Soft Tissue Components Research Articles

Does Osteoarticular Allograft Reconstruction Achieve Long-term Survivorship after En Bloc Resection of Grade 3 Giant Cell Tumor of Bone?

En bloc resection of benign tumors is only indicated in aggressive lesions with substantial destruction of the affected bone. Few reports have evaluated the long-term outcome of Grade 3 giant cell tumor of bone (GCTB; defined as severe bone destruction and soft tissue extension) treated with en bloc resection and reconstruction with a massive allograft. We recently reported that patients with benign tumors achieved better allograft reconstruction survivorship compared with those treated for a malignant bone tumor. In light of that finding, we wondered whether osteoarticular allografts would be a viable long-term alternative for Grade 3 GCTB, which could be important in some countries because of greater availability and lower costs compared with endoprostheses. We analyzed a group of patients with Grade 3 GCTBs treated with en bloc resection and osteoarticular allograft reconstruction in terms of (1) survivorship free from allograft removal at 10 years; (2) survivorship free from reoperation for any reason at 10 years, (3) functional results as measured by the Musculoskeletal Tumor Society (MSTS) score, (4) assessment of arthrosis at the knee. We retrospectively analyzed all patients with a Grade 3 GCTB treated between 1980 and 2007. Only patients treated with en bloc resection and reconstruction with massive osteoarticular allografts were included in the analysis. The indication for osteoarticular reconstruction during that time included severe bone destruction with intraarticular compromise of the tumor, intraarticular fracture because of tumor growth, the presence of inadequate remaining subchondral bone to resist normal loading (for the distal femur or proximal tibia), and the preservation of a soft-tissue component (ligaments or meniscus) for articular stability. During the period, 75 patients were treated with en bloc resection. Patients treated with intralesional curettage (n = 7), reconstruction with an endoprosthesis (n = 2), intercalary arthrodesis (n = 13), or unicondylar reconstruction (n = 14) were excluded. Of the original 75 treated with en bloc resection, 52% (39) were treated with osteoarticular allograft reconstruction, and no patient was lost to follow-up before 2 years or had substantial missing data. However, of the 39 patients, another 21% (8) have not been seen in the last 5 years, but these were included here because they reached the 10-year minimum surveillance period before being lost. Twenty-three of those 39 patients were previously reported by our group and 16 new patients (treated between 1980-1985) were included in this series (eight distal radius, six distal femur, two proximal tibias), extending the follow-up period and including more patients for analysis. The median (range) follow-up duration was 26 years (10 to 34). We assessed survivorship using a Kaplan-Meier analysis, we drew MSTS scores retrospectively from patients´ medical records, and we graded arthrosis using the Ahlbäck scale for the knee (which was by far the most common joint involved, n = 31, and so it was the joint we assessed for the presence of arthrosis). The survivorship free from allograft removal was 85% at 10 years (95% CI 74 to 96). The allograft survivorship free from reoperation for any reason at 10 years was 72% (95% CI 59 to 87). The median (range) MSTS score was 28 points (19 to 30). The grade of arthrosis in the knee at last follow-up was analyzed in 20 patients and classified in nine as Ahlbäck Type 4, in six as Type 3, in three as Type 2 and in two as Type 5. Osteoarticular allograft reconstruction after a Grade 3 GCTB en bloc resection showed excellent long-term survivorship. We believe these results compare favorably with other studies on endoprosthetic reconstruction and head-to-head studies of these approaches should be performed; these would need to be multicenter trials. In the meantime, in locations where endoprostheses are unavailable or too expensive, we believe our results support the use of osteoarticular allografts. Level IV, therapeutic study.

