Stage IIC Research Articles

Management of nontraumatic osteonecrosis of the femoral head using impaction bone grafting via a light bulb window through a safe surgical dislocation approach

Purpose The aim was to appreciate the clinical and radiological results of impacted bone graft via bone window on the head-neck junction for treatment of nontraumatic avascular necrosis of femoral head through a safe surgical dislocation approach. Patients and methods A total of 33 hips in 26 patients were managed with femoral head osteonecrosis by impaction of autogenous iliac bone graft via bone window on the head-neck junction (light bulb) through a safe surgical dislocation approach. There were eight females and 18 males, with a mean age of 29.06 years (ranging from 14 to 46 years) with stage II and III avascular necrosis of the femoral head according to Association Research Circulation Osseous (ARCO). The results were studied based on variations in the Harris hip score and progress in radiographic stages. Results These 26 patients were followed up from 24 to 48 months (mean: 33.9 months). The mean Harris hip score was 82.78 (range from 66 to 95) after last follow-up when compared with 60.45 (range from 41 to 85) preoperatively. The clinical success for ARCO stage II was 75% (100% in stage IIA, 83.3% in stage IIB, and 50% in stage IIC) and for ARCO stage III was 43.5% (70% in stage IIIA, 60% in stage IIIB, and 0% in stage IIIC), whereas the overall radiographic progression was found in 15 of 33 hips (45.4%), where nine of them (27.3%) progressed to radiographic failure (femoral head collapse) and required total hip arthroplasty. Conclusions Impaction of autogenous bone graft through a safe surgical dislocation via a bone window creates a mechanical and biological condition for graft incorporation, and therefore, it may be the treatment of choice in nontraumatic osteonecrosis of the femoral head at the precollapse stage (stage II and early III), especially with a small-sized lesion, with a better outcome in idiopathic type.

Considering adjuvant therapy for stage II melanoma.

Melanoma is among the few cancers that demonstrate an increasing incidence over time. Simultaneously, this trend has been marked by an epidemiologic shift to earlier stage at diagnosis. Before 2011, treatment options were limited for patients with metastatic disease, and the median overall survival was less than 1 year. Since then, the field of melanoma therapeutics has undergone major changes. The use of anti–CTLA‐4 and anti‐PD1 immune checkpoint inhibitors and combination BRAF/MEK inhibitors for patients with BRAF V600 mutations has significantly extended survival and allowed some patients to remain in durable disease remission off therapy. It has now been confirmed that these classes of agents have a benefit for patients with stage III melanoma after surgical resection, and anti‐PD1 and BRAF/MEK inhibitors are standards of care in this setting. Some patients with stage II disease (lymph node‐negative; American Joint Committee on Cancer stage IIB and IIC) have worse melanoma‐specific survival relative to some patients with stage III disease. Given these results, expanding the population of patients who are considered for adjuvant therapy to include those with stage II melanoma has become a priority, and randomized phase 3 clinical trials are underway. Moving into the future, the validation of patient risk‐stratification and treatment‐benefit prediction models will be important to improve the number needed to treat and limit exposure to toxicity in the large population of patients with early stage melanoma.

Current trend of surgery in juvenile nasopharyngeal angiofibroma: a hospital based retro-prospective study

