Sphincter Involvement Research Articles

79O - A multicenter phase II study of neoadjuvant FOLFOXIRI followed by concurrent capecitabine and radiotherapy for high risk rectal cancer: A final report

BackgroundWe investigated the feasibility of adding FOLFOXIRI to neoadjuvant chemoradiotherapy for patients (pts) with high risk rectal adenocarcinoma (T3-4 +/- node positivity, threatened margin and/or sphincter involvement). MethodsEligible patients were treated with 4 cycles of modified FOLFOXIRI (D1: CPT-11 165mg/m2, D1: oxaliplatin 85mg/m2, D1-2 200mg/m2 leucovorin, D1-2 5FU 400mg/m2 30min, then D1-2 5FU 600mg/m2 over 22hrs, with GCSF support), followed by capecitabine (825mg/m2 b.d) given concurrently during pre-operative radiotherapy (CRT, 50.4 Gy, 28 fr, 5 wks). Pts underwent surgery at planned 8-10 weeks after CRT, followed by adjuvant chemo. The primary endpoints were pathologic complete response rate (pCR) and objective response rate (ORR, RECIST ver 1.1). Results40 eligible pts were enrolled (median age 60 yrs; male:female=82%:18%), 1 pt was excluded before starting treatment. Baseline stage distribution was stage II (10.2%), IIIB (64.1%) and IIIC (25.7%). Of the 39 pts evaluated for response (ITT), ORR to FOLFOXIRI was 38.5% (15 PRs, 24 SDs); ORR to CRT was 64.1% (25 PRs, 9 SDs, 1 PD, 4NA). Total of 28 pt (out of 38 evaluated, 73.7%) had a reduced overall TNM stage. Of the 27 pts who underwent surgery (18.5% had permanent stoma), pCR rate was 25.9%, 26 pts had negative and 1 pt had close margin, respectively. At median follow-up of 30.2 months, the 2-yr overall survival and relapse-free rates were 79.3% and 82.8%, respectively. The top three most common grade 3-4 toxicities: (1) To FOLFOXIRI were diarrhea (12%), neutropenia (7.7%) and hyponatremia (5.1%); (2) To CRT – diarrhea (2.5%), RT-dermatitis (2.5%) and rectal hemorrhage (2.5%). No treatment-related deaths or perioperative mortality were encountered. ConclusionsIn summary, neoadjuvant FOLFOXIRI followed by Cape-RT for high risk rectal cancer is feasible and the pCR rate compares favorably with the historic rate of 13.8% with CRT alone (Yeung et al. Hong Kong Med J 2016;22) This strategy is being evaluated in a randomized study. Clinical trial identificationNCT01941641. Legal entity responsible for the studyThe Chinese University of Hong Kong. FundingHong Kong Research Grant Council General Research Fund 471613. DisclosureAll authors have declared no conflicts of interest.

Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve.

Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40-50 cases. The experience among taTME surgeons beyond their learning curve is limited. A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed. Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality. Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.

Frequency and characteristics of short versus longitudinally extensive myelitis in adults with MOG antibodies: A retrospective multicentric study

