Radiologic Control Research Articles

Esophageal perforation in premature newborns

BACKGROUND: Esophageal perforation is a rare entity in newborns. This condition is most common in premature babies with very low and extremely low birth weight. The major cause of such pathology is considered to be iatrogenic trauma of either pharynx or esophagus, their soft tissues being delicate and tender enough to produce delamination and perforation of their wall. As a rule, this occurs as a complication of either a difficult tracheal intubation soon after birth or during some troubles with oro- or nasogastric tube insertion. AIM: To analyze our experience of revealing and treatment of esophageal perforation in preterm babies, and to demonstrate conservative approach as a possible as well as reasonable option in such cases. METHODS: A retrospective study of neonatal esophageal perforation cases was performed, including newborns without any congenital esophageal malformations or previous surgical procedures. During 2017–2022 9 newborns with esophageal perforation were treated at neonatal intensive care unit and neonatal departments of Childrens’ City Multidisciplinary Clinical Specialized Center of High Medical Technologies of Saint Petersburg. All of them were premature, 2 having very low, and 7 having extremely low birth weight. The incidence of that condition appeared to be 1:1320 live births. RESULTS: 8 patients were treated conservatively. This included adjustment of artificial lung ventilation, pain control, antibiotics, cancellation of gastric enteral feeding and administration of total parenteral nutrition. Babies with hydrothorax, pneumothorax or ascites underwent thoraco- or laparocentesis. 2 patients died, both being born at 23th week of gestation. In both cases death occurred from polyorganic insufficiency. The mortality rate appeared to be 22%. CONCLUSION: In most cases the esophageal perforation in premature babies can be treated conservatively, the efficacy of such treatment being largely dependent on early diagnosis of this complication. An important key-point in it is a radiologic control of gastric tube location.

Intraarterial Administration of Peptide Receptor Radionuclide Therapy in Patients with Advanced Meningioma: Initial Safety and Efficacy.

Peptide receptor radionuclide therapy (PRRT) is a treatment option for patients with advanced meningioma. Recently, intraarterial application of the radiolabeled somatostatin receptor agonists has been introduced as an alternative to standard intravenous administration. In this study, we assessed the safety and efficacy of intraarterial PRRT in patients with advanced, progressive meningioma. Methods: Patients with advanced, progressive meningioma underwent intraarterial PRRT with [177Lu]Lu-HA-DOTATATE. The safety of PRRT was evaluated according to the Common Terminology Criteria for Adverse Events version 5.0. Treatment response was assessed according to the proposed Response Assessment in Neuro-Oncology criteria for meningiomas and somatostatin receptor-directed PET/CT. Results: Thirteen patients (8 women, 5 men; mean age, 65 ± 13 y) with advanced meningioma underwent 1-4 cycles (median, 4 cycles) of intraarterial PRRT with [177Lu]Lu-HA-DOTATATE (mean activity per cycle, 7,428 ± 237 MBq; range, 6,000-7,700 MBq). Treatment was well tolerated with mainly grade 1-2 hematologic toxicity. Ten of 13 patients showed radiologic disease control at follow-up after therapy (1/10 complete remission, 1/10 partial remission, 8/10 stable disease), and 9 of 13 patients showed good control of clinical symptoms. Conclusion: Intraarterial PRRT in patients with advanced meningioma is feasible and safe. It may result in improved radiologic and clinical disease control compared with intravenous PRRT. Further research to validate these initial findings and to investigate long-term outcomes is highly warranted.

Single versus double retrograde intramedullary nail technique for treatment of displaced proximal humeral fractures in children: A retrospective cohort study.