<p class="abstract"><strong>Background:</strong> The aim of the present study was to know the current trends of surgery, to determine the surgery of choice according to stage and complications, rate of recurrence of following surgery.</p><p class="abstract"><strong>Methods:</strong> Retro-prospective study was carried out from August 2004 to July 2014, in which 31 prospective and 8 prospective cases were included. All the details of patients like general examination, ENT examination, computed tomography or magnetic resonance imaging scan finding, staging, and approach of surgery, complications, and recurrence rate were recorded. </p><p class="abstract"><strong>Results:</strong> In our study all the patients were male and the mean age was 15.74 years (age ranged 11 to 22 years). Most frequent sign and symptoms were epistaxis (92.4%), nasal blockage (90%), and facial swelling (18%). Most common surgical approach was ‘trans palatine approach’ (51% cases) belongs to stage IIa, IIb, IIc, IIIa, IIIb and ‘lateral rhinotomy approach’ used in 35% cases. And by endoscopic approach (only 5.1% cases) were operated due to lack of embolization technique. Overall recurrence was about 29% (66% cases belonged to stage III). Postoperative complications were septal perforation 33%, palatal perforation 9.5%, facial disfiguration 9.5% and 9.5% hypertrophic scar.</p><p class="abstract"><strong>Conclusions:</strong> Our study we concluded that, 92% of patients age group 11 to 20 years and all were males. Epistaxis and nasal obstruction were the most common symptoms. Most of the recurrent tumor belonged to stage III tumor. Most appropriate surgical approach for stage I, IIa and IIb was transpalatine approach and for stage IIc and IIIa was lateral rhinotomy. Complete excision of intracranial extension of tumor was difficult and causes recurrence of diseases.</p>

Effect of cytokines on NK cell activity and activating receptor expression in high-risk cutaneous melanoma patients.

Stage II melanoma patients have high risk for regional and distant metastases and may benefit from novel therapeutic strategies. To clarify the role of NK cells in Stage II melanoma, we characterized the cytotoxic activity of NK cells and the expression of various activating and inhibitory receptors in high-risk cutaneous melanoma patients (Stages IIB and IIC) compared to low-risk patients (Stage IA). Native and cytokine-treated peripheral blood mononuclear cells were used for functional and phenotypical analyses. Compared to Stage IA-B patients, Stage IIB-C patients showed significantly decreased NK cell activity, as well as decreased expression of the activating NKG2D and CD161 receptors, most likely due to increased serum levels of the immunosuppressive cytokine TGF-β1 in these patients. Interestingly, treatment of periperal blood mononuclear cells with IFN-α, IL-2, IL-12 or the combination of IL-12 and IL-18 significantly induced NK cell activity for both groups of melanoma patients. However, only low-risk patients had a significant increase in the expression of the NKG2D receptor after in vitro treatment with IFN-α, as well as an significant increase in the expression of CD161 after treatment with IFN-α or IL-12. Although IL-2 induced the expression of NKG2D in both groups of patients, this increase was significantly lower in high-risk melanoma. NK cell parameters may be useful as biomarkers of disease progression in localized melanoma patients. Our results further suggest that the use of NK cell-activating cytokines in combination with inhibitors of immunosuppressive factors like TGF-β1 could be a therapeutic option for the treatment of high-risk cutaneous melanoma patients.

Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Health-related quality of life in patients with fully resected BRAFV600 mutation–positive melanoma receiving adjuvant vemurafenib

Aim of studyThe aim of the study was to assess the impact of treatment with adjuvant vemurafenib monotherapy on health-related quality of life (HRQOL) in patients with resected stage IIC–IIIC melanoma. MethodsThe phase 3 BRIM8 study (NCT01667419) randomised patients with BRAFV600 mutation–positive resected stage IIC–IIIC melanoma to 960 mg of vemurafenib twice daily or matching placebo for 52 weeks (13 × 28-day cycles). Patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) version 3 at baseline, cycle 1 (days 1, 15 and 22), cycle 2 (days 1 and 15), day 1 of every subsequent 4-week cycle, the end-of-treatment visit and each visit during the follow-up period. ResultsCompletion rates for the EORTC QLQ-C30 questionnaire were high (>80%). There was a mean decline in the global health status (GHS)/quality of life (QOL) score of 17.4 (±22.9) and 17.3 (±24.1) points at days 15 and 22 of cycle 1, respectively, among vemurafenib-treated patients who recovered to approximately 10 points below baseline for the remainder of the treatment period. A similar trend was observed in all functional scales except for cognitive function (<10-point change from baseline at all visits) and in the symptom scores for appetite loss, fatigue and pain. As observed for the GHS/QOL score, all scores rapidly returned to baseline after completion of planned vemurafenib treatment or treatment discontinuation. ConclusionsThe schedule of HRQOL assessments allowed for an accurate and complete evaluation of the impact of acute treatment-related symptoms. Vemurafenib-treated patients experience clinically meaningful moderate worsening in some treatment- or disease-related symptoms and GHS/QOL that resolve over time.