Objectives: We aim to (1) determine the frequency and distinctive features of short myelitis (SM) and longitudinally extensive transverse myelitis (LETM) in a cohort of adults with myelin oligodendrocyte glycoprotein (MOG)-antibody (Ab)-associated myelitis and (2) determine baseline prognostic factors among MOG-Ab-positive patients whose disease started with myelitis. Material and Methods: We retrospectively analyzed clinical and paraclinical variables from a multicentric French cohort of adults with MOG-Ab-associated myelitis. At last follow-up, patients were classified into two groups according to the severity of the Expanded Disability Status Scale (EDSS) as ⩽2.5 or ⩾3.0. Results: Seventy-three patients with at least one episode of myelitis over disease course were included; among them, 28 (38.4%) presented with SM at the time of the first myelitis. Motor and sphincter involvement was less frequently observed in SM (51.9% and 48.2%, respectively) than in LETM patients (83.3% and 78.6%, respectively), p = 0.007 and p = 0.017; 61% of LETM patients displayed brain lesions compared to 28.6% in the SM group, p = 0.008, and the thoracic segment was more frequently involved in the LETM (82.2%) than in the SM group (39.3%), p < 0.001. EDSS at last follow-up was higher in LETM (median 3.0 (interquartile range: 2.0–4.0)) compared to SM patients (2.0, (1.0–3.0)), p = 0.042. Finally, a higher EDSS at onset was identified as the only independent risk factor for EDSS ⩾3.0 (odds ratio, 1.40, 95% confidence interval (CI): 1.01–1.95, p = 0.046). Conclusion: SM in MOG-Ab-associated disease is not rare. The severity at onset was the only independent factor related to the final prognosis in MOG-Ab-associated myelitis.

FISTULOTOMY FOR THE SURGICAL TREATMENT OF PERIANAL FISTULA OF CRYPTOGLANDULAR ORIGIN

Perianal fistula usually results from a non-specific infection of the cryptic glands located at the anal dentate line. Identification of the exact course of a perianal fistula and the extent of anal sphincteric complex involvement are of paramount importance, in order to design the therapeutic and interventional approach and achieve the best results without impairment of the anorectal function. Several interventional methods are in use for the surgical treatment of CPF, including fistulotomy, insertion of cutting “seton”, core fistulectomy, ligation of the intersphincteric fistulous track (LIFT), rectal advancement flap, injection of fibrin glue at the fistulous track, insertion of fistulous plug, and obliteration of the fistulous track with the use of Laser. In clinical practice a combination of the aforementioned methods can be used, in particular for the complex-high or recurrent fistulae.

MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management.

Rectal cancer is prone to local recurrence and systemic metastasis. However, owing to improvements in TNM staging and treatment, including a more widespread use of rectal MRI and increased radiologist awareness of the key rectal cancer TNM staging features, the mortality rate of rectal cancer has been declining over the past few decades in adults over 50 years of age. Currently, rectal MRI plays a key role in the pre- and posttreatment evaluation of rectal cancer, assisting the multidisciplinary team in tailoring the most appropriate treatment option. The benefits achieved with rectal MRI are strictly dependent on obtaining good-quality images, which is important for the characterization of the main anatomic structures and their relationship with the tumor. In primary staging, rectal MRI helps the radiologist (a) describe the tumor location and morphology, (b) provide its T and N categories, (c) detect the presence of extramural vascular invasion, and (d) identify its relationship with surrounding structures, including the sphincter complex and involvement of the mesorectal fascia. These features help diagnose locally advanced rectal tumors (categories T3c-d, T4, N1, and N2), for which neoadjuvant chemoradiotherapy (CRT) is indicated. In restaging after neoadjuvant CRT, in addition to reassessing the features noted during primary staging, rectal MRI can help in the assessment of treatment response, especially with the emergence of nonsurgical approaches such as "watch and wait." ©RSNA, 2019.

Multiple solitary plasmacytoma of the spine with compressive cervical myelopathy: A rare case report and review of literature

We present a case of multifocal plasmacytoma, one of the rarest hematological malignancies, with an unusual presentation of cervical myelopathy. A 60-year-old male presented with features of cervicalgia and radiculomyelopathy. There was a history of significant weight loss over 2 months with no sphincter involvement. Neurological examination showed spastic quadriparesis with extensor plantars. Radiological workup showed multiple lytic lesions from C3 to C6 with cord compression and myelomalacic changes. The patient underwent three-level corpectomy (C5–C7) with cord decompression. Reconstruction was done with an expandable titanium cage, and anterior cervical plating from C4 to T1 was done. The histopathology and immunohistochemistry markers enabled in clinching this rare diagnosis of multifocal plasmacytoma. It is essential to distinguish early between various entities among plasmacytoma as each one has a different clinical course and prognosis. Multiple solitary plasmacytoma presenting de novo with cord compression and myelopathy is an extremely rare presentation.

Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization

BackgroundVertebral body hemangiomas with myelopathy are difficult to manage. ObjectiveThe objective of this study was to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented short-segment fusion in vertebral hemangioma (VH) with myelopathy and long-term outcome (>24 months). Clinical Materials and MethodsThis prospective study included symptomatic VH with cord compression with myelopathy. Pathologic fractures and deformity or multilevel pathologies were excluded from the study. Surgery consisted of intraoperative bilateral pedicular absolute alcohol (<1% hydrated ethyl alcohol) injection, laminectomy, and cord decompression at the level of pathology followed by a short-segment instrumented fusion using pedicle screws. ResultsThe study included 33 patients (mean 26.9±13.2, range: 10–68 years, 18 females). The clinical features of the study were myelopathy in all patients (5 paraplegic), sphincter involvement (13), and mid back or lower back pain (7). The preoperative American Spinal Injury Association (ASIA) scores were A (7), B (11), C (6), D (8), and E (1). Majority of the patients had single vertebral involvement (30) and three patients had multiple-level involvement. Six patients underwent surgery earlier (one underwent alcohol embolization). The mean surgical time was 124±39 minutes, and the average blood loss was 274±80 cc. The mean amount of absolute alcohol injected was 14.6±5.7 cc (two patients required 20 and 25 cc). Immediate embolization was achieved in all patients, allowing laminectomy and easy removal of soft-tissue hemangioma. Post surgery, one patient had transient deterioration, and the condition of the rest of the patients improved (sphincters improved in nine patients) at a follow-up ranging 28–103 months (mean 47.6±22.3). Follow-up ASIA scores were E (26), D (4), B (2), and C (1). All patients showed evidence of bone sclerosis and relief of cord compression on follow-up imaging. ConclusionsThis is the largest study in literature showing excellent improvement, low reoperation rates after ethanol embolization, and short-segment fixation.

Spinal Meningiomas Prognostic Evaluation Score (SPES): predicting the neurological outcomes in spinal meningioma surgery.

Among many factors leading to a worse functional prognosis in spinal meningioma (SM) surgery, in a previous study, we recognized anterior/anterolateral axial topography, sphincter involvement at first evaluation, surgery performed on a recurrence, and worse preoperative functional status. The purpose of this paper is to evaluate the cumulative weight of these factors on prognosis through a multinomial logistic regression model performed on an original evaluation scale designed by the authors on the ground of the experience of the neurosurgical departments of our University. The original SM database composed of 173 cases was classified in regard to sex, age, symptoms, axial and sagittal location, Simpson grade resection, and functional pre/postoperative status. Fine presurgical and follow-up reevaluations were available. The authors propose a scale (Spinal Meningiomas Prognostic Evaluation Score (SPES)) of preoperative evaluation to assess the surgery-related risk of neurological worsening experienced by the patients included in the present cohort. The authors describe a strong statistical association between the SPES and the follow-up Frankel and McCormick scores (r = - 460 and .441, p .001, both). Through a univariate ANOVA analysis, we disclosed that patients presenting scores 2 and 3 had a significantly higher association to lesser Frankel and McCormick postoperative scores, in respect to patients presenting SPES scores 0-1 (univariate ANOVA, p .008 and .011). Anterior or anterolateral axial location, operating on a recurrence of SM, sphincter involvement, and worse functional grade at onset present, along with the SPES scores are fairly predictive and reliable in respect to the long-term results of patients suffering from SM.