Highly displaced proximal humeral fractures in children with low remodeling potential need to be reduced and fixed. The use of two flexible retrograde nails became the most popular fixation technique due to the excellent functional outcome, the low complication rates, and the possibility of early mobilization. A modified single retrograde technique has been suggested by the authors to address the main disadvantage of this technique, the long operative duration. The aim of this study was to compare these techniques in terms of efficacy, and clinical and radiological outcomes. We performed a retrospective, monocentric study. Two groups of patients were defined: One was treated with the standard flexible retrograde double nail technique and the other with the modified single nail technique. The demographic and fracture characteristics were similar in both groups and the postoperative immobilization with a simple sling for 2 weeks. We compared the surgical duration for the initial fixation and hardware removal procedures. The Quick Disabilities of the Arm, Shoulder, and Hand score, the secondary displacement at 1-week follow-up, the radiological union at 6-week follow-up, and the perioperative and short-term complications were also assessed for both groups. The surgical duration of the initial fixation procedure was significantly shorter in single nail technique group (p = 0.005). The percentage of excellent Quick Disabilities of the Arm, Shoulder, and Hand score (0) was similar in the two groups (p = 0.98). No secondary displacement was reported for the double nail technique group. In only one patient from the single nail technique group, we detected a secondary displacement at the first week control which did not need reoperation. In both groups, fractures were healed on the 6-week radiologic control. No cases of infection, superficial skin irritation, neurological damage, or complications related to implant removal were reported in both groups. The single nail technique of fixation proximal humeral fractures in children addresses the disadvantage of long surgical times, described until today, with the double nail technique without compromising the excellent functional and radiological short-term outcomes. level III.

P-031 TREATMENT OF A VOLUMINOUS INGUINOSCROTAL HERNIA AFTER A PREOPERATIVE PNEUMOPERITONEUM PREPARATION

Abstract Voluminous inguinoscrotal hernias that have lost their “right of domain”, are usually hard to repair, and need preoperative preparations to reduce the risk of complications after the treatment, such as compartment syndrome, intestinal ischemia, and respiratory problems. In this e-poster, we present a case report of a patient who had a voluminous inguinoscrotal hernia containing most of the small intestine and the entire right colon, which we treated after a preoperative pneumoperitoneum preparation (PPP). The preparation was conducted 20 days before the surgery and the pneumoperitoneum was created through a percutaneous catheter that we inserted in the epigastric region after a radiologic control. We injected 1000 ml of air per day, and the dose was adapted to the clinical tolerance of the patient. We performed a reintegration of the hernia's volume, a resection of the hernial sac, and a reduction of the size othe profound inguinal ring via a Raphia, no intestinal resections were made, and the postoperative course was uneventful. We plan a second intervention that consists of a hernia repair by a mesh insertion and a resection of the extra skin developed as a result of the voluminous hernia. PPP is an interesting way to prepare the abdominal cavity to receive the component of a voluminous hernia after its reduction. The patient should be closely monitored during the preparation and after the surgery in order. Sometimes a second operation is necessary for definitive cure or aesthetic needs.

Stereotactic Radiosurgery Outcomes in Medically and Surgically Failed or Nonsurgical Candidates with Medically Failed Prolactinomas: A Systematic Review and Meta-Analysis.

Objective Prolactinomas are treated with dopamine agonists (DAs) as first-line therapy and transsphenoidal surgery as an alternative approach for medically failed tumors. We sought to summarize the efficacy of stereotactic radiosurgery (SRS) in the medically and surgically failed prolactinomas as well as in nonsurgical candidates with medically failed prolactinomas by systematic review and meta-analysis. Method A literature search was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guideline. Results A total of 11 articles (total N = 709) met inclusion criteria. Thirty-three percent of patients were able to achieve endocrine remission at a mean follow-up of 54.2 ± 42.2 months with no association between stopping DA and endocrine remission. Sixty-two percent of patients were able to achieve endocrine control with DA therapy and 34% of patients were able to decrease the dose of DA dose when compared with pre-SRS DA dose at the end of the follow-up period. However, 54% of patients required DA at the end of the follow-up to control hyperprolactinemia. Ninety percent of patients were able to achieve radiologic control at the end of the follow-up in comparison to pre-SRS imagings. Furthermore, 26% of patients newly developed hypopituitarism (one or more pituitary hormones) post-SRS throughout the follow-up period. Conclusion This systematic review and meta-analysis demonstrates SRS as an effective adjunct therapy in medically failed nonsurgical candidates or surgically and medically recalcitrant prolactinomas with a 33% chance of achieving endocrine remission, 62% of patients achieved hormonal control with DA and GKRS (gamma knife radio-surgery), with a 34% chance of decreasing DA dose and 90% chance of achieving radiologic control.

