Outcomes and complications of surgical treatment modalities for simple bone cysts of the humerus in children and adolescents

PURPOSE

The aim of this study was to evaluate and compare different surgical treatment modalities for simple bone cysts (SBC) of the humerus regarding their effectiveness and recurrence rate.

METHODS

In this retrospective study, patients who received surgical treatment for previously untreated primary SBCs of the humerus were analyzed. Demographic data, cyst-specific as well as treatment-specific parameters, complications, treatment failures, and recurrence rates were collected and correlated with different treatment modalities. Observed procedures were categorized as open procedure (n=20) or osteosynthesis alone (n=3). For the open procedure group, four subgroups could be defined.

RESULTS

Twenty-three patients were included. The mean age at diagnosis was 11.6 ± 2.5 years, and the mean postoperative follow-up was 3.9 ± 2.6 years (range 1.0-10.3). After surgical intervention, a total of five (21.7%) patients showed at least one recurrence. Fracture occurred in three (13.0%) cases. The incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group, with five (83.3%) of six cases showing recurrence, than in the other subgroups (≤ 25.0%) including the osteosynthesis alone group (p=.024). For the open procedure group, the failure-free survival rates were 80.0% after two years and 50.4% after five years. For the three cases treated by osteosynthesis alone, no failures were observed.

CONCLUSION

Open procedures showed similar failure rates except for the subgroup using curettage, allograft, and adjuvants which showed significantly higher treatment failure. Promising results were observed in the group which received solely osteosynthesis without cyst excision or filling, as no treatment failure was observed here.

Does cryotherapy decrease the local recurrence rate in the treatment of an aneurysmal bone cyst? A comparative assessment

Curettage with or without the use of adjuvants is the standard of care in the treatment of an aneurysmal bone cyst (ABC). Historically, our approach combined curettage, high-speed burr drilling, and cryoablation. However, treatments varied based on age, tumor location, and surgeon preference. We asked: (1) Does cryoablation in addition to curettage and burr drilling decrease the local recurrence rates? (2) Are there any risk factors for the local recurrence rate? (3) Does cryoablation improve postsurgical functional outcomes in these patients? Patients treated for an ABC, between January 2006 and December 2019 were included in this retrospective analysis. Patient and surgical characteristics, such as age, gender, tumor location, type of treatment, time of follow-up, recurrence rate, and functional outcome measured by the Musculoskeletal Tumor Society Score 1993 (MSTS93) score were compared between those treated with and without cryoablation. Both groups, without cryoablation (n = 88) and with cryoablation (n = 42), showed no significant difference in local recurrence rates (9.1% vs. 7.1%, p = 0.553) and functional outcomes as measured by the MSTS93 score (28.9 vs. 27.8, p = 0.262). Risk factors analyzed did not significantly affect local recurrence risk, except for secondary ABC diagnosis (p = 0.017). The cryoablation group had a more extended follow-up (45.6 vs. 73.2 months, p < 0.001), reflecting a shift in practice over time. We found no significant difference in local recurrence rate or functional outcome in patients treated with or without cryoablation. Formal curettage with additional high-speed burr drilling provides effective tumor control and favorable functional outcomes, negating the need for adjuvant cryoablation.

Surgical management of proximal femoral unicameral bone cyst in children

Aims

The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up.

Methods

This multicentre retrospective study was conducted in 20 tertiary paediatric hospitals in France, Belgium, and Switzerland, and included patients aged < 16 years admitted for UBC treatment in the proximal femur from January 1995 to December 2017. UBCs were divided into seven groups based on the index treatment, which included elastic stable intramedullary nail (ESIN) insertion with or without percutaneous injection or grafting, percutaneous injection alone, curettage and grafting alone, and insertion of other orthopaedic hardware with or without curettage.

Results

A total of 201 patients were included in the study. The mean age at diagnosis was 8.7 years (SD 3.9); 77% (n = 156) were male. The mean follow-up was 9.4 years (SD 3.9). ESIN insertion without complementary procedure had a 67% UBC healing rate after the first operation (vs 30% with percutaneous injection alone (p = 0.027), 43% with curettage and grafting (p = 0.064), and 21% with insertion of other hardware combined with curettage (p < 0.001) or 36% alone (p = 0.014)). ESIN insertion with percutaneous injection presented a 79% healing rate, higher than percutaneous injection alone (p = 0.017), curettage and grafting (p = 0.028), and insertion of other hardware combined with curettage (p < 0.001) or alone (p = 0.014). Patients who underwent ESIN insertion with curettage had a 53% healing rate, higher than insertion of other hardware combined with curettage (p = 0.009). The overall rate of postoperative complications was 25% and did not differ between groups (p = 0.228). A total of 32 limb length discrepancies were identified.

Conclusion

ESIN insertion, either alone or combined with percutaneous injection or curettage and grafting, may offer higher healing rates than other operative procedures. Limb length discrepancy remains a major concern, and might be partly explained by the cyst's location and the consequence of surgery. Therefore, providing information about this risk is crucial.

Extended curettage for tumour-induced osteomalacia in the bone

BACKGROUND

extended curettage is generally used to treat infiltrative bone tumours. However, the extent of the curettage performed in previous studies remains unclear. This study aimed to investigate the efficacy of extended curettage for bone tumour-induced osteomalacia.

METHODS

we included 12 patients with tumour-induced osteomalacia who underwent extended curettage at our hospital between 2000 and 2022. Extended curettage was applied in cases where tumour resection could cause functional impairment or necessitate complex reconstruction. We investigated patients' clinical and oncological outcomes.

RESULTS

patients had a mean age of 55 (24-81) years, and the median follow-up duration after surgery was 3.9 (1.0-14.0) years. The causative tumours were located in the pelvis and lumbar spine. Imaging revealed the tumours to be of the sclerotic, intertrabecular, lytic and mixed types. Intraoperative 3D fluoroscopy was used in 10 patients. Extended curettage with high-speed burring and adjuvant therapy with cauterization using an electric scalpel and ethanol resulted in a remission rate of 83%; no recurrence or metastasis was observed in cases of early postoperative biochemical remission. In cases where the causative tumour was at the lumbar spine and ischium close to the acetabulum, no postoperative biochemical remission was observed, and conservative treatment was continued. Except for one patient with a tumour in the lumbar spine, all patients could walk without a cane.

CONCLUSIONS

extended curettage for bone tumour-induced osteomalacia is oncologically and functionally favourable, especially in cases where resection of the causative tumour could cause functional impairment or necessitate complex reconstruction.

Presence of 10 transformation zone cells in endocervical curettage should not be required for adequacy

OBJECTIVES

In another publication, we concluded endocervical curettage (ECC) should have a minimum number of squamous cells for adequacy, similar to the requirements for adequate cervical Papanicolaou smears. Here, we investigate if also, similar to cervical Papanicolaou smears, the presence of at least 10 cells from the endocervical/transformation zone (EC/TZ) in ECCs should be used as a quality assurance measure or if, instead, at least 10 EC/TZ cells should be part of the adequacy criteria for ECC, with an emphasis on diagnosis of at least high-grade squamous dysplasia (HGD).

METHODS

All patients with at least HGD diagnosed on an excisional biopsy specimen (loop electrosurgical excision procedure [LEEP]) from May 1, 2018, to December 31, 2019, and an ECC in the preceding 6 months at our institution were included. Number of EC/TZ cells present in ECCs was counted visually and categorized as less than or greater than 10 TZ cells. A χ2 test was used to evaluate the proportion of ECCs with and without HGD and the presence or absence of at least 10 EC/TZ cells. Given our recent work encouraging at least 1000 squamous cells in an ECC to be considered adequate, we also evaluated only ECCs with greater than 1000 squamous cells with and without HGD and the presence or absence of at least 10 EC/TZ cells. P value was <.05.

RESULTS

Fifty-one LEEPs with HGD and a preceding ECC in the previous 6 months were identified. Of the 51 ECCs, 6 had fewer than 10 EC/TZ cells and 45 had at least 10 EC/TZ cells. A similar proportion of the ECCs with HGD had at least 10 EC/TZ cells as those without HGD (93% vs 86%, P = .53). Using only ECCs with greater than 1000 squamous cells, we still found no statistical difference in the proportion of ECCs with HGD having greater than 10 EC/TZ cells compared to those without HGD (91% vs 100%, P = .49).

CONCLUSIONS

We found that the presence of at least 10 EC/TZ cells does not increase the likelihood of finding HGD in an ECC performed in the 6 months prior to a LEEP with HGD. Similar to the use of the TZ component in cervical Papanicolaou smears, the presence or absence of at least 10 TZ cells in an ECC should only be considered a quality assurance measure and not be used as a criterion for adequacy of the specimen.

Second curettage versus conventional chemotherapy in avoiding unnecessary chemotherapy and reducing the number of chemotherapy courses for patients with gestational trophoblastic neoplasia: A systematic review and meta-analysis

BACKGROUND

Chemotherapy is the recommended treatment for gestational trophoblastic neoplasia (GTN). Second curettage had been advocated to avoid unnecessary chemotherapy and to reduce the courses of chemotherapy; however, consensus has not been reached as there are arguments claiming its inability of inducing complete regression.

OBJECTIVES

The present study was performed to clarify the effectiveness of second curettage for avoiding unnecessary chemotherapy and lowering the number of chemotherapy courses in patients with post-molar GTN.

SEARCH STRATEGY

Seven predominant electronic databases were searched, including four English databases and three Chinese databases, from the inception of each database until January 31, 2023.

