Radiomics-based machine learning approach for the prediction of grade and stage in upper urinary tract urothelial carcinoma-a step towards virtual biopsy

OBJECTIVES

Upper tract urothelial carcinoma is a rare, aggressive lesion, with early detection a key to its management. This study aimed to utilise computed tomographic urogram data to develop machine learning models for predicting tumour grading and staging in upper urothelial tract carcinoma patients and to compare these predictions with histopathological diagnosis used as reference standards.

METHODS

Protocol-based computed tomographic urogram data from 106 patients were obtained and visualised in 3D. Digital segmentation of the tumours was conducted by extracting textural radiomics features. They were further classified using 11 predictive models. The predicted grades and stages were compared to the histopathology of radical nephroureterectomy specimens.

RESULTS

Classifier models worked well in mining the radiomics data and delivered satisfactory predictive machine learning models. The MultiLayer Panel showed 84% sensitivity and 93% specificity while predicting upper tract urothelial carcinoma grades. The Logistic Regression model showed a sensitivity of 83% and a specificity of 76% while staging. Similarly, other classifier algorithms (e.g., Support Vector classifier) provided a highly accurate prediction while grading upper tract urothelial carcinoma compared to clinical features alone or ureteroscopic biopsy histopathology.

CONCLUSION

Data mining tools could handle medical imaging datasets from small (<2 cm) tumours for upper tract urothelial carcinoma. The radiomics-based machine learning algorithms provide a potential tool to model tumour grading and staging with implications for clinical practice and the upgradation of current paradigms in cancer diagnostics.

CLINICAL RELEVANCE

Machine learning based on radiomics features can predict upper tract urothelial cancer grading and staging with significant improvement over ureteroscopic histopathology. The study showcased the prowess of such emerging tools in the set objectives with implications towards virtual biopsy.

Telogen effluvium and COVID-19: a cross-sectional study

OBJECTIVE

COVID-19 is a febrile infectious disease caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). This virus affects several organs, including the skin. Acute telogen effluvium (TE) is a non-scarring hair loss characterized by diffuse hair shedding that begins three months after a stressful event and can last up to six months. COVID-19 infection is one of these potential stressors. Recently, there has been a reported link between increased scalp hair shedding and post-infection patients during the COVID-19 outbreak. The present work aimed to study the possible effects of COVID-19 on hair and the relationship between COVID-19 and TE and to assess the level of awareness about TE in the Asir region of Saudi Arabia.

SUBJECTS AND METHODS

A questionnaire-based cross-sectional study was conducted using a pre-validated questionnaire. The study involved 561 participants from the Asir region of Saudi Arabia. Eligible participants were individuals from the Asir region who were 20 years of age or older, had previously contracted COVID-19 and had no history of TE before infection. All statistical methods used were two-tailed with an alpha level of 0.05, considering significance if the p-value was lower than or equal to 0.05.

RESULTS

A total of 1,000 eligible participants completed the study questionnaire. The mean age was 32.5 ± 13.9 years, and 494 (88.1%) participants were females. In addition, 558 (99.5%) of the study participants had received the COVID-19 vaccine. A total of 411 (73.3%) participants experienced an increase in hair loss after COVID-19 infection, and 171 (30.5%) began suffering from pain when combing their hair. In addition, 182 participants (32.4%) had a family history of TE. Only 109 (10.9%) participants had a good awareness level about TE, while 452 (80.6%) had an overall poor awareness level. There was a significant relationship between the level of awareness and age, where 23.9% of the participants aged 20-29 years had a good level of awareness vs. 16.1% of others aged 40 years or older (p = 0.041). Moreover, 26.9% of participants with a family history of TE had a good awareness of TE, vs. 15.8% of those with no family history of TE (p = 0.002). In addition, significant correlations were found between increased hair loss post-COVID-19 infection and female gender (77.3% vs. 43.3%; p = 0.001) as well as suffering from pain when combing hair (86.5% vs. 65.5%; p = 0.001).

