Challenging Clinical Scenario Research Articles

Minimally Invasive Distal Biceps Tendon Reconstruction With Semitendinosus Allograft and Dual Unicortical Button Fixation

Complete rupture of the distal biceps tendon is routinely treated with direct repair; however, chronic, mid-substance, or musculotendinous tears are challenging clinical scenarios for surgeons. Although attempts at direct repair should be considered, in cases of severe retraction or tendon deficiency, a reconstruction may be warranted. Herein the authors describe a technique for distal biceps reconstruction using allograft with a Pulvertaft weave via a standard anterior incision, similar to primary repair, with a small catchment incision more proximally for tendon retrieval. Use of this technique with dual unicortical buttons allows for early range of motion, restoration of the distal footprint, and improved biomechanical construct strength, which has proven invaluable in a population of elite and highly active military servicemembers.

Outcomes of Surgical Resection and VNS in Patients with Medically Refractory Epilepsy and GAD65 Antibody Positivity (S40.004)

<h3>Objective:</h3> To determine effectiveness of vagus nerve stimulator (VNS) and surgical resection in patients with drug-resistant epilepsy associated with glutamic acid decarboxylase 65 (GAD65) antibodies. <h3>Background:</h3> Epilepsy associated with high-titer GAD65 antibodies is often refractory to immunotherapies and antiseizure medications (ASMs), underscoring the need for alternate treatment strategies. <h3>Design/Methods:</h3> We retrospectively identified Mayo Clinic Rochester patients (January 2003 – April 2022) with drug-resistant epilepsy and high serum GAD65-antibody titers (&gt;20 nnmol/L) who underwent surgical resection and/or VNS implantation. A “favorable” surgical outcome was defined as Engel I-II, and a responder to VNS was defined as a &gt;50% reduction in seizure frequency from baseline. <h3>Results:</h3> We identified 15 patients (13 females, 86.7%) who underwent surgical resection (n=7), VNS implantation (n=6), and both (n=2). Patients had failed a median of 5.5 anti-seizure medications. Twelve patients had GAD65 tested in the CSF, all were positive (median titer 3.8). Of the nine patients who underwent surgical intervention (all involving the temporal region), three (33.3%) had a favorable outcome, which was sustained for at least 3.5 years in one, 10 years in another, and the third was lost to follow-up after 1 year. Pathology was available in four patients, only one had evidence of inflammation. Of the 8 patients who underwent VNS implantation, 3 (37.5%) were initially considered a responder, but this was not sustained in two of the three. No clinical factors were statistically associated with favorable surgical or VNS outcomes. <h3>Conclusions:</h3> Temporal surgical resection and VNS are not highly effective in drug-resistant autoimmune-associated epilepsy related to high-titer GAD65 antibodies. Additional therapies are greatly needed for this challenging clinical scenario. <b>Disclosure:</b> Dr. Zhao-Fleming has nothing to disclose. Dr. Britton has received personal compensation in the range of $0-$499 for serving as a Online course with American Clinical Neurophysiology Society. The institution of Dr. Dubey has received personal compensation in the range of $500-$4,999 for serving as a Consultant for UCB. The institution of Dr. Dubey has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Astellas. The institution of Dr. Dubey has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Argenx. Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for AGRIMS. Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Advances in Neurology . Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Moffit Cancer Center . Dr. Dubey has received research support from Department of Defense . Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Smith has received research support from CURE Epilepsy.

Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients.

In patients with AF, the presence of left atrial/left atrial appendage (LA/LAA) thrombus is related to an increased risk of thromboembolic events. Anticoagulation therapy, either with vitamin K antagonists or novel oral anticoagulants (NOACs) is therefore mandatory in AF with LA/LAA thrombus in order to lower the risk of stroke or other systemic embolic events. Despite the efficacy of these treatments, some patients will have persistent LAA thrombus remaining or may have contraindications to oral anticoagulation. Currently, little is known about the occurrence, risk factors and resolution rate of LA/LAA thrombus in patients who are already under optimal chronic oral anticoagulation, including vitamin K antagonists or NOACs. The common action in clinical practice in this scenario is switching from one to another anticoagulant drug exhibiting a different mechanism of action. Repeated cardiac imaging is then advised within several weeks to visually verify thrombus dissolution. Finally, there is a substantial scarcity of data on the role and optimal use of NOACs after LAA occlusion. The aim of this review is to critically evaluate data and provide up-to-date information on the best antithrombotic strategies in this challenging clinical scenario.