SUN-181 A Case of Metastatic Merkel Cell Carcinoma Within a Cortisol-Producing Adrenal Adenoma

Introduction:Metastasis within another tumor is rare, and exceedingly more rare within a functional adrenal adenoma. Merkel cell carcinoma (MCC) is an aggressive and rare neuroendocrine carcinoma of the skin. We present a patient with history of MCC who presented with an adrenal mass, found to be metastatic MCC within a cortisol-producing adrenal adenoma.Case description:54 year old male with a history of type 2 diabetes, hypertension, MCC of right thigh, presented for adrenal mass. He was initially evaluated in the ER for severe abdominal pain for 4 days. He had a CT abdomen done, which showed 6cm right adrenal mass with extensive fat and soft tissue component within it. Hounsfield units within solid area measured up to 47 units, and surrounding area measured -3 Hounsfield units.His history was significant for MCC of right thigh, type 2 diabetes, HTN, obesity and OSA. Pathology from MCC resection showed no evidence of invasion and clear margins, but he did have microscopic focus on inguinal lymph node biopsy. His PET scan was negative except for low uptake in a 6cm right adrenal lesion that was considered benign-appearing. He completed radiation therapy to right thigh and groin.Physical exam was notably negative for any cushingoid features. Aldosterone, renin and plasma metanephrines were normal. Cortisol after dexamethasone suppression test was elevated, and ACTH and DHEAS were low, raising suspicion of Cushing’s syndrome. He had right adrenalectomy and was then started on steroid replacement. Pathology showed adrenocortical adenoma with a 2cm well-circumscribed mass within the adenoma positive for metastatic MCC with lymphovascular invasion. ACTH stimulation testing was performed at follow up after holding hydrocortisone for over 24 hours, and was consistent with suppression of glucocorticoid axis in the contralateral adrenal gland.Discussion:MCC and metastasis within a functional adrenal tumor are both rare occurrences. Our patient had positive regional lymph node involvement at the time of diagnosis, and although the initial PET scan was interpreted as showing an benign adrenal adenoma, it is likely that this represented distant metastasis. Labs indicated that the surrounding adenoma was likely cortisol-producing. To our knowledge, this is the first case reported of metastatic MCC within a functional adrenal adenoma.

MON-434 Encapsulated Follicular-Variant of Micropapillary Carcinoma Presenting with Distant Bony Metastasis

INTRODUCTION The incidence of thyroid cancer has risen steadily over the last decades, in part due to increasing diagnosis of apparently low-risk well-differentiated cancers. The outcomes of well-differentiated thyroid cancers, including follicular variant papillary thyroid carcinoma (PTC), are believed to be quite favorable, with a largely indolent benign course. We examine an encapsulated follicular-variant of micropapillary carcinoma presenting with distant bony metastasis. CASE 55-year-old lady presented to clinic after biopsy of iliac crest (IC) mass revealed thyroid tissue. One year prior she started having dull pain at right hip, attributed to increased physical activity. She noticed a tender “lump” on her right hip. CT revealed destructive right iliac 8 cm mass with extraosseous soft tissue component, central necrosis, and eccentric calcifications; and right ovarian cyst. Right IC biopsy was consistent with thyroid tissue with positive Thyroglobulin and TTF-1 immunostains. Physical exam was normal, except for mild tachycardia, hypertension, right flank large rounded mass fixed to IC, tender to palpation without erythema or warmth on overlying skin. Thyroid ultrasound showed normal thyroid gland except 5.58 x 6.22 x 7.76 mm left lobe nodule without increased vascularity but with coarse peripheral calcification. FNA was unsatisfactory. Thyroid function tests revealed undetectable TSH, elevated FT4, FT3, and markedly elevated thyroglobulin and TSI. PET/CT scan showed focal area of mild FDG avidity, corresponding to the right iliac crest mass, without additional areas of FDG avidity suggestive of metastatic disease or primary neoplastic process. Three weeks after presentation, patient began having symptoms of hyperthyroidism. As FT4 and FT3 continued to rise, she was started on propranolol and methimazole. Due to inadequate response, methimazole was switched to high dose propylthiouracil with mild improvement. Thyroid uptake and scan and SPECT-CT revealed increased thyroid uptake and thyromegaly consistent with Graves’ disease and redemonstrated large right IC lesion with increased uptake in the periphery and central photopenia, suggesting metastatic thyroid malignancy. Pathology from total thyroidectomy reported encapsulated follicular variant of PTC, confined to the left lobe of the thyroid, without extrathyroidal extension, greatest tumor dimension 0.6cm. As metastasis to the IC were unlikely to have originated from this small encapsulated thyroid cancer, it was recommended to proceed with right oophorectomy for suspected malignant struma ovarii and IC lesion debulking. Surgical pathology revealed right ovary and fallopian tube without pathologic changes or features of teratoma and tissue from right iliac mass consistent with PTC. Patient is off all antithyroid medications and remains biochemically euthyroid, awaiting radioactive iodine therapy.