SELECTION CRITERIA

Studies were included if they were: (1) human, (2) explicitly indicated exposure to second curettage, (3) explicitly indicated control to conventional chemotherapy, (4) explicitly indicated the participants were patients with gestational trophoblastic neoplasia (GTN), and (5) compared the outcome of interest as the number of the course of chemotherapy.

DATA COLLECTION AND ANALYSIS

Two authors extracted and analyzed the data independently. Disagreements were reconciled by reviewing the full text by a third author. The data of study location, data collection, study design, number of participants, intervention strategy, control strategy, the follow-up period, outcome, adverse events were analyzed.

MAIN RESULTS

With regard to avoiding unnecessary chemotherapy, the overall pooled effect size of the second curettage group had a significant advantage over the conventional chemotherapy group with an OR of 0.02 (95% CI: 0.00-0.06). Meanwhile, for reducing the number of chemotherapy courses, the overall pooled effect size of the second curettage group had significant advantage over the conventional chemotherapy group with a mean difference of -2.11 (95% CI: -3.72 to -0.51).

CONCLUSION

The second curettage group had a significant advantage over the conventional chemotherapy group in avoiding unnecessary chemotherapy and reducing the number of chemotherapy courses. Further larger multi-center randomized controlled trials should be conducted to confirm our results and to clarify the optimal patients' group for second curettage in patients with post-molar GTN.

Intralesional curettage and surgical adjuvants in the treatment of giant cell tumor of bone: meta-analysis and systematic review

BACKGROUND

The ideal treatment for giant cell tumor of bone (GCTB) is still controversial. Various surgical adjuvants have been introduced following intralesional curettage to improve local control rates. However, findings from relevant studies are inconsistent, and no consensus has been reached. The purpose of this study is to determine what intraoperative adjuvant is effective in decreasing the recurrence of GCTB.

METHODS

We performed a systematic review and meta-analysis of articles published in the PubMed and Embase electronic databases which assessed the recurrence rate of GCTB following intralesional curettage with or without various surgical adjuvants. Two authors independently evaluated all publications. Meta-analysis was performed with Stata/MP (Version 17.0, StataCorp LLC, TX, USA) and Review Manager (RevMan, Version 5.4.1, The Cochrane Collaboration, 2020). Pooled risk ratio (RR) was used for analysis, with P values less than 0.05 considered statistically significant.

RESULTS

Twenty-four studies involving 2,579 patients were included in this analysis. The overall recurrence rates for patients treated with or without high-speed burring (HSB) are 11.9% (26/218) and 47.7% (92/193), respectively. The pooled RR for tumor recurrence is 0.33 (95% CI: 0.22 to 0.49, P<0.001). In the meanwhile, the overall recurrence rates for patients treated with or without chemical adjuvants are 23.5% (77/328) and 26.1% (73/280), respectively, with a pooled RR of 0.84 (95% CI: 0.63 to 1.10, P=0.89). Additionally, the overall recurrence rates for patients treated with or without polymethyl methacrylate (PMMA) are 20.4% (205/1,006) and 33.4% (314/939), respectively, with a pooled RR of 0.59 (95% CI: 0.50 to 0.69, P<0.001).

CONCLUSIONS

Intraoperative application of HSB or PMMA has an additional antitumor effect, while the use of phenol or H2O2 fails to make any significant difference (PROSPERO: CRD42022344262).

Curettage combined with decompression for the treatment of ameloblastoma in children: report of two cases

BACKGROUND

Ameloblastoma (AM) is the most common benign odontogenic tumor, which is more often detected in the mandible than maxilla, especially the mandibular body and mandibular angle. Pediatric AM is a rare disease, especially in patients aged 10 and younger. Compared with the mainstream osteotomy and reconstructive surgery for adult ameloblastoma, there is more room for discussion in the treatment of pediatric ameloblastoma. The postoperative functional and psychological influence can not be ignored. Especially for children in the period of growth and development, an osteotomy is often challenging to be accepted by their parents. We report two patients with ameloblastoma under 10 years old who are treated with curettage and fenestration, which is a beneficial method for children with ameloblastoma.

CASE PRESENTATION

We present two cases of classic ameloblastoma in children. We describe in detail the patients' characteristics, treatment processes, and follow-up result. The bone formation and reconstruction in the lesion area after fenestration decompression and curettage are recorded at every clinic review. The surgical details and principles of curettage and decompression are also described and discussed. The two patients have good bone shape recovery and no recurrence.

CONCLUSIONS

Children are in the growth and development period and possess an extremely strong ability of bone formation and reconstruction. Based on the principles of minimally invasive and functional preservation, we believe that curettage combined with decompression can be the first choice for treating AM in children, especially for mandibular lesions.

Treatment of Unicameral Bone Cysts Utilizing the Sclerograft™ Technique

PURPOSE

To evaluate the Sclerograft™ procedure, which is an image-guided, minimally invasive approach of chemical sclerotherapy followed by bone grafting of unicameral bone cysts (UBC).

MATERIALS AND METHODS

A retrospective evaluation from August 2018 through August 2023 was performed at a single institution on patients that underwent the Sclerograft™ procedure for UBCs. Radiographic healing was evaluated utilizing the Modified Neer Classification. Two different regenerative grafts, CaSO4-CaPO4 and HA-CaSO4 were utilized. A total of 50 patients were evaluated with 41 patients grafted with CaSO4-CaPO4 and 9 patients grafted with HA-CaSO4.

RESULTS

The average age of the patient was 12.1 years with an average radiographic follow-up of 14.5 months. Average cyst size was 5.5 cm in the largest dimension and average cyst volume was 20.2 cc. 42 out of 50 (84%) showed healed cysts (Modified Neer Class 1) on the most recent radiograph or MRI. Recurrences occurred on average at 7.2 months. Activity restrictions were lifted at 3-4.5 months post-procedure. Cyst stratification by size did not show a difference in recurrence rates (p = 0.707). There was no significant difference in recurrence rate between lesions abutting the physis compared to those that were not abutting the physis (p = 0.643). There were no major complications.

CONCLUSIONS

The Sclerograft™ procedure is an image-guided approach to treating unicameral bone cysts, utilizing chemical sclerosis and regenerative bone grafting. The radiographic healing of cysts compares favorably to open curettage and grafting as determined utilizing previously published trials.

Use of Surgical Adjuvants Does Not Decrease Recurrence of Aneurysmal Bone Cysts in Surgical Intervention With Pediatric Patients

BACKGROUND

Aneurysmal bone cysts (ABCs) are benign active tumors often requiring intralesional curettage with or without adjuvants. The primary aim of this study was to analyze whether recurrence is influenced by the use of surgical adjuvants in pediatric patients with ABCs. Secondary aims examined recurrence rates based on age, sex, and physeal contact.

METHODS

A retrospective review was performed at a tertiary pediatric hospital from 2004 to 2020. Inclusion criteria consisted of patients treated surgically for histologically confirmed ABCs with a minimum of 6 months follow-up. Patients with treatment for a recurrent tumor or incomplete records were excluded. Patient demographics, location of the lesion, treatment technique, and incidence of recurrence were collected. Statistical analyses were performed using STATA.

RESULTS

There were 129 patients (74 males and 55 females) with a mean age of 11.5 ± 4.1 years and an average follow-up of 29.0 ± 25.4 months. The most common locations for ABCs were the femur and tibia. Of the patients, 53.5% had tumors abutting the physis, 28.7% had no physeal contact, and 17.8% had insufficient imaging to evaluate physeal contact. Surgical adjuvants (high-speed burr, coagulation, liquid nitrogen, and/or hydrogen peroxide) were used in 91 of the 129 cases (70.5%). There was no significant difference in recurrence when comparing those who received an adjuvant and those who did not (25.3% vs 23.7%, P = 1.000). Physeal contact was also not significantly associated with recurrence ( P = 0.146). Finally, patients younger than 6 years old were significantly more likely to have recurrence compared with those 6 years old or older (66.7% vs 21.7%, P = 0.007).

CONCLUSION

Our study found no association between the use of surgical adjuvants and the risk of recurrence after intralesional curettage for ABCs. Although our study did demonstrate that patients 6 years old or younger had an increased rate of recurrence, no significant association was found regarding physeal contact or sex. These data indicate that surgical adjuvant may not affect the recurrence rates of pediatric patients with ABCs.

LEVEL OF EVIDENCE

Level III. This retrospective review compares rates of recurrence based on the choice of surgical adjuvant.

Aneurysmal bone cyst: Is selective arterial embolization effective as curettage and bone grafting?

INTRODUCTION

Aneurysmal bone cyst (ABC) is a lytic benign bone lesion representing about 1% of all primary bone tumors. Method to treat ABC's have developed over time. The standard of care cure for ABC has been curettage with or without bone grafting of the defect but is burdened by recurrence rates of approximately 25%-31%. Based on the assumption that ABCs usually supplied by one or more pathological feeding arteries, selective arterial embolization has been described as an adjuvant preoperative procedure to reduce intra-operative hemorrhage, and as primary treatment for lesions in difficult surgical access. In the current study, we therefore asked whether (1) a single or a repeat selective arterial embolization (SAE) for treating ABCs would produce comparable healing rates compared with curettage and bone grafting; (2) evaluated the relationship of recurrence in relation to the site of the cyst, the age, and gender of the patients; and (3) the two techniques differ in term of long-term complication.

MATERIAL AND METHODS

We retrospectively reviewed 265 patients who underwent curettage and bone grafting or SAE performed at our institute from 1994 to 2018. The diagnosis of ABC was always established with percutaneous CT-guided biopsy or open biopsy. Patients were followed clinically with plain radiographs or CT scan at 3, 6, 9, and 12 months then annually in the absence of symptoms. Treatment success was determined evaluating pre- and postprocedural imaging according to Chang classification.