MP11-10 ISOLATED IN-FIELD RECURRENCE FOLLOWING RADICAL PROSTATECTOMY AND RADIATION

You have accessJournal of UrologyCME1 Apr 2023MP11-10 ISOLATED IN-FIELD RECURRENCE FOLLOWING RADICAL PROSTATECTOMY AND RADIATION Cameron J. Britton, Ahmed M. Mahmoud, Austin Martin, Mohamed E. Ahmed, Jack R. Andrews, R. Jeffrey Karnes, Matthew K. Tollefson, and Eugene D. Kwon Cameron J. BrittonCameron J. Britton More articles by this author , Ahmed M. MahmoudAhmed M. Mahmoud More articles by this author , Austin MartinAustin Martin More articles by this author , Mohamed E. AhmedMohamed E. Ahmed More articles by this author , Jack R. AndrewsJack R. Andrews More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , Matthew K. TollefsonMatthew K. Tollefson More articles by this author , and Eugene D. KwonEugene D. Kwon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003226.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Following local therapy for prostate cancer (PCa), 20-50% of men develop biochemical recurrence, requiring additional treatment. For a select number of men, there is persistence of local disease following salvage therapy without distant metastasis, termed in-field recurrence (IFR). This presents a challenging clinical scenario, with little data guiding optimal management. Our group sought to define the natural history, oncologic outcomes, and treatment patterns associated with IFR. METHODS: We queried a prospectively maintained, single institution, prostate cancer registry to identify men developing IFR following radical prostatectomy and radiation from 1990-2020. IFR was defined as biopsy-proven recurrent PCa or presence of persistent choline-avid lesions in the prior radiation field without concerns for metastasis on choline PET imaging. Clinicopathologic features were recorded. Continuous features were summarized with medians and interquartile ranges (IQRs) and categorical features were summarized with frequencies and percentages. RESULTS: In total, 110 patients with IFR were identified. Clinicopathologic features are listed in Table 1. Median time to IFR after salvage therapy was 78 months (IQR 50-126). Median follow-up after IFR was 69 months (IQR 40-97). IFR characteristics are documented in Table 2. At last follow-up, 98 patients recurred at a median of 10 months (IQR 3-27). Distant metastasis developed in 50 patients (45%) at a median of 27 months (IQR 14-50). Twenty patients (18%) had persistent or recurrent local disease following initial management. Fourteen died from PCa at a median of 39 months after treatment of IFR (IQR 23-60). Median follow-up from IFR was 76 months (IQR 48-100) in those alive at last follow-up. CONCLUSIONS: We found IFR presents years following completion of therapy for initial PCa recurrence. While curative management strategies may be attempted, local and distant metastatic recurrence is common and often requires systemic androgen-deprivation therapy. However, many patients experience durable long-term survival. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e127 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cameron J. Britton More articles by this author Ahmed M. Mahmoud More articles by this author Austin Martin More articles by this author Mohamed E. Ahmed More articles by this author Jack R. Andrews More articles by this author R. Jeffrey Karnes More articles by this author Matthew K. Tollefson More articles by this author Eugene D. Kwon More articles by this author Expand All Advertisement PDF downloadLoading ...

