Challenging Clinical Scenario Research Articles

Comparative Analysis of Chat-Based Artificial Intelligence Models in Addressing Common and Challenging Valvular Heart Disease Clinical Scenarios.

Comparative Analysis of Chat-Based Artificial Intelligence Models in Addressing Common and Challenging Valvular Heart Disease Clinical Scenarios.

RADT-13. A BIOLOGIC EQUIVALENT DOSE COMPARISON BETWEEN RADIOSURGERY AND COLLAGEN TILE BRACHYTHERAPY FOR POST-OPERATIVE TREATMENT OF A BRAIN METASTASIS RESECTION CAVITY

Abstract INTRODUCTION Recurrence of a previously irradiated brain metastasis represents a challenging clinical scenario. Repeat radiosurgery results in sub-optimal local control (LC). Two independently published prospective cohort studies demonstrated durable LC in this setting with collagen tile brachytherapy (CTBT), a novel Cesium-131 carrier. Here we compare biologically equivalent dosimetric parameters of CTBT to radiosurgery to understand dose metrics that may underlie durable LC from CTBT. METHODS A patient was selected from the multi-institutional prospective CTBT registry (NCT04427384) with a brain metastasis resection cavity near brainstem. Planning was performed for radiosurgery (30Gy in 5 fractions, BED of 48Gy) and CTBT (Cs-131, activity of 3.5U). To directly compare dosimetric parameters between radiosurgery and CTBT, biologic equivalent doses (BED) were calculated for brainstem(α/β of 3, BED3) and oncologically at-risk tissue(α/β of 10, BED10). TG101 brainstem dose-constraints were referenced, and respective BED were calculated. RESULTS The resection cavity was 4mm away from brainstem and contained 7 CTBT tiles (28 Cs131 seeds). Gradient index (GI) (24Gy BED10 volume/48Gy BED10 volume) was 3.8 for radiosurgery and 2.2 for CTBT. Conformality index (CI) (48Gy BED10 volume/CTV volume) was 1.2 for radiosurgery and 2.6 for CTBT. BED10 to 90% of the cavity wall (2mm rim around the resection cavity) was 49.6Gy for radiosurgery and 92.6Gy for CTBT. BED3 dose limit goals (max dose 31Gy in 5 fractions, BED3 95.1Gy and threshold dose 23Gy in 5 fractions, BED3 of 58.3Gy to 0.5cc) were met for both radiosurgery and CTBT. CONCLUSION BED comparisons demonstrate that CTBT leads to higher CI, lower GI, and higher dose to the cavity wall than radiosurgery while meeting BED3 dose limit goals to an adjacent organ at risk. These dose characteristics might underlie durable LC seen in the recurrent brain metastasis setting, though larger scale analyses are being performed with with clinical outcomes on NCT04427384.

Platelet-Based Dose-Adjusted Low Molecular Weight Heparin Treatment Is Efficacious and Safe in Newly Diagnosed Acute Leukemia Patients with Catheter-Related Thrombosis

