renal cell carcinoma patients because previous studies demonstrated the overall survival benefit of metastasectomy. However, since all reports were retrospective studies, physicians could exclude the patients who were not expected to show the efficacy of metastasectomy. Therefore, an adequate patient selection for metastasectomy is important. A common factor predicting better overall survival was complete resection. Radiotherapies for metastatic lesions during systemic therapy showed approximately 90% local disease control rate at 1 year. However, no report has demonstrated that radiotherapy improves survival so far. Since surgical and focal treatments for metastatic renal cell carcinoma patients generally have minimal evidence, further investigations are needed.

Survival outcomes of emergency thoracotomy in severely injured patients performed by a general surgeon at a rural university hospital in Thailand

Background: Emergency thoracotomy is a potentially life-saving maneuver for trauma patients in extremis. Since trauma scenarios, in rural locations, usually occur with a high incidence of a severe injury that leads to hemorrhagic shock or cardiopulmonary arrest. The objective of this study was to analyze the experience in emergency thoracotomy performed by a general surgeon in a rural area in Thailand. Methods: This retrospective study was conducted by analyzing the patient records including demographics, mechanisms of injuries, specific organ injury, surgical approach, life-saving surgical procedure, and postoperative outcome for all patients who underwent emergency thoracotomy in the Department of Surgery, Srinakharinwirot University hospital between January 2010 and December 2020. Results: Twelve patients underwent emergency thoracotomy within 1 hour after arrival and were equally divided between blunt and penetrating injuries with 6 (50%). A mean patient age of 34.8 ± 15.2 years (range 16–55), mean systolic blood pressure on arrival was 65.8 ± 35.2 mmHg (range 0–100 mmHg), and the mean injury severity score (ISS) was 54.6 ± 25.2 (range 26–75). Profound hemorrhagic shock is a major indication for emergency thoracotomy. The overall survival rate was 41.7% (5/12 patients) without survivors from cardiac injuries. Four patients (66.7%) in the penetrating and 1 patient (16.7%) in the blunt intrathoracic injury group were survived and discharged from the hospital. Conclusion: Emergency thoracotomy offers a chance for survival at 41.7% for trauma patients who present with extremes in this study. Rapid decision-making, good operative technique, and adequate patient selection are crucial for reasonable outcomes.

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

IntroductionSurgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. MethodsRetrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007–2018. The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients ≥75 years (elderly). Results79 patients were included, 21 of them older than 75 years (27%); within this group, 23’9% were over 80 years old. The ASA of both groups was similar. Patients ≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P = .037).Morbidity was higher in the elderly (61.9% vs. 46.6%), although without differences. Patients aged ≥75 years had more non-surgical complications (33.3%, P = .050), being pneumonia the most frequent. Postoperative mortality was higher in the ≥75 years (9 vs. 0%; P = .017). The overall survival and disease-free survival did not show significant differences in both groups. ConclusionsElderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Fluocinolone acetonide implant in diabetic macular edema: International experts' panel consensus guidelines and treatment algorithm.

Center-involving diabetic macular edema (DME) is a leading cause of vision impairment in working-age adults. While its management is particularly challenging in a poorly compliant population, continuous innovation and the advent of new molecules have improved its outcome. The control of glycemia and of systemic aggravating factors remain essential to slow down progression of disease complications including DME. The indications for macular laser photocoagulation has progressively been phased out as a standard of care and replaced by local intraocular anti-VEGFs biologics and glucocorticoids (GCs). Intravitreal GCs in controlled-release drug delivery systems have allowed to reduce injection frequency and treatment burden. The non biodegradable Fluocinolone Acetonide (FAc) implant allows a long-lasting stabilization of both functional and anatomic improvements. However, adequate patient selection and monitoring through regular follow-up are essential for optimal results. Based on their experience and the latest literature, the aim of the present review is to provide international expert panel consensus on the place of the FAc implant in the treatment algorithm of DME, as well as its safety profile and how to manage it.

Venogenic erectile dysfunction: diagnosis on computed tomography cavernosography and endovascular treatment using an anterograde access via deep dorsal penile vein