RESULTS

Two hundred and nineteen were treated with curettage and bone grafting (curettage group), and 46 with SAE Group. Of the 219 patients treated with Curettage and bone grafting (curettage group), 165 out of 219 (75.3%) experienced bone healing, while local recurrence was observed in 54 cases (24.7%) after 12 months on average (range: 3-120 months) from surgery. After the first SAE, bone ossification was seen in 27 (58.7%), without needing any further treatment. Eleven recurred patients were treated with SAE (four patients need two while seven need three SAE to heal), and eight patients with curettage and bone grafting. Thirty-eight out of 46 (82%) patients experienced bone ossification regardless the number of SAE. The overall rate of local recurrence for all patients was 26.7%. SAE group presented a lower complication rate (6%) where two patients experienced skin necrosis, and one limb-length discrepancies (2% of all cohort).

DISCUSSION

The use of SAE is an attractive option to treat ABC as it combines on one hand a lower complication rate than curettage and bone grafting, on the other it can be carried out in case of nonresectable ABCs, significantly reducing the size of viable ABC lesions, fostering bone remodeling and mineralization, and most importantly, significantly improving the patient's quality of life.

Assessment of middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy

Objectives

To compare pre- and post-operative pure tone audiometric and impedance audiometric analysis following conventional and endoscopic microdebrider assisted adenoidectomy and compare the outcomes.

Methods

Patients diagnosed with chronic adenoiditis were divided in groups of 25 each. Patients in the first group underwent conventional curettage adenoidectomy, while those in second group underwent endoscopic microdebrider assisted adenoidectomy. Pre- and post-operative pure tone and impedance audiometry were performed for all patients and outcomes were compared.

Results

The endoscopic microdebrider assisted method resulted in significantly better outcomes compared to conventional curettage. Criteria such as hearing threshold (p value 0.004 at second follow-up), peak pressure (p value 0.045 at first follow-up) and tympanogram (p value 0.016) showed that the endoscopic method was better, while peak compliance (p value 0.340 at first follow-up) did not show any significant difference between groups.

Conclusions

The endoscopic microdebrider assisted method for adenoidectomy has a definite advantage of better visualisation resulting in better clearance of tissue, leading to enhanced middle ear function compared to conventional curettage.

Fracture risk after intralesional curettage of atypical cartilaginous tumors

INTRODUCTION

The need for curettage of atypical cartilaginous tumors (ACT) is under debate. Curretage results in defects that weaken the bone potentially leading to fractures. The purpose of this study was to retrospectively determine postoperative fracture risk after curettage of chondroid tumors, including patient-specific characteristics that could influence fracture risk.

METHODS

A total of 297 adult patients who underwent curettage of an ACT followed by phenolisation and augmentation were retrospectively evaluated. Explanatory variables were, sex, age, tumor size, location, augmentation type, and plate fixation. The presence of a postoperative fracture was radiologically diagnosed. Included patients had at least 90 days of follow-up.

RESULTS

A total of 183 females (62%) were included and 114 males (38%), with an overall median follow-up of 3.2 years (IQR 1.6-5.2). Mean diameter of the lesions was 4.5 (SD 2.8) cm. Patients received augmentation with allograft bone (n = 259, 87%), PMMA (n = 11, 3.7%), or did not receive augmentation (n = 27, 9.1%). Overall fracture risk was 6%. Male sex (p = 0.021) and lesion size larger than 3.8 cm (p < 0.010) were risk factors for postoperative fracture.

INTERPRETATION

Curettage of ACT results in an overall fracture risk of 6%, which is increased for males with larger lesions.

Cryosurgery versus curettage for intraepidermal carcinoma: A randomized controlled trial

BACKGROUND

Cryosurgery is a common destructive treatment method for intraepidermal carcinoma (IEC) above the knee. Curettage alone is a simple, non-aggressive and inexpensive treatment method commonly used on benign skin lesions. However, only one study has assessed curettage for treatment of IEC.

OBJECTIVE

We aimed to (1) compare the effectiveness of cryosurgery (standard method) to curettage (experimental method) for treatment of IEC in regard to overall clearance rates at 1-year follow-up, and (2) investigate whether wound healing times differed between the treatment groups.

METHODS

In this randomized and controlled, non-inferiority trial, adult patients with one or more IEC with a diameter of 5-20 mm, located above the knee and suitable for destructive treatment were recruited from Sahlgrenska University Hospital (Gothenburg, Sweden). Lesions were randomized to treatment with either cryosurgery or curettage. Wound healing was assessed by a nurse after 4-6 weeks and through self-report forms. Overall clearance was assessed by a dermatologist after 1 year.

RESULTS

In total, 183 lesions in 147 patients were included, with 93 lesions randomized to cryosurgery and 90 to curettage. Eighty-eight (94.6%) of the lesions in the cryosurgery group and 71 (78.9%) in the curettage group showed an overall clearance at the 1-year follow-up visit (p = 0.002). The non-inferiority analysis was inconclusive. Curettage resulted in both shorter self-reported wound healing times (mean time 3.1 vs. 4.8 weeks, p < 0.001) and a larger proportion of healed wounds after 4-6 weeks (p < 0.001).

CONCLUSIONS

Cryosurgery and curettage both result in high clearance rates for treatment of IEC, but cryosurgery is significantly more effective. On the other hand, curettage may result in shorter wound healing times.

Curettage and colour-A technique for defining tumour depth on the ear in the Mohs and non-Mohs setting

For tumours of the ear that are suspected to involve auricular cartilage, precise definition of the extent of involved deep margin can be difficult. As large resections of cartilage can be cosmetically disfiguring with limited repair options, we propose a simple and effective technique to facilitate a targeted deep margin resection using a curette and a surgical marking pen.

Total Knee Arthroplasty for Osteoarthritis Is Uncommon after Intralesional Curettage in Giant Cell Tumor of Bone

Giant cell tumor of bone (GCTB) is most often treated with intralesional curettage; however, periarticular lesions have been shown to increase risk for osteoarthritis. Additionally, the location of these lesions may occasionally preclude a joint-sparing procedure in recurrent tumors. This study sought to investigate rates of secondary arthroplasty in long-term follow-up of knee GCTB. Cases of knee GCTB treated at our institution were reviewed. Rates of recurrence and secondary arthroplasty were recorded, and Kaplan-Meier survival analyses were performed. The records of 40 patients were reviewed. Local recurrence occurred in 25% of patients. The 1-, 5-, and 10-year recurrence-free survival (RFS) probability was 87.4% (95% CI, 77.0-97.7), 72.4% (95% CI, 57.6-87.2), and 72.4% (95% CI, 57.6-87.2), respectively. Function improved after surgery with a mean preoperative MSTS score of 14.9 (standard deviation [SD] 8.4) and mean postoperative MSTS score of 25.1 (SD 5.6) (p <0.001). Three patients had evidence of radiographic osteoarthritis at the last follow-up though they did not require arthroplasty. Arthroplasty was performed as a secondary procedure in six patients. Five patients underwent arthroplasty for recurrent tumors after initial treatment with curettage and one patient underwent patellar arthroplasty for osteoarthritis after initial treatment with an allograft composite arthroplasty. Arthroplasty is performed as a secondary procedure in patients with GCTB at a relatively infrequent rate and more often for cases of recurrent disease than for osteoarthritis. Overall, patients treated for GCTB have improved functional outcomes after surgery than before. Large, multi-institutional studies may be required to assess the incidence of secondary osteoarthritis requiring arthroplasty as this was an infrequent finding in our cohort.

Factors Affecting Postoperative Complications of Suction-Curettage by Arthroscopic Shaver for Bromhidrosis

BACKGROUND

Suction-curettage by arthroscopic shaver is the most effective treatment for bromhidrosis; however, postoperative complications require wound management and exhibit a high risk of hypertrophic scarring. We investigated factors affecting postoperative complications.

METHODS

We retrospectively evaluated data for 215 patients (430 axillae) with bromhidrosis treated with suction-curettage by arthroscopic shaver between 2011 and 2019. Cases followed for less than 1 year were excluded. Complications of hematoma or seroma, epidermis decortication, skin necrosis, and infection were recorded. Multinomial logistic analysis was used to calculate odds ratios and corresponding 95% confidence intervals for the complication of the surgery, adjusting for relevant statistically significant variables.

RESULTS

Complications occurred in 52 axillae (12.1%). Epidermis decortication occurred in 24 axillae (5.6%), with a significant difference for age (P < 0.001). Hematoma occurred in 10 axillae (2.3%) with a significant difference in tumescent infiltration use (P = 0.039). Skin necrosis occurred in 16 axillae (3.7%) with a significant difference for age (P = 0.001). Infection occurred in 2 axillae (0.5%). Severe scarring occurred in 15 axillae (3.5%), with complications related to more severe skin scarring (P < 0.05).

CONCLUSION

Older age was a risk factor for complications. Use of tumescent infiltration resulted in good postoperative pain control and less hematoma. Patients with complications presented with more severe skin scarring, but none experienced limited range of motion after massage.

Long term outcome of surgical treatment of chondroblastoma: analysis of local control and growth plate/articular cartilage related complications

BACKGROUND

Chondroblastoma (CBL) is a rare benign chondroid producing bone tumor that typically occurs in epiphysis or apophysis of growing children and young adults. Intralesional curettage is the treatment of choice, while resection is required in selected cases, even though the use of minimally invasive ablation techniques has been advocated. Authors reviewed a series of 75 CBLs with the aim of assess risk factors for local recurrence, the growth plate related complications after epiphyseal curettage and the risk of arthritis of the adjacent joint after epiphyseal curettage.