Spinal Epidermoids - Rare Tumours Posing a Diagnostic Dilemma

Spinal epidermoids are rare tumors comprising less than 1% of all intraspinal tumors. These tumors are usually found as intramedullary space occupying lesions (SOLs) in cervico-dorsal and as intradural SOLs in lumbo-sacral region. Thier origin has been advocated to be congenital or acquired. These tumors have been reported in patients of age group 03 yrs to 55 yrs in various case reports/small series in literature. The usual presentation is that of slowly progressive spastic paraparesis / quadriparesis with or without sphincter involvement as in IMSOLs / IDEMs lesions of the spinal cord. These tumors pose a diagnostic dillema due to there rarity. The diagnosis of these tumors may be delayed as they have similar symptoms and signs as in any other intradural spinal patholgy. The preoperative diagnosis can be made with reasonable certainity dedicated MRI sequences (diffusion weighted & ADC) are carried out. Since these tumors are benign, an early diagnosis gives the patient a realtively good prognosis. We report two such unusual cases which came as diagnostic surprise on operative table and that too within a period of 06 months. Microscopic total excision relatively early in the course of the illness in both these patients had satisfactory outcome with good neurological recovery and no recurrence over last 24 months.

High-resolution manometry in patients with idiopathic inflammatory myopathy: Elevated prevalence of esophageal involvement and differences according to autoantibody status and clinical subset.

In this study we assessed high-resolution manometry (HRM) findings in patients with dermatomyositis and polymyositis. From 2008 to 2015, we performed a cross-sectional study of myositis patients. A survey of esophageal symptoms and HRM data were analyzed and compared among different clinical and serologic groups. Twenty-four (45%) of the 53 patients included in the study had manometric involvement that was not correlated with any esophageal symptom (P = 0.8). Failed waves (34% vs. 0%, P = 0.004) and decreased upper esophageal sphincter pressure (50 vs. 70 mm Hg, P = 0.03) were more common in polymyositis than in dermatomyositis patients. Jackhammer esophagus was more common in anti-TIF1-γ patients (30% vs. 9%, P = 0.04), and lower esophageal sphincter involvement (47% vs. 25%, P = 0.03) was more prevalent in patients with the antisynthetase syndrome. Esophageal involvement is common in myositis patients, but it correlates poorly with esophageal symptoms. Specific clinical and serologic groups have different manometric features. Muscle Nerve 56: 386-392, 2017.

Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Remarks on 173 Cases.

Spinal meningiomas are common spinal tumors, in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring a less favorable prognosis. To correlate these data with clinical/functional outcome. Two hundred twenty-four consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these, 51 were excluded for incomplete clinical data or follow-up. The remaining 173 cases were classified in regards to sex, age, symptoms, axial location, Simpson grade resection, and functional pre-/postoperative status. Most recurring onset symptoms were pain (32.9%) and motor deficit (31.8%); thoracic spine was the most severely affected (69.8%). Functional improvement on the follow-up was observed in 86.7% of cases; 6.4% of patients resulted stable and 6.9% worsened. A low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grades I and II) was conducted in 98.8%, and a macroscopically complete removal without dural resection or coagulation (Simpson grade III) was performed in 1.2%. Of the meningiomas, 98.3% were classified as WHO grade I. Recurrence rate was 2.3%, and 7 cases presented complications (4 of 7 required surgical procedure). We can affirm that negative prognostic factors in our study were anterior or anterolateral axial location, prolonged presentation before diagnosis, WHO grade >I, Simpson grade resections II and III, sphincter involvement, and worse functional grade at onset.

Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient.

Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. Success rate was 97.7% with a healing time of 4weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors.

Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity. Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed. All procedures were successfully completed without conversion. Average body mass index was 32kg/m2. The mean operative time and blood loss were 370min and 130ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14months, all patients remain disease-free. Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.

Magnetic resonance imaging of perianal Crohn's disease.

