Surgery Therapy Research Articles

Adjuvant Therapy for High-risk Endometrial Carcinoma

About one-fifth of endometrial cancers are ‘high risk’, which carries a poorer prognosis. Management strategies to optimise their survival have been under investigation for many years. Despite recent advances, their overall survival remains relatively poor. The definition of high risk in endometrial cancers has been based on clinicopathological factors until recently, when molecular profiling has shown greater discrimination. There is, however, poor correlation between traditional clinicopathological factors and their molecular profile. This is the subject of ongoing trials to better individualise adjuvant post-hysterectomy treatment. The management of high-risk tumours is traditionally based on surgery followed by radiotherapy, despite no proven overall survival benefit in early stages. The place of chemotherapy remains under investigation, with recent trials showing benefit in more advanced stages. The Post Operative Radiation Therapy in Endometrial Carcinoma (PORTEC) and Gynecologic Oncology Group trials support the use of chemoradiation and chemotherapy for stage III and adverse histological subgroups. In addition, there is now early evidence of correlation between benefit from adjuvant chemotherapy based on molecular alterations in the tumour cells. In this review, we look at the current evidence on management strategies in the evolving era of molecular diagnosis and stratification.

The rate of estrogen receptor-conversion associated with tumor progression in estrogen receptor-positive breast cancer patients following adjuvant Tamoxifen administration.

BackgroundHormone Receptor (HR)‐discordance between primary breast cancer and metastasis is a known biological phenomenon. Discordance studies usually comprise a heterogeneous group of HR‐positive and negative patients and allow for the comparison of changes in HR‐status from the primary to the recurrent disease. However, in a clinical setting, the rate of estrogen receptor‐conversion following endocrine therapy with agents such as Tamoxifen (TAM) in estrogen receptor‐positive cancers is of primary interest as opposed to total receptor discordance.AimTo investigate the rate of estrogen receptor‐conversion associated with tumor progression in estrogen receptor‐positive breast cancer patients following adjuvant TAM administration and to compare the results with the meta‐analysis data of HR‐discordance studies.Methods and ResultsA retrospective double‐center review of biomarkers in 67 estrogen receptor‐positive breast cancer patients who underwent TAM treatment in the adjuvant setting. The estrogen and progesterone receptor‐status were compared at the time of diagnosis and following relapse and the Disease‐free Survival, mean duration of TAM treatment as well as the operative, radiation, and cytotoxic therapies registered before TAM treatment, were recorded.Initially, all patients were estrogen receptor‐positive. The average age at the time of diagnosis was 52.8 ± 12.4 years. After recurrence, only 47 patients (70.1%) were still estrogen receptor‐positive with a highly significant loss of estrogen receptor‐expression in 29.9% of cases. The mean duration of TAM treatment was 40.7 ± 19.9 months. 45 patients (i.e., 67.2%) progressed during the TAM treatment and the remaining 22 patients (32.8%) developed relapse after the TAM treatment had finished. Initially, there were 82.1% progesterone receptor‐positive and 17.9% progesterone receptor‐negative, but after relapse the progesterone receptor‐positive cases diminished significantly to 53.7%, showing a progesterone receptor‐loss of 28.4%.ConclusionThe rate of estrogen receptor‐loss associated with tumor progression following TAM treatment is approximately 30%, which is of clinical relevance in order to evaluate further endocrine efficacy in these patients. This rate of receptor conversion is roughly 6‐13% higher compared to the recently published meta‐analysis data of discordance studies. This discrepancy could possibly be due to anti‐hormonal therapy with TAM accentuating receptor conversion.

