INNOVATIONS IN ORTHOPEDIC SURGERY: MINIMALLY INVASIVE TECHNIQUES FOR JOINT REPLACEMENT AND REPAIR

The scientists compared the outcomes of a minimally invasive operation approach (MIO) to a conventional poster lateral (PL) method in overall hip replacement (OHR) in terms of itchiness, damage to muscles, and bleeding. The factors that researchers examined were the levels of Haemoglobin (Hg), a marker for oxygen depletion, the quantity of Interleukin-6 (IL6), a marker for inflammation, the heart-type fatty acid binding protein (HTFABP), and the health of the muscles. The study's findings showed that IL6 content increased beyond pre-operative levels as a result of the two surgeries. At 6 hours after surgery, the mean IL6 concentration in the PL group was 79.6 pg/ml while in the MIO group it was 76.4 pg/ml. The highest values after 24 hours of therapy were 100 pg/ml in the PL group and 92.3 pg/ml in the MIO category. In each category, IL6 levels had dropped up to this point. The post-operative mean HTFABP concentration in the MIO organization was greater (12.5 mg/l) than in the PL organization (18.3 mg/l) in terms of muscle damage. One day after surgery, however, it reached an apex and began to decline in both groups. The amounts of Hg lost throughout the procedure decreased for both sets. 12.5 g/dl of mercury was present. The MIO grouping had PL 72 hours following a procedure, while the PL grouping had 10.3 g/dl. Between the two surgical methods, there were no obvious differences in bleeding, muscle damage, or edema. These results led the researchers to draw the conclusion that there were little differences between the MIO anterior method and the traditional PL technique in terms of muscle damage, blood loss, or irritability. The lack of a learning curve in the study may account for the lack of alterations seen, they hypothesized, rendering the use of the term "MIO" in describing the approach as less traumatizing dubious. The study's methodology, sample sizes, and all other relevant material were left out, making it impossible to evaluate the study's validity and generalizability in its entirety.

Cancer Aging Research Group (CARG) score in older adults undergoing curative intent chemotherapy: a prospective cohort study

IMPORTANCE

The Cancer Aging Research Group (CARG) toxicity score is used to assess toxicity risk in geriatric patients receiving chemotherapy.

OBJECTIVE

The primary aim was to validate the CARG score in geriatric patients treated with curative intent chemotherapy in predicting grade 3-5 toxicities.

DESIGN

This was a longitudinal prospective observational study.

SETTING

Tata Memorial Hospital, Mumbai, India, a tertiary cancer care referral centre.

PARTICIPANTS

Patients, aged ≥65 years, with gastrointestinal, breast or gynaecological stage I-III cancers being planned for curative intent chemotherapy. A total of 270 patients were required for accrual in the study.

EXPOSURES

Total risk score ranged from 0 (lowest toxicity risk) to 19 (highest toxicity risk).

MAIN OUTCOMES AND MEASURES

The primary endpoint of the study was to evaluate whether the CARG risk score predicted for grade 3-5 toxicities.

RESULTS

The study cohort of 270 patients had a mean age of 69 (65-83) years, with the most common cancers being gastrointestinal (79%). Fifty-two per cent of patients had atleast one grade 3-5 toxicity. The risk of toxicity was increased with an increasing risk score (42% low risk, 51% medium risk and 79% high risk; p<0.001). There was no association between either Eastern Cooperative Oncology Group (ECOG) performance status (p=0.69) or age-adjusted Charlson Comorbidity Index (p=0.79) risk categories and grade 3-5 chemotherapy toxicities.

CONCLUSIONS AND RELEVANCE

This study validates the CARG risk score in predicting for grade 3-5 toxicities in geriatric oncology patients receiving curative intent chemotherapy and can be considered as the standard of care before planning chemotherapy in every elderly patient.

TRIAL REGISTRATION NUMBER

CTRI/2016/10/007357; Results.