Radial Head Fixation vs Replacement in Terrible Triad: Preliminary Results of a Prospective Cohort Study with Patient Reported Outcome.

The combination of posterior elbow dislocation, radial head fracture, and coronoid fracture has been named "terrible triad" as this injury is difficult to treat and yield poor outcomes. Some studies compared the results of radial head fixation to replacement in isolated radial head fractures, very few reports have tried to compare both treatment modalities in the setting of a terrible triad injury.The aim of this study was to compare the functional outcome of radial head fixation vs replacement in terrible triad injuries of the elbow. A single-center, prospective cohort study was conducted at an academic Level 1 Trauma Center from April 2016 to April 2019.A total of 30 patients with terrible triad injury of the elbow were enrolled. The primary outcome was the Quick Disability of Arm, Shoulder and Hand (Quick-DASH) at 1year. The secondary outcomes were to report the Mayo Elbow Performance Score (MEPS)at 1 year and elbow range of motion. At final follow up for each patient (13.4 ± 1.2months) The Quick-DASH score at 1year for fixation group was 5 ± 2.3, for the replacement group it was 7.1 ± 7.1. The MEPS at 1year for fixation group was 93.6 ± 8.4, for the replacement group it was 90.9 ± 9.4.Loss of elbow extension at 1year for fixation group was 17.1° ± 10.7°, for replacement group it was 18.75° ± 11.5°. A systematic approach to address the bony and soft tissue components of terrible triad elbow injury is crucial to obtain satisfactory outcome. Our study shows that radial head repair andreplacement, in the setting of terrible triad injury,yields comparable results. Level II, Therapeutic study.

Risk stratification for central conventional chondrosarcoma of bone: A novel system predicting risk of metastasis and death in the Cancer Registry of Norway cohort.

Interobserver variability in histological grading of central conventional chondrosarcoma (CCCS) limits the quality of patient information and research progression. We aim to quantify known and new prognostic variables and propose a risk stratification model. We selected 149 cases from the Cancer Registry of Norway. Cox proportional hazard models were estimated. Based on these results a dichotomous risk classification was proposed and presented by Kaplan-Meier estimates for rates of local recurrence, metastasis, and disease-specific survival. The influence of axial skeletal location (Hazard ratio [HR] = 19.06), a soft tissue component ≥1 cm (HR = 13.45), and histological grade 3 (HR = 16.46) are all significant in predicting the rate of metastasis. The creation of a variable combining axial skeletal location and a soft tissue component ≥1 cm strongly predicts the risk of metastasis (HR = 14.02; P < .001) and death (HR = 2.74; P = .030) at multivariate analysis, making the histological grade insignificant. Together with metastasis at diagnosis (HR = 285.65; P < .001), this forms the basis of our proposed risk stratification, producing a small high-risk group (39 cases with 33% risk of metastasis) and a large low-risk group (103 cases with 2% risk of metastasis) without a histological grade. Axial skeletal location and a soft tissue component ≥1 cm combined divides a CCCS cohort into low- and high-risk groups without a histological grade.

Post-traumatic Sacral Epidermoid Cyst Masquerading as Chordoma on Imaging: A Case Report

Intradural spinal epidermoid cysts are rare, benign lesions either acquired from trauma, surgery, lumbar puncture or arise as congenital lesions, particularly associated with spinal dysraphism. Epidermoid cyst arising from the spine with expansile destruction of vertebrae has not been reported yet in the literature. We report a case of 36-years male presented with history of fall 8 years back with progressive symptoms of lower back pain, weakness of left lower limb and bladder/bowel incontinence. Computed tomography revealed large lytic expansile, midline sacral vertebral lesion with soft tissue component and multiple calcific foci. Magnetic resonance imaging demonstrated large non-enhancing heterogeneous mass showing restricted diffusion on diffusion weighted images. The patient underwent biopsy confirming the diagnosis of an epidermoid cyst. The possibility of an epidermoid tumor should be kept in the differential diagnosis in patients presenting with post-traumatic sacral mass.