Proton Therapy for Head and Neck Cancer: Current Clinical Applications and Future Direction

Intensity-modulated radiation therapy (IMRT) using X-rays is a standard technique implemented for treating head and neck cancer (HNC). Compared to 3D conformal RT, IMRT can significantly reduce the radiation dose to surrounding normal tissues by using a highly conformal dose to the tumor. Proton therapy is a type of RT that uses positively charged particles named protons. Proton therapy has a unique energy deposit (i.e., Bragg peak) and greater biological effectiveness than that of therapy using X-rays. These inherent properties of proton therapy make the technique advantageous for HNC treatment. Recently, advanced techniques such as intensity-modulated proton therapy have further decreased the dose to normal organs with a higher conformal dose to the tumor. The usage of proton therapy for HNC is becoming widespread as the number of operational proton therapy centers has increased worldwide. This paper aims to present the current clinical evidence of proton therapy utility to HNC clinicians through a literature review. It also discusses the challenges associated with proton therapy and prospective development of the technique. Key Words: Proton therapy, Intensity-modulated proton therapy, Radiation therapy, Head and neck cancer

NRG Oncology Survey of Monte Carlo Dose Calculation Use in US Proton Therapy Centers.

Purpose/Objective(s)Monte Carlo (MC) dose calculation has appeared in primary commercial treatment-planning systems and various in-house platforms. Dual-energy computed tomography (DECT) and metal artifact reduction (MAR) techniques complement MC capabilities. However, no publications have yet reported how proton therapy centers implement these new technologies, and a national survey is required to determine the feasibility of including MC and companion techniques in cooperative group clinical trials.Materials/MethodsA 9-question survey was designed to query key clinical parameters: scope of MC utilization, validation methods for heterogeneities, clinical site-specific imaging guidance, proton range uncertainties, and how implants are handled. A national survey was distributed to all 29 operational US proton therapy centers on 13 May 2019.ResultsWe received responses from 25 centers (86% participation). Commercial MC was most commonly used for primary plan optimization (16 centers) or primary dose evaluation (18 centers), while in-house MC was used more frequently for secondary dose evaluation (7 centers). Based on the survey, MC was used infrequently for gastrointestinal, genitourinary, gynecology and extremity compared with other more heterogeneous disease sites (P < .007). Although many centers had published DECT research, only 3/25 centers had implemented DECT clinically, either in the treatment-planning system or to override implant materials. Most centers (64%) treated patients with metal implants on a case-by-case basis, with a variety of methods reported. Twenty-four centers (96%) used MAR images and overrode the surrounding tissue artifacts; however, there was no consensus on how to determine metal dimension, materials density, or stopping powers.ConclusionThe use of MC for primary dose calculation and optimization was prevalent and, therefore, likely feasible for clinical trials. There was consensus to use MAR and override tissues surrounding metals but no consensus about how to use DECT and MAR for human tissues and implants. Development and standardization of these advanced technologies are strongly encouraged for vendors and clinical physicists.

NEW EFFECTIVE METHODS OF TREATMENT OF PERSISTENT INFERTILITY IN COWS (CORPUSLUTEUMPERSISTENS)

This article examines the persistent corpus luteum, the causes of infertility among cows, quantitative levels of steroid hormones in the serum of experimental cows, experimental cows were fertilized twice at 12-hour intervals using the manoservical method, and 3 months after insemination, cows were examined by commission-rectal studies. The application of symptomatic and operative therapies in the treatment of persistent corpus luteum, and the results of experiments, discussions were noted.

Pathochistological and immunohistochemical study in small intestine metastasis as first clinical expression of invasive lobular breast carcinoma: Prognosis and complex treatment

The gastrointestinal metastases (GIM) of breast carcinoma (BC) are a rare clinical finding, even more rarely diagnosed as initial symptoms at unknown BC. We present a 50-year-old woman with metastases in the terminal ileum combined with multiple bone metastases from an unknown invasive carcinoma of left mammary gland. Gastrointestinal metastases are rarely observed in invasive lobular breast carcinoma. Differential diagnosis between intestinal metastases from primary BC and primary intestinal neoplasm is extremely difficult. Determination of tumor pathohistogenesis require careful pathohistological and immunohistochemical analysis. Complex treatment follows the primary neoplasm principles. The prognosis in such clinical cases is unfavorable, but after timely complex oncological treatment, including emergency operation, chemotherapy, hormone and target therapy, 36 monthly survival is achieved. Keywords: gastrointestinal metastases; invasive lobular breast carcinoma; pathohistological analysis; immunohistochemical analysis; complex treatment.