Squamous Cell Carcinoma Arising in a Mature Cystic Teratoma of the Ovary: A Case Report

Mature cystic teratomas account for about 30-45% of all ovarian tumors. Malignant transformation in these tumors is a rare event, occurring in only 0.17-2% of cases, with squamous cell carcinoma being the most common type. As there are no specific signs and symptoms to suggest malignancy in dermoid cyst, it is difficult to predict, and most cases are diagnosed postoperatively. We report a 55-year-old postmenopausal lady who presented with the complaint of pain in abdomen and abdominal distension for four months and a large complex abdomino-pelvic mass evident clinically and radiologically. Final histopathology was reported as malignant transformation in mature cystic teratoma. The patient was assigned to squamous cell carcinoma of the ovary arising in a mature cystic teratoma, surgical stage IIC. In view of the poor prognosis, adjuvant chemotherapy was given.

Robotic Tumor Debulking off External Iliac Vessels for the Management of Recurrent Ovarian Cancer

To show a surgical video in which an isolated mass was resected off the external iliac vessels for the management of recurrent ovarian cancer. Case report. Tertiary referral center in New Haven, Connecticut. This is a step-by-step demonstration of a robotic tumor debulking in a patient with isolated recurrence of epithelial ovarian cancer [1-3]. The patient is a 70-year-old woman with Lynch syndrome who received a diagnosis for stage IIC high-grade serous ovarian adenocarcinoma and underwent complete debulking in 1996. She had most recently been on pembrolizumab for microsatellite instability-high tumor until February 2019, when she received a diagnosis for isolated hypermetabolic mass in close proximity to the external iliac vessels and right iliac fossa. The patient was placed in dorsal low lithotomy Trendelenburg position, and 15° leftward tilt of the table was obtained to expose the right pelvic sidewall and iliac fossa. To optimally target the surgical field of interest, all robotic trocars were placed in a straight line starting from 5 cm above symphysis pubis on the left side to left subcostal line between the midline vertical and the left midclavicular lines, as per the manufacturer's port placement guidelines (Fig. 1). Robotic resection of the tumor nodule off the external iliac vessels was successfully performed with adequate range of motion provided by the arms and without any complications. Trocar placement should be tailored to the site of surgical interest. Robotic-assisted laparoscopy should be considered as a valid alternative to the traditional open approach, when managing solitary masses in patients with recurrent ovarian cancer.

2480 Nivolumab-Induced Hepatitis and Vesiculopustular Skin Rash in a Patient With Metastatic Melanoma

INTRODUCTION: The advent of immunotherapy has been hailed as a breakthrough in cancer treatment. However, it comes with a multitude of immune mediated adverse effects. Gastrointestinal adverse effects include hepatitis and colitis. Immunotherapy related hepatitis can range from asymptomatic elevation of liver enzymes (grade 1) to decompensated liver failure (grade 4). CASE DESCRIPTION/METHODS: 82 years old male with stage IIC Malignant Melanoma of right posterior diagnosed in 2014, treated with wide excision. In December 2016, PET scan revealed right chest wall lesion, treated with re-excision. c-kit and BRAF were negative. In June 2017, PET scan showed metastatic disease involving lung, pancreas, gluteus maximus and left flank. The patient was started on Nivolumab. After 7 cycles, the PET scan became negative for any metastatic lesions. After 8 cycles, he had a severe morbilliform, vesiculopustular rash secondary to Nivolumab. Skin Biopsy showed a lymphocytic infiltrate with scattered eosinophils and numerous neutrophils. High dose prednisone was started with tapering for 3 months. Nivolumab was temporarily held and resumed after a good response to steroids. After 14 cycles, the patient developed malaise, fatigue, nausea and mild abdominal pain. ALT was 393, AST 302, ALK 164. Bilirubin was 1.1. Hepatitis A, B, and C testing were negative, anti-liver kidney microsomal antibody and anti-mitochondrial antibody was negative, acetaminophen level was normal, CT and Ultrasound of the liver were negative for metastatic lesions or other hepatic pathology. No recent change in medication or alcohol use was reported. As per ASCO guidelines, hepatitis was classified as Grade III (ALT and AST &gt;5-20 times the upper limit of normal). The patient was started on 100 mg prednisone daily with tapering for 2 months. Liver enzymes normalized and symptoms resolved. Nivolumab was discontinued. PET scan 6 months from the last cycle showed disease in remission. DISCUSSION: Treatment of immunotherapy induced hepatitis depends on severity. Immunotherapy can be continued in grade 1, temporarily held in grade 2, and permanently discontinued in grade 3 and 4 as per guidelines. High dose steroids (prednisone 1-2 mg/kg) with tapering serve as the mainstay of treatment. Mycophenolate or azathioprine can be considered in refractory cases. However, it needs further research whether immunotherapy can be re-trialed in patients with grade 3 toxicity, who have responded well to the steroids, and would potentially benefit from a repeat trial.