Role of diffusion weighted MR-imaging in the evaluation of malignant mediastinal lesions

BackgroundConducted studies showed that the ADC (apparent diffusion coefficient) values of malignant mediastinal lesions are significantly lower than those of benign lesions. Investigators determined cut-off ADC values to differentiate the two; concluding that ADC value is a promising noninvasive, imaging parameter that helps assess and characterize mediastinal tumors.Taking this a step forward, the primary objective of our prospective study was to investigate the potential of DW-MRI (diffusion-weighted magnetic resonance imaging) to characterize malignant mediastinal lesions using their ADC values.Thirty-three patients that underwent MRI of the chest with DWI and latter pathologically diagnosed with a malignant mediastinal lesion were included in this study. Lesions’ ADC values were measured and correlated with the histopathological results. The statistical significance of differences between measurements was tested using the one-way ANOVA (analysis of variance) test; p values equal to or less than 0.05 were considered significant.ResultsThere was no statistically significant difference between the ADCmean values of the histopathological groups of lesions assessed with the overlap of their ADCmean values. The average ADCmean value of NHL (non-Hodgkin lymphoma) was evidently lower than that of HD (Hodgkin disease) with no overlap between their ADCmean values. DWI failed at characterizing one lesion in this study as a malignant tumor, namely an immature teratoma (germ-cell tumor). Again DWI could not be used to evaluate a mass, latter pathologically diagnosed as an angiosarcoma, because of its overall hemorrhagic nature showing no definite non-hemorrhagic soft tissue components. The aforementioned results did not differ considerably when minimum ADC was used instead of mean ADC.ConclusionThere was no statistically significant difference between the ADC values of the malignant mediastinal lesions evaluated. However, regarding lymphoma subtypes, our limited sample study of lymphoma suggested a considerable difference between the ADC values of Hodgkin disease and non-Hodgkin lymphoma.

Preservation of Bone and Soft Tissue Components of the Alveolar Ridge during Immediate Implantation in the Aesthetic Zone of Jaws with Bone Deficiency.

The use of immediate implantation (directly into the extracted tooth socket) in the aesthetic zone is a rather difficult task due to the specific structural features of the bone tissue of the alveolar processes and parts of the jaw.The aim of the study was to develop and evaluate the efficacy of the new method of immediate implantation during restoration of teeth in the anterior part of the jaw with bone deficiency, which allows obtaining a high aesthetic result.Materials and MethodsThe clinical study involved patients with partially edentulous anterior maxillae, chronic apical periodontitis and dental root fractures in the absence of possibility to restore these teeth with orthopedic structures. To identify the main criteria determining smile aesthetics, the detailed analysis of changes in the bone and soft tissues of the alveolar processes was made based on tooth extraction causes and dates. These criteria included gum biotype, the height of the distal and mesial interdental papillae; the width of the keratinized attached gingival area, gingival zeniths, the alveolar ridge thickness. The condition of the facial alveolar bone wall in the planned intervention area was assessed and its thickness was measured using cone-beam CT scan of the jaw. These parameters were measured during traditional immediate implantation, immediate implantation with a free connective tissue graft, implantation performed using the method developed by the authors and during delayed implantation in the anterior part. In each patient, the obtained data were compared with the results in the respective teeth area on the opposite side before the surgery, 4, 6 months and 1 year after the surgery.ResultsClinical and X-ray studies of the developed method of immediate implantation in the aesthetic zone of the jaw with bone deficiency in the facial alveolar bone wall have convincingly demonstrated its efficacy in the long term (1 year after the surgery). The proposed protocol has made it possible to reduce the length of rehabilitation time, and most importantly, to stabilize and preserve the alveolar ridge architecture.ConclusionThe proposed method showed the promising outlook for dental implant-supported restoration in difficult anatomical conditions.