METHODS

We retrospectively review 69 CBLs treated with intralesional curettage and 6 treated with resection from March 1995 to February 2020. The median age was 18.8 years (7 to 42, median 16). The site was proximal humerus in 18 cases, proximal tibia in 17, distal femur in 16, talus in 6, femur's head in 4, calcaneus in 3, acromion in 3, trochanteric region in 2, distal tibia in 2, patella in 2, supracetabular region in 1 and distal humerus in 1 patient.

RESULTS

Mean follow-up was 124.2 months (24 to 322, median 116). Among patients treated with curettage, 7.3% of local recurrence was observed and 12 (17.4%) patients developed osteoarthritis of the adjacent joint. Five patients (7.3%) presented limb length discrepancy of the operated limb ranging from 0.5 to 2 cm. Recurrence free survival rate was 94.2% at 5 and 91.6% at 10 years. A mean Musculoskeletal Tumor Society (MSTS) of 29.3 points (20 to 30, median 30) was observed.

CONCLUSION

More than 90% of CBLs were successfully treated with aggressive curettage but segmental resection is required in selected cases. In a relatively small proportion of cases long term complications can occur due to growth plate damage or osteoarthritis.

TRIAL REGISTRATION

Retrospectively registered.

Efficacy and safety of super pulse CO2 laser-assisted punctoplasty with canalicular curettage in primary canaliculitis

The objective of this study was to evaluate the efficacy and safety of super pulse CO2 laser-assisted punctoplasty with canalicular curettage in primary canaliculitis. In this retrospective serial case study, the clinical data of 26 patients who underwent super pulse CO2 laser-assisted punctoplasty for the treatment of canaliculitis were collected from January 2020 to May 2022. The clinical presentation, intraoperative and microbiologic findings, surgical pain severity, postoperative outcome, and complications were studied. Of the 26 patients, most were females (female:male 20:6), with a mean age of 60.1 ± 16.1 years (range, 19-93). Mucopurulent discharge (96.2%), eyelid redness and swelling (53.8%), and epiphora (38.5%) were the most common presentations. During the surgery, concretions were present in 73.1% (19/26) of the patients. The surgical pain severity scores ranged from 1 to 5, according to the visual analog scale, with a mean score of 3.2 ± 0.8. This procedure resulted in complete resolution in 22 (84.6%) patients and significant improvement in 2 (7.7%) patients, and 2 (7.7%) patients required additional lacrimal surgery with a mean follow-up time of 10.9 ± 3.7 months. The surgical procedure of super pulse CO2 laser-assisted punctoplasty followed by curettage appears to be a safe, effective, minimally invasive, and well-tolerated treatment for primary canaliculitis.

Comparing clinical outcomes between extended curettage and wide resection in Enneking stage 3 giant cell tumor of bone

PURPOSE

Our objectives were (1) to compare the recurrence, metastases, and complication rates of patients with Enneking stage 3 GCTB who underwent extended curettage vs wide resection and (2) examine the factors which might influence surgical options for each patient.

METHODS

We retrospectively reviewed the records of patients with Enneking stage 3 GCTB from January 2006-December 2015. Extended curettage was performed in patients in whom there was a moderate expansile lesion, minimal/no articular cartilage damage, and less than 50% of cortical deformation compared to its circumference from a CT scan/MRI. The percentages of cortical deformation were collected. Surgical complications, recurrence, and metastatic rates were analyzed.

RESULTS

There were 28 extended curettage and 41 wide resections. The mean percentages of cortical deformation compared to circumference were 52.6% (range, 23.9-81.9%) and 91.6% (range, 52.1-100%)(P < 0.01) for the curettage and wide resection groups, respectively. There were three recurrences, 2/28 (7.1%) from the curettage group and 1/41 (2.4%) from the resection group (P = 0.56). There were no cases of pulmonary metastasis. There were two complications in the curettage group and five complications in the resection group.

CONCLUSION

Both extended curettage and wide resection are useful methods to treat Enneking stage 3 GCTB. Extended curettage with proper technique is a viable option showing no difference in local recurrence rate and potentially fewer complications. Preference to do extended curettage in patients in whom when the articular cartilage has minimal or no destruction, a moderate expansile lesion and the cortical deformation is less than 50% of the circumference.

Packing with alpha-tricalcium phosphate followed by curettage and phenol-ethanol ablation for appendicular giant cell tumor of bone

Giant cell tumor of bone (GCTB) is an intermediate and locally aggressive bone tumor. Alpha-tricalcium phosphate (alpha-TCP) is an adjustable bone substitute used to fill various sizes of bone cavities after curettage for GCTB. This study aimed to evaluate the surgical outcome of packing with alpha-TCP followed by curettage and phenol-ethanol ablation. We retrospectively reviewed data of 16 patients with GCTB who underwent primary surgery in our institute between January 2009 and April 2021. Data of Campanacci grading system; number of local recurrences and distant metastases; local recurrence-free survival rate using the Kaplan-Meier method; oncological outcomes; and complications after surgery (secondary osteoarthritis and postoperative fracture) were evaluated in this study. Regarding the Campanacci grading system, 2 patients were classified as grade I, 14 as grade II, and none as grade III. The 5-year local recurrence-free survival rate was 77.8% in all cases. Lung metastasis was not detected in this study. Oncological outcomes were: continuous disease free, 13 patients; alive with disease, 3 patients; and no evidence of disease or death of disease, none of the patients. Secondary osteoarthritis after surgery was not detected in the present study. Packing with alpha-TCP followed by curettage and phenol-ethanol ablation for appendicular GCTB may be safe and effective in suppressing the risk of secondary osteoarthritis.

[Stratified research on related risk factors of CINⅡ+ in CINⅠ patients diagnosed by endocervical curettage under colposcopy]

Objective: To estimate risks of cervical intraepithelial neoplasia (CIN) Ⅱ or worse (CINⅡ⁺) on loop electrosurgical excisional procedure (LEEP) specimens with the diagnosis of endocervical curettage (ECC) CINⅠ compared with biopsy CINⅠ, and also to investigate the hierarchical management scheme of ECC CINⅠ based on the relevant factors of CINⅡ⁺ risk. Methods: (1) A retrospective computer-based research for subjects enrolled in the Obstetrics and Gynecology Hospital, Fudan University from Jan. 2013 to Jun. 2021 was performed. The case group comprised women with an ECC CINⅠ (ECC results of CINⅠ with colposcopy-directed biopsy results ≤CINⅠ), and the control group comprised women with a biopsy CINⅠ (colposcopy-directed biopsy results of CINⅠ with negative ECC findings) were divided after LEEP surgery and diagnosis in the next three months. The clinical data of all patients before LEEP were analyzed, and the pathological diagnosis between two groups after LEEP was compared. (2) Variables, including age, cytology, high-risk human papillomavirus (HR-HPV), ECC results, cervical transformation zone (TZ) and colposcopy impression, were included to describe the characteristics and compare the incidence of LEEP CINⅡ⁺. (3) Univariate analysis and Multivariate logistic regression method were used to analyze the related factors that affect the LEEP CINⅡ⁺ in CINⅠ patients. Further, the specific risks caused by related factors and conduct a stratified study in LEEP CINⅡ⁺ were analyzed. Results: (1) Overall, 2 581 women with ECC CINⅠ or biopsy CINⅠ diagnosis who underwent LEEP participated in the study with the mean age (43.6±9.5) years old. Chi square test found that the age and cytology of patients in ECC CINⅠ group were statistically different from those of biopsy CINⅠ group (all P<0.05). There was no significant difference in HR-HPV detection, TZ type and colposcopy impression between the two groups (all P>0.05). ECC CINⅠ comprised 957 women, with LEEP histopathology results revealing 288 (30.1%, 288/957) CINⅡ⁺, which was significantly higher than that of biopsy CINⅠ which was comprised 1 624 women, with LEEP histopathology results showing 333 (20.5%, 333/1 624) CINⅡ⁺ (χ²=30.31, P<0.001). (2) Compared by LEEP CINⅡ⁺ with LEEP ≤CINⅠ group, there were no significant difference in the age, HR-HPV, colposcopy impression (all P>0.05); but there were significantly differences in cytology, ECC CINⅠ, type Ⅲ TZ (all P<0.001). Multivariate logistic regression analysis showed that atypical squamous epithelial cells (ASC-H; OR=2.77, 95%CI: 2.04-3.77), high-grade squamous intraepithelial lesions and worse (HSIL⁺; OR=2.93, 95%CI: 2.24-3.81), ECC CINⅠ (OR=1.89, 95%CI: 1.56-2.29) and type Ⅲ of TZ (OR=1.76, 95%CI: 1.45-2.11) were independent risk factors for LEEP CINⅡ⁺ (all P<0.05). (3) When cytology was ≤low-grade squamous intraepithelial lesion (LSIL) and ≥ASC-H, the detection rate of CINⅡ⁺ in ECC CINⅠ was significantly higher than that of biopsy CINⅠ (all P<0.001). In ECC CINⅠ, the rate of CINⅡ⁺ with cytology ≤LSIL was significantly lower than that in cytology ≥ASC-H (56.0% vs 25.9%; χ²=49.38, P<0.001). In type Ⅰ/Ⅱ of TZ, the detection rate of CINⅡ⁺ between ECC CINⅠand biopsy CINⅠ had no significantly different; while in type Ⅲ of TZ, there was significantly different (72.7% vs 46.2%; χ²=4.02, P=0.045). In ECC CINⅠ, type Ⅲof TZ was significantly higher in the rate of CINⅡ⁺ than that of type Ⅰ/Ⅱ of TZ (72.7% vs 21.7%; χ²=16.38, P<0.001). When cytology ≥ASC-H, type Ⅲ of TZ and colposcopy impression of HSIL were combined, the rate of CINⅡ⁺ in ECC CINⅠ was 6/6 while 1/3 in biopsy CINⅠ. Conclusions: Cytology ≥ASC-H, ECC CINⅠ and type Ⅲ TZ are the risk factors of LEEP CINⅡ⁺. However, cytology ≥ASC-H is more valuable in predicting LEEP CINⅡ⁺ than ECC CINⅠ. For patients with ECC CINⅠ to perform LEEP, it is recommended that cytology ≥ASC-H is taken as the first level stratification, and type Ⅲ TZ is taken as the second level stratification. The colposcopy impression of patients is recommended for a reference parameter.

Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage

OBJECTIVE

The aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE).

MATERIALS AND METHODS

This was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed.

RESULTS

A total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months.

CONCLUSION

UAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.

COMPARISON OF LONG-TERM CLINICAL RESULTS OF MICRODEBRIDER AND COLD BLADE ADENOIDECTOMY

The advantages of endoscopic shaver adenectomy are safety, accuracy of tissue removal, and low relapse rate. However, there is a lack of information about long-term clinical results of this method in the literature that arose a necessity of conducting such a study. The objective of the study - to consider the clinical efficacy of shaver adenectomy in the long-term observation period after the surgery (12-24 months). The study presents a comparison of the long-term results of endoscopic modified microdebrider adenotomy (EMMA) (a variant of shaver transoral combined adenotomy developed by the authors) in 203 children and the cold blade adenectomy (25 children). Evaluation of the results was carried out according to the survey of parents and clinical examination of children 12-24 months after the surgery. According to the survey, EMMA was 22.02% more effective according to the "restoration of nasal breathing" criterion and by 22.5% by the "frequency of acute respiratory infections" criterion in comparison with the cold blade adenectomy. The implementation of this technique in combination with tympanopuncture in children with secretory otitis on the background of pharyngeal tonsil hypertrophy allows achieving better results in the restoration of auditory function by 16.6%. Endoscopic modified microdebrider adenectomy is an effective and safe method for treating children with adenoid hypertrophy, which, according to the results of a long-term observation, allowed achieving a better level of nasal breathing and reducing the frequency of acute respiratory infections compared with cold blade adenectomy.

Computerised tomography features of giant cell tumour of the knee are associated with local recurrence after extended curettage

Background

Extended curettage has increasingly become the preferred treatment for giant cell tumour of bone (GCTB), but the high recurrence rate after curettage poses a major challenge for orthopaedic surgeons. Computed tomography (CT) is valuable in the evaluation of GCTB. Our aim was to identify specific features of GCTB around the knee in pre-operative CT images that might have prognostic value for local recurrence.

Methods

We retrospectively analyzed data from 124 patients with primary GCTB around the knee who underwent extended curettage from 2010 through 2019. We collected demographic, clinical, and therapeutic data along with several CT-derived tumour characteristics. CT-derived tumor characteristics included tumour size, the distance between the tumour edge and articular surface (DTA), and destruction of posterior cortical bone (DPC). Akaike information criterion (AIC) was used to select which variables to enter into multivariate logistic regression models and to determine significant factors affecting recurrence.

Results

The total recurrence rate was 21.0% (26/124), and the average follow-up time was 69.5 ± 31.2 months (24–127 months). Age, DTA (< 2 mm), and DPC were significantly related to recurrence, as determined by multivariate logistic regression. The C-index of the final model was 0.79 (95% CI: 0.71 to 0.88), representing a good model for predicting recurrence.

Conclusion

Identifying certain features of GCTB around the knee on CT has prognostic value for patients treated with extended curettage. A three-factor model predicts tumour recurrence well after extended curettage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05260-6.

Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital

BACKGROUND

Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team.

METHODS

The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up.

RESULTS

The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months.

CONCLUSION

Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A Systematic Review on the Treatment of Dermatosis Papulosa Nigra

Dermatosis papulosa nigra (DPN) is a benign skin condition that is primarily reported in skin of color patients. While prevalent, treatment options are limited and the benign course of DPNs may cause them to be overlooked by clinicians. However, large and multiple lesions in cosmetically sensitive areas may be emotionally and socially distressful to patients. There are few literature reviews examining treatment options for this condition. A literature search was performed using PubMed, Medline, Embase, and Web of Science databases. 67 articles were identified and 15 studies met the inclusion criteria. Our findings demonstrate that laser therapy is becoming increasingly utilized as a safe and efficacious treatment for DPNs in skin of color patients. J Drugs Dermatol. 20(4):467-472. doi:10.36849/JDD.2021.5555.

Novel Treatment of In-Transit Metastatic Melanoma With Shave Excision, Electrodesiccation and Curettage, and Topical Imiquimod 5% Cream

In-transit metastatic melanoma is classified as a regional intralymphatic metastasis of melanoma. Currently, there is no standardized regimen used to treat in-transit metastatic melanoma, and therapy is individualized based on the patient. While many patients undergo surgical procedures, those with surgical contraindications or declination face challenges when attempting to find adequate treatment options. This case report demonstrates the successful treatment of multiple in-transit metastatic melanoma lesions using the combination of shave excision, electrodesiccation and curettage, and topical imiquimod cream. Several months later, examination showed clinical resolution of the original metastatic lesions. This treatment regimen may provide an alternative option for a select group of patients with certain comorbidities and therapeutic contraindications. J Drugs Dermatol. 20(5):555-557. doi:10.36849/JDD.5675.

A Comparison of Ultrasound Guided Curettage With and Without Uterine Artery Embolization on Controlling Intraoperative Blood Loss for a Cesarean Scar Pregnancy Treatment: Study Protocol for a Randomized Clinical Trial

Introduction

Cesarean scar pregnancy affects 6% of all ectopic pregnancies in women with prior cesarean section, and there is currently no consensus on the optimal treatment. Options of surgical treatment have a risk of intraoperative blood loss; therefore, uterine artery embolization (UAE) has been considered as an option of reducing intraoperative blood loss. However, UAE may be overused in clinical practice, especially in China. We present this protocol for a randomized clinical trial investigating the necessity of performing UAE for cesarean scar pregnancy, in combination with surgical suction curettage, taking into account the different subtypes of cesarean scar pregnancy. We recently developed a risk-scoring system (QRS) to estimate intraoperative blood loss, with 93.8% sensitivity and 6.3% false negative. Through this randomized clinical trial, we will retrospectively validate the QRS score on predicting intraoperative blood loss.

Methods and Analysis

We propose undertaking a randomized clinical trial sequentially recruiting 200 patients. All the patients will randomly receive ultrasound guided curettage with or without UAE. Data on the subtypes of cesarean scar pregnancy (Types 1 and II and III) detected by ultrasound will be collected before operation. The score on estimating intraoperative blood loss assessed by our recently developed quantitative risk-scoring system (QRS) will be collected before the operation. We will primarily compare the duration of the operation, intraoperative blood loss, and complications between the two groups. We will also retrospectively analyze the association of subtypes of cesarean scar pregnancy and the options of treatment and validate the QRS score. Outcomes of subsequent pregnancy within the 2-year follow-up will be secondary outcomes.

Trial Registration Number

[website], identifier ChiCTR2100041654.

Giant Cell Tumor of Bone in the Talus Treated by Extended Curettage and Synthetic Bone SubstituteReport of a Rare Case

Giant cell tumor of bone is extremely rare in the talus and is usually observed in the third decade of life. Herein, we report a case of a 19-year-old male with a giant cell tumor of bone in the talus mimicking a simple bone cyst that was treated by intralesional curettage and, for the first time, bone grafting with a synthetic bone substitute. The patient had no evidence of recurrence at 7-year follow-up but did have non-progressing mild degenerative joint disease and slightly limited range of movement at the ankle joint.

Actinic Keratoses: Reconciling the Biology of Field Cancerization with Treatment Paradigms

This Perspective briefly reviews the relationship between UV-induced mutations in habitually sun-exposed human skin and subsequent development of actinic keratoses (AKs) and skin cancers. It argues that field therapy rather than AK-selective therapy is the more logical approach to cancer prevention and hypothesizes that treatment early in the process of field cancerization, even prior to the appearance of AKs, may be more effective in preventing cancer as well as more beneficial for and better tolerated by at-risk individuals. Finally, the Perspective encourages use of rapidly advancing DNA analysis techniques to quantify mutational burden in sun-damaged skin and its reduction by various therapies.

Mid-term results of intralesional extended curettage, cauterization, and polymethylmethacrylate cementation in the treatment of giant cell tumor of bone: A retrospective case series

OBJECTIVE

The aim of this study was to present the mid-term functional outcomes and recurrence rate in patients with giant cell tumor of bone (GCTB) treated by intralesional extended curettage, electrocauterization, and polymethylmethacrylate (PMMA) cementation.