Per-vaginal Management of a Fetal Ascites Intended Dystocia in a Cross Breed Cow: A Case Study

This article discussed about a case of per-vaginal management of dystocia in a cross breed cow due to fetal ascites cause. A 3.5 years old cross breed cow was presented at Mobile Veterinary Clinic, Gosaba Block, South 24 Paragans, West Bengal with a history of prolonged labor. The water bag was ruptured but there was no progression of parturition. Per-vaginal examination revealed that the cervix was completely dilated and the fetus was in anterior longitudinal presentation with an extremely distended abdomen. The case was diagnosed as dystocia due to fetal ascites. After epidural anesthesia, the abdominal wall of fetus was punctured with a fetotomy knife and about 5-7 liters of clear straw colored ascitic fluid was evacuated. Finally fetus was removed by gentle traction. Post operative therapy with antibiotics, analgesic, intravenous fluid and multivitamin successfully cured the anima

Pemilihan Terapi Konservatif dan Operatif pada Endometriosis

Abstract. Abdominal pain during menstrual periods (dysmenorrhea), accompanied by pelvic pain, and infertility are symptoms that patients with endometriosis often complain of. Endometriosis is a chronic,inflammatory condition estrogen-dependent characterized by proliferation of the endometrial glands and stroma outside the uterine cavity. Endometriosis occurs in nearly 2-10% of women of childbearing age, 35-50% of women with pelvic pain or infertility. Incidence peaks at age 25-35 years, but is also at risk in young women with dysmenorrhea or pelvic pain. Women with endometriosis need management for pain, infertility or both. Treatment options depend on the age of the patient, the severity of clinical symptoms, the patient's fertility plan, previous management, and the location of the pain. Then It was adjusted to conservative or operative therapy based on the patient’s fertility plan.

Clinical and Radiological Outcomes of Operative Therapy in Insertional Achilles Tendinopathy With Debridement and Double-Row Refixation.

Background:Insertional Achilles tendinopathy (IAT) is a painful pathology in which the strongest and thickest tendon of the human body is affected. Different conservative and operative treatments have been described to address this pathology. This study aimed to evaluate the medium-term clinical and radiological outcomes of patients who underwent a surgical therapy via a longitudinal tendon-splitting approach with debridement and double-row refixation.Methods:All patients were assessed pre- and postoperatively using a visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score, the Foot and Ankle Outcome Score (FAOS), and the Foot Function Index (FFI). Additionally, a lateral radiograph of the foot was performed to assess the postoperative result. Forty-two patients with confirmed IAT who underwent surgery between 2013 and 2017 with a longitudinal tendon-splitting approach and tendon refixation using a double-row refixation system were evaluated. The average follow-up was 32.8 (range, 18-52) months. We included 26 female and 16 male patients with an average age of 56.8 (range, 27-73) years.Results:The mean VAS improved from 8.91 ± 1.0 preoperatively to 1.47 ± 2.5 postoperatively (P < .01). AOFAS scores improved significantly from 51.0 ± 12.5 preoperatively to 91.3 ± 14.3 postoperatively (P < .01). All total and subscores of the FFI and FAOS saw a significant improvement at follow-up (P < .01). Lateral radiographs showed recurrent calcification in 30 patients (71.4%).Conclusion:We found that, at an average of 33 months posttreatment, insertional Achilles tendinopathy via a longitudinal tendon-splitting approach resulted in good outcomes for patients after failure of initial conservative therapy. Recurrent calcification seems to be very common but shows no association with inferior outcomes or the return of symptoms.Level of Evidence:Level IV, retrospective case series.