Current practices in temporal arachnoid cysts: a survey among Brazilian neurosurgeons

Introduction: There has been no consensus for the best treatment strategy for TACs. The aim of this survey was to aggroup the different practices between Brazilian pediatric neurosurgeons in the management of a children with TAC Galassi Type II and III. Methods: contributors answered a case questionnaire about TACs and select the answer that better reflect their conduct in asymptomatic or symptomatic patients (chronic headache, epilepsy and psychomotor retardation). Results: all respondents confessed that had doubts about TACs and 59-75% was not satisfied only with brain MRI. Fundoscopy was the most required exam (28-35%), followed by EEG/VideoEEG (19-20%), ICP-NI (16%) and MRI CSF flowmetry (12-13%). For asymptomatic, 61-85% suggested follow-up with clinical, radiologic and fundoscopic control. Still, surgery was the choice for 61-70% in symptomatic patients. The preferred technique for TAC type II was endoscopic cysto-cisternostomy (32%) and for type III craniotomy and arachnoid cyst marsupialization (25%). Discussion: Since the past 14 years, more information has become available about the natural history of TACs and innovative technologies arises for its management helps. Treatment is still debated, but endoscopy is increasingly common and proved to be safe and effective. Conclusion: modern technologies allow more security and subsidies to treatment chosen and even though for TAC Galassi type III open craniotomy still is preferred than endoscopic surgery, nowadays the least invasive treatment have been the choice for TAC Galassi Type II. The years of experience in endoscopy and the more availability of the tool into hospitals maybe contributed to this pattern change.

153 An International Multicenter Matched Cohort Analysis of Incidental Meningioma Progression During Active Surveillance or After Stereotactic Radiosurgery: The IMPASSE Study

INTRODUCTION: The optimal management of patients with an incidental meningiomas remains unclear. The aim of this study was to characterize the radiologic and neurological outcomes of expectant and SRS management of asymptomatic meningioma patients. METHODS: Using data from 14 centers across 10 countries, the study compares SRS outcomes to active surveillance of asymptomatic meningiomas. Local tumor control of asymptomatic meningiomas and development of new neurological deficits attributable to the tumor were evaluated in the SRS and conservatively managed groups. RESULTS: In unmatched cohorts, 727 meningioma patients underwent SRS and were followed for a mean of 57.2 months. In the conservatively managed cohort, 388 patients were followed for a mean of 43.5 months. Tumor control was 99.0% of SRS and 64.2% of conservatively managed patients (p<0.001; OR 56.860 (95% CI 26.253–123.150)). New neurological deficits were 2.5% in the SRS and 2.8% of conservatively managed patients (p=0.764; OR 0.890 (95% CI 0.416–1.904)). After 1:1 propensity matching for patient age, tumor volume, location, and imaging follow-up, tumor control in the SRS and conservatively managed cohorts was 99.4% and 62.1%, respectively (p<0.001; OR 94.461 (95% CI 23.082-386.568)). In matched cohorts, new neurological deficits were noted in 2.3% of SRS treated and 3.2% of conservatively managed patients (p=0.475; OR 0.700 (95% CI 0.263–1.863)). CONCLUSION: SRS affords superior radiologic tumor control compared to active surveillance without increasing the risk of neurological deficits in asymptomatic meningioma patients. While SRS and active surveillance are reasonable options, SRS appears to alter the natural history of asymptomatic meningiomas including tumor progression in the majority of patients treated.

Thermographic diagnostics of instability of endoprostheses of large joints with assessment of somatosympathetic vasomotor reflex

Forty two patients with total hip (12 patients) and total knee (30 patients) replacements were examined by computer thermography method. Total joint replacement was performed after bone tumor resection. It was shown that additional afferent impulsation occured at implant loosening and the degree of vertical polysegmental irradiation of sympathic neurons excitation as well as the deficit of spinal cord inhibition on the side of arthroplasty incresed. Thermographic evaluation of the amplitute and volume of somatosympathic vasomotor reflex is an effective for the diagnosis of joint prosthesis loosening and it is subsidiary to the radiologic control.