Second malignancy post-chemoradiation in head and neck cancer patients

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Background: There is limited data available in the literature regarding incidence and treatment of second malignancy post-chemo-radiation (CTRT) in head and neck cancer patients. Hence we planned this analysis to address this lacuna in the current literature. Methods: We have already published a randomized study of 536 head and neck cancer patients, comparing radical CTRT with weekly cisplatin with or without nimotuzumab. The database of this study was used for the current analysis. Data regarding occurrence, site, stage, treatment details and outcomes were extracted from the database. Continuous variables were expressed in terms of the median with range, while non-continuous variables were reported in percentage. Kaplan Meier method was used for estimating the overall survival (OS). Results: Out of 536 patients, 18 (3.35%) patients developed second malignancy. The most common site was head and neck (44.44%) followed by lung (27.77%), prostate, ovary, breast, gallbladder and thyroid. 16/18 (88.88%) patients developed metachronous, while 2/18 (11.11%) had synchronous second malignancy. Most of the patients (55.55%) presented with locally advanced and metastatic disease, while 44.44% of patients had early-stage disease. 8/18 (44.44%) patients received palliative treatment. Of these, 6/18 (33.33%) patients received best supportive care and 2/18 (11.11%) patients were given palliative chemotherapy and palliative radiotherapy. 10/18 (55.55%) patients received radical treatment in the form of radical surgery (22.22%), CTRT (11.11%) and radical radiotherapy (5.55%), while 16.66% patients were kept under observation only. The median OS after the diagnosis of second malignancy was 451 days (95% CI, 301.45-600.59). It was seen that median OS the diagnosis of second malignancy in the aerodigestive and non-aerodigestive system was 446 days (95% CI, 39.10 - 852.89) and 840 days (95% CI, 278.46 - 1401.53), log-rank test P-value = 0.24. Conclusions: Second malignancy is not an uncommon phenomenon in head and neck cancer patients after CTRT and if properly taken care of, the improved outcome can be expected.

Clinico-pathological correlates and survival outcomes in 214 resected ampullary adenocarcinomas - are outcomes different in intestinal and pancreatobiliary subtypes with adjuvant gemcitabine?

BACKGROUND

Evidence suggests that intestinal type (IT) and pancreatobiliary (PB) subtypes of ampullary adenocarcinoma (AC) may have different outcomes. The current study evaluated differences in outcomes between these subtypes and the benefit of adjuvant chemotherapy (AT).

METHODS

A prospectively maintained database of patients who underwent upfront resection for AC from January 2012 to March 2016 was conducted. A dedicated pathologist reported differentiation between IT and PB subtypes.

RESULTS

214 patients were included for analysis: 105 PB subtype and 109 IT subtype. With a median follow up of 46.3 months, estimated 4 year overall survival (OS) was 65.8%. In patients with stage II-III disease, lymph-node ratio (LNR) < 0.2 [Not reached (NR) vs. 30.72 months; p = 0.002], absence of perineural invasion (PNI) (NR vs. 31.61 months; p = 0.032) and AT (gemcitabine - 96.1%) (NR vs. 22.28 months) were prognostic for superior OS. There was no difference in OS between IT and PB subtypes, but both subtypes with stage II-III disease benefitted from AT statistically as compared to observation (IT: NR vs. 28.62 months; PB: 18.46 months vs. 58.09 months; p < 0.001).

CONCLUSIONS

AC-IT and AC-PB did not have a different OS when treated with resection and adjuvant gemcitabine, though adjuvant therapy benefitted both subtypes individually.

A randomized phase 3 trial comparing nimotuzumab plus cisplatin chemoradiotherapy versus cisplatin chemoradiotherapy alone in locally advanced head and neck cancer

BACKGROUND

Because the addition of nimotuzumab to chemoradiation in patients with locally advanced head and neck cancer improved outcomes in a phase 2 study, the authors conducted a phase 3 study to confirm these findings.

METHODS

This open-label, investigator-initiated, phase 3, randomized trial was conducted from 2012 to 2018. Adult patients with locally advanced head and neck cancer who were fit for radical chemoradiation were randomized 1:1 to receive either radical radiotherapy (66-70 grays) with concurrent weekly cisplatin (30 mg/m² ) (CRT) or the same schedule of CRT with weekly nimotuzumab (200 mg) (NCRT).The primary endpoint was progression-free survival (PFS); key secondary endpoints were disease-free survival (DFS), duration of locoregional control (LRC), and overall survival (OS). An intent-to-treat analysis also was performed.