Novel Geometry of an Extended Length Chimeric Scapular Free Flap for Hemimandibular Reconstruction: Nuances of the Technique Streamlined by In-House Virtual Surgical Planning and 3D Printing for a Severely Vessel-Depleted Neck

Subscapular-based flaps have historically maintained an unparalleled ability to provide a multitude of bone and soft tissue components based on a single vascular pedicle. However, these flaps are often not thought of as an ideal choice for composite defects requiring extended lengths of bone for reconstruction. The ability to harvest long segments of bone and reliably perform multiple contouring osteotomies is fundamental to long-span composite mandibular reconstruction, and microvascular surgeons are often met with significant reconstructive challenges when fibular free flaps cannot be used owing to variant vascular anatomy or occlusive atherosclerotic disease in these specific clinical scenarios. This challenge is further compounded by treatment-related vessel depletion in the neck, which reduces the availability of suitable recipient vessels in close proximity to the reconstruction. We present a case in which all of the aforementioned challenges presented in a single individual, who concomitantly required hemimandibular reconstruction with treatment related vessel depletion in the neck and unsuitable bilateral vascular anatomy in the legs precluding the use of a fibular free flap. This case demonstrates a previously unreported flap component geometry for hemimandibular reconstruction using an extended-length chimeric scapular free flap with scapular tip, lateral scapular border, and parascapular fasciocutaneous skin paddle components.

Radial extracorporeal shock wave therapy in flexor tendon pathology of the hand: A feasibility study

Radial extracorporeal shock wave therapy (rESWT) is an effective and safe non-invasive therapeutic option for various musculoskeletal pathologies. However, data on possible application of radial extracorporeal shock waves (rESWs) on soft tissue components of fingers is still scarce. We now aimed to analyze the feasibility of applying rESWs to human fingers ex vivo. Fresh frozen human cadaveric fingers were exposed to rESWs of varying energy density. The penetration of the rESWs into the soft tissue was determined using pressure sensitive Fuji films that were placed underneath the flexor tendons and other soft tissue components at the proximal phalanx. Then, rESWs were applied and activation of the Fuji film was recorded. Software based image analysis was performed on all films treated with rESWT under ultrasound gel. Penetration of the rESWs through the soft tissue was detected in all settings. Increasing energy density of the rESWs resulted in increasing film activation. Image analysis of films used under ultrasound showed a significant difference among the groups. The results of this study demonstrate that rESWs can penetrate soft tissues including the flexor tendons of human cadaveric fingers. rESWT should be considered as a valuable potential therapeutic option of different finger pathologies. Further studies focusing on the clinical application of rESWT for finger pathologies are required.

Eosinophilic granuloma: an unusual finding in adults

ABSTRACT A 45-year-old man presents with occipital headache for about one month, resistant to analgesic therapy, and palpable nodule at the pain site. At initial evaluation, the nodule was 1.5 cm in diameter without apparent skin alteration. Ultrasonography revealed a well-defined osteolytic lesion and doubtful communication with the dura mater. The study was complemented with computed tomography and contrast-enhanced magnetic resonance, both identifying lytic lesion with soft tissue component and contrast enhancement, without diffusion restriction, guiding the diagnostic hypothesis of eosinophilic granuloma. Surgical treatment with mass excision and anatomopathological evaluation was made, which confirmed the radiological diagnostic hypothesis. After three months of follow-up, the patient remained symptom-free and radiographic control showed no signs of relapse.

Primary bone lymphoma: pictorial essay.

Primary bone lymphoma is a rare neoplasm that can initially present as local pain, a palpable mass, and pathologic fracture. It can also be discovered as an incidental finding on an imaging examination. It is defined as a bone marrow tumor with no involvement of other sites, lasting at least six months. The diagnosis is confirmed by biopsy and immunohistochemical analysis. Although the imaging characteristics are nonspecific, there are certain findings that, when correlated with clinical and epidemiological aspects, can increase the level of suspicion of primary bone lymphoma. The classic imaging aspect is a bone lesion with a soft-tissue component that preserves the cortical layer more than would be expected given the invasive nature of the lesion. Magnetic resonance imaging is the best imaging method to evaluate the extent of involvement of adjacent compartments, whereas computed tomography depicts the cortical layer in greater detail, as well as being an important tool for biopsy guidance. Other imaging modalities are also discussed, such as X-ray, ultrasound, bone scintigraphy, and positron emission tomography/computed tomography. The aim of this paper is to describe the most common findings obtained with the various imaging methods used in patients with a confirmed diagnosis of primary bone lymphoma.