CONCLUSIONS

In our study, the incidence of TE was highly related to COVID-19 infections among both sexes. However, the incidence was greater among the female population. The awareness level toward post-COVID-19 TE was poor among most of the participants in our study.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Synergistic antibacterial and mosquitocidal effect of Passiflora foetida synthesized silver nanoparticles

Silver nanoparticles are opted to have various applications in different fields ranging from traditional medicines to culinary items. It is toxic and most effective against bacteria, fungi viruses, parasites, parasite carrying vectors such as mosquitoes and their larvae and other eukaryotic microorganisms at low concentration without any side effects and toxicity to humans. In view of these data, the present research has been investigated by synthesizing silver nanoparticles using 1mM silver nitrate and aqueous extract of Passiflora foetida. The variation of nanoparticles in size and shape concerning the concentration of extract prepared were analysed. The formation of silver nanoparticles was confirmed by colour changing from yellowish green to reddish-brown implicating the surface plasmon resonance. Further, it was concluded by obtaining an absorbance peak at 420 nm using UV-Visible spectrophotometer analysis. FTIR analysis was used to identify the capping ligands, which included alkanes, aromatic groups and nitro compounds. The average grain size of ~12 nm to 14 nm with crystalline phase was revealed by X-ray Diffraction studies. The SEM images depicted the surface morphology with agglomeration; TEM studies showed the shape of nanoparticles as spherical and hexagonal with sizes ranging from 40 nm to 100 nm and EDAX analysis confirmed the presence of elemental silver as the principal constituent. The characterized silver nanoparticles were then tested for synergistic antibacterial effects with tetracycline, and the results show that they are more active against E. coli and S. aureus, but moderately effective against B. cereus and K. pneumoniae . It also had a strong larval and pupal toxic effects on the dengue vector, Aedes aegypti with the highest mortality. As a result, silver nanoparticles could be a viable alternative for a variety of applications.

ST Segment myocardial infarction due to totally occluded unprotected left main coronary artery (TOULM): an insight from nationwide database

Objective

This study sought to describe the clinical profile, management and short-term outcomes of patients with ST elevation myocardial infraction (STEMI) due to totally occluded unprotected left main coronary artery (TOULM).

Methods

This is a retrospective analysis of nationwide STEMI database of patients who underwent primary percutaneous intervention (PPCI). Patients with TOULM are defined as having 100% acute thrombotic occlusion of the left main artery or subtotal occlusion with no more than TIMI 1 flow.

Results

Between January 2011 and February 2022, 7107 patients underwent Primary Percutaneous Intervention for STEMI. 35 cases (0.5%) of all STEMI were due to TOULM. The average age of patients with TOULM was 51±14 years, predominantly male (94%) and had no prior cardiac history (94%). 11 patients (31%) suffered cardiac arrest and 16 (45%) were on mechanical ventilation prior to arrival to cardiac catheterization laboratory.

The right coronary artery was the dominant vessel in 29 (89%) patients. Right to left collaterals were present in 15 (42%), absent in 8 (23%) and unknown (the right coronary artery was injected after TOULM intervention or not injected) in 12 (34%) patients. Mechanical circulatory support was used in 37% of the cases (IABP 8, ECMO 3 and ECMO plus IABP 2). Revascularization was achieved with PCI and stenting in 30 patients (86%). Five patients underwent urgent CABG after balloon angioplasty. Survival to hospital discharge was 55%.

Conclusions

STEMI due to TOULM is a rare occurrence and involved mainly male with no prior cardiac history. Despite all the patients in our series undergoing revascularization, the in-hospital mortality is almost 50%. One major limitations of our study is we had no post-mortem data of any patient who died prior to coronary angiography, which potentially will lead to higher recorded cases of TOULM related mortality.

Funding Acknowledgement

Type of funding sources: None.

The effect of 805 nm near-infrared photobiomodulation on proliferation and differentiation of bone marrow stem cells in murine rats

OBJECTIVE

To evaluate the effect of near infra-red gallium-aluminium-arsenide (GaAlAs) diode laser (805 nm) irradiation on proliferation and differentiation of rat femoral bone marrow-derived mesenchymal stem cells (BMSCs) cultured in osteogenic medium.

MATERIALS AND METHODS

BMSCs were obtained from femurs of 60 Sprague Dawley rats (200 gm). The control group comprised isolated BMSCs supplemented with an osteogenic differentiation medium. On the other hand, in the experimental group, the BMSCs were irradiated with a near-infrared laser in addition to an osteogenic differentiation medium. The experimental group was irradiated with a soft tissue laser comprising of allium-aluminium-arsenic (Ga-Al-Ar) Diode at a near-infrared wavelength of 805 nm in continuous mode. The different output powers applied were 0.5 W, 1.0 W, 1.5 W and 2.0 W respectively. Various energy levels of 1, 4, 7 and 10 J were used for irradiation. Alkaline phosphatase (ALP) assay and Alizarin staining were performed to confirm osteogenic differentiation. Statistical analysis was done using a one-way ANOVA and a p-value of <0.05 was considered significant.