RESULTS

In total, 536 patients were allocated equally to both treatment arms. The median follow-up was 39.13 months. The addition of nimotuzumab improved PFS (hazard ratio [HR], 0.69; 95% CI, 0.53-0.89; P = .004), LRC (HR, 0.67; 95% CI, 0.50-0.89; P = .006), and DFS (HR, 0.71; 95% CI, 0.55-0.92; P = .008) and had a trend toward improved OS (HR, 0.84; 95% CI, 0.65-1.08; P = .163). Grade 3 through 5 adverse events were similar between the 2 arms, except for a higher incidence of mucositis in the NCRT arm (66.7% vs 55.8%; P = .01).

CONCLUSIONS

The addition of nimotuzumab to concurrent weekly CRT improves PFS, LRC, and DFS. This combination provides a novel alternative therapeutic option to a 3-weekly schedule of 100 mg/m² cisplatin in patients with locally advanced head and neck cancer who are treated with radical-intent CRT.

Gemcitabine-cisplatin (GC) as adjuvant chemotherapy in resected stage II and stage III gallbladder cancers (GBC): a potential way forward

Data on adjuvant chemotherapy with gemcitabine-cisplatin (GC) in resected gallbladder cancers (GBC) are scarce. Patients who underwent upfront curative resection for GBC from 2010 to 2016 were analyzed. Patients with stage II-III GBC treated with adjuvant GC were analyzed. A total of 242 patients were evaluated, of whom 125 patients received GC regimen as adjuvant chemotherapy. The median age was 50 years (range 31-74), majority were female (77.6%), and 37 patients (29.6%) had raised CA 19.9 levels at baseline. One hundred and thirteen patients (90.4%) underwent radical cholecystectomy with R0 resections. Median number of GC administered was 6, with completion rates of 84%. Toxicity data were comprehensively available for 110 patients, with common grade 3 and grade 4 being neutropenia (9.9%), fatigue (7.3%) and febrile neutropenia (3.6%), respectively. With a median follow-up of 36.88 months, 3-year RFS was 60.3%. Patients with stage II (28%; n = 35), stage IIIA (28%; n = 35) and stage IIIB GBC (44%; n = 55) had a 3-year OS of 91.9, 67 and 58.1% (p = 0.001), respectively. Patients with stage II-III GBC undergoing R0 resections receiving adjuvant GC have good tolerance, high completion rates and encouraging outcomes in a non-trial high GBC prevalence scenario.

Early outcomes of exon 11 mutants in GIST treated with standard dose Imatinib

BACKGROUND

The exon 11 KIT mutant gastrointestinal stromal tumors (GIST) is a heterogeneous cohort with variable biological behavior based on different mutational subtypes.

METHODS

Patients with histologically proven GIST with KIT exon 11 mutations were selected from a prospectively maintained database, and evaluated for clinical characteristics and event free survival (EFS). Patients were divided into mutations upstream to codon 557 (G1), mutations involving codon 557-558 (G2) and mutation downstream to codon 558 (G3).

RESULTS

A total of 90 patients satisfied the inclusion criteria for study. Substitutions, indels and duplications were seen in 23 patients. Deletions were seen in 67 patients, of which 44 patients had large deletions (>6 base pairs), while 23 has small deletions (<6 base pairs). Complex mutations were seen in 15 patients. G2 mutations were noted in 33 patients, while G1 and G3 mutations were seen 32 and 25 patients respectively. With a median follow-up of 26 months, estimated median EFS for the entire cohort was 55 months. The G2 cohort had an inferior EFS compared to the G1 and G3 cohorts (46 vs. 55 months), but this did not achieve statistical significance (univariate analysis: P=0.075). On multivariate analysis, patients undergoing radical intent surgery vs. no surgery (58 vs. 55 months; P=0.005) and G1 or G3 vs. G2 cohort (P=0.058) showed trend towards improved EFS.