Concurrent Platysmaplasty and Genioplasty Using a Novel Intraoral Approach

Facial aging patients frequently seek improved neck and jawline definition. Microgenia, or lack of chin support, is often overlooked or underdiagnosed in these patients. The authors propose a simultaneous genioplasty, in addition to platysmaplasty and face/neck lift, to address both soft-tissue and bony components, and enhance the cervicomental area. The platysmaplasty is performed in a novel fashion using the intraoral genioplasty incision. The operative sequence includes intraoral incision, platysmal exposure, fat excision, platysmal tightening, genioplasty osteotomy/fixation, and external skin redraping (face/neck lift). Case examples are shown to illustrate appropriate candidate selection and results. Parameters for success include increased chin-throat distance and definition, improved cervicomental angle, and soft-tissue rejuvenation. The novel approach the authors describe enables discrete access to the platysmal and submental region and provides bony definition to help optimize the soft-tissue drape and definition. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Isolated Mandibular Metastasis Detected on Staging 18FDG PET/CT Scan in a Case of Carcinoma Urinary Bladder.

Isolated mandibular metastasis is very rare from carcinoma urinary bladder with no locoregional lymph node involvement. Here, we present a case where staging fluorodeoxyglucose - positron emission tomography - computed tomography (FDG PET-CT) scan showed an FDG avid primary lesion in carcinoma urinary bladder with FDG avid erosion in the right mandibular condyle. However, since no pelvic lymph nodes were involved, the mandibular lesion was kept on follow-up and cystoprostatectomy was performed. Follow-up FDG PET-CT scan after 6 months revealed an osteolytic destructive lesion in the mandible with associated soft tissue component and the biopsy confirmed this as metastatic lesion.

Spinal Tuberculosis Mimicking as Prostate Cancer Metastases in Ga-68 Prostate-specific Membrane Antigen Positron-emission Tomography/Computed Tomography.

Prostate-specific membrane antigen (PSMA) is a type II transmembrane glycoprotein which is overexpressed in prostate cancer. However, the widespread use of PSMA positron-emission tomography (PET) scan revealed various nonprostatic PSMA-avid diseases. Here we present a report of a known case of carcinoma prostate, post orchidectomy, radiotherapy, on hormonal therapy with complain of back pain, referred for Ga68 PSMA PET/CT scan. The scan revealed PSMA-avid lesion of contiguous D6 and D7 vertebrae with associated soft-tissue component. The biopsy of the lesion was suggestive of tuberculosis.

A correlative study to evaluate the effect of various skeletal and dentoalveolar parameters on smile esthetics in different malocclusion groups

Introduction: The smile is one of the most effective means by which people convey their emotions and from a social standpoint, it is viewed frontally more often than in profile. Smiles can be either posed or spontaneous. Peck and Peck classified smiles as Stages I and II, and Ackerman et al . classified smiles into two basic types: the social smile and the enjoyment smile. Each type involves a different anatomic presentation of the elements of the display zone. Smile characteristics are determined by the interplay of static and dynamic relationships between the dentoskeletal and soft-tissue components of the face. Hence, a study was planned to understand the influence of various skeletal and dentoalveolar parameters on smile esthetics in different malocclusion groups. Materials and Methods: Sixty subjects in the age range of 17–25 years were selected and skeletally divided into Groups I and II on the basis of beta angle, ANB angle, and Wits appraisal. Group II was further subdivided into two groups on the basis of Angle's classification of the malocclusion. Various skeletal and dental parameters were measured on cephalogram and smile measurements were made on facial photographs in Adobe Photoshop. Various statistical tests were applied for assessment and comparison of various skeletal and dentoalveolar parameters and their correlation with smile esthetics were in different malocclusion groups. Results: Upper lip length was maximum in Class II div 2 malocclusion patients and least in Class I malocclusion patients. It was maximum in horizontal growth pattern patients. It decreased with the increase in proclination of upper incisors. Maxillary incisal display at rest and smile was maximum in Class II div 1 malocclusion patients and least in Class II div 2 malocclusion patients. It was maximum in vertical growth pattern individuals. It increased with the increase in proclination of upper incisors. A similar tendency was shown by the Morley ratio and modified smile. Lip competency was maximum in Class II div 2 patients and minimum in Class II div 1 patients. It was maximum in horizontal growth pattern patients. Proclination of the incisors decreased the lip competency. Conclusions: Different skeletal patterns exhibit their characteristic smile features. Orthodontic treatment should be planned considering the correlation of skeletal and dental effects on smile esthetics.