1326P - External validation of the 8th Edition Melanoma Staging System of the American Joint Committee on Cancer (AJCC) using the surveillance, epidemiology and end results (SEER) program

BackgroundChanges to the AJCC melanoma staging system eighth edition (AJCC-8) should be independently validated to assess its prognostic performance compared with the seventh edition (AJCC-7) in accurately staging melanoma. MethodsWe used the SEER-18 registry from 2010 to 2015 to extract patient-, tumour-related and survival data. Kaplan-Meier analysis was used for overall survival (OS) and cancer-specific survival (CSS) for AJCC-7 and AJCC-8. Cumulative hazard functions were computed using Nelson-Aalen function. ResultsOf 126,408 individuals, 59,989 (47%) and 60,411 (48%) had available data for pathological and clinical stage OS analysis, respectively. The 12-month OS for AJCC-7 among pathologically staged patients were: stage IA 99%, stage IB 99%, stage IIA 96%, stage IIB 94%, stage IIC 87%, stage IIIA 98%, stage IIIB 94%, stage IIIC 82% and stage IV 41%. The 12-month OS for AJCC-8 patients was similar to AJCC-7 but was 88% for stage IIIC and 65% for stage IIID. The 12-month risk of dying for pathological stage IIIC was 13% compared to 41% for pathological stage IIID (p<0.001). Stage IV individuals with an elevated LDH had worse OS and CSS at all other measured time-points up to 60 months compared to those with a normal LDH. Stage IV individuals with brain metastases (M1d) also had worse OS and CSS at all other measured time-points up to 60 months compared to other stage IV subgroups. ConclusionsThe discriminatory ability of the AJCC-7 and AJCC-8 melanoma staging system appear comparable. Changes in AJCC-8 identifies individuals with a poorer prognostic within new subgroups. These include the subgroups of stage IIID and M1d within stage IV individuals, and the addition of elevated LDH as a prognostic marker in stage IV disease. However, advanced T stage, node-negative tumours experienced worse survival compared with earlier T stage, node-positive tumours requiring further research to evaluate the underlying biology of these tumour subgroups. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Male sex and Breslow thickness are important risk factors for recurrence of localized melanoma in Korean populations

Predicting the recurrence of localized melanoma is important; however, studies investigating risk factors for recurrence of localized melanoma are lacking in Asian populations. To identify risk factors for recurrence of localized melanoma in Korean patients. We retrospectively reviewed patients with cutaneous melanoma without evidence of metastasis from 2000 to 2017. Logistic and Cox regression analyses were conducted for recurrence. The average follow-up time was 46.2months. We reviewed the data of 340 patients diagnosed with cutaneous melanoma and staged as melanoma in situ, stages I and II. Acral melanoma (70.3%, 239/340) was the predominant subtype. Ninety-two patients (27.1%) had a recurrence after primary melanoma removal (29 local recurrences, 49regional metastases, and 28 distant metastases). Some patients had multiple types of recurrence at the same time. Male sex (P=.030) and Breslow thickness greater than 1mm(P=.008) correlated with an increased risk of recurrence. Breslow thickness greater than 2.5mm in males and greater than 4mm in females showed a higher predictive value for recurrence than traditional stages IIB and IIC (hazard ratio 3.743 vs 2.972). This was a single-center retrospective study. In patients with localized cutaneous melanoma, male sex and Breslow thickness are the most important prognostic factors for recurrence in Korean populations. Different cutoff values of Breslow thickness may better predict recurrence according to sex.