Successful treatment of perianal Crohn's disease requires knowledge of the location and nature of the fistulous tracts. Both Magnetic resonance imaging (MRI) and ultrasound are superior to clinical evaluation for complex disease.1 Preoperative assessment leads to a significant decrease in recurrences from undiagnosed extensions and abscesses.2 Ultrasound using an endoanal, transvaginal, or transperineal approach, with or without the use of hydrogen peroxide, is accurate in determining this information. This is however operator dependent and relies on the availability of local expertise. MRI using a body coil provides accurate assessment but, unlike ultrasound, is less dependent on operator expertise.1 A standard study should be aligned along the length of and perpendicular to the anal canal and include three-plane T2 fat saturated and T1 fat saturated post contrast imaging. A T1 sequence without fat saturation is useful to determine the site of fibrotic tracts from prior surgery, successful medical therapy, and after complex graft surgery. The advantage of post contrast imaging is in defining the tracts and differentiating between granulation tissue and abscess formation. Additional sequences such as 3D-volume post contrast and diffusion weighted imaging may be of assistance in demonstrating active disease; however, the latter may lack anatomical registration.3 Anatomically, cranially, the internal sphincter extends above the external sphincter, while caudally the external sphincter extends below the internal sphincter. The external sphincter may be shorter in women and is often partly deficient anteriorly because of prior obstetric trauma.4 Important information to convey to the treating physician is the number and course of the tracts, the level of the internal openings, the length of sphincter involvement, presence of secondary fistula tracts/ramifications, supralevator extension, and abscesses. The standard Park's classification allows clear communication; however, the St James University Hospital MRI fistula classification may also be used.5, 6 The Leuven scoring system provides quantitative assessment for use in research studies.7 Fistula tracts may be composed entirely of granulation tissue or contain a thin ribbon of fluid. Any fluid component over 3 mm should be considered an abscess.8 Any fistula tract that extends cranial to the anal canal midpoint should be specifically noted to the surgeon, as surgical division of the sphincter in these cases may lead to incontinence.9 Where an anti-tumor necrosis factor agent has healed the external opening, MRI is useful to demonstrate residual unhealed tracts that may predispose to early relapse if treatment is discontinued prematurely.10 In cases with chronic ongoing sepsis, it is important to assess for malignant transformation evidenced by lobular and septated high T2 signal and contrast enhancing tissue expansion of a fistula tract.11 Clear communication between the referrer and radiologist is paramount in achieving successful outcomes. This should include any prior surgical history describing clinically evident fistula openings according to the clock face location and the level of expected internal openings, preferably the most recent operative note indicating the site of surgery and Seton placement. If there has been complex fistulization to the vagina and urethra, this should be noted as this may not be encompassed in the standard imaging field of view.

Perineal Colostomy Post Amputation of Rectum

The operation described by Miles in 1908, an effective method in the radical treatment of tumors of the anus and lower rectum [1], and with better survival, leaves the stigma of the definitive iliac colostomy that leads to various psychosocial disorders [2]. Seeking to reduce social and family rejection, in addition to gas elimination and lack of control of the stools by the absence of sphincter, several methods of stools retention have been described [3-6]. Dr. Lázaro Da Silva, in Brazil, made the first perineal valve colostomy in 1991, when performing 2 to 3 extra-mucosal circular seromiotomies with invaginating seromuscular synthesis, with the meso-redundant occupying the pelvis, the distal valve stayed extra peritoneal and the proximal fixed to the promontory, this prevents or delays the excretion of stools directly [7]. It is indicated in patients proposed for abdominoperineal resection post-neoadjuvant, benign lesions with extensive sphincter involvement, extensive or intractable stenosis after perineal radiotherapy. This procedure is reserved for young or older patients in good physical condition, good cognitive level and without indication of postoperative radiotherapy [8].

Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Clinical and Surgical Remarks on 173 Cases

Introduction Spinal meningiomas are common spinal tumors in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement or spinal root involvement can bring to a less favorable prognosis. Aim of this work is to systematically the influence of this factors in the neurological outcomes of our patients. Matherial and Methods 224 consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these 51 were excluded for incomplete clinical data or follow up. The remaining 173 cases were classified regarding to: sex, age, symptoms, axial location, Simpson Grade resection, Functional pre/postoperative status. Results Most recurring onset symptoms were pain (32,9%) and motor deficit (31,8%); Thoracic spine was the most severely affected (69,8%). The functional improvement on the follow up was observed in 86,7% of cases, 6,4% of patients resulted stable and 6,9% worsened; a low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42,2%); a gross total resection (Simpson Grade I and II) was conducted in 98,8% and a macroscopically complete removal without dural resection or coagulation (Simpson III) was performed in 1,2%. 98,3% of meningiomas were classified as Grade I WHO. Recurrence rate was of 2,3% and 7 cases presented complications (4 of 7 required surgical procedure). Conclusions We can adfirm that negative prognostic factors in our study were: anterior or antero-lateral axial topography, long-lasting symptoms before diagnosis, WHO Grade &gt; I, Simpson Grade resection II and III, sphincter involvement and worse functional grade at onset.

Myelitis: Differences between multiple sclerosis and other aetiologies

BackgroundMyelitis can appear as an initial symptom in the context of demyelinating diseases, systemic inflammatory diseases, and infectious diseases. We aim to analyse the differences between myelitis associated with multiple sclerosis (MS) and myelitis resulting from other aetiologies. MethodsSingle-centre, retrospective analysis of patients with initial myelitis (2000-2013). Demographic, aetiological, clinical, radiological and prognostic variables were analysed and compared between patients with myelitis from MS and those with myelitis due to other aetiologies. ResultsWe included 91 patients; mean follow-up was 7 years. Diagnoses were as follows: MS 57 (63%), idiopathic transverse myelitis 22 (24%), associated systemic diseases 6 (7%), and other diagnoses (6%). Myelitis due to MS was associated with younger age of onset (35±11 vs 41±13; P=.02), more pronounced sphincter involvement (40.4% vs 27.3%; P=.05), greater multifocal involvement in spinal MRI (77.2% vs 26.5%; P=.001), shorter lesion extension (2.4 vs. 1.4 vertebral segments; P=.001), cervical location (82.5% vs 64.7%; P=.05) and posterior location (89.5% vs 41.2%; P=.001). Myelitis due to other aetiologies more frequently showed anterior location (47.1% vs 24.6%; P=.02), and central cord involvement (47.1% vs 14.1%; P=.001), with better recovery at one year of follow up (EDSS 2.0 vs 1.5; P=.01). Multivariate analysis showed that multifocal spinal cord involvement (OR 9.38, 95% CI: 2.04-43.1) and posterior cord involvement (OR 2.16, 95% CI: 2.04-2.67) were independently associated with the diagnosis of MS. ConclusionsA high percentage of patients with an initial myelitis event will be diagnosed with MS. The presence of multifocal and posterior spinal cord lesions was significantly associated with the diagnosis of MS.

Spinal tumors: Trends from Northern India.

Introduction and Methods:We retrospectively analyzed 111 patients with spinal tumors operated over a period of 9 years to observe the relative frequency of different lesions, their clinical profile, functional outcome and prognostic factors. 30/111 (27%) were extradural, 40/111 (36.1%) were intradural extramedullary (IDEM) and 41/111 (36.9%) were intramedullary spinal cord tumors (IMSCTs). Mean age at surgery was 30.81 years (range 1–73 years). The average preoperative duration of symptoms was 16.17 months (15 days to 15 years). Major diagnoses were ependymomas and astrocytomas in IMSCT group, schwanommas and neurofibromas in IDEM group, and metastasis, lymphoma in extradural group. The common clinical features were motor weakness in 78/111 (70.27%), sensory loss in 55/111 (49.54%), pain 46/111 (41.44%), and sphincter involvement in 47/111 (42.43%) cases.Results:Totally, 88/111 (79.27%) patients had improvement in their functional status, 17/111 (15.31%) remained same, and 6/111 (5.4%) were worse at time of their last follow-up. The mean follow-up was 15.64 months (1.5 m−10 years). Totally, 59 out of 79 patients, who were dependent initially, were ambulatory with or without the aid. Most common complication was persistent pain in 10/111 (9%) patients and nonimprovement of bladder/bowel symptoms in 7/111 (6.3%). One patient died 3 months after surgery.Conclusions:(1) Congenital malformative tumors like epidermoids/dermoids (unrelated to spina bifida) occur more frequently, whereas the incidence of spinal meningioma is less in developing countries than western populations. (2) The incidence of intramedullary tumors approaches to that of IDEM tumors. Intramedullary tumors present at a younger age in developing countries. (3) Rare histological variants like primitive neuroectodermal tumors should also be considered for histological differential diagnosis of spinal tumors. (4) Preoperative neurologic status is the most important factor related to outcome in spinal tumors.