RESULTS

According to our findings, 1.27 J/cm2 was the optimal energy density value that significantly increased the BMSC proliferation at the output of 1.5 W with the power density of 1.27 W/cm2. On 1.27 J/cm2, there was a significant difference compared to the control group on the first day, and the osteogenic differentiation increased significantly on the 4th day compared to the 1st day.

CONCLUSIONS

According to our findings, 1.27 J/cm2 was the optimal energy density value that significantly increased the BMSC proliferation at the output of 1.5 W with the power density of 1.27 W/cm2.

Reliability of high-resolution CT scan in diagnosis of ossicular tympanosclerosis

OBJECTIVES

To evaluate the reliability of high-resolution CT scans (HRCT scans) in the diagnosis of tympanosclerosis and to determine its benefit to predict the post-surgical hearing outcome based on comparing radiological and surgical findings.

METHODS

A retrospective study at a tertiary institute included 940 ears that underwent tyampanoplasty for chronic suppurative otitis media (CSOM) between January 2013 and March 2017. Preoperative temporal bone HRCT scans were analyzed to check for the prediction of tympanosclerosis and ossicular fixation. Intraoperatively, ossicular chain integrity was checked. Preoperative and postoperative audiometric evaluations using air-bone gap (ABG) were compared. A postoperative pure-tone ABG of 20 dB or less was considered as a successful hearing result. Results are compared with historical control groups, the study has been reviewed and approved by the IRB at the medical research center in Hamad Medical Corporation; however, it is a retrospective study so no informed consent was obtained from the patients.

RESULTS

The study included 940 ears that underwent tympanoplasties due to CSOM, where 238 out of 940 (25.3%) of ears showed tympanosclerosis during tympanoplasty, intraoperatively, tympanosclerosis was localized to the eardrum in 174 of the 238 involved ears (73.1%), A 64 out of 238 (26.9%) of the ears with tympanosclerosis showed ossicular fixation, divided as 45 ears with Incudo-malleal fixation, 14 ears with stapes fixation, and 5 ears with triple ossicular fixation. HRCT scan of the temporal bone was suggestive of ossicular chain fixation in 79 cases distributed as 55 incudo-malleal fixations, 19 stapes fixation, and 5 complete ossicular fixations, with a sensitivity of 96.8%, and specificity of 98%. The audiological results were analyzed, with a patient follow-up after 6 months.

CONCLUSIONS

Our study showed that CT scans when combined with the clinical findings can be an informative guide to otolaryngologists for preoperative evaluation and counseling of tympanosclerosis surgeries.

The benefit of trans-attic endoscopic control of ossicular prosthesis after cholesteatoma surgery

OBJECTIVE

To show the efficiency of using transmastoid atticotomy (TMA) endoscopy on the outcome of ossiculoplasty in patients with cholesteatoma. TMA is often performed as part of the surgical management of patients with middle ear cholesteatoma extending to the epitympanum. TMA can also be used as an access for endoscopic view to confirm the right alignment and stability of the ossicular prosthesis because the reconstruction of the tympanic membrane will obscure the visualization of the prosthesis.

METHODS

A retrospective study was done at a tertiary referral institute, including 133 ears with cholesteatoma that underwent canal wall-up tympanomastoidectomy (CWU) with ossicular reconstruction using titanium prosthesis between August 2013 and August 2015. Post packing of the ear canal and position, stability, and axis of the prosthesis were checked using endoscope positioned in the attic through TMA. A postoperative pure-tone average air-bone gap (ABG) of 20 dB or less was considered as a successful hearing result. Results are compared with historical control groups.

RESULTS

Of the 133 ears, 88 patients underwent reconstruction with partial ossicular replacement prosthesis (PORP), whereas the rest (45 patients) had total ossicular replacement prosthesis (TORP). A postoperative ABG ≤ 20 dB was obtained in 77.4% of all the patients (79.5% for PORP; 73.3% for TORP).

CONCLUSION

Endoscopic assessment of the ossicular prosthesis via the attic, after repositioning of the tympanomeatal flap and packing the ear canal, decreases the risk of immediate ossiculoplasty failure and improves the functional outcome after ossicular chain reconstruction in cholesteatoma surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2754-2759, 2019.