A100 CAVERNOUS TRANSFORMATION OF THE PORTAL VEIN IN A PEDIATRIC PATIENT WITH GOLDENHAR SYNDROME: A CASE REPORT

Abstract Background Goldenhar syndrome is a rare congenital condition thought to arise from the first and second branchial arches and typically asymmetrically affects the eyes, ears, and spine. Portal vein thrombosis/cavernous transformation is one of the main causes of portal hypertension in children. It is often associated with risk factors such as catheterization of the umbilical vein in the neonatal period, omphalitis, intra-abdominal infections in the neonatal period and prothrombotic conditions. This is a challenging clinical scenario as it leads to portal hypertension and variceal bleed with no chronic liver disease stigmata and liver function is essentially normal. While previous European literature from the early-2000s reported associated portal vein anomalies in Goldenhar syndrome, we are not aware of any recent and/or Canadian pediatric cases. Purpose We report a Canadian case of cavernous transformation of the portal vein with resulting gastrointestinal bleeding in a child with Goldenhar syndrome. Method Case report Result(s) A pediatric patient with a postnatal suspicion of Goldenhar syndrome, with confirmation by 6 months of age, presented with an acute 3-day history of melena, on the context of a recent viral illness and ibuprofen use. Laboratory testing showed a normocytic anemia (Hb 68) with a normal INR (1.1). The rest of the workup was unremarkable. There was no history of catheterization of the umbilical vein on the neonatal period nor other hematological complications. To assess for potential duplication cyst as differential diagnosis, a computerized tomography of the chest, abdomen and pelvis was ordered and revealed suspected cavernous transformation of the portal vein with suspected varices near the gastroesophageal junction and within the abdomen, and hepatomegaly with spleen size at the upper limit of normal. Octreotide was started after the CT results. A gastroscopy was done 24h after presentation and found portal hypertensive gastropathy and esophageal varices (2 Grade II and 1 Grade I). Sclerotherapy was performed. Post-gastroscopy ultrasound supported earlier radiographic findings of cavernous portal vein transformation and hepatosplenomegaly. Moreover, the ultrasound noted normal flow direction in the portal and hepatic veins. The patient has not re-presented for further episodes of gastrointestinal bleeding. Conclusion(s) This case report supports the previously reported association between Goldenhar syndrome and portal venous anomalies. Early consideration may lead to prompt diagnosis and management of the potentially life-threatening complications of portal hypertension in this population. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Cyst Formation After Subepithelial Connective Tissue Grafting: Management and Review.

Lesion formation after soft tissue gingival grafting is a rare but challenging clinical scenario to manage. This report presents a unique case of cyst formation after connective tissue grafting. All previously reported cases are confined to the mandibular labial lateral-canine space, whereas the present case is the first found in the maxilla. These cysts manifest clinically 9 months to 1.5 years after grafting and may communicate with the surface, as evidenced by sinus tract or cystic discharge. Because of the unique nature of these lesions with respect to clinical history, appearance, symptoms, and location, the differential diagnosis should be limited. The treatment recommendation is complete surgical excision, which should eliminate the risk of recurrence. In this report, a novel case is presented, and the literature is reviewed to discuss etiology and provide treatment recommendations. Int J Periodontics Restorative Dent 2023;43:257-263. doi: 10.11607/prd.5300.

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma.

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Stroke in Pregnancy and Puerperium - Current Knowledge, Questions and Controversies

Stroke associated with pregnancy and the postpartum period (SiPP) is not common but its consequences can be devastating both for the mother and the child. Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. SiPP is heterogeneous both in aetiology and presentation as it includes both ischemic and haemorrhagic events as well as cerebral venous thrombosis. Specific risk factors for SiPP have been identified and well described, such as hypertensive disorders of pregnancy and a prothrombotic state. However, it is still a controversial issue if pregnancy should be considered a risk factor for stroke, although pregnancy and postpartum period clearly increase the stroke risk compared to non-pregnant time. Recent European Stroke Organization [ESO] guidelines addressed the management of acute SiPP while other issues, particularly primary and secondary prevention are still under investigated. There is also a lack of research and knowledge regarding long-term mother and foetus/child outcomes post-SiPP. This paper addresses current knowledge on SiPP management and prognosis and discusses new challenging clinical scenarios including the relationship between COVID-19 infection and SiPP.