The role of multi-parametric MRI in loco-regional staging of men diagnosed with early prostate cancer

To review the use of multi-parametric MRI (mpMRI) in loco-regional assessment of men with early prostate cancer. mpMRI comprises anatomic T2 and T1 sequences supplemented by functional imaging techniques such as diffusion-weighted and dynamic contrast enhanced (DCE) imaging. mpMRI is gaining increasing acceptance for prostate cancer detection and staging of early disease. It can facilitate targeted therapies, guide surgical options and enable active surveillance within suitable patients. The technique can be performed at 1.5 or 3 Tesla, but sequence optimization is critical to successful implementation of mpMRI. T2 and diffusion-weighted sequences are minimal requirements and are often complemented by DCE images. When performed at high spatial resolution, DCE facilitates detection of disease, as well as assessment of extra-capsular extension, distal urethral sphincter and seminal vesicles involvement. Pre-biopsy mpMRI is recommended for both detection and staging as it avoids biopsy artefact, and when normal, has a negative predictive value of 95% for significant cancer. mpMRI reliably detects clinically significant prostate tumour and ideally should be performed prior to biopsy. It provides an accurate method for local disease staging and facilitates a growing range of treatment options for patients with early disease.

Mielitis. Diferencias entre esclerosis múltiple y otras etiologías

BackgroundMyelitis can appear as an initial symptom in the context of demyelinating diseases, systemic inflammatory diseases, and infectious diseases. We aim to analyse the differences between myelitis associated with multiple sclerosis (MS) and myelitis resulting from other aetiologies. MethodsSingle-centre, retrospective analysis of patients with initial myelitis (2000-2013). Demographic, aetiological, clinical, radiological and prognostic variables were analysed and compared between patients with myelitis from MS and those with myelitis due to other aetiologies. ResultsWe included 91 patients; mean follow-up was 7 years. Diagnoses were as follows: MS 57 (63%), idiopathic transverse myelitis 22 (24%), associated systemic diseases 6 (7%), and other diagnoses (6%). Myelitis due to MS was associated with younger age of onset (35±11 vs. 41±13; P = .02), more pronounced sphincter involvement (40.4 vs. 27.3%; P=.05), greater multifocal involvement in spinal MRI (77.2 vs. 26.5%; P=.001), shorter lesion extension (2.4 vs. 1.4 vertebral segments; P=.001), cervical location (82.5 vs. 64.7%; P=.05) and posterior location (89.5 vs. 41.2%; P=.001). Myelitis due to other aetiologies more frequently showed anterior location (47.1 vs. 24.6%; P=.02), and central cord involvement (47.1 vs. 14.1%; P=.001), with better recovery at one year of follow up (EDSS 2.0 vs. 1.5; P=.01). Multivariate analysis showed that multifocal spinal cord involvement (OR 9.38, 95% CI: 2.04-43.1) and posterior cord involvement (OR 2.16, 95% CI: 2.04-2.67) were independently associated with the diagnosis of MS. ConclusionsA high percentage of patients with an initial myelitis event will be diagnosed with MS. The presence of multifocal and posterior spinal cord lesions was significantly associated with the diagnosis of MS.