Virtual Surgical Planning in Subscapular System Free Flap Reconstruction of Midface Defects

ObjectivesReconstruction of the midface has many inherent challenges, including orbital support, skull base reconstruction, optimizing midface projection, separation of the nasal cavity and dental rehabilitation. Subscapular system free flaps (SF) have sufficient bone stock to support complex reconstruction and the option of separate soft tissue components. This study analyzes the effect of virtual surgical planning (VSP) in SF for midface on subsite reconstruction, bone segment contact and anatomic position. Materials and MethodsRetrospective cohort of patients with midface defects that underwent SF reconstruction at a single tertiary care institution. ResultsNine cases with VSP were compared to fourteen cases without VSP. VSP was associated with a higher number of successfully reconstructed subunits (5.9 vs 4.2, 95% CI of mean difference 0.31–3.04, p = 0.018), a higher number of successful bony contact between segments (2.2 vs 1.4, 95% CI of mean difference 0.0–1.6, p = 0.050), and a higher percent of segments in anatomic position (100% vs 71%, 95% CI of mean difference 2–55%, p = 0.035). When postoperative bone position after VSP reconstruction was compared to preoperative scans, the difference in anteroposterior, vertical and lateral projection compared to the preoperative ‘ideal’ bone position was <1 cm in 82% of measurements. There were no flap losses. ConclusionVSP may augment SF reconstruction of the midface by allowing for improved subunit reconstruction, bony segment contact and anatomically correct bone segment positioning. VSP can be a useful adjunct for complex midface reconstruction and the benefits should be weighed against cost.

Frequency of Complicated Symptomatic Bone Metastasis Over a Breadth of Operational Definitions

Numerous randomized trials have demonstrated noninferiority of single- versus multiple-fraction palliative radiation therapy (RT) in the management of uncomplicated bone metastases; yet there is neither a clear definition of what constitutes a complicated lesion, nor substantial data regarding the prevalence of such complicating features in clinical practice. Thus, we identify a range of evidence-based operational definitions of complicated symptomatic bone metastases and characterize the frequency of such complicating features at a high-volume, tertiary care center. A retrospective review of patients seen in consultation for symptomatic bone metastases between March 1, 2007, and July 31, 2013, at Johns Hopkins Hospital identified patient and disease characteristics. Descriptive statistics characterized the frequency of the following complicating features: prior RT, prior surgery, neuraxis compromise, pathologic fracture, and soft tissue component at the symptomatic site. A range of definitions for complicated bone metastases was evaluated based on combinations of these features. Uni- and multivariable logistic regressions evaluated the odds of complicated bone metastases as a function of site of primary cancer and of the symptomatic target lesion. A total of 686 symptomatic bone metastases in 401 patients were evaluated. Percent of target sites complicated by prior RT was 4.4%, prior surgery was 8.9%, pathologic fracture was 20.6%, neuraxis compromise was 52.0% among spine and medial pelvis sites, and soft tissue component was 38.6%. More than 96 possible definitions of complicated bone metastases were identified. The presence of such complicated lesions ranged from 2.3% to 67.3%, depending on the operational definition used. Odds of a complicated lesion were significantly higher for spine sites and select nonbreast histologies. In this retrospective study, we found complicated symptomatic bone metastases may be present in up to two-thirds of patients. Literature review also demonstrates no clear standard definition of complicated bone metastases, potentially explaining underutilization of single-fraction palliative RT in this setting.