Mild Crohn's Disease: Definition and Management.

Crohn's Disease (CD) is a chronic inflammatory disease that can lead to progressive damage to the gastrointestinal tract and significant disability. Early, "top-down" biologic therapy is recommended in moderate-to-severe CD to induce remission and to prevent hospitalization and complications. However, an estimated 20-30% of patients with CD have a mild disease course and may not garner sufficient benefit from expensive, immunosuppressing agents to justify their risks. Herein, we review characteristics of patients with mild CD, the available options for disease treatment and monitoring, and future directions of research. For ambulatory outpatients with low-risk, mild, ileal or ileocolonic CD, induction of remission with budesonide is recommended. For colonic CD, sulfasalazine is a reasonable choice, although other aminosalicylates have no role in the treatment of CD. No large, randomized trial has supported the use of antibiotics or antimycobacterials in the treatment of CD. Partial Enteral Nutrition and Crohn's Disease Exclusion Diets may be appropriate for inducing remission in some adult patients, with trials ongoing. Select patients with mild-to-moderate CD may benefit from maintenance therapy with azathioprines or gut specific biologics, such as vedolizumab. The role of complementary and alternative medicine is not well defined. The identification, risk stratification, and monitoring of patients with mild CD can be a challenging clinical scenario. Some patients with low risk of disease progression may be appropriate for initial induction of remission with budesonide or sulfasalazine, followed by close clinical monitoring. Future research should focus on pre-clinical biomarkers to stratify disease, novel therapies with minimal systemic immune suppression, and validation of rigorous clinical monitoring algorithms.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma.

The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma.

The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

Rare Diagnoses and Diagnostic Pitfalls in Female Genital Tract Neoplasms: A Case Series

There is a wide spectrum of disorders that may originate from different parts of the female genital tract. They are often unique and rare, posing a diagnostic challenge for reporting pathologists. Their uniqueness lies in the rare histomorphologic picture and challenging clinical scenarios, accentuated by a paucity of available literature. Sometimes, histomorphology alone may not be sufficient for diagnosis, and ancillary studies like Immunohistochemistry (IHC) may help arrive at a definitive diagnosis. Present article represents a series of six unique cases. The first case presented with virilising features and menstrual irregularities. Gross examination of the adnexal neoplasm showed solid yellowish-orange areas, which were diagnosed as Steroid Cell Tumour (SCT), Not Otherwise Specified (NOS) based on histomorphology. This diagnosis was further substantiated by diffuse and strong Inhibin positivity on IHC. The second case presented with huge abdominal distention and markedly raised CA-125 levels. It was diagnosed as mucinous carcinoma with a focus of Benign Brenner Tumour. The third case presented with postmenopausal bleeding and underwent radical hysterectomy. Gross examination revealed simultaneous involvement of the unilateral adnexa, and it was finally diagnosed as endometrioid carcinoma with adnexal metastasis, International Federation of Gynaecology and Obstetrics (FIGO) stage IIIA. The fourth case was a cervical carcinoma with histomorphology suggestive of high-grade, but it did not fit into any of the known subtypes of adenocarcinoma. Therefore, it was reported as Adenocarcinoma NOS with focal mucinous differentiation. The fifth case was a rare cervical Adenosquamous Carcinoma (ASCC) with both malignant squamous and glandular components. The sixth case was of mesenchymal origin in the vulva, namely Aggressive Angiomyxoma (AA). All these cases highlight the fact that pathologists should be well aware of these entities to make an appropriate diagnosis.

Allergic Contact Dermatitis (ACD) to Topical Products in Orthopedic Surgery: Clinical Characteristics and Treatment Strategies.