Balloon expandable Stent utility for early Secondary Prevention of new Cerebral Ischemic events Caused by Intracranial Atherosclerotic Stenosis. Technical Nuances

Objective: Recurrent cerebral ischemic events are estimated to appear in between 12-15% of symptomatic intracranial atherosclerotic disease (ICAD), regardless of the use of leading pharmacological therapies. Balloon expandable stent (balloon mounted coronary stent) could represent a feasible alternative in this disease’s treatment. This study pretends to report the balloon-expandable placement experience in our center. Materials and Methods: A unicentric retrospective study dated between September 2009 and March 2018 was conducted. Patients previously diagnosed with ICAD and symptomatic stenosis treated with balloon-expandable stent were included. Clinical features, morbidity, mortality, short and long-term evolution, and pre-and post-treatment angiographic features were analyzed, as well as a mean 8 years-period follow-up. Data are presented as means, frequencies, and percentages for categorical variables, and ranks for continuous variables. Statistical analysis was carried by IBM SPSS Statistics Base V22.0 (IBM Corporation, Mexico). A Wilcoxon Signed-rank test statistical analysis was performed. Statistical significance was considered when a p-value lesser than 0.05 was measured for every result. Results: A total of 6 patients with 7 affected vessels were treated, with an average age of 62.7 years. Affected and treated vessels were located in the Internal Carotid Artery (ICA) segment in 42.9%, Vertebral Artery (VA) V4 segment in 14.3%, Middle Cerebral Artery (MCA) M1 segment in 28.5%, and Posterior Cerebral Artery (PCA) P1 segment in 14.3%. The incidence of peri-operatory thrombotic events was 0%. Intracranial hemorrhage presented in 0% of cases. Recurrent ischemic or thrombotic events were not reported in a 97-months mean follow-up. 71.4% of patients scored ≤2 in the modified Rankin Score (mRS) pre-treatment, in a 90 day and 12-month follow-up. 100% presented a favorable evolution with mRS ≤2. Restenosis cases were not reported in radiologic control and retreatment was not needed in a 97-month mean follow-up. Conclusions: This study suggests that balloon-expandable stent therapy with some technical endovascular variants for its navigation and placement could be a safe and effective alternative in the treatment of ICAD as a means of cerebral ischemic event early secondary prevention. We propose to consider not to limit endovascular treatment exclusively to those symptomatic ICAD patients refractory to medical-exclusive treatment, as a means to reduce the risk of presenting a new neurological deficit. Further expanded clinical trials are needed to confirm these findings and the advantage of this kind of stents against other kinds reported in the literature.

Results of glenohumeral arthrodesis with dual pelvic reconstruction plates in young patients

Purpose: The aim of this study was to evaluate the long-term outcome of shoulder arthrodesis with plate fixation and primary autogenous grafting in terms of pain, functional status, and arthrodesis position. Method and Material: The study included 8 patients (7 males and 1 female; mean age: 46.5 years; range: 42 to 55 years) who underwent arthrodesis with plate fixation and primary autogenous grafting. Mean follow-up period was 18 months. Four cases had blast injury, TB shoulder in 2 patients, sequalae of septic arthritis and paralytic disorder in 1 each. Arthrodesis was performed in all cases according to AO principles with plate fixation and primary autogenous grafting. Follow-up assessments included monthly radiologic control for union, the visual analog scale (VAS) for pain and the Oxford shoulder score (OSS) for functional status. Results: Radiological fusion was seen in all cases in an average of 16 (range: 12 to 18) weeks, and arthrodesis was stable at physical examination. The accompanying humerus shaft fracture was also fixed with plate. One patient with traumatic palsy experienced a humerus fracture distal to the arthrodesis plate at the 8th postoperative month. Two patients had a superficial wound infection after surgery. One patient had hardware symptoms and latissmus dorsi flap was done. The target positions of 30° of abduction, 30° of forward flexion, and 30° of internal rotation were achieved with an average deviation of 7°. Mean active abduction was 68.1° (range: 55° to 90°), flexion was 67.5° (range: 60° to 85°), and internal rotation was at the level of trochanter. The mean OSS was 35.9 (range: 32 to 40), and the mean VAS score was 2.9 (range: 1 to 7). Conclusion: Our findings show that AO reconstruction plate and primary autogenous bone grafting is a safe and effective arthrodesis method that can also be used as a salvage procedure.

An international multicenter matched cohort analysis of incidental meningioma progression during active surveillance or after stereotactic radiosurgery: the IMPASSE study.