Introduction: Catheter-related thrombosis (CRT) is a major complication in patients with acute leukemia. Severe thrombocytopenia related to either the concomitant disease or therapy underscores the challenge of CRT management, resulting in the use of suboptimal anticoagulation, potentially leading to high rates of short-term complications, including recurrent thromboembolism and hemorrhage. Due to the paucity of data regarding the impact of reduced-dose anticoagulation on this clinical setting, the current study aimed to assess the safety and efficacy of this treatment approach to CRT management in this challenging patient population. Methods: In this retrospective, case-control study, all adult (age ≥18 years) acute leukemia patients, who had arrived at the Rambam Health Care Campus (RHCC, Haifa, Israel) between 1.11.2004-30.6.2022 to receive anti-leukemia therapy via a peripherally inserted central catheter (PICC) line were screened. The inclusion criteria were: patients with acute myeloid, promyelocytic and lymphoid leukemia (AML, APL, and ALL, respectively) and CRT confirmed by Doppler ultrasound within 3 months of leukemia diagnosis. Patients were divided into full- (i.e., 1 mg/kg bid) vs. partial-dose low molecular weight heparin (LMWH) groups. The LMWH dose was based on the platelet count with a cutoff of 50K/L, distinguishing between the selected doses. Primary endpoints: A record of venous thromboembolism (VTE; including pulmonary embolism (PE), deep vein thrombosis (DVT), and catheter-related thrombosis (CRT) recurrence within 12 months as well as a major hemorrhage (including intracranial, retinal and gastrointestinal hemorrhage) within 6 months. Secondary endpoints: blood product requirement (unit/day) before and after the CRT diagnosis (from leukemia diagnosis till CRT identification and 90 days or death (if prior) from the event, respectively) assessed in a self-controlled case series manner. Data were collected from the hospital electronic medical records. Chi-square and paired samples Wilcoxon tests were utilized for statistical analysis. Results: Overall,195 patients [aged 54±15 years; 103 (53%) males], diagnosed with CRT were included. The most frequent leukemia diagnosis was AML (n=149; 76%), with ALL and APL established in 23 (12%) patients each. CRT was diagnosed in the left upper limb in 136 (70%) patients, with 99 (46%) patients suffering from DVT. Eighty-eight (45%) patients were treated with full-dose LMWH. Recurrent VTE was identified in 11(12.5%) patients treated with full-dose LMWH vs. 9 (8.4%) receiving partial-dose LMWH (p-value 0.484), while major hemorrhage was diagnosed in 12 (13.6%) patients from the former group vs. 14 (13.0%) patients from the latter group (table 1). Similar results were documented upon stratification to deep vs. superficial CRT, and the leukemia type. The packed red blood cell (RBC) administration rate was lower in the post-CRT phase (0.12 units/day, IQR 0.06-0.20) compared to the pre-CRT phase (0.20 units/day, IQR 0-0.36; p-value <0.0001). Platelet utilization rates were similar in both the pre-CRT and post-CRT phases (0.05 units/day, IQR 0-0.24 and 0.06 units/day, IQR 0.01-0.16, respectively; p-value 0.126). Comparable results were observed in both full and partial-dose LMWH groups. Conclusion: LMWH dose adjustment based on platelet counts, in newly diagnosed acute leukemia patients with CRT, is not associated with higher rates of VTE recurrence. Moreover, this strategy does not result in major hemorrhagic complications even in patients with severe thrombocytopenia. Notably, RBC infusion requirements were lower in the post-CRT diagnosis phase, while platelet transfusion was similar during the pre- and post-CRT phases. This analysis, including a large number of patients, demonstrates that the adjusted therapy is safe and efficient in this challenging clinical scenario.

Challenging clinical scenario: Germ cell tumor masquerading as peripheral precocious puberty in a one-year-old boy from Pakistan

Challenging clinical scenario: Germ cell tumor masquerading as peripheral precocious puberty in a one-year-old boy from Pakistan

Amputation VS Revascularization in a Patient with Diabetic Foot

Diabetic foot complications are a prevalent and serious consequence of diabetes mellitus, often necessitating complex clinical decisions. Among these decisions, the choice between amputation and revascularization in patients with diabetic foot poses a significant clinical dilemma. This article provides a comprehensive review of the epidemiology, significance, definition, risk factors, complications, and management options associated with amputation and revascularization in diabetic foot patients. The discussion evaluates the factors influencing the choice between these two interventions and explores their respective outcomes. Ultimately, this review underscores the importance of a multidisciplinary approach, patient-centered care, and shared decision-making in addressing this challenging clinical scenario.

Deep Learning Image Reconstruction Algorithm for CCTA: Image Quality Assessment and Clinical Application.