The potential for many of the commonly used surgical site wound adhesives, skin antiseptic solutions, topical antibiotics, and suture materials to sensitize and subsequently result in allergic contact dermatitis (ACD) has become increasingly recognized within orthopedic surgery. Particularly with subsequent exposure to the offending allergen, the cutaneous allergic reaction may present in a similar fashion to cellulitis, thus making early differentiation between the two etiologies to initiate the appropriate and timely treatment crucial. Recognition of the characteristic appearance and severity of ACD surrounding a surgical wound often drives the initial management. This typically consists of anti-histamines, topical corticosteroids, and possible removal of the offending allergen for low grade findings and oral steroids and prophylactic oral antibiotics for the more severe reactions. Multidisciplinary care, including the expertise of a dermatologist or wound care specialist when faced with this challenging clinical scenario is critical and elective patch testing may be indicated to ascertain the exact allergen involved, particularly in patients with a prior history of wound issues. Finally, any clinical cases of ACD following an orthopedic procedure should be documented in the patient's chart so that exposure can be avoided with any future surgery.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma.

How should fertility-sparing treatment of patients with endometrial carcinoma be performed? Forty-eight recommendations were formulated on fertility-sparing treatment of patients with endometrial carcinoma. The standard surgical treatment of endometrial carcinoma consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in endometrial carcinoma in a multidisciplinary setting. While addressing also work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility-sparing treatment. A collaboration was set up between the ESGO, the European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE), aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide. ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practising clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgement was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. The multidisciplinary development group formulated 48 recommendations in four sections; patient selection, tumour clinicopathological characteristics, treatment and special issues. Of the 48 recommendations, none could be based on level I evidence and only 16 could be based on level II evidence, implicating that 66% of the recommendations are supported only by observational data, professional experience and consensus of the development group. These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. All costs relating to the development process were covered from ESGO, ESHRE and ESGE funds. There was no external funding of the development process or manuscript production. G.S. has reported grants from MSD Italia S.r.l., advisory boards for Storz, Bayer, Astrazeneca, Metronic, TESARO Bio Italy S.r.l and Johnson & Johnson, and honoraria for lectures from Clovis Oncology Italy S.r.l. M.G. has reported advisory boards for Gedeon Richter and Merck. The other authors have reported no conflicts of interest. This document represents the views of ESHRE, ESGO and ESGE which are the result of consensus between the relevant stakeholders and where relevant based on the scientific evidence available at the time of preparation. The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type.

CNS prophylaxis in aggressive B-cell lymphoma

The prevention of central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) continues to be one of the most contentious areas of lymphoma management. Outcomes for patients with secondary CNS lymphoma (SCNSL) have historically been very poor. However, in recent years improved responses have been reported with intensive immunochemotherapy approaches, and there is a growing interest in potential novel/cellular therapies. Traditional methods for selecting patients for CNS prophylaxis, including the CNS International Prognostic Index, are hampered by a lack of specificity, and there is accumulating evidence to question the efficacy of widely employed prophylactic interventions, including intrathecal and high-dose methotrexate (HD-MTX). Given the potential toxicity of HD-MTX in particular and the ongoing need to prioritize systemic disease control in high-risk patients, there is an urgent need to develop more robust methods for identifying patients at highest risk of CNS relapse, as well as investigating prophylactic interventions with greater efficacy. Here we review new evidence in this field from the last 5 years, focusing on the potential use of molecular diagnostics to improve the identification of high-risk patients, recent large data sets questioning the efficacy of HD-MTX, and the current approach to management of patients with SCNSL. We provide a suggested algorithm for approaching this very challenging clinical scenario.

Outcome of Intermittent Thoracentesis versus Pigtail Catheter Drainage for Hepatic Hydrothorax.