METHODS

In this retrospective observational study, 79 consecutive patients (41 females, 38 males; mean age=39 years; age range=19-62 years) who were diagnosed and treated for GCTB between 2005 and 2017 were identified from hospital medical records. All patients were treated by intralesional extended curettage using high-speed burr, electrocauterization of the cavity, and filling the defect with PMMA. No additional local adjuvants were used. The mean follow-up period was 47 months (range=24-96). The tumors were graded according to the radiological classification system described by Campanacci. Functional outcomes were evaluated using the Musculoskeletal Tumor Society Score (MSTS) preoperatively, one year postoperatively, and at the final follow-up. Postoperative complications and recurrence rates were recorded.

RESULTS

Twenty-nine tumors were located in the distal femur, 23 in the proximal tibia, nine in the distal radius, five in the proximal humerus, five in the pelvis, three in the proximal fibula, two in the distal ulna, two in the distal tibia, and one in the second metatarsal. According to Campanacci classification, 37 tumors were grade III, 32 grade II, and 10 grade I. The mean MSTS score was 46.1% (range 40.2 to 71.4%) preoperatively, 91.7% (range 73.3% to 100%) one year postoperatively, and 86.3 % (range 66.2% to 96,1%) at the final follow-up. The overall complication rate was 7.6%; which included local tumor recurrence in four patients, superficial wound infection in one, and deep wound infection in another. The recurrence rate was 5.1% (4 patients). Recurrent tumors were located at the distal femur in three patients and proximal tibia in one.

CONCLUSION

With satisfactory functional results and low recurrence rates at the mid-term follow-up, GCTB can be treated effectively with intralesional extended curettage, electrocauterization, and PMMA cementation.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Cold versus hot adenoidectomy: A prospective, randomized controlled trial

OBJECTIVE

Adenoidectomy can be performed using the cold method (mainly adenoid curettes) or the hot method (suction diathermy). Both techniques have similar intra and postoperative outcomes. However, the long-term clinical outcome of improving sleep disorder symptoms has not been well established. The objective of this study was to compare outcomes of hot method and cold method adenoidectomy one year following the surgery.

STUDY DESIGN

A prospective, randomized, single-blinded study of children under age 16 years who underwent adenoidectomy during the years 2014-2017. Patients were randomized to hot or cold adenoidectomy techniques.

SETTING

A tertiary health care referral center.

SUBJECTS AND METHODS

The final analysis included 58 children, mean age 5.9 years (range 1.2-15). The primary outcome was change in the Pediatric Sleep Questionnaire (PSQ) scores one month and one year after surgery. The secondary outcome was complication rate.

RESULTS

Clinical and demographic parameters were similar between the patients in the hot method group (n = 30) and the cold method group (n = 28). Adenoid size and estimated bleeding were similar between the groups. At one month after surgery, PSQ score was improved by a mean + 0.31 in the hot method group compared to +0.32 in the cold method group (p = 0.54). Improvement in PSQ scores was greater following hot than cold adenoidectomy at one year after surgery (+0.31 points vs. +0.22 points, p = 0.009).

CONCLUSION

Hot adenoidectomy is associated with better outcome than the cold technique, as reflected by PSQ scores one year after the surgery.

Cytology and curetting diagnosis of endocervical adenocarcinoma

INTRODUCTION

Papanicolaou testing is effective in identifying squamous intraepithelial lesions of the cervix. Endocervical adenocarcinoma (EAC) and adenocarcinoma in situ (AIS) are far less commonly identified. Endocervical curettings (ECCs) are usually obtained after colposcopic biopsy, sample the endocervical canal, and aid in the detection of endocervical glandular lesions. Here, we examine the utility of Papanicolaou testing and endocervical curetting for detecting AIS and EAC.

MATERIALS AND METHODS

Cases from 2007 to 2019 with a histologically confirmed diagnosis of AIS and EAC were identified and the clinical data and diagnostic material, including the cytology and surgical specimens, obtained.

RESULTS

A total of 108 cases of AIS and EAC were identified, Papanicolaou tests were performed in 97 of these cases, and ECC in 87. AIS or EAC were detected in 46.4% of Papanicolaou tests; 41.4% of ECC showed AIS or EAC. A total of 92.7% of cases were positive for high-risk human papillomavirus (HPV) and concurrent squamous intraepithelial lesion was present in 53.3% of cases. AIS or EAC were more commonly identified in cases without concurrent squamous intraepithelial lesions.

CONCLUSIONS

Papanicolaou testing and endocervical curettings have a low detection rate for AIS and EAC. The majority of AIS and EAC cases test positive for high-risk HPV. Papanicolaou test and ECC show different detection rates and are complementary tools in patients with AIS and EAC. In some settings, an ECC can increase the diagnostic sensitivity and specificity of the pathologic diagnosis.

Cost-effectiveness of second curettage for treatment of low-risk non-metastatic gestational trophoblastic neoplasia

OBJECTIVE

Low-risk non-metastatic gestational trophoblastic neoplasia (GTN) has been treated with single agent chemotherapy, but second curettage is emerging as an alternative strategy with reported cure rates of 40%. We sought to estimate the cost-effectiveness of second curettage as the first line treatment of low-risk GTN.

METHODS

A decision-analytic model was created using TreeAge software to compare costs and outcomes for women with WHO staged low-risk GTN undergoing treatment with 5-day methotrexate (MTX), biweekly pulsed actinomycin-D, or second curettage. Probabilities were derived from the literature. Outcomes of interest included side effects from chemotherapy, need for additional agents, hemorrhage, uterine perforation, and cure rates. Utilities were applied to discounted life expectancy at a rate of 3% to generate quality adjusted life years (QALYs). Sensitivity analyses were then performed in order to assess the robustness of our assumptions.

RESULTS

Of the three treatment arms, MTX was associated with the lowest cost and had similar QALYs to the other studied modalities. Second curettage was associated with 49 additional cures when applied to a theoretic cohort of 1000 women, as well as an additional 83 hemorrhages and 17 uterine perforations. Sensitivity analysis on the cure rate of second curettage revealed that second curettage was not cost-effective over MTX unless its probability of cure was 98%.

CONCLUSION

Our study found 5-day MTX was the cost-effective strategy for treatment of women with low-risk, non-metastatic GTN when compared to second curettage and actinomycin-D. In a carefully selected patient population, second curettage may be an additional treatment strategy.

Femoral pseudotumor secondary to injury in a patient with idiopathic thrombocytopenic purpura: Case report

RATIONALE

Idiopathic thrombocytopenic purpura (ITP) is the condition of having a low platelet count of unknown causes and is a poorly understood acquired hemorrhagic disease involving destruction of platelets in the reticuloendothelial system induced by antiplatelet antibodies. Patients with ITP can have traumatic intra-articular, intraosseous or soft tissue hemorrhage which may present as a rare intraosseous pseudotumor on medical imaging.

PATIENT CONCERNS

A 30-year old male patient had complaint of pain in the right leg for 1 year. Laboratory test revealed a much lower platelet count (3-12 × 10/L).

DIAGNOSES

Radiography and computed tomography showed expansive bone destruction in the distal segment of the right femur, and magnetic resonance imaging revealed heterogeneous signal intensity in the lesion. Lesion curettage and pathology showed an expansion cyst with a really thin cortical bone shell containing serum-like red liquid and some sediment-like deposit. Consequently, the diagnosis of a pseudotumor was confirmed.

INTERVENTIONS

Lesion curettage and bone graft surgery were performed, and 8 units of platelet were transfused to the patient. Giant cell reaction was found on the shell of the lesion, but no tumor cell was found on pathological examination.

OUTCOMES

The platelet count was 308 × 10/L 5 days after operation, and the clotting time was normal. At 6 month follow-up after lesion curettage, the patient remained normal with no deterioration in the lesion site.

CONCLUSION

The diagnosis of a pseudotumor of ITP relies mainly on imaging findings of the lesion and, in particular, knowledge of the underlying bleeding disorders. Radiologist and pathologist should be aware of the characteristics of this rare complication of ITP and other bleeding disorders like hemophilia in order to avoid misinterpretation of the lesion as a tumor or infection disease.

Evaluation of a routine second curettage for hydatidiform mole: a cohort study

OBJECTIVE

The aim of this study was to evaluate routine second curettage for hydatidiform mole (HM) by comparing the characteristics and outcomes of developing gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

This was a cohort study including 173 patients diagnosed with HM between January 2002 and August 2019 who were followed up at Nagoya University Hospital, Japan. After an evacuation, 105 and 68 patients were managed with the routine method (routine group) and elective method (elective group) for a second curettage, respectively. The routine second curettage was performed around 7 days after the first evacuation. Patients in the elective group underwent a second curettage if there was ultrasonographic evidence of molar remnants in the uterine cavity. Socio-clinical factors were retrospectively compared between the routine and elective groups, and between patients showing regression and those who developed GTN.

RESULTS

The incidence of GTN was 15.2% in the routine group and 20.6% in the elective group, and the difference was not significant (P = 0.364). The median GTN risk score was significantly higher in the routine group than in the elective group (P = 0.033). Presence of a complete HM, gestational age, and a pre-treatment human chorionic gonadotropin level of ≥ 200,000 mIU/mL were independent risk factors for GTN in molar patients.

CONCLUSION

The incidence of GTN was unchanged but the risk score of GTN was higher in the routine group than in the elective group. Routine second curettage may not be necessary, but further study will be needed to confirm this.