The increasing number of coronary computed tomography angiography (CCTA) requests raised concerns about dose exposure. New dose reduction strategies based on artificial intelligence have been proposed to overcome limitations of iterative reconstruction (IR) algorithms. Our prospective study sought to explore the added value of deep-learning image reconstruction (DLIR) in comparison with a hybrid IR algorithm (adaptive statistical iterative reconstruction-veo [ASiR-V]) in CCTA, even in clinical challenging scenarios, as obesity, heavily calcified vessels and coronary stents. We prospectively included 103 consecutive patients who underwent CCTA. Data sets were reconstructed with ASiR-V and DLIR. For each reconstruction signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) was calculated, and qualitative assessment was made with a four-point Likert scale by two independent and blinded radiologists with different expertise. Both SNR and CNR were significantly higher in DLIR (SNR-DLIR median value [interquartile range] of 13.89 [11.06-16.35] and SNR-ASiR-V 25.42 [22.46-32.22], P < 0.001; CNR-DLIR 16.84 [9.83-27.08] vs CNR-ASiR-V 10.09 [5.69-13.5], P < 0.001).Median qualitative score was 4 for DLIR images versus 3 for ASiR-V ( P < 0.001), with a good interreader reliability [intraclass correlation coefficient(2,1)e intraclass correlation coefficient(3,1) 0.60 for DLIR and 0.62 and 0.73 for ASiR-V].In the obese and in the "calcifications and stents" groups, DLIR showed significantly higher values of SNR (24.23 vs 11.11, P < 0.001 and 24.55 vs 14.09, P < 0.001, respectively) and CNR (16.08 vs 8.04, P = 0.008 and 17.31 vs 10.14, P = 0.003) and image quality. Deep-learning image reconstruction in CCTA allows better SNR, CNR, and qualitative assessment than ASiR-V, with an added value in the most challenging clinical scenarios.

Flexor Tendon Injuries and Hand Tendinorrhaphy: A Comprehensive Review

Flexor tendon injuries of the hand represent a challenging clinical entity with significant functional implications. This comprehensive article delves into the intricate realm of flexor tendon injuries, shedding light on the pathophysiology, diagnostic approaches, and treatment modalities, with a primary focus on the surgical technique of tendinorrhaphy. The article commences with an exploration of the anatomy and biomechanics of flexor tendons, elucidating the pivotal role they play in hand function. It subsequently outlines the diverse etiologies that lead to tendon injuries, encompassing traumatic, iatrogenic, and spontaneous causes, while emphasizing the importance of prompt and accurate diagnosis through clinical assessment, imaging, and functional testing. A detailed exposition of the principles and techniques of tendinorrhaphy follows, elucidating the surgical intricacies involved in repairing damaged flexor tendons. The article discusses suture materials, repair methods, and rehabilitation protocols, highlighting the importance of postoperative care and meticulous hand therapy in optimizing outcomes. Furthermore, this article critically reviews emerging trends and innovations in the field, including the use of tissue engineering, biomaterials, and minimally invasive approaches, all of which hold promise for enhancing the management of flexor tendon injuries. In conclusion, this article offers a comprehensive overview of flexor tendon injuries in the hand and underscores the pivotal role of tendinorrhaphy as a cornerstone in their treatment. With a holistic perspective on the subject, it provides clinicians and researchers with a valuable resource to navigate the intricacies of this challenging clinical scenario and fosters ongoing advancements in the field of hand surgery.

Tailoring guideline-directed medical therapy in heart failure with reduced ejection fraction: A practical guide.

According to the 2021 European Society of Cardiology guidelines, the four pillars of medical therapy in heart failure with reduced ejection fraction (HFrEF) include sodium-glucose co-transporter-2 inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and angiotensin-converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors. However, in clinical practice, concomitant use of all four drug groups in target doses is often limited by their intolerance or fear of potential complications. Herein, we present strategies to initiate or modify HFrEF therapy in frequent but challenging clinical scenarios (symptomatic hypotension, atrial fibrillation, kidney disease or worsening renal function, hyperkalemia) in a way that does not lead to unnecessary reduction or cessation of life-saving treatment.

Ethical considerations in closed loop deep brain stimulation

BackgroundClosed-loop deep brain stimulation (DBS) uses feedback to infer a clinical state and adjust stimulation accordingly. This novel mechanism has several potential advantages over conventional DBS including reducing stimulation-induced side effects, improving battery longevity, and alleviating symptoms not optimally treated with standard protocols. However, several ethical challenges may arise with the implementation of this technology, particularly with respect to clinical decision making. ObjectiveTo discuss potential ethical and clinical dilemmas encountered in using closed-loop DBS for neurological and psychiatric disorders. MethodsThe relevant literature is reviewed and supplemented with discussion of ethically challenging clinical scenarios. We outline an ethical framework for addressing these issues and provide practical recommendations for clinicians and researchers. ResultsEthical considerations in closed-loop DBS revolve around five key principles: 1) risk/benefit analysis; 2) inclusion and exclusion criteria; 3) respect for patient autonomy; 4) quality of life and patient benefit; and 5) concerns associated with recording neural activity. Conclusion(s)Developing and implementing a pragmatic framework for ethical considerations in closed-loop DBS will be critical as this technology is utilized in patients with both neurologic and psychiatric indications.