Background/Aims: The management of hepatic hydrothorax (HH) remains a challenging clinical scenario with suboptimal options. We investigated the effect and safety of pigtail catheter drainage compared to intermittent thoracentesis. Methods: This multicenter, retrospective study included 164 cirrhotic patients with recurrent pleural effusion from March 2012 to June 2017. Patients with neoplasms, cardiopulmonary disease, and infectious conditions were excluded. We compared the clinical outcomes of pigtail catheter drainage versus thoracentesis for variables including complications related to procedures, overall survival, and re-admission rates. Results: A total of 164 patients were divided into pigtail catheter (n = 115) and thoracentesis (n = 49) groups. During the follow-up period of 6.93 months after discharge, 98 patients died (pigtail; n = 47 vs. thoracentesis; n = 51). The overall survival (p = 0.61) and 30-day mortality (p = 0.77) rates were similar between the pigtail catheter and thoracentesis groups. Only MELD scores were associated with overall survival (adjusted HR, 1.08; p < 0.01) in patients with HH. Spontaneous pleurodesis occurred in 59 patients (51.3%) in the pigtail catheter group. Re-admission rates did not differ between the pigtail catheter and thoracentesis groups (13.2% vs 19.6% p = 0.7). A total of five complications occurred, including four total cases of bleeding (one patient in the pigtail catheter group and three in the thoracentesis group) and one case of empyema in the pigtail catheter group. Conclusions: Pigtail catheter drainage is not inferior to that of intermittent thoracentesis for the management of HH, proving it may be an effective and safe clinical option.

Robotic Surgery for Stone Disease.

To evaluate recent literature regarding the role of robotic technology in the treatment of nephrolithiasis with particular attention to complex technical procedures. Robotic platforms including single-port robotics have been widely adopted in urological practice for the treatment of both malignant and benign conditions and has led to an expansion of the utilization of robot-assisted surgery to tackle challenging clinical scenarios such as bladder neck reconstruction, upper urinary tract reconstruction, and more recently complex stone disease. Presently, the American Urological Association guidelines on the surgical management of stones advise against using robotic, open, or laparoscopic techniques as a first-line approach for most patients with stone disease with the exception for patients with anatomical abnormalities, large or complex stones, or patients requiring a concomitant reconstructive operation. Clinicians have demonstrated the safety and feasibility of surgical robotics in the treatment of stone disease for a variety of operations including robotic pyeloplasty, pyelolithotomy, ureterolithotomy, and surgical interventions in urinary diversions as well as novel technologies for robotic ureteroscopy and percutaneous access. Numerous clinicians have demonstrated the safety and feasibility of using robot-assisted surgery to treat nephrolithiasis, mainly in complex renal anatomy. Further research is necessary to identify the best candidates for utilization of robotics in complex stone disease, and further technological developments will continue to further advance the use of these platforms in the treatment of nephrolithiasis.

Arthroscopic Biologic Tuberoplasty for Irreparable Rotator Cuff Tears: An Expedited Technique

Massive irreparable rotator cuff tears in patients for whom arthroplasty is not an option can be a challenging clinical scenario for shoulder surgeons to manage. To achieve the best patient outcomes, a myriad of options has been presented in the literature, including debridement with biceps tenotomy or tenodesis, various tendon transfer procedures, superior capsular reconstruction, biceps tendon rerouting, bursal acromion resurfacing, balloon spacers, and tuberoplasty. While debridement with biceps tenotomy and superior capsular reconstruction have historically provided improvements in patient-reported outcomes, high rates of arthritis progression and failure of graft healing have been noted with these techniques, respectively. The superior capsular reconstruction has also proven to be technically challenging. The biologic tuberoplasty procedure was developed after several studies noted a lack of correlation between graft healing and improvement in patient-reported outcomes in superior capsular reconstructions, as long as the tuberosity remained covered with the graft. We present a technically efficient and expedited technique using an acellular human dermal allograft.