Primary cutaneous biphasic sarcomatoid basal cell carcinoma with myoepithelial carcinoma differentiation: A new variant

Isolated cases of basal cell carcinoma (BCC) with partial myoepithelial component have been described. However, myoepithelial differentiation has not been described in sarcomatoid basal cell carcinomas, which usually show features resembling osteosarcoma, chondrosarcoma, or leiomyosarcoma. We report a case of an 87-year-old man with a forehead lesion that histologically showed a minor component of conventional nodular BCC in transition with a major biphasic sarcomatoid growth composed of invasive spindle-cell and epithelial-like components, the latter with a reticular pattern and scattered ductal structures. Both components showed cytological atypia and high mitotic rate (26/10HPF), with atypical mitotic figures. BER-EP4 immunostaining was exclusively found in the nodular BCC component whereas the sarcomatoid component revealed immunostaining for α-smooth muscle actin (SMA), muscle-specific actin (MSA), calponin, and p63 in both epithelial-like and spindle-cell populations. Focal immunoreactivity was observed in the epithelial component for S100 and glial fibrillary acidic protein (GFAP). Furthermore, EWSR1-PBX1 gene fusion was also detected. This is to our knowledge, the first fully documented case of biphasic sarcomatoid BCC with myoepithelial carcinoma differentiation.

Review of 16 cases of aneurysmal bone cyst in the proximal femur treated by extended curettage and cryosurgery with reconstruction using autogenous nonvascularized fibula graft

BACKGROUND

Aneurysmal bone cyst (ABC) is an aggressive benign lesion that may sometimes be difficult to treat. Lesions that occur in the proximal femur require to be addressed aggressively because of the high rate of local recurrence and the risk of fracture. Few articles report the experience of management of ABC in the proximal femur. This location presents a surgical challenge due to its anatomical and biomechanical peculiarity.

METHODS

We retrospectively reviewed 16 cases with ABC in the proximal femur that were treated in our institution between 2005 and 2014, utilizing extended curettage and liquid nitrogen as adjuvant therapy and reconstruction using nonvascularized autogenous fibular strut graft. The mean follow-up period was 50.5 months. Five cases presented as recurrent cases, while four cases presented with pathological fractures.

RESULTS

The functional score ranged from 70 to 90 on modified Musculoskeletal Tumor Society score with a mean score of 81.25, which is considered to be excellent function. Time for graft incorporation ranged from 10 to 12 weeks. One case got local recurrence, and one case got early surgical site infection.

CONCLUSIONS

Extended curettage and cryotherapy represent a recommended approach for management of ABC in the proximal femur with favorable results.

Curettage as first surgery for bone giant cell tumor : adequate surgery is more important than oncology training or surgical management by high volume specialized teams

We reviewed the files of 203 patients with extremities GCTB treated with curettage as first surgery from 1990 to 2013. Median follow-up was 84.2 months. We evaluated whether the years of practice and training in orthopaedic oncology are associated with local recurrences, function and complications after curettage as first surgery for giant cell tumour of bone (GCTB). Local recurrences were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Function was not significantly different between orthopaedic oncology trained and non-trained surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. The only important univariate and multivariate predictor for local recurrence was PMMA adjuvant. Complications were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Curettage may be effectively performed as first surgery for GCTB by early-career (< 10 years of practice) non-trained orthopaedic oncology orthopaedic surgeons. PMMA adjuvant is recommended after appropriate curettage.

Comparison of curettage and bone grafting combined with elastic intramedullary nailing vs curettage and bone grafting in the treatment of long bone cysts in children

To compare the efficacy of curettage and bone grafting combined with elastic intramedullary nailing (EIN) vs curettage and bone grafting in the treatment of long bone cysts in children and to clarify the necessity of using EIN in the treatment of bone cysts.Sixty-two patients were involved in this study from Jan. 2009 to Sept. 2017 (43 males, 19 females; 27 humeri, 35 femurs); the patients were assigned to an EIN group, comprising 30 patients who underwent curettage and bone grafting combined with EIN, or to a non-elastic intramedullary nailing (NEIN) group, comprising 32 patients who underwent curettage and bone grafting alone. The prognosis of the 2 groups was assessed with reference to the standard of Capanna.No statistically significant differences in sex, age, location, activity, pathological fracture, cyst volume, operative time and intraoperative blood loss were found between the 2 groups (P > .05). The effective rate was 90.0% in the EIN group and 68.8% in the NEIN group, and the difference was statistically significant (P < .05).Compared to simple curettage and bone grafting, curettage and bone grafting combined with EIN treatment can significantly improve the prognosis of children with bone cysts. It is recommended that EIN be added to bone cyst curettage and bone grafting.

Intralesional treatment versus wide resection for central low-grade chondrosarcoma of the long bones

BACKGROUND

Grade I or low-grade chondrosarcoma (LGCS) is a primary bone tumour with low malignant potential. Historically, it was treated by wide resection, since accurate pre-operative exclusion of more aggressive cancers can be challenging and under-treatment of a more aggressive cancer could negatively influence oncological outcomes. Intralesional surgery for LGCS has been advocated more often in the literature over the past few years. The potential advantages of less aggressive treatment are better functional outcome and lower complication rates although these need to be weighed against the potential for compromising survival outcomes.

OBJECTIVES

To assess the benefits and harms of intralesional treatment by curettage compared to wide resection for central low-grade chondrosarcoma (LGCS) of the long bones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE and Embase up to April 2018. We extended the search to include trials registries, reference lists of relevant articles and review articles. We also searched 'related articles' of included studies suggested by PubMed.

SELECTION CRITERIA

In the absence of prospective randomised controlled trials (RCTs), we included retrospective comparative studies and case series that evaluated outcome of treatment of central LGCS of the long bones. The primary outcome was recurrence-free survival after a minimal follow-up of 24 months. Secondary outcomes were upgrading of tumour; functional outcome, as assessed by the Musculoskeletal Tumor Society (MSTS) score; and occurrence of complications.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recognised by Cochrane. We conducted a systematic literature search using several databases and contacted corresponding authors, appraised the evidence using the ROBINS-I risk of bias tool and GRADE, and performed a meta-analysis. If data extraction was not possible, we included studies in a narrative summary.

MAIN RESULTS

We included 18 studies, although we were only able to extract participant data from 14 studies that included a total of 511 participants; 419 participants were managed by intralesional treatment and 92 underwent a wide resection. We were not able to extract participant data from four studies, including 270 participants, and so we included them as a narrative summary only. The evidence was at high risk of performance, detection and reporting bias.Meta-analysis of data from 238 participants across seven studies demonstrated little or no difference in recurrence-free survival after intralesional treatment versus wide resection for central LGCS in the long bones (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.92 to 1.04; very low-certainty evidence). MSTS scores were probably better after intralesional surgery (mean score 93%) versus resection (mean score 78%) with a mean difference of 12.69 (95% CI 2.82 to 22.55; P value < 0.001; 3 studies; 72 participants; low-certainty evidence). Major complications across six studies (203 participants) were lower in cases treated by intralesional treatment (5/125 cases) compared to those treated by wide resection (18/78 cases), with RR 0.23 (95% CI 0.10 to 0.55; low-certainty evidence). In four people (0.5% of total participants) a high-grade (grade 2 or dedifferentiated) tumour was found after a local recurrence. Two participants were treated with second surgery with no evidence of disease at their final follow-up and two participants (0.26% of total participants) died due to disease. Kaplan-Meier analysis of data from 115 individual participants across four studies demonstrated 96% recurrence-free survival after a maximum follow-up of 300 months after resection versus 94% recurrence-free survival after a maximum follow-up of 251 months after intralesional treatment (P value = 0.58; very low-certainty evidence). Local recurrence or metastases were not reported after 41 months in either treatment group.

AUTHORS' CONCLUSIONS

Only evidence of low- and very low-certainty was available for this review according to the GRADE system. Included studies were all retrospective in nature and at high risk of selection and attrition bias. Therefore, we could not determine whether wide resection is superior to intralesional treatment in terms of event-free survival and recurrence rates. However, functional outcome and complication rates are probably better after intralesional surgery compared to wide resection, although this is low-certainty evidence, considering the large effect size. Nevertheless, recurrence-free survival was excellent in both groups and a prospective RCT comparing intralesional treatment versus wide resection may be challenging for both practical and ethical reasons. Future research could instead focus on less invasive treatment strategies for these tumours by identifying predictors that help to stratify participants for surgical intervention or close observation.

Extraperiosteal segmental excision for osteofibrous dysplasia of tibia with reconstruction by liquid nitrogen-treated recycled autograft

BACKGROUND

Osteofibrous dysplasia usually progresses until ten years of age and occasionally regresses spontaneously after puberty. Patients with osteofibrous dysplasia usually require close observation. Surgery is an option considered only for extensive, deforming lesions and those with pathological fractures and rapid progression prior to puberty. If surgery is indicated, the traditional intra-lesional curettage or subperiosteal resection usually leads to high recurrence. Hence, extraperiosteal wide excision and various methods of reconstruction after resection have been advocated for this lesion. We reviewed the clinical results of patients managed with extraperiosteal segmental excision and reconstruction by liquid nitrogen-treated tumor-bearing autograft combined with allograft.

METHODS

From January 2010 to December 2014, twelve patients with final diagnosis of tibial osteofibrous dysplasia were studied retrospectively. All these patients were treated with extraperiosteal segmental excision and reconstruction by liquid nitrogen-treated tumor-bearing autograft combined with allograft.

RESULTS

The patient group consisted of 5 males and 7 females, with a median age of 13 years (6-24 years). 3 lesions were located in left tibia and 9 in right. The median length of resected segment was 8 cm (5-11 cm). The patients were followed for 36-84 months (median 52 months). Follow-up radiographs showed that the median time for complete union of the grafted bone was 9 months (6-15 months). There was no evidence of recurrence. All patients had full range of motion in the knee and ankle joints after surgery.