CONCLUSIONS

In patients with GIST exon 11 codon 557-558 mutation subset there is a trend towards an inferior survival even when treated with imatinib mesylate (IM).

Unusual presentation of dedifferentiated liposarcoma as paratesticular mass

A 75-year-old male presented with complaint of painless left inguinoscrotal mass slowly increasing in size since 9 years. Clinical impression was malignancy arising in left testis or cord. Initial incisional biopsy was reported as fibromatosis. Later on wide excision of tumor was done and histopathology showed dedifferentiated liposarcoma with areas of fibromatosis.

Reye Syndrome – A Case Report with Review of Literature

Here we describe a case of Reye syndrome diagnosed at postmortem liver biopsy of a three-year oldgirl who presented with vomiting, low grade fever for three days and loss of consciousness for 18hours. Clinically, the differential diagnoses were meningitis, encephalitis and septicemia. No historyof past illness or any drug ingestion including aspirin were present. Laboratory investigationsindicated a diagnosis of Reye syndrome. The child was given supportive treatment but died aftertwo days of admission and postmortem needle-biopsy of the liver showed microvesicular steatosisconsistent with Reye syndrome.Key words: Microvesicular steatosis, mitochondrial hepatopathy, Reye syndrome, Reye-like syndrome

Reye syndrome: a case report with review of literature

Here we describe a case of Reye syndrome diagnosed at postmortem liver biopsy of a three-year old girl who presented with vomiting, low grade fever for three days and loss of consciousness for 18 hours. Clinically, the differential diagnoses were meningitis, encephalitis and septicemia. No history of past illness or any drug ingestion including aspirin were present. Laboratory investigations indicated a diagnosis of Reye syndrome. The child was given supportive treatment but died after two days of admission and postmortem needle-biopsy of the liver showed microvesicular steatosis consistent with Reye syndrome.

Primary malignant melanoma of vagina--a case report with review of literature

Primary vaginal malignant melanoma is a very rare tumor with less than 300 cases reported to date. We describe a case of primary vaginal melanoma and review the literature. A 60 years postmenopausal female patient presented with painless mass coming out of the vagina with occasional bleeding for last 2-3 weeks. On vaginal examination there was a firm polypoidal growth of size 7 cm attached to the right lateral wall of vagina and coming out of the introitus. Histopathology of the mass showed features of malignant melanoma. Wide local excision was done and adjuvant therapy was given. However patient came back after three months with widespread metastasis and expired 6 months after the initial diagnosis. Vaginal melanoma is a very aggressive tumor and the overall prognosis is very poor despite the treatment modality.

Primary Malignant Melanoma of Vagina – A Case Report with Review of Literature

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Nasal glioma: a case report

Here we describe a rare case of nasal glioma in a 14 year old boy who presented with history of right nasal obstruction and nasal discharge since 6 months. On examination a pale mass was seen filling the right nasal cavity and extending down in the oropharynx. Clinical impression was antrochoanal polyp. Excision of the mass was carried out and sent for histopathology which showed presence of glial tissue and the diagnosis was made as nasal glioma.

Antioxidant therapy in the prevention of organ dysfunction syndrome and infectious complications after trauma: early results of a prospective randomized study

Reactive oxygen species have been implicated in the etiology of multiorgan dysfunction syndrome and infectious complications in trauma patients by either direct cellular toxicity and/or the activation of intracellular signaling pathways. Studies have shown that the antioxidant defenses of the body are decreased in trauma patients; these include glutathione, for which N-acetylcysteine is a precursor, and selenium, which is a cofactor for glutathione. Eighteen trauma patients were prospectively randomized to a control or antioxidant group where they received N-acetylcysteine, selenium, and vitamins C and E for 7 days. As compared with the controls, the antioxidant group showed fewer infectious complications (8 versus 18) and fewer organs dysfunctioning (0 versus 9). There were no deaths in either group. We conclude that these preliminary data may support a role for the use of this antioxidant mixture to decrease the incidence of multiorgan dysfunction syndrome and infectious complications in the severely injured patient. This remains to be confirmed in larger trials.