Re-evaluation of hypoplastic left heart syndrome from a developmental and morphological perspective

Background

Hypoplastic left heart syndrome (HLHS) covers a spectrum of rare congenital anomalies characterised by a non-apex forming left ventricle and stenosis/atresia of the mitral and aortic valves. Despite many studies, the causes of HLHS remain unclear and there are conflicting views regarding the role of flow, valvar or myocardial abnormalities in its pathogenesis, all of which were proposed prior to the description of the second heart field. Our aim was to re-evaluate the patterns of malformation in HLHS in relation to recognised cardiac progenitor populations, with a view to providing aetiologically useful sub-groupings for genomic studies.

Results

We examined 78 hearts previously classified as HLHS, with subtypes based on valve patency, and re-categorised them based on their objective ventricular phenotype. Three distinct subgroups could be identified: slit-like left ventricle (24%); miniaturised left ventricle (6%); and thickened left ventricle with endocardial fibroelastosis (EFE; 70%). Slit-like ventricles were always found in combination with aortic atresia and mitral atresia. Miniaturised left ventricles all had normally formed, though smaller aortic and mitral valves. The remaining group were found to have a range of aortic valve malformations associated with thickened left ventricular walls despite being described as either atresia or stenosis. The degree of myocardial thickening was not correlated to the degree of valvar stenosis. Lineage tracing in mice to investigate the progenitor populations that form the parts of the heart disrupted by HLHS showed that whereas Nkx2–5-Cre labelled myocardial and endothelial cells within the left and right ventricles, Mef2c-AHF-Cre, which labels second heart field-derived cells only, was largely restricted to the endocardium and myocardium of the right ventricle. However, like Nkx2–5-Cre, Mef2c-AHF-Cre lineage cells made a significant contribution to the aortic and mitral valves. In contrast, Wnt1-Cre made a major contribution only to the aortic valve. This suggests that discrete cardiac progenitors might be responsible for the patterns of defects observed in the distinct ventricular sub-groups.

Conclusions

Only the slit-like ventricle grouping was found to map to the current nomenclature: the combination of mitral atresia with aortic atresia. It appears that slit-like and miniature ventricles also form discrete sub-groups. Thus, reclassification of HLHS into subgroups based on ventricular phenotype, might be useful in genetic and developmental studies in investigating the aetiology of this severe malformation syndrome.

Contralateral sinus involvement of surgically treated unilateral allergic fungal rhinosinusitis

Recurrence of allergic fungal rhinosinusitis (AFRS) is well recognized. However, there is scarcity in the literature describing involvement of the non-diseased sinuses. We aimed to evaluate the recurrence forms of unilateral AFRS as well as to study the possible predictor factors of developing the disease in the contralateral side. Patients with exclusive unilateral AFRS from (2010 to 2015) were enrolled in multi-institutional case-control study. All patients were evaluated after endoscopic sinus surgery for recurrence. Patient's records were reviewed for demographics, medical treatment, and clinical, radiological, and surgical data. A total of 68 patients were identified. Delayed contralateral involvement after the initial surgery was found in 30.8% with mean duration of recurrence 16.9 months. A significant association was found with the presence of pre-operative contralateral symptoms and signs of inflammation (OR 3.49, 95% CI 1.19-10.22, p value 0.02). Post-operative use of budesonide irrigation was associated with less contralateral involvement (OR 0.11, 95% CI 0.01-0.87, p value 0.01). Association of other variables like: comorbidities, perioperative use of systemic steroid, radiological signs, extent of surgery, additional surgery to the contralateral side, and post-operative use of systemic steroids did not show statistical significance. Involvement of the contralateral sinuses in 30% of unilateral AFRS cases is considered significant. The non-diseased sinuses should be involved in the routine endoscopic examination and post-operative treatment. Further studies are necessary to investigate the possibility of prophylactic surgical intervention of the non-diseased sinuses.

Preoperative Predictors in Chronic Suppurative Otitis Media for Ossicular Chain Discontinuity: A Cross-Sectional Study

OBJECTIVE

Ossicular discontinuity may result from chronic suppurative otitis media and is usually detected intraoperatively. Our objective is to determine whether a preoperative audiogram can preoperatively predict the presence or absence of ossicular discontinuity.

METHODS

A cross-sectional study was prospectively run on our patients, aged 12-75 years, ultimately operated on for chronic suppurative otitis media. Preoperative audiograms were analyzed to measure frequency-specific air-bone gap (ABG) cutoff values. Intraoperatively, ossicular chain integrity was carefully checked. Logistic regression analysis was done to obtain a predictive model.