Salvage Radiotherapy as a Bridge for Relapsed Secondary CNS Lymphoma.

Secondary CNS lymphoma (SCNSL) is a challenging clinical scenario observed in 2-5% of non-Hodgkin lymphoma patients, for which a standard of care has not been defined. We studied the indications for, and outcomes of SCNSL patients referred for radiotherapy (RT). We identified patients with aggressive B cell lymphoma who received brain RT for SCNSL between 1999-2023 at a tertiary cancer center. Patients were grouped and analyzed by RT indication. Overall survival (OS) was determined from RT start using the Kaplan-Meier method. OS analysis comparing patients who did and did not receive therapy after RT was landmarked at 60 days from start of RT to minimize immortal time bias. "SCNSL-directed therapy" is defined as systemic therapy for the treatment of SCNSL, as opposed to CNS prophylaxis. We identified 99 SCNSL patients treated with RT. To account for the heterogeneity of RT referrals, we focused on the most common indication: salvage of radiographic progression after SCNSL-directed systemic therapy (n = 58). Among this group, median age was 62 (interquartile range [IQR]: 48-69) and 86% had diffuse large B cell histology. At initial lymphoma diagnosis, 10% of patients had CNS involvement, 90% received Rituximab-based therapy, and 25% received prior CNS prophylaxis. For SCNSL directed therapy, 90% received methotrexate (MTX)-based regimen. Median time from initial SCNSL diagnosis to RT was 4.4 months (IQR 1.7-7.0), with a median of 2.0 lines of therapy prior to RT (IQR 1.0-3.0). 86% of patients were symptomatic at RT with median KPS of 70 (IQR: 60-80). RT targets included whole brain (86%) and partial brain (14%). 1 patient had craniospinal RT. Median RT dose was 30 Gy (IQR: 24-30) over 10 fractions. Median OS for the entire salvage cohort was 3.5 months (m). Landmark analysis 2m post RT showed that median OS differed when patients were stratified by receipt of further therapy: CAR-T (9.4m, n = 4), hematopoietic cell transplant (8.5m, n = 6), other systemic therapy (4.4m, n = 17), no systemic therapy (0.6m, n = 10) (p = 0.0004). 29% of patients who received further therapy after RT achieved long term survival. In our cohort, most SCNSL patients are referred for salvage RT, with a median OS of 3.5m. 86% of patients had neurologic symptoms after having failed a median of 2 lines of SCNSL-directed therapy; the clinical urgency of this scenario implies that without RT, patients may not have been suitable candidates for further therapy. However, among patients for whom RT was successfully used to bridge to additional therapy, 29% could achieve long-term survival. This study supports further investigation of RT as a combined modality strategy for relapsed/refractory SCNSL, including with emerging cellular therapies.

Chronic constrictive pericarditis: a rare cardiac involvement in primary Sjögren’s syndrome

BackgroundConstrictive pericarditis represents a chronic condition and systemic inflammatory diseases are a known, yet uncommon, cause. Pericardial involvement is seldom reported in primary Sjögren’s syndrome, usually occurring in association with pericardial effusion or pericarditis.We report a case of constrictive pericarditis with an insidious course and unusual evolution associated with primary Sjögren’s syndrome. Due to the challenging nature of the diagnosis, clinical suspicion and multimodality imaging are essential for early identification and prompt initiation of treatment. Long-term outcomes remain uncertain.To the best of our knowledge, no other cases linking this autoimmune disease to constrictive pericarditis have been reported.Case presentationWe present the case of a 48-year-old male patient with moderate alcohol habits and a history of two prior hospitalizations. On the first, the patient was diagnosed with primary Sjögren’s syndrome after presenting with pleural effusion and ascites, and empirical corticosteroid regiment was initiated. On the second, two-years later, he was readmitted with complaints of dyspnea and abdominal distension. Thoracic computed tomography revealed a localized pericardial thickening and a thin pericardial effusion, both of which were attributed to his rheumatic disease. A liver biopsy showed hepatic peliosis, which was considered to be a consequence of glucocorticoid therapy. Diuretic therapy was adjusted to symptom-relief, and a tapering corticosteroid regimen was adopted.Four years after the initial diagnosis, the patient was admitted again with recurrent dyspnea, orthopnea and ascites. At this time, constrictive pericarditis was diagnosed and a partial pericardiectomy was performed.Although not completely asymptomatic, the patient reported clinical improvement since the surgery, but still with a need for baseline diuretic therapy.ConclusionAlbeit uncommon, connective tissue disorders, such as primary Sjögren’s syndrome, should be considered as a potential cause of constrictive pericarditis, especially in young patients with no other classical risk factors for constriction.In this case, after excluding possible infectious, neoplastic and autoimmune conditions, a primary Sjögren´s syndrome in association with constrictive pericarditis was assumed. This case presents an interesting and challenging clinical scenario, highlighting the importance of clinical awareness and the use of multimodal cardiac imaging for early recognition and treatment.