Achieving Therapeutic Anti-Xa Levels Using Rivaroxaban for Venous Thromboembolism in a Morbidly Obese Patient with a BMI >70

Background: Anticoagulation (AC) is the cornerstone of treatment for venous thromboembolism (VTE). Direct oral anticoagulants (DOACs) have become the standard of care during the acute and extended phases of therapy for VTE, mostly due to their ease of use, efficacy, and safety profiles. There is a 9.2% prevalence of severe obesity (BMI>40) in Americans as of 2017-2020 with a 6.2-fold increased risk of VTE in obese individuals. The 2021 International Society on Thrombosis and Haemostasis (ISTH) guidelines recommend using standard dosages of DOACs in patients with a BMI >40 kg/m2 or weight >120 kg. Despite these recommendations, their use in severely obese individuals at extremes of weight like our patient with a BMI > 70 kg/m2 remains uncertain. Case Presentation Herein, we present a 38-year-old morbidly obese female with no significant past medical history who presented with an acute worsening of dyspnea on exertion saturating 60% on room air. The diagnosis of intermediate-high risk pulmonary embolism (PE) was made based on computed tomographic angiography (CTA) with right ventricular strain and elevated cardiac biomarkers. A concomitant proximal DVT from the left common femoral to the distal peroneal vein was also noted. The patient's weight was 243kg with a calculated BMI of 72.3 kg/m2. After the patient had received parenteral anticoagulation with heparin for 4 days, it was decided to switch to Rivaroxaban 15mg BID for 21 days followed by 20 mg daily. With a history of irregular menses, the patient developed heavy menstrual bleeding (HMB) following the initiation of rivaroxaban. Her hemoglobin remained stable with no blood transfusion requirements. However, this led to the decision to switch to rivaroxaban 20 mg PO daily earlier than planned due to a lack of improvement in menstrual bleeding which was considered to be clinically relevant non-major bleeding (CRNMB). Despite this switch, there was no effect on efficacy and the patient did not develop any signs or symptoms of VTE recurrence during her prolonged hospital stay with a significant improvement in her oxygenation levels and VTE symptomatology. In our patient, we demonstrated the use of rivaroxaban in a morbidly obese individual with a BMI>70 by achieving therapeutic anti-Xa levels. Figure 1 shows the therapeutic peak and trough anti-Xa levels throughout the patient's hospitalization. The highest Anti Xa level of 314 mcg/mL was reported on day 19 correlating with the patient's menorrhagia, which self-limited with the transition from rivaroxaban 15 mg twice daily to 20 mg daily. Discussion: Two pivotal clinical trials, the EINSTEIN-DVT/PE trials, where 14% of patients in both arms weighed >100 kg, showed that patients on rivaroxaban (15 mg BID for 3 weeks, followed by 20 mg once daily) vs those on enoxaparin followed by a vitamin K antagonist, had no significant difference in recurrence rates of VTE and bleeding rates [Moore KT, et Al. Influences of Obesity, Am J Med 2017]. A recent post-hoc analysis of the EINSTEIN DVT/PE trials also portrayed no correlation between weight/BMI and risk of recurrent VTE or bleeding in those who received rivaroxaban. Our case illustrates the attainment of therapeutic anti-Xa levels with no recurrent VTE in our morbidly obese patient. Despite her heavy menstrual bleeding, the bleeding was controlled once the switch to rivaroxaban 20mg daily was completed. Another study in which its heaviest participant at 172 kg, showed compelling evidence that morbid obesity has minimal influence on the safety and efficacy of rivaroxaban [Speed V, et al. Fixed dose rivaroxaban. JTH 2020]. This remains true for our patient at 243 kg. Conclusion: Our case demonstrates that standard doses of rivaroxaban for the treatment of DVT/PE in individuals with morbid obesity with BMI>70 kg/m2 can be effective, and safer for the initial phase of treatment for VTE and in prevention of VTE recurrence. It also portrays that increased dosages attempting to account for high bodyweight/fat can potentially result in major bleeding events. Despite the 2021 ISTH guidelines, further prospective studies and randomized controlled trials are warranted, to assess the safety and efficacy of DOACs in VTE, particularly in such challenging clinical scenarios like morbid obesity. Alongside clinical assessment, additional studies will be essential to evaluate the need for universal and external validation of anti-Xa levels in patients taking DOACs. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Chemotherapy Dose Reductions and Dose Delays Due to Thrombocytopenia

