Nonsurgical Therapeutic Modalities Research Articles

Therapeutic outcomes and survival analysis of Extramammary Paget's disease: A multicentre retrospective study of 249 patients

Evidence regarding long-term therapeutic outcomes and disease-specific survival (DSS) in Extramammary Paget's disease (EMPD) is limited. To assess the DSS and outcomes of surgical and nonsurgical therapeutic modalities in a large cohort of EMPD patients. Retrospective chart review of EMPD patients from 20 Spanish tertiary care hospitals. Data on 249 patients with a median follow-up of 60months were analyzed. The estimated 5-, 10-, and 15-year DSS was 95.9%, 92.9%, and 88.5%, respectively. A significantly lower DSS was observed in patients showing deep dermal invasion (≥1mm) or metastatic disease (P<.05). A ≥50% reduction in EMPD lesion size was achieved in 100% and 75.3% of patients treated with surgery and topical therapies, respectively. Tumor-free resection margins were obtained in 42.4% of the patients after wide local excision (WLE). The 5-year recurrence-free survival after Mohs micrographic surgery (MMS), WLE with tumor-free margins, WLE with positive margins, radiotherapy, and topical treatments was 63.0%, 51.4%, 20.4%, 30.1%, and 20.8%, respectively. Retrospective design. EMPD is usually a chronic condition with favorable prognosis. MMS represents the therapeutic alternative with the greatest efficacy for the disease. Recurrence rates in patients with positive margins after WLE are similar to the ones observed in patients treated with topical agents.

Phase I therapy in periodontics and periodontal regeneration: Gate to success in dentistry- A review

Periodontal disease is a multifactorial inflammatory condition comprising of a complex interaction between pathogenic bacteria, environmental and acquired factors and host related factors. It is well known that to achieve successful result one must focus on eliminating the cause of disease. In this review we will be discussing most important phase in dental treatment i.e Phase I therapy because the basis of any dental problem ever seen is primarily or secondarily due To “Plaque” Hence Pahse-I Therapy.Scaling and root planning (SRP) is a conventional, non-invasive periodontal therapy and when used alone or as adjunct with other non-surgical therapeutic modalities have shown a great success in dental procedures.

Novel approaches in search for biomarkers of cholangiocarcinoma.

Cholangiocarcinoma (CCA) arises from the ductular epithelium of the biliary tree, either within the liver (intrahepatic CCA) or more commonly from the extrahepatic bile ducts (extrahepatic CCA). This disease has a poor prognosis and a growing worldwide prevalence. The poor outcomes of CCA are partially explained by the fact that a final diagnosis is challenging, especially the differential diagnosis between hepatocellular carcinoma and intrahepatic CCA, or distal CCA and pancreatic head adenocarcinoma. Most patients present with an advanced disease, unresectable disease, and there is a lack in non-surgical therapeutic modalities. Not least, there is an acute lack of prognostic biomarkers which further complicates disease management. Therefore, there is a dire need to find alternative diagnostic and follow-up pathways that can lead to an accurate result, either singlehandedly or combined with other methods. In the "-omics" era, this goal can be attained by various means, as it has been successfully demonstrated in other primary tumors. Numerous variants can reach a biomarker status ranging from circulating nucleic acids to proteins, metabolites, extracellular vesicles, and ultimately circulating tumor cells. However, given the relatively heterogeneous data, extracting clinical meaning from the inconsequential noise might become a tall task. The current review aims to navigate the nascent waters of the non-invasive approach to CCA and provide an evidence-based input to aid clinical decisions and provide grounds for future research.

Pain Complaints in Patients Undergoing Orthognathic Surgery.

The aim of this retrospective study was to assess the frequency of orofacial (nonodontogenic, neuropathic, or atypical) and temporomandibular joint (TMJ) and/or masticatory muscle pain in orthognathic patients in a tertiary institution. A total of 286 consecutive patients undergoing sagittal split osteotomy from 2014 to 2016 were included. Thirty-nine (13.6%) patients presented with TMJ pain and 10 (3.5%) with orofacial nonodontogenic pain before orthognathic surgery; 79.6% (39/49) of these patients had no pain 1 year after surgery. Twenty-nine patients (12.2%) with no preoperative orofacial pain and 22 (9.3%) without preoperative TMJ pain presented with pain 1 year after surgery. Fifty-one (17.8%) of the 286 patients treated for orthognathic cases at our center over the 3-year period presented with pain 1 year after surgery. Most patients were managed conservatively with nonsurgical therapeutic modalities including counseling, physical therapy, warmth application, and bilateral chewing and splint therapy. In patients with TMJ pain refractory to conservative treatment, arthroscopic surgery was advised and successful in all patients for both pain reduction and improvement of the maximal interincisal opening. TMJ symptoms do develop after orthognathic surgery in patients with and without a previous history of TMJ complaints. Most patients can be managed with nonsurgical therapeutic modalities.

Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.

Perianal Paget's Disease: Presentation of Twelve Cases and a Literature Review

Purpose. Perianal Paget's disease (PPD) is a rare intraepithelial adenocarcinoma. To date, ~200 cases have been reported, representing ~20% of all extramammary Paget's disease cases. The standard treatment is wide local excision, although PPD has a high recurrence rate. Here, we review our management for PPD and review the currently recommended treatment approaches. Methods. In this study, we reviewed 12 patients diagnosed with PPD between 1995 and 2014. Clinical data including age, sex, symptoms, symptom duration, histopathology, treatment modality, recurrence, follow-up duration, and survival outcome were evaluated. We also reviewed the published literature from 1990 to 2014 to identify the treatment strategies used in 213 cases of PPD. Results. Twelve patients with in situ disease with a median age of 70.8 (65-76) years, including 3 female patients (25%), were diagnosed with PPD. Eleven patients underwent surgery. The mean follow-up time was 92.1 (36-200) months. One patient died from liver cancer and bone metastasis, and the remaining patients are alive; 10 are disease-free and 1 experienced postsurgical local recurrence. This patient refused extensive radical excision, so radiotherapy (32 Gy in 16 fractions) was administered and the patient remains disease-free after 4 years. Conclusion. Surgery is the mainstay treatment for PPD. Nonsurgical modalities could be considered an alternative to surgery for those with noninvasive PPD who refuse radical surgery or who are medically unfit for surgery. Further research and follow-up are needed to compare the effectiveness of surgical and nonsurgical therapeutic modalities for PPD.

Histologic findings on prostate needle core biopsies following cryotherapy as monotherapy for prostatic adenocarcinoma

The histologic features seen in the prostate following cryotherapy can be highly variable. However, most previous studies were performed on specimens following salvage cryotherapy, which introduces additional confounding variables of the histologic changes after the other primary treatment modalities. We examined prostate needle core biopsies from a cohort of patients following cryotherapy as monotherapy for prostatic adenocarcinoma, to evaluate the true spectrum of morphologic changes in the prostate. Cases that had prior radiation therapy or androgen-deprivation therapy were excluded from the study. Thirty cases were identified. The average patient age was 69 years (range, 51-81 years), and the average time interval between cryotherapy and repeat biopsy was 19.2 months (range, 2-60 months). The original Gleason scores were as follows: 3 + 3 = 6 in 14 (46%) of 30 cases, 3 + 4 = 7 in 8 (27%) of 30 cases, 4 + 3 = 7 in 2 (7%) of 30 cases, 4 + 4 = 8 in 3 (10%) of 30 cases, 4 + 5 = 9 in 2 (7%) of 30 cases, and 5 + 4 = 9 in 1 (3%) of 30 cases. Postcryotherapy, 11 of 30 cases (37%) had recurrent/residual prostatic adenocarcinoma, which showed no therapy-related changes, similar to the residual benign glands. Gleason scores were higher in 5 (46%) of 11 cases, same in 4 (36%) of 11 cases, and lower in 2 (18%) of 11 cases. Multiple additional histologic findings were documented. Unlike other nonsurgical therapeutic modalities, cases with recurrent/residual prostatic adenocarcinoma and benign glands showed therapy-related changes predominantly involving the stroma. It is therefore conceivable that benign or malignant prostatic glands are either completely destroyed during cryotherapy or left unaltered if not in the direct field of cryoablation.