Perspectives and institutional policies on patient safety and image quality regarding the use of knee-spanning external fixators in MRI: A survey study of the Society of Skeletal Radiology.

Concerns regarding patient safety and image quality have made the use of knee-spanning external fixators in MRI a challenging clinical scenario. The purpose of our study was to poll practicing musculoskeletal radiologists on their personal experiences regarding the use of knee-spanning external fixators in MRI in an effort to consolidate practice trends for the radiologists' benefit. A 27-item survey was created to address the institutional use, safety, adverse events, quality, and perspectives of the radiologist related to MRI of an externally fixated knee. The survey was distributed to 1739 members of the Society of Skeletal Radiology. A total of 72 members of the Society of Skeletal Radiology completed the survey. Most notably, 40 of 72 (55.56%) respondents are permitted to place a knee-spanning external fixator inside the MR bore at their institution, while19 of 72 (26.39%) respondents are not permitted to do so. Fourteen of 32 (43.75%) respondents have institutional guidelines for safely performing an MRI of an externally fixated knee. Twenty-five of 32 (78.13%) respondents are comfortable permitting an MRI of an externally fixated knee. We found a general lack of consensus regarding the decision to scan a patient with a knee-spanning external fixator in MRI. Many institutions lack safety guidelines, and providers rely upon a heterogeneous breadth of resources for safety information. A re-examination of the FDA device labeling nomenclature and expectations of the individual manufacturers may be needed to bridge this gap and help direct management decisions placed upon the provider.

Evaluation of factors predicting the benefit from systemic oncological treatment for severely ill hospitalized patients: a retrospective study

BackgroundPatients with cancer in the disease’s end-stage with poor performance represent a challenging clinical scenario, as they have high chance of a fatal outcome due to clinical conditions, oncological emergencies, and/or metastatic disease. This study examines the factors predicting the potential benefit of “urgent” chemotherapy during hospitalization in this setting, thus addressing a research gap.MethodsThis retrospective observational study was conducted in the largest cancer center in the outskirts of São Paulo. It identified factors predicting the benefit from antineoplastic treatment in severe in-hospital patients admitted during 2019–2020, considering post-chemotherapy survival time as the main dependent variable. Data were retrieved from medical records. All patients aged ≥ 18 years, with an ECOG-PS score ≥ 2, and undergoing non-elective systemic cancer treatment were included.ResultsThis study evaluated 204 records, of which 89 were included in the final analysis. A statistically significant association with the worse outcome (death within 30 days of chemotherapy) was found with higher ECOG performance status; chemotherapy dose reduction; lower values of serum albumin, hemoglobin, and creatinine clearance; and higher values of leukocytes, neutrophils, direct bilirubin, urea, and C-reactive protein. In the multivariate analysis, only albumin remained statistically associated with the outcome (hazard ratio = 0.35; confidence interval: 0.14, 0.90; p = 0.034).ConclusionsSerum albumin and other clinical and laboratory variables might be associated with early post-treatment deaths in patients with cancer. The study data might help guide the decision to administer systemic treatment in this scenario and manage critically ill patients. This study adds to our knowledge of the factors predicting the objective benefits from “heroic” or “urgent” chemotherapy for hospitalized and severely ill patients with cancer.