BackgroundThe underlying etiologies of erectile dysfunction may be manifold. Among them, vasculogenic etiologies are of increasing relevance and are not strictly limited to the elderly population. According to recent study, venogenic erectile dysfunction appears to be even more relevant than arteriogenic erectile dysfunction. Venogenic erectile dysfunction due to venous leakage causes insufficient penile blood retention. Proper diagnosis of venous leakage should include both color Doppler flow analysis and computed tomography cavernosography for adequate patient selection and treatment planning. Besides surgical ligation of penile draining veins, endovascular treatment methods may demonstrate more promising results. Especially endovascular embolization of venous leakage using an anterograde access via deep dorsal penile veins appears to be more beneficial for patients’ clinical outcome and awareness of this technique should be raised among endovascular interventionalists.Case presentationA 47-year-old man was diagnosed with venogenic erectile dysfunction due to venous leakage on color Doppler flow analysis and computed tomography cavernosography. He did not respond to PDE-5-inhibitors. This patient demonstrated major venous leakage of paired deep dorsal penile veins via periprostatic veins and internal pudendal veins draining into both iliohypogastric veins. This patient’s venous leak was treated with endovascular embolization using an anterograde access via deep dorsal penile veins.ConclusionThis patient’s erectile dysfunction due to venous leakage, based on findings in color Doppler flow analysis and computed tomography cavernosography, was embolized using an anterograde access via deep dorsal penile veins as a minimally-invasive endovascular treatment option.

Use of Cultivated Epidermal Allograft in Chronic Wounds: A Novel Therapeutic Alternative.

Chronic wounds represent a frequent cause of consultation for plastic and reconstructive surgeons. The use of epidermal culture stands out because they provide complete epithelialization, adequate aesthetic-functional results, and no morbidity for the patient. Epifast® is a pre-manufactured cultured epidermal allograft derived from the amplification in vitro of human keratinocytes. A prospective longitudinal multicenter study was carried out in four chronic wound reference centers, which were in charge of plastic and reconstructive surgery services. For a standardized wound bed preparation, the protocol synthesized by the acronym "TIME" was used. At the end of the "TIME" protocol, the pre-fabricated allograft was applied and removed 7 days after its application. A total of 133 patients with diagnosis of chronic wound were included in the study. The median age was 69.3 ± 13.6 years. The most common comorbidity found was diabetes mellitus type 2 in 71.4% of the patients (n = 95) and systemic arterial hypertension in 60.2% of the patients (n = 80). The most frequent location of chronic wounds was seen in the lower extremity with 45.1% (n = 60). The mean duration for it to close was 46 ± 14 days, in which they closed within the first 3 months in 93% (n = 125) of the cases. About 91.7% (n = 122) of the wounds achieved total closure. Cultured epidermal allograft, combined with a meticulous technique and an adequate selection of patients, represents a safe and effective tool for chronic wounds.

Uloga stereotaksične radioterapije u lečenju metastaza u jetri kolorektalnog karcinoma

Colorectal cancer is third most common malignant disease and second leading cause of cancer-related deaths worldwide. In 2020, there were 5900 new cases in Serbia and around 3300 number of deaths related to this disease. Metastatic disease is most frequently located in liver. Surgery is first option if complete resection of liver metastases is achievable. Since liver metastases are resectable in 10 - 20% of cases, there is a possibility of implementation of other treatment modality. Alternative for surgery in local treatment of unresectable metastases are stereotactic body radiation therapy (SBRT), interstitial and intraluminal brachytherapy, transarterial chemoembolization, hepatic arterial infusion chemotherapy, selective internal radiation therapy with yttrium-90 resin microspheres, cryoablation, radiofrequency, chemical, and microwave ablation. Candidates for SBRT are patients with unresectable liver metastatic disease and patients with comorbidities which disable surgical treatment, with adequate function of uninvolved liver tissue. Respiration induced motion of target volume can be reduced by introduction of motion management strategies such as infrared markers, deep inspiration breath hold, abdominal compression, respiratory tracking and gating. CyberKnife, TomoTherapy machine and modified linear accelerators are used for delivering SBRT. These units allow us to deliver dose more precisely and to make dose escalation. Different regimes of fractionation are optional, from single fraction to hypo fractionation regimes, and doses are typically around 30 - 60 Gy in 3 fractions. Low toxicity rates in patients with liver metastases treated with SBRT are in relation with precise treatment planning, dose prescription and fractionation. Results of research suggest that delivery of large doses can provide high rate of local response, but on the other hand there is possibility of disease progression out of target volumes. With adequate selection of patients with unresectable liver metastases, the implementation of SBRT, especially in combination with effective systematic treatment modalities, can provide better local control with extension of survival.