Impact of American Joint Committee on Cancer 8th edition classification on staging and survival of patients with melanoma

ObjectiveThe American Joint Committee on Cancer (AJCC) 8th staging system introduced several revisions. To assess the impact of the 8th edition American Joint Committee on Cancer (AJCC8) staging system on subgrouping and survival, patients with melanoma from two tertiary skin cancer centres were classified according to both the 7th edition American Joint Committee on Cancer (AJCC7) and AJCC8. MethodsA total of 1948 patients aged ≥18 years with cutaneous melanoma stage II-IV were included. The impact of sex and age on reclassification was assessed by log binomial models. The inverse probability of censoring weighting method was used to compute ROC curves from time-to-event data to assess the discriminatory ability of AJCC7 and AJCC8. Melanoma-specific survival (MSS) and overall survival (OS) were calculated, and age- and sex-adjusted MSS hazard ratios were estimated using Cox proportional hazards models. ResultsOf all, 23.5% of patients were assigned a different subgroup when classified according to AJCC8. Owing to upshifting to stage IIIC (AJCC7 24.8% vs. AJCC8 50.8%), patient numbers of stages IIIA and IIIB decreased from 28.7% to 16.2% and 46.5% to 28.3%. The prediction accuracy for AJCC7 and AJCC8 was comparable (integrated time-dependent area under the curve [AUC] of 0.75 and 0.74, respectively). Five-year MSS of IIB and IIC AJCC8 was poor and lower than that of IIIA AJCC8 (80%, 67% and 89%, respectively). Compared to results of the International Melanoma Database and Discovery Platform, 5-year MSS was 10–15% points lower for stages IIC, IIIB and IIIC. ConclusionsUpshifting affects primarily stage III subgroups, while effects in stage II are minor. Stage IIB/C (AJCC8) patients have 67–80% MSS and should be considered for adjuvant treatment, while in stage IIIA, the indication of adjuvant treatment is questionable.

Nationwide Patterns of Care for Stage II Nonseminomatous Germ Cell Tumor of the Testicle

BackgroundManagement strategies for advanced testicular cancer published from a few, high-volume clinical centers may not be generalizable. ObjectiveTo discern treatment patterns for stage II nonseminomatous germ cell tumor (NSGCT) in a nationwide cancer registry. Design, setting, and participantsThe National Cancer Database was queried for patients with a stage II NSGCT from 2004 to 2014. Patients were stratified by clinical nodal status: cN1/stage IIA, cN2/stage IIB, and cN3/stage IIIC. Outcomes measurements and statistical analysisLogistic regression was performed to determine factors independently associated with primary retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and postchemotherapy RPLND (PC-RPLND). Results and limitationsA total of 2203 patients (stages IIA, n=1060; IIB, n=869; and IIC, n=274) met the inclusion criteria. Overall, 83% of patients underwent primary chemotherapy, while 17% underwent primary RPLND. Stratified by stage, use of primary chemotherapy was 78%, 88%, and 86% for stages IIA, IIB, and IIC, respectively. Overall, 24% of patients underwent PC-RPLND. Factors independently associated with a lower likelihood of undergoing primary RPLND were a more recent diagnosis and a higher clinical nodal stage. Conversely, patients treated at high-volume facilities were more likely to receive primary RPLND. Factors associated with a higher likelihood of undergoing PC-RPLND included a higher clinical nodal stage, treatment at a high-volume center, and a greater distance of patient travel. Associations based on serum tumor markers could not be assessed. ConclusionsFor clinical stage II NSGCT, nationwide utilization of primary chemotherapy is increasing compared with RPLND and is the preferred therapy for more advanced nodal disease. Primary RPLND may be underutilized in stage IIA disease. Utilization of PC-RPLND is driven by nodal stage as well as accessibility of a high-volume center. Patient summaryThe use of primary retroperitoneal lymph node dissection (RPLND) in early nodal disease is declining, while upfront chemotherapy is increasingly utilized. Primary RPLND may identify patients who are actually pN0 and would not benefit from systemic chemotherapy. Primary RPLND and postchemotherapy RPLND are performed more frequently at centers of excellence.