Occipital Artery to Middle Cerebral Artery Direct Bypass: A Salvage Revascularization Technique for Ischemic Moyamoya Disease

The main treatment for moyamoya disease (MMD) is revascularization surgery. Most bypasses use the superficial temporal artery (STA) as the donor vessel. However, even if the STA-middle cerebral artery (MCA) bypass is functioning, the affected hemisphere can continue to be symptomatically malperfused. We sought to assess the efficacy of salvage direct revascularization surgery using the occipital artery (OA) as a donor vessel in patients with ischemic MMD who experience continued cerebral malperfusion despite previous successful STA-MCA bypass. We retrospectively analyzed the cerebrovascular databases of 2 surgeons and described patients in whom the OA was used as the donor vessel for direct revascularization. Seven patients were included (5 women). Previous STA-MCA bypasses were direct (n= 2), indirect (n= 3), or combined/multiple (n= 2). The mean (SD) interval between STA-MCA and OA-MCA procedures was 29.2 (13.1) months. Despite an intact STA-MCA bypass in all 7 cases, all 7 patients had recurrent symptoms and demonstrated residual impaired cerebral perfusion. All 7 patients underwent successful OA-MCA direct revascularization. Follow-up perfusion imaging was obtained for 6 of 7 patients. All 6 of these patients demonstrated improved cerebral blood flow to the revascularized hemispheres. All 7 patients demonstrated clinical improvement. Patients with ischemic MMD who have continued symptoms and cerebral malperfusion despite previous successful STA-MCA bypass present a challenging clinical scenario. Our series highlights the potential utility of the OA-MCA direct bypass as a salvage therapy for these patients.

Tailoring guideline-directed medical therapy in heart failure with reduced ejection fraction: A practical guide.

According to the 2021 European Society of Cardiology guidelines, the four pillars of medical therapy in heart failure with reduced ejection fraction (HFrEF) include sodium-glucose co-transporter-2 inhibitors, beta-blockers, mineralocorticoid receptor antagonists and angiotensin-converting enzyme inhibitors or angiotensin receptor-nephrilysin inhibitors. However, in clinical practice, concomitant use of all four drug groups in target doses is often limited by their intolerance or fear of potential complications. Herein, we present strategies to initiate or modify HFrEF therapy in frequent but challenging clinical scenarios (symptomatic hypotension, atrial fibrillation, kidney disease or worsening renal function, hyperkalemia) in a way that does not lead to unnecessary reduction or cessation of life-saving medications.

Proceedings of the 14th International Newborn Brain Conference: Long-term outcome studies, developmental care, palliative care, ethical dilemmas, and challenging clinical scenarios in neonatal neurology.

Proceedings of the 14th International Newborn Brain Conference: Long-term outcome studies, developmental care, palliative care, ethical dilemmas, and challenging clinical scenarios in neonatal neurology.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BackgroundAortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.Case presentationA 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.ConclusionAortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

The adjunct use of descending neurogenic-evoked potentials when transcranial motor-evoked potentials degrade into warning criteria in pediatric spinal deformity surgery: minimizing false-positive events.

This studies objective was to evaluate the utility of descending neurogenic-evoked potentials (DNEPs) in the setting of transcranial motor-evoked potentials (TCeMEPs) degradation into warning criteria during pediatric spinal deformity surgery. An institutional spinal cord monitoring database was queried to identify all primary and revision pediatric spinal deformity cases, < / = 21years of age performed from 1/2006 to 12/2021, in which TCeMEPs were the primary motor tract assessment modality which degraded into warning criteria, with subsequent initiation of adjunct DNEPs. Fourteen surgical cases (0.42%; 3351 total cases) in fourteen patients met inclusion criteria. Mean age was 13.2years (7.5-21.3). syndromic (n = 7), kyphosis (n = 3), congenital (n = 2), and idiopathic (n = 2). Three-column osteotomies (3CO)were done in eight patients. TCeMEPs degraded into warning criteria during screw placement (n = 7), 3CO performance/closure (n = 4), or deformity correction (n = 3). DNEPs were present in all cases of warning-criteria TCeMEPs and one case had degradation of DNEPs. Intraoperative Stagnara wake-up tests were performed in only 2/14 cases, with one transient new neurologic deficit (NND). In this specific scenario, DNEPs sensitivity was 50%, specificity 100%, positive predictive value 100%, and negative predictive value 92% to detect aNND. DNEPs were useful in assessing spinal cord function in the setting of TCeMEP data degradation in complex pediatric deformity surgeries. DNEPs demonstrated a higher specificity and positive predictive value in this clinical setting than TCeMEPs when assessing long-term neurologic function after surgery. Based on this small cohort, DNEPs appear to be a useful adjunct modality to TCeMEPs, in this challenging clinical scenario.