Topikalni preparati u lečenju mišićno-skeletnog bola

Musculoskeletal pain is a global health and socioeconomic problem. Chronic musculoskeletal pain (MSC) is a pain that lasts for at least 3 months, becomes a disease itself. Given the constant increase in the frequency of musculoskeletal pain, it is necessary to work on improving prevention, early diagnosis and therapy, in order to improve outcomes and reduce treatment costs. Causes of MSC pain can be degenerative and / or inflammatory changes of joint and extra-articular structures, as well as dynamic vertebral segment. The use of symptomatic therapy for pain and swelling must be based on adequate patient selection, selection of the painful condition, with a balance between the risks of use and benefits. The stepwise approach of the WHO (World Health Organization) analgesic ladder represents an escalation strategy from weak to strong analgesics in pain therapy. Nonsteroidal anti-inflammatory drugs are used in the treatment of mild to moderate acute and chronic musculoskeletal pain with an inflammatory component. The choice of nonsteroidal anti-inflammatory drugs in the treatment of pain is useful as monotherapy and as a component of multimodal analgesic therapy. The average prescribed daily dose, as well as the length of drug use in the treatment of musculoskeletal pain must be in accordance with the guidelines. Topical application of NSAID-s is the therapy of choice within the pharmacological approach in elderly patients, with acute and chronic musculoskeletal pain in accordance with modern guidelines.

Unresectable Hepatoblastoma, Living Donation and Pre-Transplant Factors Associated with Event-Free Survival

Background: The mainstays of irresectable hepatoblastoma (HB) treatment are surgical resection and cisplatin based (CB) chemotherapy (CHT). However, adequate patient selection is a key to achieve acceptable disease-free survival in patients with unresectable HB undergoing liver transplantation (LT). Procedure: This single-center retrospective analysis of 28 children with HB submitted to LDLT from 1996 to 2019 aimed at determining the pre-transplant factors associated with worse post-transplant event-free survival. The clinical variables collected were gender, age, PELD score (Pediatric End-Stage Liver Disease scoring system), type of neoadjuvant CHT (CB versus other regimens), pre- and post- CHT AFP levels, %AFP reduction post CHT (AFP pre-CHT – AFP post- CHT /AFP pre- CHT), PRETEXT stage, primary versus rescue LDLT, time between diagnosis and LDLT, presence of metastases at diagnosis, follow-up time. Results: Patients were divided in groups according to the occurrence of the event (recurrence/death) after LDLT – 10 patients in the event-yes and 18 patients in the event-no. Probability of 5-y event-free survival was 63.9%. AFP reduction &lt; 70% (HR=4.33, 95%CI 1.1 to 16.95, p=0.03), and time from diagnosis to LT &gt; 12 months (HR=4.11, 95%CI 1.14 to 14.76, p=0.03) were associated with higher recurrence/death in the Cox regression analysis. Alpha-fetoprotein (AFP) reduction post-CHT &gt; 70% had a good performance in determining disease-free survival, with a calculated AUC of 0.8. Conclusion: LT for HB is the preferred treatment option for unresectable HB, with no distant metastasis and adequate response to CHT. AFP reduction &lt; 70%, and time from diagnosis to LT &gt; 12 months were associated with higher recurrence/death However, due to the limited number of patients in this study, a larger number of patients is required to corroborate these findings.

Primary central nervous system lymphoma - an overview

Introduction. Primary central nervous system lymphoma is a rare entity mostly presenting with non-GCB diffuse large B-cell lymphoma, being confined to the brain, spinal cord, meninges, and eyes. Diagnosis. The diagnosis is frequently established by stereotactic or open the brain biopsy, but in some cases with isolated leptomeningeal involvement, the only way is to identify atypical/monoclonal lymphocytes in cerebrospinal fluid. By workup, we aim to define the extent of disease in the central nervous system and to exclude systemic involvement. Treatment. Treatment is tailored according to the patient?s age, fitness, vital organ function, comorbidities, and available therapy. The backbone of induction treatment is high-dose methotrexate, usually within polychemotherapy. Consolidation phase is a matter of debate between two approaches: 1. high dose chemotherapy with autologous stem cell transplantation, which appears to be the preferable option for young fit patients, and 2. whole brain radiotherapy, preserved for transplant-ineligible ones. Whole brain radiotherapy has been raising concerns because of frequent cognitive impairment, which has been significantly diminished by reducing the irradiation dose. Despite a comprehensive treatment approach, many patients relapse, and since the prognosis of relapsed/refractory disease is devastating, there is a sense of urgency for novel treatment strategies. Several targeted agents and immunomodulatory drugs have been investigated in the settings of both relapsed/refractory and initial therapy, but with limited success. Ibrutinib monotherapy can induce durable remissions in the first line, but in relapse/refractory settings, the results are controversial. Conclusion. Adequate patient selection and new prospective trials should improve survival and preserve the patient?s neurological status.

Submucosal tunneling endoscopic resection for large esophageal leiomyoma: technical aspects and risk of complications

This report demonstrates the advantages of tunnel dissection ensuring organ-sparing procedure with the best functional result. However, intra- and postoperative complications are possible after STER. The risk of complications and complexity of surgery depend on transverse size (>3.5 cm), shape and localization of tumor. Larger neoplasm is accompanied by more difficult surgery and higher risk of complications. Therefore, adequate selection of patients for STER is essential.