Clinical and Patient‐Centered Outcomes After Minimally Invasive Non‐Surgical or Surgical Approaches for the Treatment of Intrabony Defects: A Randomized Clinical Trial

The present study aims to compare the performance of minimally invasive non-surgical and surgical approaches for the therapy of intrabony defects. Twenty-nine patients who presented with intrabony defects were randomly assigned to: 1) a minimally invasive non-surgical technique (MINST) group, or 2) minimally invasive surgical technique (MIST) group. The chair time of each therapeutic procedure was calculated. The probing depth (PD), position of the gingival margin (PGM) and relative clinical attachment level (RCAL) were evaluated at 3 and 6 months after treatments. The patient perception of discomfort/pain experienced during and after therapy and patient satisfaction regarding treatments were also evaluated. Significant PD reductions, RCAL gains, and no changes in the PGM were obtained at 3 and 6 months in MINST and MIST groups (P <0.05). No differences were observed between groups at any time points (P >0.05). Patient-oriented outcomes did not demonstrate differences between therapeutic approaches (P >0.05). Significant higher chair times were required in the MIST group than in the MINST group (P <0.05). Minimally invasive non-surgical and surgical approaches were successfully used for the treatment of intrabony defects and achieved periodontal health in association with negligible morbidity and suitable patient satisfaction. However, non-surgical therapeutic modality presented an advantage in terms of a reduction of treatment chair time.

Contemporary management of sinonasal cancer

Sinonasal cancer is a relatively uncommon entity encountered by head and neck oncologists, rhinologists, and skull base surgeons. Recent innovations in surgical and nonsurgical therapeutic modalities raise the question of whether there has been any measurable improvement for treatment outcomes. A retrospective review of data from recent studies that focus on surgery, radiation, and chemotherapy, or combinations thereof, was conducted. Surgery continues to be the preferred treatment and provides the best results, albeit with an inherent bias based on patient selection. For advanced disease (T4 lesions), the survival rate remains only modest. Complications of treatment, including both surgical and radiation therapy, have been reduced. There is a need to improve the efficacy of treatment for this disease. Recommendations for the future direction of therapeutic investigations are outlined.

Epigenetic DNA hypermethylation in cholangiocarcinoma: potential roles in pathogenesis, diagnosis and identification of treatment targets

Cholangiocarcinomas (CCs) are highly lethal malignant tumours arising from the biliary tract epithelium. The disease is notoriously difficult to diagnose and is usually fatal because of its typically late clinical presentation and the lack of effective non-surgical therapeutic modalities. The overall survival rate, including resected patients is poor, with less than 5% of patients surviving 5 years, a rate which has not changed significantly over the past 30 years. Although CC is a relatively uncommon tumor, interest in this disease is rising as incidence and mortality rates for intrahepatic cholangiocarcinoma are increasing markedly worldwide. A variety of risk factors, including primary sclerosing cholangitis, liver fluke infestation, and hepatolithiasis have been described. However, for most CCs the cause is unknown, and affected individuals have no history of exposure to, or association with, known risk factors. Recent advances in molecular pathogenesis have highlighted the importance of epigenetic alterations in the form of promoter region hypermethylation and histone deacetylation in addition to genetic changes in the process of cholangiocarcinogenesis. This review provides a comprehensive overview of the genes reported to be methylated in CC to date and their putative roles in cholangiocarcinogenesis. Future directions in the study of methylated genes and their potential roles as diagnostic and prognostic markers are also discussed.

M14-01: Mediastinal staging of NSCLC and 18FDG PET

M14-01: Mediastinal staging of NSCLC and 18FDG PET

The Interdisciplinary Concept in Treating Patients with Malignant Anterior Skull Base Tumors and Outcomes

Objective: Malignant tumors of the anterior skull base are complex lesions that require an understanding of the tumor pathology, principles of resection, and nonsurgical therapeutic modalities. In order to justify a complex interdisciplinary surgical approach, the indications and contraindications for resection should be influenced by prognostic factors and anticipated outcome.

Hepatic resection compared to percutaneous ethanol injection for small hepatocellular carcinoma using propensity score matching