Pancreaticoduodenectomy outcomes for locally advanced right colon cancers: A systematic review

BackgroundPancreaticoduodenectomy (PD) with right hemicolectomy (RH) to treat locally advanced right colon cancer (LARCC) has been rarely reported in the literature. Herein, we characterize clinicopathologic factors and evaluate outcomes of en bloc PD and RH for LARCC. MethodsA systematic review of the literature was conducted on PubMed using MeSH terms (“pancreaticoduodenectomy” or “pancreas/surgery” or “duodenum/surgery” or “colectomy”) and (“colonic neoplasms”). Data was extracted from patients who underwent en bloc PD and RH for LARCC. Factors investigated included patient demographics, surgical and pathologic parameters, postoperative complications, disease recurrence, and survival. ResultsOur search yielded 27 articles (106 patients), including 1 case from our institution. Most patients were male (62.1%), median age 58 years (range 34–83). Surgical procedures performed included en bloc RH with PD (n = 91, 85.8%) and en bloc RH with pylorus-preserving PD (n = 15, 14.2%). Among reported, 95.5% of patients (n = 63), underwent R0 resection. One or more complications were reported in 33 patients (52.4%). Median survival was 168 months. Survival after resection was 75.9% at 2 years and 66.3% at 5 years. Overall survival was greater in patients with no lymph node involvement (IIC versus IIIC, hazard ratio 8.4, P = .003). Five-year survival for patients was 84.9% in patients with stage IIC versus 46.4% in patients with stage IIIC. There were 3 postoperative mortalities. ConclusionThis data demonstrates that en bloc PD and RH is rarely performed yet can be a potentially safe treatment option in patients with LARCC. Lymph node involvement was the only independent prognostic factor.

Clinical heterogeneity of elderly melanoma patients in the real-world setting: Potential implications for treatment outcomes following immune based therapy.

e21026 Background: Recent studies have indicated that immune checkpoint inhibitor treatment of metastatic melanoma is effective irrespective of older age. However, in the real world setting, not all older patients (pts.) diagnosed with high-risk cutaneous melanoma have same levels of immune function due to wide variation of older age and aging associated diseases that adversely influence it. Frailty associated with co-morbidities, autoimmunity, cancer, and their treatments are three such conditions that influence treatment outcomes following immune based treatment of melanoma in older subjects. To better understand this interaction between melanoma, aging-associated diseases and potential outcomes following immune checkpoint inhibitor treatment in the real world, we reviewed clinical data of elderly melanoma pts. from the University of Connecticut's Neag Cancer Center following an IRB approval. Methods: We retrospectively reviewed clinical characteristics of elderly pts. diagnosed with high-risk cutaneous melanoma (Stage IIC, III, IV) at the University of Connecticut from 2012-2019. Pts. over the age of 60 years were divided into two main groups: Group I ("Fit elderly") and Group II ("Elderly with immune suppressive conditions"). Group II pts. were further divided into three subgroups: A ("Co-morbidities and frailty"), B ("Autoimmunity and its treatment") and C ("Cancer and its treatment"). Results: From 2012-2019, a total of 56 elderly pts. diagnosed with high-risk cutaneous melanoma were stratified as the following: Group I - 31 pts. (55%) and Group II - 25 pts. (45%); among the Group II pts., Group A contained 14 pts. (56%), Group B 5 pts. (20%), and Group C 6 pts. (24%). The median age for all 56 elderly pts. was 77 yrs. (range 61 to 99). In Group I, the median age was 73 yrs. (range 61-91). In Group II, the median age was 82 years (range 66-99); A median age 85 yrs (range 66-99), B median age 78 yrs (range 66-86), and C 80.5 yrs. (range 66-86). 9 out of 56 pts. (16%) did not receive immune checkpoint inhibitor treatment, of which 7 pts. (56%) were frail and 2 pts. (22%) were non-frail. Conclusions: Our data indicate that the existence of significant clinical heterogeneity among high-risk elderly melanoma pts. encountered in the community setting reflects a wide spectrum of immune function. Larger studies stratifying elderly subjects by co-morbidities and immune suppressive conditions will help shed accurate light on clinical relevance of immune based treatment of melanoma in older subjects.