The neglected biliary mucus and its phosphatidylcholine content: a putative player in pathogenesis of primary cholangitis-a narrative review article.

Primary sclerosing cholangitis (PSC) is a rare progressive cholangitis resulting in cirrhosis and cholangiocellular carcinoma. The pathogenesis is unclear and an effective medical therapy is not available. It is highly associated to ulcerative colitis for which recently a disturbance of the tight junction (TJ) barrier has been claimed as etiologic feature. Genetic mouse models with intestinal TJ disruption showed a defective transport of phosphatidylcholine (PC) to intestinal mucus. Consequently, an ulcerative colitis phenotype developed. In the present study we evaluate whether there is also a paracellular transport of PC through TJ to the apical side of cholangiocytes. As in ulcerative colitis, a TJ defect could lead to deficient PC in biliary mucus. It would impair the protective barrier against aggressive bile acids in bile. Indeed with polarized biliary tumor cells a vectorial transport of PC from basal to luminal side was demonstrated using a transwell culture system. PC was not taken up by the cells but moved paracellularly via TJ to the apical side driven by luminal HCO3− generated by the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) and the anion exchange protein 2 (AE2). If such a TJ-mediated PC translocation to the apical surface of cholangiocytes could be disrupted in a genetic mouse model, a PSC phenotype would be expected. With such an experimental model functional operative therapies can be evaluated. We propose that disruption of TJ mediated paracellular transport of PC to the apical side of cholangiocytes could lead to biliary mucus PC depletion. This may be a pathogenetic factor for development of PSC.

The value of PIVKA-Ⅱ versus AFP for the diagnosis and detection of postoperative changes in hepatocellular carcinoma

ObjectiveTo explore the diagnostic value of abnormal prothrombin Ⅱ (PIVKA-Ⅱ) and alpha-fetoprotein (AFP) in primary hepatocellular carcinoma (HCC). MethodsFrom 2018 0.01 to 2020.01, there were 158 patients with primary liver cancer caused by chronic hepatitis B (male 116, women 42) and 62 patients with chronic hepatitis B (male 34, female 28). The levels of serum PIVKA-Ⅱ and AFP were measured, and the results were statistically analyzed. ResultsThe value of PIVKA-Ⅱin liver cancer group was distinctly higher than that in chronic viral hepatitis B group, the difference is statistically significant (P ​< ​0.05). So does the value of AFP. Draw the subject working characteristic curve (ROC curve), the area under the curve of AFP and PIVKA-Ⅱ is 0.799 and 0.836, and that of the combination of AFP and PIVKA-Ⅱ is 0.854, the sensitivity is 57.6%,68.4%,72.2%,respectively, the specificity is 93.5%, 98.4%, 96.8%, respectively. After operation or interventional therapy, the value of PIVKA-Ⅱ in liver cancer group was clearly lower than that before treatment, and the difference was statistically significant. ConclusionIn the diagnostic value of primary liver cancer, PIVKA-II combined with AFP is higher than PIVKA-II, while AFP has the lowest benefit. We also find that PIVKA-II has higher disease monitoring value than AFP.

Prevalence and Prognosis of Lynch Syndrome and Sporadic Mismatch Repair Deficiency in Endometrial Cancer.