The optimal management of patients with incidental meningiomas remains unclear. The aim of this study was to characterize the radiologic and neurological outcomes of expectant and stereotactic radiosurgery (SRS) management of asymptomatic meningioma patients. Using data from 14 centers across 10 countries, the study compares SRS outcomes to active surveillance of asymptomatic meningiomas. Local tumor control of asymptomatic meningiomas and development of new neurological deficits attributable to the tumor were evaluated in the SRS and conservatively managed groups. In the unmatched cohorts, 727 meningioma patients underwent SRS and were followed for a mean of 57.2 months. In the conservatively managed cohort, 388 patients were followed for a mean of 43.5 months. Tumor control was 99.0% of SRS and 64.2% of conservatively managed patients (P < .001; OR 56.860 [95% CI 26.253-123.150]). New neurological deficits were 2.5% in the SRS and 2.8% of conservatively managed patients (P = .764; OR 0.890 [95% CI 0.416-1.904]). After 1:1 propensity matching for patient age, tumor volume, location, and imaging follow-up, tumor control in the SRS and conservatively managed cohorts was 99.4% and 62.1%, respectively (P < .001; OR 94.461 [95% CI 23.082-386.568]). In matched cohorts, new neurological deficits were noted in 2.3% of SRS-treated and 3.2% of conservatively managed patients (P = .475; OR 0.700 [95% CI 0.263-1.863]). SRS affords superior radiologic tumor control compared to active surveillance without increasing the risk of neurological deficits in asymptomatic meningioma patients. While SRS and active surveillance are reasonable options, SRS appears to alter the natural history of asymptomatic meningiomas including tumor progression in the majority of patients treated.

СУПРАПАТЕЛЛЯРНЫЙ ОСТЕОСИНТЕЗ ПРИ ПЕРЕЛОМАХ ПРОКСИМАЛЬНОГО ОТДЕЛА ГОЛЕНИ

The treatment of extraarticular proximal tibia fractures is characterized by the difficulties in obtaining the proper reduction and high rate of complications due to the typical soft-tissue injuries. The literature data on the use of suprapatellar approach for intramedullary nailing of exraarticuar fractures of the proximal tibia are analyzed in the article with special attention to the surgical technique of fracture reduction and nail application. Current data shows that the suprapatellar approach is safe when performed properly and has no adverse influence on the knee joint. The reduction of the fracture and intraoperative radiologic control are simplified by this technique, but additional reduction tools shall be available.

Transarterial chemoembolization of unresectable systemic chemotherapy refractory liver metastases: a retrospective single-center analysis.

The purpose of this study was to evaluate the therapeutic efficacy and safety of transarterial chemoembolization (TACE) in the treatment of patients with unresectable colorectal cancer liver metastases (CRCLM) who had failed systemic chemotherapy. In addition, the role of TACE in the treatment of CRCLM is also worth discussing. This single-center retrospective study evaluated the consecutive medical records of patients with CRCLM treated with TACE from June 2014 to June 2018, who had failed at least two lines of prior chemotherapy. Therapeutic response, overall survival (OS), progression-free survival (PFS), and complications were recorded. Fifty-three eligible patients were included in our study. The objective tumor radiologic regression and disease control rates were 52.8% and 79.2%, respectively. Median OS and PFS were 15 months (95% confidence interval [CI] 13.1 months, 16.9 months) and 6 months (95% CI 4.7 months, 7.3 months), respectively. Multivariate analysis found that synchronous metastatic disease, presence of extrahepatic metastasis, and Child-Pugh score B were independent prognostic factor for OS and PFS. Two patients (3.8%) had severe complications. The results of subgroup analysis showed that synchronous liver metastasis and extrahepatic metastasis had an effect on the prognosis of patients, while the primary tumor sites (rectum, left, and right colon) had no effect on the prognosis. TACE is well tolerated and effective in patients with unresectable chemotherapy refractory CRCLM. Meanwhile, the results of this study also indicated that TACE is still a better treatment for these patients.

Phase II randomized study of abiraterone acetate plus prednisone (AAP) added to ADT versus apalutamide alone (APA) versus AAP+APA in patients with advanced prostate cancer with noncastrate testosterone levels: (LACOG 0415).