The solved and unresolved issues of melanoma staging: A comparison of American Joint Committee on Cancer (AJCC) 7th versus 8th edition.

9578 Background: The recently revised (AJCC) Staging Manual, 8th edition, introduced changes including removal of mitotic index and addition of the IIID substage. There is active debate on the utility of this revision, especially, without the inclusion of a novel prognostic biomarker, during an era of major therapeutic shifts and amidst accrual of adjuvant clinical trials for high-risk resected primary melanoma. We examined whether re-staging primary melanoma patients using the new AJCC 8 system yielded improved prognostication as compared to AJCC 7. Methods: We compared the impact of changes in staging criteria in stage I-III melanoma patients who were prospectively enrolled in a NYU clinicopathological database between January 2010 and December 2016 with active protocol-driven follow up (FU). We assessed primary tumor category (T) and nodal status (N) according to both AJCC 7 and 8. Progression free survival (PFS) and overall survival (OS) curves were generated for both editions and then stratified by substage. We analyzed discordance using Cox Regression Models. Results: 1,379 patients (56% male, mean thickness 1.6, median FU 34.8 months) were included in the analyses. All but one patient remained in the same ‘major’ stage using AJCC 7 and 8 (stage I- 998; II- 224, 225; III- 157, 156) whereas 44% of stage III substage classifications were discordant comparing AJCC 7 to 8. Despite removing mitoses as a criterion for Stage I, there was no significant change between editions in PFS/OS when evaluating major and substages of stage I. Stage IIC patients had worse PFS/OS than stage IIIA patients in AJCC 8 (PFS p = 0.04, OS p = 0.02). AJCC 8, which implemented four rather than three substages, had improved PFS prognostication (c-index = 0.59 vs 0.66, p = 0.05 for AJCC 7 vs 8). Conclusions: Our results reinforce the added value of AJCC 8 compared to 7, as removing an operator dependent variable is more practical for stage I, and increased influence of thickness/ulceration and the addition of a new substage is more prognostically informative for stage III. Nevertheless, the poor prognosis of stage IIC patients, despite nodal negative disease, continues to be an unaddressed gap within our current staging framework.

The Endoscopic Endonasal Approach for the Treatment of Juvenile Angiofibromas

Background and ObjectivesJuvenile angiofibroma (JA) is a benign tumour, for which the treatment of choice is surgery. It may be associated with significant morbidity because of its anatomical location and its locally destructive growth pattern. Severe haemorrhage constitutes a high risk in JA and its surgical management can be complex. The management of JA remains a challenge. The objective of this study was to review a series of patients with JA treated via the endonasal/endoscopic approach. Material and MethodsMedical records of patients operated for JA were reviewed. Main outcome measures: tumour stage, intraoperative blood loss, complications and persistence/recurrence rates. ResultsA total of 30 male patients and one female were included. The mean age was 17 years. Using the Radkowski classification, one JA was classified as stage I, 5 stage IIA, 9 stage IIB, 4 stage IIC, 10 stage IIIA and 2 stage IIIB. Thirty-nine percent of the JA was classified as advanced stage JA (IIIA and IIIB). The mean blood loss was 1.156mL except in one case, no significant complications were observed. Tumour persistence/recurrence was observed in 2 JA (6%), at the end of the follow-up. Mean postoperative follow-up time was 86 months. ConclusionsThis retrospective study supports the notion that endonasal endoscopic approaches for a JA are a feasible option associated with good long-term results.