RESULTS

A total of 270 patients (306 ears) were included. Frequency-specific ABG cutoff values can predict ossicular discontinuity, namely: high ABGs at 1,000 Hz (>27.5 dB) and 2,000 Hz (>17.5 dB) are the most reliable variables associated with ossicular discontinuity.

CONCLUSION

Preoperative audiograms can predict the presence of ossicular discontinuity in chronic suppurative otitis media. Large ABGs at both 1,000 and 2,000 Hz can predict ossicular discontinuity with a great degree of certainty.

Chemical Closure of Tympanic Membrane Perforation: Call for Caution

Chemical closure of tympanic membrane perforation is a commonly practiced office-based otological procedure, which is labeled to be effective and safe. In this paper, we report a case of a young lady with disastrous complications following an attempt of chemical cauterization of her perforated tympanic membrane.

Ligands with an NPNPN-framework and their application in chromium catalysed ethene tri-/tetramerization

Novel Cr(iii) catalysts supported by linear phosph(iii)azanes of the type R(1)R(2)N-P(Ph)-NR(3)-P(Ph)-NR(4)R(5) have been prepared, all of which, upon activation with MMAO-3A, are highly active for ethene tri-/tetramerization with considerable selectivity. The effect of ligand substitution as well as solvent on the catalytic performance has been examined.

Refining the phenotypical and mutational spectrum of Taybi-Linder syndrome

Taybi-Linder syndrome (TALS, OMIM 210710) is a rare autosomal recessive disorder belonging to the group of microcephalic osteodysplastic primordial dwarfisms (MOPD). This syndrome is characterized by short stature, skeletal anomalies, severe microcephaly with brain malformations and facial dysmorphism, and is caused by mutations in RNU4ATAC. RNU4ATAC is transcribed into a non-coding small nuclear RNA which is a critical component of the minor spliceosome. We report here four foetuses and four unrelated patients with RNU4ATAC mutations. We provide antenatal descriptions of this rare syndrome including unusual features found in two twin foetuses with compound heterozygosity for two rare mutations who presented with mild intrauterine growth retardation and atypical dysmorphic facial features. We also carried out a literature review of the patients described up to now with RNU4ATAC mutations, affected either with TALS or Roifman syndrome, a recently described allelic disorder.

Tympanoplasty in adhesive otitis media: A descriptive study

OBJECTIVES/HYPOTHESIS

There is no consensus among clinicians regarding the best treatment strategy for adhesive otitis media (AdOM). It is common practice to only intervene in the presence of recurrent infections or significant conductive hearing loss. In an attempt to provide evidence regarding the efficacy and safety of surgical intervention, we have analyzed the long-term outcome of tympanoplasty for AdOM .

STUDY DESIGN

Prospective study.

METHODS

From January 2013 to April 2014, 57 patients with AdOM (60 ears) who fit our criteria for tympanoplasty were recruited and underwent tympanoplasty using tragal cartilage combined with transtympanic ventilation tube and cortical mastoidectomy. Otorrhea control, graft uptake, hearing level changes, and complications were evaluated within a 3-year period of follow-up.

RESULTS

Otorrhea was controlled in 94% of the ears. Tympanic membrane healing was achieved in all ears except one ear, which had myringitis. Overall there was significant improvement in hearing. Whereas the mean preoperative air-bone gap (ABG) was 30.4 ± 4.0 dB, postoperative mean ABG was 8.6 ± 6.9 dB at 1 year. Closure of ABG to within 20 dB was achieved in 46 ears (83.6%). One ear showed a drop in bone conduction level by 25 dB. No iatrogenic cholesteatoma was detected in any of the cases.

CONCLUSION

This study demonstrated that tympanoplasty has favorable outcomes in AdOM . Risks of iatrogenic sensorineural hearing loss or cholesteatoma formation are negligible.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2804-2810, 2016.

The pentacyclic triterpenoids in herbal medicines and their pharmacological activities in diabetes and diabetic complications

Pentacyclic triterpenoids including the oleanane, ursane and lupane groups are widely distributed in many medicinal plants, such as Glycyrrhiza species, Gymnema species, Centella asiatica, Camellia sinensis, Crataegus species and Olea europaea, which are commonly used in traditional medicine for the treatment of diabetes and diabetic complications. A large number of bioactive pentacyclic triterpenoids, such as oleanolic acid, glycyrrhizin, glycyrrhetinic acid, ursolic acid, betulin, betulinic acid and lupeol have shown multiple biological activities with apparent effects on glucose absorption, glucose uptake, insulin secretion, diabetic vascular dysfunction, retinopathy and nephropathy. The versatility of the pentacyclic triterpenes provides a promising approach for diabetes management.