BackgroundStandard screening of endometrial cancer (EC) for Lynch syndrome (LS) is gaining traction; however, the prognostic impact of an underlying hereditary etiology is unknown. We established the prevalence, prognosis, and subsequent primary cancer incidence of patients with LS-associated EC in relation to sporadic mismatch repair deficient (MMRd)-EC in the large combined Post Operative Radiation Therapy in Endometrial Carcinoma-1, -2, and -3 trial cohort.MethodsAfter MMR-immunohistochemistry, MLH1-promoter methylation testing, and next-generation sequencing, tumors were classified into 3 groups according to the molecular cause of their MMRd-EC. Kaplan-Meier method, log-rank test, and Cox model were used for survival analysis. Competing risk analysis was used to estimate the subsequent cancer probability. All statistical tests were 2-sided.ResultsAmong the 1336 ECs, 410 (30.7%) were MMRd. A total of 380 (92.7%) were fully triaged: 275 (72.4%) were MLH1-hypermethylated MMRd-ECs; 36 (9.5%) LS MMRd-ECs, and 69 (18.2%) MMRd-ECs due to other causes. Limiting screening of EC patients to 60 years or younger or to 70 years or younger would have resulted in missing 18 (50.0%) and 6 (16.7%) LS diagnoses, respectively. Five-year recurrence-free survival was 91.7% (95% confidence interval [CI] = 83.1% to 100%; hazard ratio = 0.45, 95% CI = 0.16 to 1.24, P = .12) for LS, 95.5% (95% CI = 90.7% to 100%; hazard ratio = 0.17, 95% CI = 0.05 to 0.55, P = .003) for “other” vs 78.6% (95% CI = 73.8% to 83.7%) for MLH1-hypermethylated MMRd-EC. The probability of subsequent LS-associated cancer at 10 years was 11.6% (95% CI = 0.0% to 24.7%), 1.5% (95% CI = 0.0% to 4.3%), and 7.0% (95% CI = 3.0% to 10.9%) within the LS, “other,” and MLH1-hypermethylated MMRd-EC groups, respectively.ConclusionsThe LS prevalence in the Post Operative Radiation Therapy in Endometrial Carcinoma trial population was 2.8% and among MMRd-ECs was 9.5%. Patients with LS-associated ECs showed a trend towards better recurrence-free survival and higher risk for second cancers compared with patients with MLH1-hypermethylated MMRd-EC.

Operative Treatment Options for Patellofemoral Arthritis: An Expert Recommendation of the AGA Patellofemoral Committee.

Background:The operative therapy of patellofemoral arthritis requires an individual approach depending on the underlying injury. However, the literature lacks recommendations for its course of action.Purpose:To generate an expert recommendation of therapy for different patellofemoral abnormalities in patients suffering from isolated patellofemoral arthritis.Study Design:Consensus statement.Methods:To generate recommendations, the AGA Patellofemoral Committee performed a consensus process using the Delphi method based on the available literature on isolated patellofemoral arthritis.Results:In most statements and recommendations, a high percentage of consensus could be found. However, also in the expert group of the AGA Patellofemoral Committee, some controversies on the treatment of patellofemoral arthritis exist.Conclusion:The operative therapy of isolated patellofemoral arthritis is a challenging topic that leads to controversial discussions, even in an expert group. With this consensus statement of the AGA Patellofemoral Committee, recommendations on different operative treatment options were able to be generated, which should be considered in clinical practice.

DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers

BackgroundVenous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration.An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy.MethodsThis is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates.DiscussionThis trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence.Ethical committee referenceC.A. 2111 Galway Clinical Research Ethics CommitteeRegistrationClinical Trials.gov registration NCT03640689, Registered on 21 August 2018.

Acquired lymphangioma circumscriptum of the vulva treated with ablative radiofrequency

(LC) is a benign disorder involving the lymphatic system of skin and subcutaneous tissue. A case of acquired LC of the vulva in a57-year-old woman with a 10 -15 year history of lymphoedema of the left leg and vulvar lesions (vesicles and papulovesicles) following cervical cancer operation and subsequent radio therapy is presented. The patient was treated with ablative radiofrequency and was free of lesions for 6 months.