Long-term outcomes of SBRT for PSMA PET detected oligometastatic prostate cancer

BackgroundOligometastatic disease in prostate cancer (PCa) is a challenging clinical scenario encountered more frequently with the widespread adoption of PSMA-PET. SBRT aims to defer androgen deprivation and may deliver sustained biochemical failure (BF) free survival in selected patients. Little long-term data is currently available regarding the effectiveness of this approach.MethodsA retrospective single institution study of PSMA-PET directed SBRT without initial ADT for oligo-metachronous PCa. Median dose/fractionation was 24 Gy in 2# to bones and 30 Gy in 3# to lymph nodes. The primary endpoint was time to BF (PSA + 0.2 ug/L above nadir). Secondary endpoints included time to ADT for relapse (i.e. palliative ADT), BF defined as PSA nadir + 2 ug/L, toxicity, patterns of failure and survival. Patients were excluded if they received ADT with their SBRT, had short disease-free interval, or > 3 metastases on PSMA-PET.Results103 patients treated from November-2014 to December-2019 were analysed from our prospective database. Median follow-up was 5 years. 64 patients were treated for nodal only disease, 35 bone only and 4 mixed. 15% were free of any BF at 5 years with median time to BF of 1.1 years. 32% (33/103) of patients had further curative-intent radiation treatment following their first BF after SBRT, including subsequent SBRT. Eight patients underwent potentially curative treatment for their second or third relapse. Allowing for salvage treatment, 29/103 (28%) were biochemically disease free at last follow up. At 5 years, 39% of patients had never received any ADT and 55% had not started ADT for relapse with a median time to ADT for relapse of 5.5 years. There were 2 grade 3 toxicities (rib fracture and lymphoedema), and no local failures.ConclusionPSMA-PET guided SBRT for oligo-metachronous PCa recurrence in appropriately triaged patients results in excellent local control, low toxicity and over 50% ADT free at 5 years.

Five-year survival of resectable stageIIIA non-small cell lung cancer in Brazil.

In stageIIIA non-small cell lung cancer (NSCLC), surgery plays a role in terms of multimodal treatment. Surgery rates have increased in recent years, mainly due to the combination of more accurate imaging tools, electromagnetic navigation bronchoscopy, robotic bronchoscopy, robotic surgery, and a wide range of challenging clinical scenarios to lead surgeons and oncologists to include surgery as an option in therapeutic management. To assess the prognostic factors, the 5-year overallsurvival (OS) and cancer-specific survival (CSS) of patients with resectable stageIII-NSCLC. Patients'information was extracted from 76 Hospitals'Cancer Registry. OSand CSS were constructed using the Kaplan-Meier method, and the log-rank test was used to assess differences between curves. In addition, Cox regression was conducted to evaluate the patients'characteristics leading to better OS and CSS. Overall, 433 stageIII NSCLC surgical patients followed over 19 years were included. The median age was 61.29 ± 9.62 years, 58.4% male, 50.1% with adenocarcinoma, 29.3% with squamous cell carcinoma, 3.7% with large-cell lung carcinoma, and 16,9% with other lung cancer types. The 5-year OS was 30.6% (95% confidence interval [CI]: 27.4-36.1), and the CSS was 35.0% (95%CI: 29.4-41.0). In the Cox multivariate regression, squamous cell carcinoma was associated with reduced OS (hazard ratio [HR]: 1.40; 95%CI: 1.07-1.83; p=0.014) and CSS (HR: 1.56; 95%CI: 1.17-2.08; p = 0.002), in comparison with adenocarcinoma. The 2015-2019 quinquennial had a 50% reduction in HR (0.49; 95%CI: 0.29-0.81; p = 0.006), and the 2010-2014 group had a 40% reduction (0.59; 95%CI: 0.42-0.83; p = 0.006) in comparison with the 2000-2004 patients'group. The OS and CSS of patients with resectable stageIII NSCLC have improved over the past 19 years in our region. Squamous cell carcinoma was associated with increased mortality risk from any cause or specific cancer.