Several surgical and non-surgical therapeutic modalities have been used for the treatment of hepatocellular carcinoma (HCC). There have been several studies comparing hepatic resection (HR) and percutaneous ethanol injection (PEI) for the treatment of HCC. However, there is still disagreement about the best treatment modality. From 130 patients undergoing HR, 116 patients were individually matched to 116 controls from 249 patients undergoing PEI using propensity score matching to overcome possible biases in non-randomized study. Survival analyses were undertaken to compare these propensity score-matched groups. After matching by propensity score, the major clinical outcomes in the HR (n = 116) and the PEI (n = 116) groups were found to be similar. The 1-, 3- and 5-year overall survival rates were higher in the HR group (94.8%, 76.5% and 65.6%) compared to the PEI group (95.7%, 73.5% and 49.3%) (P = 0.059). The cumulative 1-, 3- and 5-year disease-free survival rates showed the same trend (HR: 76.1%, 50.6% and 40.6%; PEI: 62.6%, 25.5% and 19.1%) (P < 0.001). However, when stratified by Child-Pugh classification, it was no longer the case in the Child B patients. Single intrahepatic recurrence was the most common pattern of tumor recurrence after both treatments. Patients undergoing HR had a better survival profile than those undergoing PEI. However, when considering which technique to use for optimal HCC management, the individual patient's hepatic function must be considered.

The Interdisciplinary Concept in Treating Patients with Malignant Anterior Skull Base Tumors and Outcomes

Objective: Malignant tumors of the anterior skull base are complex lesions that require an understanding of the tumor pathology, principles of resection, and nonsurgical therapeutic modalities. In order to justify a complex interdisciplinary surgical approach, the indications and contraindications for resection should be influenced by prognostic factors and anticipated outcome.

Radiofrequency Ablation of Benign Cold Thyroid Nodules: Initial Clinical Experience

To evaluate the efficacy and safety of ultrasound (US)-guided percutaneous radiofrequency (RF) ablation for benign cold thyroid nodules as a nonsurgical therapeutic modality. DESIGN, INTERVENTION, AND PATIENTS: A total of 35 benign cold thyroid nodules in 30 euthyroid patients (M:F = 2:28; mean age 39.1 years) underwent percutaneous RF ablation with a 1-cm-internally cooled electrode. Seventy-seven percent (23/30) of patients required conscious sedation for discomfort. We evaluated the tumor size, cystic component, vascularity (by color Doppler US), and the severity of mass-related symptoms before treatment. We assessed the therapeutic efficacy and safety of RF ablation by clinical and US follow-up (median 6.4 months). The volume of the tumors before ablation had a range of 0.6-28.2 mL (mean, 6.3 mL). The residual volume was 53.5% +/- 26.5% of original at 1.1-2.9 months (n = 32), 36.2% +/- 27.4% at 3.0-5.9 months (n = 20), 30.7% +/- 25.0% at 6.0-8.9 months (n = 15), and 11.8% +/- 10.9% at 9.0-18.5 months (n = 13). Mixed/mainly cystic tumors showed a significantly better response than mainly solid tumors (p < 0.05). Difference in vascularity did not affect the treatment response. Thyroid function after the procedure was maintained as normal in all patients. Eighty-eight percent of the patients reported an improvement of their symptoms. There was no major complication other than vocal cord palsy in one patient (3.3%). RF ablation may be an effective and safe nonsurgical technique to treat benign cold thyroid nodules.

Défaillance multiviscérale précoce associée à la pancréatite aiguë : stratégie thérapeutique chirurgicale ou conservatrice ?

The mortality of severe acute pancreatitis still ranges between 10% and 20%. Nowadays, infected pancreatic necrosis is the leading cause of death. Despite advances in intensive care therapy, however, early and worsening multi-system organ failure remains a source of substantial morbidity and still accounts for 20–50% of the deaths. News and hotspots.– The three interrelated pathophysiological mechanisms underlying glandular necrosis include the premature intra-acinar activation of pancreatic pro-enzymes, an early pancreatic microcirculatory impairment, and the excessive stimulation of immune effector cells. In recent years, the systemic inflammatory response syndrome and the relevant cascades of inflammatory mediators have been implicated as the key factor in the emergence of remote tissue damage. Early multi-system organ failure that supervenes in the first week is typically associated with a sterile necrotizing process. The correlation between pathomorphological and clinical severity and the similarity between their respective pathophysiological mechanisms are not straightforward, however. There are no pathophysiological, clinical or economical data to support the practice of debridement of sterile necrosis to prevent or to control early multi-system organ failure. This issue has never been addressed in a controlled study. Besides intensive care support, non-surgical therapeutic modalities including urgent endoscopic sphincterotomy for impacted stones, antibiotic prophylaxis for the prevention of pancreatic infection and early jejunal nutrition have been specifically developed hopefully to attenuate multiple organ failure, to obviate the need of surgical drainage and to improve survival. Fine needle aspiration of necrotic areas must be incorporated in any conservative therapeutic strategy in order not to jeopardize those with infected necrosis that remains an absolute indication for drainage. Perspectives.– There is ample experimental and pathophysiological evidence in favour of immunomodulatory therapy in severe acute pancreatitis. The administration of one or several antagonists of inflammatory mediators possibly combined with a protease inhibitor may at last provide the opportunity to interfere with the two major determinants of prognosis: the severity of multiple organ failure and the extent of necrotic areas that creates the culture medium for bacterial superinfection. These benefits remain to be substantiated in a controlled study, however.