CONCLUSIONS

Extraperiosteal segmental excision for osteofibrous dysplasia of tibia with reconstruction by liquid nitrogen-treated recycled autograft and allograft is a good surgical option to prevent recurrence and fill bone defects in this rare lesion.

Combination of CO2 laser therapy and curettage for sebaceous gland hyperplasia

INTRODUCTION

Sebaceous hyperplasia (SH) is a common cutaneous disorder associated with cosmetic problems. Some optional treatments and various laser devices have been reported to be effective, but recurrence and cosmetic outcome have not been resolved.

METHODS

This interventional study was performed on SH lesions. First, the lesions were treated with a CO₂ laser, and then the shrunken lesions were removed with a fine, sharp curette.

RESULTS

A total of 46 patients (32 females and 14 males, mean age 39.9 ± 5.7 years) with SH skin lesions varying in severity were included in this study. The mean time of repair was 11.5 ± 1.9 days; a shorter repair time was seen in females and for mild extension lesions (p < 0.001). A fair cosmetic outcome was seen in 76.1% of cases, with better results reported for females and for skin types II and III (p < 0.001).

CONCLUSIONS

The method reported herein is an easy, rapid, and effective procedure for the complete removal of SH lesions with few complications in the majority of patients with numerous lesions and Fitzpatrick skin types II-IV. Cosmetic outcomes are better in females and skin types II and III.

ECONOMIC EFFECTIVENESS OF DIFFERENT METHODS OF ANESTHESIA OF CURETTAGE OF UTERINE CAVITY

Anesthesia of curettage of uterine cavity (CUC) at postoperative period causes additional expenses. Preventive intraoperative anesthesia makes it possible to reduce these expenses and provide significant positive economic effect on state budget. The objective of this research is determination of influence of different methods of anesthesia of CUC on cash value of anesthetic maintenance of CUC and the possibility of saving of budgetary funds. 128 women took part in the research. They underwent the procedure of CUC. Anesthetic maintenance was performed using different medicamental combinations and their dosages. Mathematical calculation of the cost of each CUC stage was done considering the cost of consumables, medical preparations and value of labor of medical staff. In the course of this research, it was proven that a combination of additional use of dexketoprofen (at the stage of premedication of CUC) and performing preventive intraoperative applicational anesthesia with bupivacaine solution can save 130 452,26UAH of wage fund per year and general budget savings within the confines of a state can each 9 954 617,67UAH per year.

Clinical analysis of uterine artery embolization combined with double balloon catheter plus curettage for patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester: Three case reports

RATIONALE

It is very difficult to treat patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester.

PATIENT CONCERNS

In this study, case 1 was with fetal malformation of 18-trisomy syndrome at gestation of 19 weeks + 2 days, case 2 was with fetal malformation of 18-trisomy syndrome at gestation of 22 weeks + 1 day, and case 3 was for intrauterine fetal death at gestation of 27 weeks. All the 3 cases were completely placenta previa.

DIAGNOSES

For the 3 patients, completely placenta previa was confirmed by ultrasound examination after hospitalization and underwent pregnancy termination for fetal death or fetal malformation in the 2nd trimester.

INTERVENTIONS

The 3 patients with placenta previa underwent pregnancy termination by mifepristone combined with ethacridine lactate in the 2nd trimester for intrauterine fetal death or fetal malformation from June 2017 to May 2018, and suffered antenatal massive hemorrhage during termination. Uterine artery embolization (UAE) was immediately performed to achieve hemostasis, then double balloon catheter (DBC) was carried out to promote cervical ripen, at last curettage was implemented with the help of ultrasound. After all these procedures, the clinical outcomes were observed.

OUTCOMES

The antenatal bleeding volume of these 3 patients were about 500, 600, and 550 mL. After implementing the combined treatment, all patients completed the abortion. The UAE-DBC time interval and DBC-curettage time interval were 58.4 and 6.0 hours, respectively, for case 1, whereas almost 0 (i.e., immediately) for cases 2 and 3. Case 1 had a fever lasting for 3 days, and the maximum body temperature was up to 39°C after UAE. Moreover, the blood culture was positive for Escherichia coli after curettage in case 1, whereas it was negative in the other 2 cases.

LESSONS

The UAE-DBC-curettage combined treatment is safe and effective for patients with placenta previa who undergo pregnancy termination and suffered massive antenatal hemorrhage in the 2nd trimester. Future studies are needed to advance our observation.

The influence of various methods of anesthesia on time of postoperative recovery of patients' conciousness after curettage of uterine cavity

OBJECTIVE

Introduction: Scientific information sources point to the significant effectiveness of curettage of uterine cavity (CUC) as a diagnostic and treatment mode of gynecologic oncology. Today the anesthesia service is able to satisfy virtually all the requirements of a surgeon and a female patient, however, some institutional factors, as for example postoperative recovery of consciousness, and factors influencing it, remain unaddressed. The aim: to explore the possibilities of influence of different combinations and dosages of medical preparations used to provide monitored anesthesia care of CUC, to change the time of postoperative recovery of patient's consciousness.

PATIENTS AND METHODS

Materials and methods: an interview of 96 patients by VAS, studies of cortisol, insulin and glucose levels in blood serum, measurements of time from the end of surgery to the awakening and complete recovery of consciousness and statistical processing of the results have been conducted.

RESULTS

Results: A combination of 50 mg of dexketoprofen and half-dose drugs for narcosis can hasten the postoperative wake-up time by 38%, while maintaining dosages can prolong by 37% on the contrary. There is a dose-dependent effect of drugs for narcosis on the time of full post-operative recovery of consciousness. The reduction of their dosages by half can reduce this time by almost 40%.

CONCLUSION

Conclusions: the dosage modification of anesthetic drugs and their combinations may have a significant effect on the time of postoperative awaking and complete recovery of consciousness in female patients after CUC. As a result, it has a positive physiological, psychological and social effect.

A novel subchondral bone-grafting procedure for the treatment of giant-cell tumor around the knee: A retrospective study of 27 cases

The vast majority of giant-cell tumors occur around the knee and characteristically affect the subchondral bone. Thermal damage to the articular cartilage arising from the application of polymethylmethacrylate (PMMA) or extensive intralesional curettage presents a challenging problem to orthopedic surgeons and patients due to compliance issues. For this reason, we developed a new subchondral bone-grafting procedure to restore massive bone defects and reduce degenerative changes in the knee.The aim of this study was to describe the novel subchondral bone-grafting procedure and evaluate clinical outcomes in patients with giant-cell tumors around the knee.This retrospective single-center study included a total of 27 patients with giant-cell tumors in the distal femur and proximal tibia admitted to our department from January 2012 to December 2015 and treated with aggressive intralesional curettage. Eleven males and 16 females were included. All cases underwent subchondral autograft bone grafting followed by bone cement reconstruction and instrument internal fixation. The Musculoskeletal Tumor Society (MSTS) score and short form-36 (SF-36) were applied to assess the functional outcome of the knee joint and quality of life. Tumor recurrence, Kellgren and Lawrence (KL) grade, and the distance of the cement to the articular surface were assessed throughout the sample.All cases were followed up after surgery for an average of 32.9 ± 7.1 months (range 25-57 months). At the end of the follow-up period, all patients were alive and free from pulmonary metastasis. Complications associated with this surgery occurred only in 1 patient (3.7%), who presented with an incision infection that resolved with regular dressing and antibiotics. No fractures, instrument breakage, or joint fluid leakage occurred. Local recurrence occurred in 1 case (3.7%) at the distal femur after 23 months and was treated by wide resection followed by prosthesis reconstruction. Twenty-four patients (89%) did not develop radiographic findings of osteoarthritis: at the final follow-up 2 patients (7.4%), had progressed to KL1 and 1 patient had progressed to KL2. According to the MSTS scoring system, the functional score of the affected knee joint at the last follow-up ranged from 80% to 97%, with an average of 87.3%. The quality of life parameters assessed by the SF-36 survey at the last follow-up ranged from 47 to 96, with an average of 77.For patients with giant-cell tumor of bone near the knee, subchondral bone grafting combined with bone cement reconstruction is recommended as a feasible and effective treatment modality.

Primary squamous cell carcinoma of the endometrium in a woman of perimenopausal age: A case report

RATIONALE

Primary squamous cell carcinoma of the endometrium (PSCCE) is a rare entity, and only sporadic cases have been reported in the literature since the 1st report in 1892. This report describes a case of a perimenopausal woman with PSCCE.

PATIENT CONCERNS

A 47-year-old, human papilloma virus type 16-positive, perimenopausal woman was admitted to our hospital with irregular vaginal bleeding for 6 months and secondary anemia.

DIAGNOSES

The patient was diagnosed with stage IIIc primary and moderately differentiated endometrial squamous cell carcinoma.

INTERVENTIONS

The patient underwent diagnostic curettage twice and cold knife conization (CKC). Following this total abdominal hysterectomy combined with bilateral adnexectomy and pelvic lymph node, dissection was performed. After the surgery, the patient was treated with radiotherapy and chemotherapy. Tumor markers were followed up regularly after the operation to monitor tumor recurrence and therapeutic effect.

OUTCOMES

Ninety-two days after the operation, there was tumor recurrence of the left pelvic cavity and the patient died after 11 months of follow-up.

LESSONS

Intrauterine pathology after the 1st diagnostic curettage suggests that high-grade squamous intraepithelial lesion should make the clinician vigilant and investigate the origin of the lesion. Magnetic resonance imaging scans and tumor markers can be used to confirm the diagnosis as soon as possible and avoid unnecessary interventions like CKC.