5505 Background: ADT combined with AAP, APA, enzalutamide or docetaxel are among the standard treatment options to patients (pts) with hormone sensitive advanced/metastatic prostate cancer (PC). However, treatment-related adverse events (TRAEs) due to ADT impact negatively on the quality of life of these patients. Effective options with fewer TRAEs are required. Methods: LACOG 0415 is a phase II, randomized trial (1:1:1) evaluating the use of AA 1000mg po + prednisone 5mg po BID + ADT versus APA 240mg po alone versus AA 1000mg po + prednisone 5mg po BID + APA 240mg po in patients with advanced PC with non-castrate testosterone levels and indication of ADT (N+ or M+ or biochemical relapse combined with PSA ≥ 20 ng/ml or with PSA≥4 ng/ml and PSA doubling-time &lt; 10 months). Stratification factors: metastatic disease (+/-). Primary endpoint was the percentage of pts who achieved PSA ≤ 0.2 ng/mL at Week 25, we estimated a PSA response rate of 65% in each of the three arms with a null hypothesis of 45%, power of 80% and alfa 5%, using Fleming one-stage method. Secondary endpoints were percentage of pts with ≥ 80% and ≥ 50% decline in PSA at week 25, radiographic progression-free survival (rPFS) and safety. Results: 128 patients were randomized between Oct 2017 and Apr 2019, and 122 pts were evaluable for PSA response. Median age was 69y (range, 53-88); most pts had ECOG PS0-1(99%). 17% of pts had biochemical relapse only, 9% N+ and 74% M+ disease. At week 25 the PSA was ≤ 0.2 ng/mL in 76% of pts in AAP+ADT arm, 59% in APA, and 80% in APA+AAP. All pts had a decline of ≥ 50% in PSA at week 25. 97% had a decline of ≥ 80% in PSA at week 25: 100% of pts in AAP+ADT arm, 95% in APA and 98% in APA+AAP. A total of 3 pts had clinical progressive disease, one in each arm. Two of them also had radiological progression at week 25, 1 pt in AAP+ADT arm and 1 pt in APA. TRAEs rates of any grade were 71% in AAP+ADT arm, 64% in APA, and 65% in APA+AAP. TRAEs rates of Grade≥3 were 12% in AAP+ADT arm, 9% in APA and 16% in APA+AAP. 9 pts (7%) discontinued the treatment before the week 25, 5(4%) of them due to toxicity: 1 pt from AAP+ADT, 2 pts from APA, and 6 pts from APA+AAP. Conclusions: The AAP+ADT and APA+AAP groups showed high effectiveness in terms of PSA response. Radiologic disease control and the decline of ≥ 80% in PSA at week 25 were similar among all treatment arms. APA alone had less toxicity. APA+AAP and APA alone are promising regimens in this setting. No new safety signal was detected in the study. Clinical trial information: NCT02867020 .

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire.

BackgroundThis retrospective study aimed to investigate the suitable indications, methodology and long-term effect of the closure of gastrointestinal (GI) fistulas using polyglycolic acid (PGA) sheets and fibrin glue (FG) and to evaluate the usefulness of a delivery technique using a guidewire.MethodsIt involved 10 applications in six patients (median age 73 (range 53 - 78) years old, three men) with GI fistulas. A guidewire was introduced endoscopically or percutaneously into the fistula beyond the opposite orifice of the fistula with radiologic control. A tapered catheter was inserted over the guidewire, and the fistula was cleaned with an adequate quantity of saline. Subsequently, a small piece of PGA sheet was skewered onto the guidewire at the center and then pushed using the tapered catheter over the guidewire and delivered into the fistula. In cases of endoscopic procedure, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG.ResultsTechnical success of fistula closure was achieved in all applications, and no complications were observed after the procedure. The long-term occlusion of the fistula was ultimately achieved in four of six patients at 202 - 654 days (median duration, 244 days) after the last procedure with one or two applications.ConclusionsThe closure of GI fistulas using PGA sheets and FG demonstrated long-term efficacy for upper GI fistula of a certain length, and the filling technique using a guidewire ensured a safe smooth procedure.

A New Foot Saving Procedure: Antibiotic-loaded Resorbable Bone-graft Substitute Instead of Amputation in Osteomyelitis/Osteitis