Association of Ultrasonographic Findings and Thyroid Malignancy: A Cross-Sectional Study

Objective: To determine the association of thyroid malignancy and the following ultrasonographic findings: presence of solid hypoechoic nodule, irregular margins (infiltrative, microlobulated, or speculated), microcalcifications or disrupted rim calcifications with small extrusive hypoechoic soft tissue component, taller than wide shape of the thyroid nodule, and evidence of extrathyroidal extension.&#x0D; Methods:&#x0D; Design: Cross-Sectional Study&#x0D; Setting: Tertiary Government Training Hospital&#x0D; Participants: Records of patients admitted to the Otorhinolaryngology- Head and Neck Surgery ward with a diagnosis of nodular non-toxic goiter, multinodular non-toxic goiter, and thyroid malignancy who underwent thyroid surgery between January 2017 and June 2018 were considered for inclusion.&#x0D; Results: A total of 33 patients, 7 males and 26 females, were included in this study. Patients’ age ranged from 26 to 69 years with an average of 46 years. Thirteen (39.4%) had malignant while 20 (60.6%) had benign histopathologic results. There was a significant association between presence of solid hypoechoic nodule (Fisher exact, n = 33, p = .0047), irregular margins and microcalcifications with malignant histopathology results (X2 (df = 1, N = 33) = 8.57, p = .003). No significant difference was noted in the proportion of subjects with malignancy according to taller than wide nodules (Fisher exact, n = 33, p = 1.000) or presence of extrathyroidal extension nodules or presence of extrathyroidal extension (Fisher exact, n = 33, p = .276). On multivariate analysis using logistic regression, only microcalcification was found to be a significant predictor of malignancy (OR = 8.96, 95% CI: 1.02 – 87.19, p = .05).&#x0D; Conclusion: There was a significant association between presence of solid hypoechoic nodule, margins and microcalcifications with thyroid carcinoma. Only microcalcification was found to be a significant predictor of thyroid malignancy on ultrasound, although our confidence interval was broad.&#x0D; Keywords: calcifications; thyroid; thyroid carcinoma; thyroid nodule; ultrasonography

Dynamic lung phantom commissioning for 4D dose assessment in proton therapy

Anthropomorphic phantoms mimicking organ and tumor motion of patients are essential for end-to-end testing of motion mitigation techniques in ion beam therapy. In this work a commissioning procedure developed with the in-house designed respiratory phantom ARDOS (Advanced Radiation DOSimetry system) is presented. The phantom was tested and benchmarked for 4D dose verification in proton therapy, which included: characterization of the tissue equivalent materials from computed tomography (CT) imaging, assessment of dose calculation accuracy in critical structures of the phantom, and testing various detectors for proton dosimetry in the ARDOS phantom.To prove the validity of the CT calibration curve, measured relative stopping powers (RSP) of the ARDOS materials were compared with values from CTs: original and overwritten with known material parameters. Override of rib- and soft-tissue phantom components improved RSP accuracy while inhomogeneous lung tissue, represented by the balsa wood, was better modelled by the CT Hounsfield units.Monte Carlo (MC) dose calculations were benchmarked against measurements with a reference Farmer chamber embedded in ARDOS material samples showing less than 3% relative dose difference. Differences between MC calculated dose distributions and those calculated by analytical algorithms for the ARDOS geometry were higher than 20% of the prescribed dose, depending on the position in the phantom.Pinpoint ionization chambers and thermoluminescence dosimeters showed differences of up to 5.5% compared to MC dose calculations for all lung setups in the static phantom. They were also able to detect dose distortions due to motion. EBT3 film dosimetry was shown to be suitable for 2D relative dose characterization, which could provide extended information on dose distributions in the penumbra area.The presented methodology and results can be used for drafting general recommendations for dynamic phantom commissioning, which is an essential step towards end-to-end evaluation of motion mitigation techniques in ion beam therapy.