Abordaje endoscópico endonasal para el tratamiento de los angiofibromas juveniles

Background and objectivesJuvenile angiofibroma (JA) is a benign tumour, for which the treatment of choice is surgery. It may be associated with significant morbidity because of its anatomical location and its locally destructive growth pattern. Severe haemorrhage constitutes a high risk in JA and its surgical management can be complex. The management of JA remains a challenge. The objective of this study was to review a series of patients with JA treated via the endonasal/endoscopic approach. Material and methodsMedical records of patients operated for JA were reviewed. Main outcome measures: tumour stage, intraoperative blood loss, complications and persistence/recurrence rates. ResultsA total of 30 male patients and one female were included. The mean age was 17 years. Using the Radkowski classification, one JA was classified as stage I, 5 stage IIA, 9 stage IIB, 4 stage IIC, 10 stage IIIA and 2 stage IIIB. Thirty-nine percent of the JA was classified as advanced stage JA (IIIA and IIIB). The mean blood loss was 1.156mL Except in one case, no significant complications were observed. Tumour persistence/recurrence was observed in 2 JA (6%), at the end of the follow-up. Mean postoperative follow-up time was 86 months. ConclusionsThis retrospective study supports the notion that endonasal endoscopic approaches for a JA are a feasible option associated with good long-term results.

Comparison of sartorius muscle-pedicle and circumflex iliac deep bone flap grafts in the treatment of early non-traumatic osteonecrosis of femoral head in young adults

ObjectiveThe aim of this study was to retrospectively compare and evaluate the midterm curative effect of two different bone flap grafts in the treatment of early non-traumatic osteonecrosis of the femoral head (ONFH). MethodsA total of 180 patients (199 hips) with early non-traumatic ONFH received surgical treatment by sartorius muscle-pedicle bone flap graft (SMBF) (104 patients, 64 males and 40 females; mean age 34.67 ± 3.24 years) or circumflex iliac deep bone flap graft (CIDBF) (76 patients, 44 males and 32 females; mean age: 35.54 ± 3.37 years) from July 2004 to July 2009. The comparison between the groups was made with Harris score before and after surgery, length of incision, operative time, amount of bleeding, postoperative X-ray. Association Research Circulation Osseous (ARCO) staging was performed. ResultsThe preoperative Harris hip score of two groups were 68.26 ± 1.26 and 69.35 ± 1.31, respectively. Patients' ARCO staging indicated 36 hips of stage IIa, 115 hips of stage IIb and 48 hips of stage IIc. The etiology of ONFH mainly including hormones (93 patients), alcohol (64 patients) and other (23 patients). The mean follow-up time of SMBF and CIDBF groups were (51.78 ± 2.35) and (52.73 ± 3.71) months, respectively. The time of removing sutures, operation time, amount of bleeding and length of incision in SMBF group were superior to those in the CIDBF group, and those differences between the SMBF and CIDBF groups were not significant (all p values > 0.28). The Harris score between the two groups was similar after operation and postoperative 12 month, and the difference was not statistically significant (p > 0.05), whereas the difference of the postoperative 24 and 48 months was statistically significant (p ˂ 0.05). X-ray analysis showed improvement of osteonecrosis in both two groups after surgery, and as time went on, the total hip amount decreased, the replacement amount increased. ConclusionBoth bone flap grafts appear to be effective methods for treatment of early osteonecrosis of femoral head (ARCOⅡ), and the SMBF is a relatively simple technique and easy for mastering, and it is a reliable method for clinical application. Level of evidenceLevel III, Therapeutic Study.

Cells to Surgery Quiz: May 2019

Cells to Surgery Quiz: May 2019