Effectivity and Efficiency of repeat testing of Health care workers (HCW) for SARS-CoV-2

On the 9th of January 2021 roughly 240 new infection cases with SARS-CoV-2 per day were detected in China, about 24.000 in Germany and 240.000 in the United States. The Chinese government declared the province to be under martial law, Germany has a lockdown where people are asked not to travel- if they do so the should self-quarantine or maybe they risk a fine and in the United States there are various restrictions and recommendations. There is no doubt that draconic measures are most efficient in order to control the spreading of the virus, but martial law as an answer to pandemic infection is considered to be incompatible with western democratic rules and constitutions. We will have to find a way in order to reduce both the morbidity and mortality due to the pandemic and the political, socioeconomic and psychological consequences. It is known that asymptomatic SARS-CoV-2 carriers can spread the infection. Asymptomatic people may carry the virus and stay asymptomatic throughout the infection or they are presymptomatic, that means they develop clinical symptoms on the day of PCR-testing or later onwards. Within a hospital, there are 6 different ways for transmission of infection: - the symptomatic, SARS-CoV-2 positive patient to another patient (i) or to healthcare workers (HCW) (ii); - asymptomatic patients to another patient (iii) or to asymptomatic HCW (iv) and - finally asymptomatic HCW to other fellow HCW (v) or to asymptomatic patients (vi). Nowadays, with deep knowledge about COVID-19 among HCWs and a vast availability of personal protection equipment, the first two possibilities play an insignificant role. Every possible routine measure is taken in order to reduce the risk of bringing COVID-19 into the hospital (iii and iv), e.g. outpatient visits are restricted to those with negative medical history for any clinical symptoms, risk factors, travel history and no fever measured at point of care; elective patients undergo an operation only if delaying operative therapy for more than three months will lead to death or irreversible deterioration of the disease and if they present with a negative PCR not older tan 72 hours; visits from friends and relatives are banned. So spread of infection by asymptomatic HCWs, infection routes (v) and (vi), is of serious concern.

Operative Therapy of Achilles Tendon Rupture - A Critical Questioning of the Actual Literature

Operative Therapy of Achilles Tendon Rupture - A Critical Questioning of the Actual Literature

Formulation and Development of Transferrin Targeted Solid Lipid Nanoparticles for Breast Cancer Therapy.

Breast cancer is conventionally treated by surgery, chemotherapy and radiation therapy followed by post operational hormonal therapy. Tamoxifen citrate is a best option to treat breast cancer because its selective estrogen receptor modulation activity. Owing to its antiestrogenic action on breast as well as uterine cells, Tamoxifen citrate shows uterine toxicity. The dose 20 mg per day of Tamoxifen citrate required to show therapeutic effect causes side effects and toxicity to vital organs such as liver, kidney and uterus. In the present study, transferrin-conjugated solid lipid nanoparticles (SLNs) were successfully prepared to enhance the active targeting of tamoxifen citrate in breast cancer. Developed formulations were evaluated for particle size, surface charge, surface morphology and in vitro dissolution studies. Developed formulations exhibited more cytotoxicity as compared to pure Tamoxifen citrate solution in time as well as concentration dependent manner on human breast cancer MCF-7 cells. Further, cell uptake and flow cytometry studies confirmed the qualitative uptake of developed D-SLN and SMD-SLN by human breast cancer MCF-7 cells. Overall, proposed study highlights that transferrin engineered nanocarriers could enhance the therapeutic response of nanomedicines for breast cancer treatment.

Fractures of the Humeral Ulnar Condyle in Children - a Rare but Complicated Injury.