Operative management of skull base malignancies: choosing the appropriate approach

Malignant tumors of the skull base are complex lesions. Identifying the indications and contraindications for resection is essential for the successful treatment of these lesions. This requires an understanding of the pathology, principles of resection, and nonsurgical therapeutic modalities. Choosing the appropriate surgical approach requires an understanding of the tumor and its association with the anatomy of the skull base. Preoperative assessment and preparation of the patient for the postoperative course, including functional and cosmetic deficits, are reviewed in the context of the specific approach. Anatomical variations encountered in the preoperative planning are discussed. A review of reconstructive alternatives is presented that is specific to the approach and anatomical violation. Finally, the use of a multidisciplinary team both in and out of the operating room is recommended, emphasizing a team approach during the resection itself.

Squamous Cell Carcinoma of the Oral Cavity: The Results of the Surgical and Non-surgical Therapeutic Modalities in a Consecutive Series of 156 Patients Treated in Copenhagen County

A retrospective study on patients, treated for intraoral squamous cell carcinoma in Copenhagen county, is reported. The material included 156 patients, 66 females and 90 males. Age at diagnosis varied between 35 and 95 years with a mean of 65 years. Mean age of females/males was 70/62 years. Twelve therapeutic modalities were performed; surgery, radiotherapy, chemotherapy and different combinations of these. Three and five years crude survival were 43% and 37%. Three and five years crude survival rates were 70% and 61% for patients in stage I, 39% and 32% for patients in stage II, 29% and 16% for patients in stage III and 19% and 17% for patients in stage IV. The results are similar to those achieved in other centers. Since no significant improvement has been noted in patient survival during the last 5–6 decades and since the therapeutic morbidity has not always been acceptable to the patients, other therapeutic principles such as the so-called minimal invasive therapy should be considered in future treatment of intraoral cancer.

Nonsurgical treatment of hepatocellular carcinoma in cirrhotic patients.

Modern imaging modalities have allowed us to make reliable diagnosis of hepatocellular carcinoma (HCC). Most of HCCs are associated with liver cirrhosis in varying stages of severity and often accompanied by new occurrences of HCC after treatment. Now, newly developed nonsurgical therapeutic modalities are used extensively and achieve good results in terms of anti-tumor effects as well as post-treatment survival.

A regional audit of the investigation and treatment of colorectal and pelvic floor disorders (1984?1991)

The activities of a regional physiology unit established for the investigation of colorectal and pelvic floor physiology in health and disease in a clinically relevant setting has been audited and its evolution described over a period of eight years. Trends in surgical treatment of some of these disorders over the same period have also been documented in the Lothian Region. Although there has been little change in the number of patients investigated annually patterns of investigation appear to change. Sphincter manometry, proctometrography and somatosensory reflex measurements have remained the most frequently performed and useful investigations. Spinal stimulation studies increased transiently because of a collaborative investigation of bowel and bladder function in patients with spinal injuries. A considerable increase in surface EMG tests and dynamic proctography has occurred. These trends are thought to be related to interest in defining evacuation dysfunction of the rectum and related problems of the pelvic floor. Isotope proctography now rivals barium videoproctography; at the same time the use of manometric colonic motility studies has diminished. Anal ultrasonography has replaced sphincter mapping in the last year and is being applied to other aspects of anorectal pathology. The last 4 years have seen the introduction and increasing use of non-surgical therapeutic modalities for the treatment of faecal incontinence and constipation: reflex electronic sphincter stimulation, biofeedback and the use of a prokinetic agent to promote colonic motility. Concomitant changes in the surgery of constipation and reconstructive anorectal procedures have been observed. It is recommended that coloproctology units should have easy access to at least one such investigation laboratory within their catchment area together with appropriate auditing facilities.