Background: Chemotherapy-induced thrombocytopenia (CIT) is a challenging clinical scenario. A recent study of 15,521 patients showed that 13% of patients with solid tumors had thrombocytopenia within 3 months (Shaw, Eur J Haematol. 2021).Unfortunately, there are no guidelines for the management of CIT. Therefore, clinicians use strategies such dose reduction (DR) and/or dose delays (DD) to reduce the bleeding risk(Kuter, Haematologica. 2022). Although the incidence of CIT in various types of cancers and chemotherapeutic agents is known, studies showing an association between DR or DD and duration of CIT are lacking. It is known that DR and DD can increase mortality(Havrilesky, Crit Reviews in Onc/Hematology. 2015; Liutkauskiene, BMC Cancer. 2018). The association of cirrhosis and duration of thrombocytopenia in patients with CIT is also not well described. Therefore, we conducted a retrospective analysis to study the association between duration of thrombocytopenia and dose delays and reduction in patients with CIT. Methods: This study was approved by the Institutional Review Board. A retrospective analysis was performed using the electronic medical record (EMR) for adult patients who received chemotherapy for breast, GI, GU, and lung cancer from January 1st, 2016, to December 31st, 2020, at Rush University Cancer Center. Adult patients who developed thrombocytopenia during treatment (platelet count < 100 × 109 /L) were included in the study. Patients with thrombocytopenia preceding the initiation of chemotherapy were excluded. One hundred thirty-five patients met the study inclusion criteria. EMR were reviewed to collect data on DR and DD that had been clearly attributed to chemotherapy by the treating oncologist's documentation. Data for age at first thrombocytopenia (following treatment initiation), total duration of thrombocytopenia, presence of cirrhosis, and presence of liver metastasis was collected. Pearson's chi-square test and logistic regression were used to test the associations between duration of thrombocytopenia (grouped as <14 days or ≥ 14 days) and the proportion of patients who experienced at least one DR or DD. We similarly tested the association between thrombocytopenia duration and cirrhosis or liver metastasis. Results: First, we analyzed the association between DR, DD, and duration of thrombocytopenia. There was no statistically significant association between duration of thrombocytopenia and DR. However, we found that patients with DD had 4.1 times the odds of having increased duration of thrombocytopenia (≥ 14 days) compared to the patients without DD (OR = 4.1, 95% CI = 2.0 - 8.5, P-value = 0.0001). Then, we studied the association between DD and duration of thrombocytopenia in patients with cirrhosis or liver metastasis. We found that in this subset patients with DD had 3.9 times the odds of having thrombocytopenia duration ≥ 14 days compared to the patients without DD (OR = 3.9, 95% CI = 1.4 - 10.8, P-value = 0.008). We then looked at the association of having cirrhosis and liver metastasis on duration of thrombocytopenia. We found that there was no statistically significant association between presence of liver metastasis and duration of thrombocytopenia. However, patients with cirrhosis had 3.5 times the odds of having thrombocytopenia duration ≥14 days compared to patients without cirrhosis (OR = 3.5, 95% CI = 1.1 - 11.3, P-value = 0.03). Discussion: Our study shows that in patients with CIT, duration of thrombocytopenia impacts the risk of DD, especially in patients with either cirrhosis or liver metastasis. The finding of interest is that patients with cirrhosis have a 4-fold increased risk of developing longer duration of thrombocytopenia, which can lead to dose delays. This raises the question of whether patients with cirrhosis should be supported by thrombopoietin receptor agonists to treat the thrombocytopenia and prevent treatment delays. Thrombopoietin (TPO) receptor agonists such as Romiplostim are showing increasing promise in the treatment of CIT, and there are currently multiple active phase III trials underway with dose-reductions and dose-delays as clinical endpoints. Further research is needed to identify risk factors that can predict the development of CIT and to identify evidence-based platelet thresholds for TPO agonist usage in CIT patients.