Ulnar humeral condyle fractures are rare paediatric elbow fractures, classified as Salter-Harris IV paediatric elbow injuries. Due to constant radiological changes in the elbow with varying manifestation of ossification centres as well as late ossification of the trochlea, diagnosis of these injuries is challenging. To avoid long-term complications, the treating surgeon should be familiar with the rare injury picture, diagnostics and adequate therapeutic measures. The present retrospective study includes data on all paediatric cases from 2002 to 2019 with primary or secondary treatment at a paediatric traumatology centre for ulnar condyle fracture with a minimum follow-up of 12 months. Range of motion, joint stability under valgus and varus stress as well as axial ratios of the injured and uninjured side were evaluated in a clinical follow-up examination. The Mayo Elbow Performance Score was used to objectify functional results. 20 children, average age 8.6 years (4 - 13) and average follow-up time 25 months, were included. Radiological evaluation based on Jakob and Fowles classification revealed a type I fracture in three cases, a type II fracture in one case and a type III fracture in 16 cases. Three cases were treated nonoperatively with an upper arm cast. 17 children were treated with open reduction and internal fixation. Diagnosis of three fractures was delayed. No postoperative complications such as infections, nerve damage or nonunions. 15 children showed free elbow function. Three children showed slightly restricted elbow extension by less than 10° and two by 10°-20°. All children showed free pro/supination. 18 children showed a physiological and bilaterally identical arm axis compared to the uninjured side. Two children showed a slightly increased cubitus valgus with a 5 - 10° difference between sides. Radiologically, two children with delayed fracture treatment showed partial necrosis of the trochlea. The Mayo Elbow Score showed good (2) to excellent results in all children (18). Very good clinical and functional results can be expected if the injury is diagnosed without delay followed by adequate therapy. Misdiagnosis of ulnar condyle fractures can be associated with the development of nonunions and functional restrictions as well as, after operative therapy, trochlear necrosis. Children up to the age of 6 in particular are at risk of misdiagnosis due to faulty assessment of the cartilaginous trochlea.

National Survey of Monte Carlo Dose Calculation Use in US Proton Therapy Centers

Monte Carlo (MC) dose calculation has appeared in primary commercial treatment planning systems (TPS) as well as various secondary (in-house) platforms. MC promises smaller dose uncertainties, particularly in patients with low density and bony heterogeneities and metal implants. Newly developed dual energy computed tomography (DECT) and metal artifact reduction (MAR) methods compliment MC capabilities. However, there are no publications to date reporting how proton therapy centers implement these new technologies, and a consensus is required for their inclusion in clinical trials. A survey was designed to query key clinical parameters: scope of MC utilization, validation methods in homogeneous and heterogeneous phantoms, clinical site-specific imaging guidance, proton range uncertainties, and how metal implants are handled. A national survey was distributed to 29 operational US proton therapy centers on 5/13/19 and updated on 10/18/19. We received responses from 25 centers (86% participation). Commercial MC is most often used for primary plan optimization or primary dose evaluation, while in-house MC is used more frequently as secondary dose evaluation. This suggests that if an institution has a commercial MC system, they are using it as their primary dose calculation and optimization engine. Based on the survey, MC is used infrequently for GU and GYN, compared to other disease sites (P<0.0016). Other than IROC and electronic density phantoms, there is no consensus over the use of heterogeneous phantoms or QA measurement methods, although 3 mm/3% is typically used in patient QA using homogeneous phantoms. MC is used (80%) for plans with apertures or range shifters. Although most centers use 3-3.5% for range uncertainties, a few centers use 5% range uncertainty for lung treatment to account for uncertainty caused by low-density heterogeneity. Although many centers have published DECT research, only 3/25 centers have implemented DECT clinically, either in the TPS or to override implant materials. Most centers (64%) treat patients with metal implants case-by-case, with a variety of methods reported. 24 centers (96%) override the surrounding tissue artifacts; however, there is no consensus on using MAR images, determining metal dimension, or assigning materials density and stopping powers among proton centers. The use of MC for primary dose calculation and optimization is positive for clinical trials, where MC is required or encouraged for several disease sites. MC may be unnecessary for homogeneous anatomy, such as GU and GYN. While variable methods exist to determine metal implant material density and dimensions, most centers override surrounding tissues. DECT has rarely been implemented clinically for patient modeling in MC, and there is no consensus over the use of heterogeneous phantoms, nor the use of metal artifact reduction images for metal implants. Standardization for the use of these advanced technologies is encouraged.