Introduction - Patients with osteomyelitis require usually antibiotic treatment over a long time period, often only to see the inflammation flare up once antibiotics are suspended. Unfortunately, patients on their side often discontinue the antibiotic treatment due to the well known collateral effects. Patients with osteitis are often polymorbid patients with several other diseases such as diabetes mellitus and polyneuropathy, arteriopathy or polyarthritis with immunosuppression. Methods - In the past two years we included 18 patients which presented all metatarsal and/or phalangeal bones of their feet with osteomyelitis/osteitis, positive bacteriological biopsies or at least undoubtedly positive radiological image findings (MRI). In all cases the diseased part of the bone was resected, a locally radical debridement of the surrounding tissue was completed and a biopsy for bacteriology and histology were sent for investigation purpose. The residual bone was then drilled open, it’s cavity prepared and filled with antibiotic-loaded (Gentamicin) resorbable bone-graft substitute under radiologic imaging control. In all cases we achieved a primary wound closure over the cement augmented bone. Results - In total, eighteen patients are currently without recurrent osteomyelitis with a mean follow-up of 9.77 months (two to twenty-four months). The Kaplan Meier curve shows 83 % survival rate without recurrent osteomyelitis at twenty-four months. Only three patient had a relapse osteomyelitis or local infection: one patient with Morbus Buerger who hurt his foot while swimming in the sea, one patient with untreatable severely compromised peripheric arterial vascular disease and one patient with diabetes mellitus and neuropathy. All other 15 cases showed a classical course of steady regression of local and systemic inflammatory response. No major amputation was needed, only two patients lost one toe primarily, mainly because of local extension of skin ulcer. 5 patients showed a somewhat delayed definitive wound closure (after more than 6-8 weeks), ten patient showed a complete cicatrization at 3 weeks. All patients were dismissed from oral or parenteral antibiotics, immediately after the operation in eight cases or after two weeks in six cases and at the most after 6 weeks in four cases; this unequal treatment was due to the fact that 6 patients where in follow up also from their family practitioner or diabetologist, whom where skeptic about this new technique without an adequate antibiotical support. Conclusion - Due to the small sample of patients there cannot be drawn any conclusion about the necessity of continuing adjuvant oral antibiotics after the implant or not, but we could not find any difference between the three variations, as the mentioned three relapses were to find by one in each group. We could demonstrate that in half of our observed patients the adjuvant antibiotics could be suspended immediately without any consequence (if not the better quality of life of the patients without pharmacological side effects). In our hands the antibiotic-loaded resorbable bone-graft substitute is easy to use, has few complications and presents a low recurrence rate of osteomyelitis treated in this way; it permits to save compromised feet in patients with a notorious tendency for complicated and long ulcer history.

Hypofractionated Radiosurgery Plus Bevacizumab for Locally Recurrent Brain Metastasis with Previously High-Dose Irradiation

Selection of appropriate treatment for patients with recurrent brain metastasis (BM) remains uncertain. Recent studies have demonstrated a significant response rate and acceptable toxicity using fractionated stereotactic radiosurgery (FSRS) in patients with locally recurrent large BM. The aim of this study was to evaluate efficacy and toxicity of FSRS with bevacizumab as a new salvage treatment for locally recurrent BM with previous high-dose irradiation. Patients with recurrent BM previously irradiated were enrolled. Salvage FSRS dose was 9.5-29 Gy (2-5 fractions) with 62%-75% isodose line by CyberKnife according to the brain tumor volume, site, and previous dose. Bevacizumab was prescribed for 4 cycles (5 mg/kg, every 3 weeks). The primary objective was to identify the overall survival after salvage treatment. Secondary objectives included clinical response (Karnofsky performance scale), imaging response (magnetic resonance imaging) and treatment-related adverse events. From December 2009 to October 2016, 24 patients were enrolled. The 1-year overall survival after salvage stereotactic radiosurgery was 87.5%. Twenty-three (96%) patients had a positive imaging response with a T2 volume reduction range of 6-22 cm3 (median 14 cm3, P= 0.032, paired t test). Significant clinical improvement was achieved (best Karnofsky performance scale score, P < 0.05, paired t test). Grade 1/2 fatigue was observed in 8 (33%) patients. Grade 3 fatigue and headache occurred in 1 patient. FSRS with adjuvant bevacizumab treatment showed favorable clinical and radiologic control as a salvage treatment regimen. The diagnoses of radiation necrosis and local recurrence after salvage FSRS warrant further study.

Surgical Clips in Breast-conserving Surgery: Do they Represent the Tumour Bed Accurately?