25 years' experience with lymphangiomas in children

BACKGROUND/PURPOSE

The management of lymphangioma in children is challenging because complete resection is difficult to achieve in some cases, and recurrences are common. The authors reviewed their experience to assess the risk factors for recurrence and the role of nonoperative treatment.

METHODS

A retrospective study over a period of 25 years was carried out. One hundred eighty-six patients with 191 lesions (five patients with de novo lesions in different sites) were treated. There were 98 boys and 88 girls. The average age at diagnosis was 3.3 years (range, fetal life to 17 years) and the average size 8 cm in diameter. Histocytological confirmation was obtained in all patients. The involved sites were head and neck, 89 patients (48%); trunk and extremities, 78 patients (42%); internal or visceral locations (eg, abdominal and thorax), 19 patients (10%). The treatment consisted of macroscopically complete excision in 145 patients (150 lesions, of which five were recurrences in different sites), partial excision in 10 patients, aspiration in five patients, laser excision in 10 patients, biopsy only in four patients, drainage and biopsy in two patients, and injection of sclerosing agents in 10 patients.

RESULTS

There were 54 recurrences; 44 underwent excision (five of them more than once), and five regressed spontaneously on follow-up. Five other recurrences were stable and not progressing. Recurrences, (defined as clinically obvious disease), were found to be 100% after aspiration, 100% after injection, 40% after incomplete excision, 40% after laser excision, and 17% after macroscopically complete excision. The recurrence rate in the last group was the highest in the head (33%), the least in the internal locations (0%), and intermediate for the cervical location (13%). There were no significant differences, in terms of outcome, between those who had their surgery immediately at the time of diagnosis (n = 101) and those who had delayed surgery (n = 85).

CONCLUSIONS

There were fewer recurrences after macroscopically complete excision. Aspiration and injection had the highest recurrence rate. Risk factors for recurrence included location, size, and complexity of lesions. A period of observation may be useful for infants to facilitate complete excision. In the present series, spontaneous regression was infrequent and was seen more often with recurrent lesions.

25 years' experience with lymphangiomas in children

BACKGROUND/PURPOSE

The management of lymphangioma in children is challenging because complete resection is difficult to achieve in some cases, and recurrences are common. The authors reviewed their experience to assess the risk factors for recurrence and the role of nonoperative treatment.

METHODS

A retrospective study over a period of 25 years was carried out. One hundred eighty-six patients with 191 lesions (five patients with de novo lesions in different sites) were treated. There were 98 boys and 88 girls. The average age at diagnosis was 3.3 years (range, fetal life to 17 years) and the average size 8 cm in diameter. Histocytological confirmation was obtained in all patients. The involved sites were head and neck, 89 patients (48%); trunk and extremities, 78 patients (42%); internal or visceral locations (eg, abdominal and thorax), 19 patients (10%). The treatment consisted of macroscopically complete excision in 145 patients (150 lesions, of which five were recurrences in different sites), partial excision in 10 patients, aspiration in five patients, laser excision in 10 patients, biopsy only in four patients, drainage and biopsy in two patients, and injection of sclerosing agents in 10 patients.

RESULTS

There were 54 recurrences; 44 underwent excision (five of them more than once), and five regressed spontaneously on follow-up. Five other recurrences were stable and not progressing. Recurrences, (defined as clinically obvious disease), were found to be 100% after aspiration, 100% after injection, 40% after incomplete excision, 40% after laser excision, and 17% after macroscopically complete excision. The recurrence rate in the last group was the highest in the head (33%), the least in the internal locations (0%), and intermediate for the cervical location (13%). There were no significant differences, in terms of outcome, between those who had their surgery immediately at the time of diagnosis (n = 101) and those who had delayed surgery (n = 85).

CONCLUSIONS

There were fewer recurrences after macroscopically complete excision. Aspiration and injection had the highest recurrence rate. Risk factors for recurrence included location, size, and complexity of lesions. A period of observation may be useful for infants to facilitate complete excision. In the present series, spontaneous regression was infrequent and was seen more often with recurrent lesions.