Radiotherapy after Breast-Conserving Surgery (BCS) is a standard treatment for breast cancer. Currently, surgical clips are used to determine the tumour bed before radiotherapy planning. This study aimed to evaluate the migration of these clips on mammograms. The study was conducted on 121 females who were treated with radiotherapy after BCS at their first radiologic control examination 6 months after the end of treatment. MLO and CC views of all cases were evaluated regarding the clips. The distance between the surgical scar centre and the centre of the area covered by the clips was measured on both MLO and CC projections and recorded separately. This distance was determined as the clip displacement. A displacement ≤10 mm was recorded as no displacement. The clips were out of the images and were not evaluated in 45 cases (37.2%) on CC and in 9 cases (7.4%) on MLO projections. There were no clip displacements in 37 (30.6%) cases on CC and in 43 (35.5%) cases on MLO views. The amount of displacement ranged from 11 to 56 mm with a mean of 24.38 mm on CC views, while on MLO projections, displacement ranged from 11 to 66 mm with a mean of 24.42 mm. A clip displacement of greater than 10 mm was found in 64.5% of cases on MLO views. Therefore, we believe that the reliability of these clips for accurate delineation of the tumour bed in radiotherapy planning is controversial and other methods must be added.

Integrating salvage hypofractionated radiosurgery plus low-dose adjuvant bevacizumab for locally recurrent brain metastasis with high dose irradiation previously.

e13579 Background: Treatment for recurrent brain metastasis remains uncertain. The purpose of this research was to evaluate the efficacy and toxicity of FSRS with adjuvant bevacizumab as a new salvage treatment for locally recurrent brain metastases with high dose irradiation previously. Methods: Patients with locally recurrent intracranial metastasis with irradiation previously were enrolled in this prospective study. Salvage FSRS dose ranged from 9.5 to 29 Gy in two to five sessions with 62–75% isodose line. Adjuvant bevacizumab was prescribed four cycles (5 mg/kg, q3w). Magnetic resonance imaging (MRI), Karnofsky Performance Scale (KPS), adverse events and clinical outcomes were recorded. The primary objective of this study was to identify the overall survival after salvage treatment. Secondary objectives included clinical response (KPS), imaging response (MRI) and adverse events. Results: From December 2009 to October 2016, 24 patients were enrolled. Of these patients, 9 received WBRT followed by SRS, and 15 underwent SRS. The median 1-year overall survival (OS) after salvage SRS was 87.5%. No treatment-related grade 4 adverse events were recorded. Grade 1/2 fatigue was observed in 8 (33%) patients followed by headache, hypertension and nausea. Grade 3 fatigue and headache occurred in 1 patient. No grade 4 toxicity was observed. Conclusions: Salvage FSRS with early use of low dose adjuvant bevacizumab treatment showed favourable clinical and radiologic control with manageable toxicity for locally recurrent brain metastasis patients who underwent high dose irradiation previously. The diagnosis of RN and LR after salvage FSRS merit further study. [Table: see text][Table: see text][Table: see text]

Outcomes in the radiosurgical management of metastatic spine disease

PurposeStereotactic body radiation therapy (SBRT) is a common treatment option for patients with metastatic tumors of the spine. The optimal treatment-, tumor-, and patient-specific characteristics necessary to achieve durable outcomes remain less well understood given the heterogeneous nature of the patient population this modality typically serves. The objective of this analysis was to better understand the determinants underlying SBRT spine treatment outcomes. Methods and MaterialsA total of 127 patients with 287 spine tumors were treated between March 2010 and May 2015. The median total doses for single-fraction and hypofractionated courses of treatment were 16 Gy (range, 16-20 Gy) and 24 Gy (range, 16-40 Gy), respectively. Radiologic local control and numeric pain score data were measured, and univariate and multivariate analyses were done to determine factors predictive of treatment response. ResultsMedian follow-up was 5.9 months (range, 1-61 months). Radiologic local control was achieved in 84.7% of patients at 6 months and in 74.7% of patients at 1 year. Local control was found to be affected by the Spinal Instability Neoplastic Score, and was worse in patients with scores ≥7 (hazard ratio [HR]: 4.25; 95% confidence interval [CI], 1.57-11.51). Patients who required upfront surgical intervention to alleviate spinal cord compression, address mechanical spinal instability, or both had worse local control than those who did not require surgery (HR: 2.32; 95% CI, 1.04-5.17). Patients treated with a hypofractionated course compared with a single fraction had worse radiologic local control (HR: 2.63; 95% CI, 1.27-5.45). No patients developed radiation-induced myelitis after treatment, and the vertebral compression fracture rate was 9.1% after SBRT. ConclusionsPatients with potentially unstable spines or needing upfront spinal surgery before SBRT are less likely to achieve durable radiologic local control. Additionally, patients treated with single-fraction regimens have improved local control compared with those treated with hypofractionated radiation.