Complications of bone tumors after multimodal therapy

Purpose

To define and compare the complications of bone tumors after resection, extracorporeal irradiation and re-implantation, with or without radiotherapy.

Materials and methods

Eighty patients (40 males and 40 females, ages 4-77 years) with 61 malignant and 19 benign bone tumors were evaluated for local and distant complications after treatment. Two groups of patients were studied: (1) 53 patients had resection without (43 patients) or with external beam radiotherapy (RadRx) (10 patients) and (2) 27 patients underwent extracorporeal irradiation and re-implantation without (22 patients) or with RadRx (5 patients). Patient follow-up varied from 1 month to 13.63 years with mean follow-up of 4.7 years. Imaging studies included bone and chest radiography, spin echo T1- and T2-weighted (or STIR) magnetic resonance imaging (MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), computed tomography (CT) for thoracic and abdominopelvic metastases and 3-phase technetium-99m-labeled-methylene-diphosphonate (Tc99m MDP) scintigraphy for bone metastases.

Results

DCE-MRI differentiated the rapidly enhancing recurrences, residual tumors and metastases from the slowly enhancing inflammation, and the non-enhancing seromas and fibrosis. Recurrences, metastases (mainly to lung and bone), and seromas were greater than twice as frequent in patients after resection than after ECCRI. Although 11.3% of post-resection patients had residual tumor, no ECRRI-treated patient had residual tumor. In contrast, after ECRRI, infection was almost three times as frequent and aseptic loosening twice as frequent as compared with the post-resection patients. Bones treated with RadRx and/or ECRRI showed increased prevalence of fractures and osteoporosis. In addition, muscle inflammation was more common in the externally irradiated patient as compared with the patient who did not receive this therapy. However, another soft tissue complication, heterotopic ossification, was rare in the patient after RadRx, but 25.6% of patients after resection and 40.9% after ECRRI showed heterotopic ossification. Unusual complications after resection or ECRRI involved adjacent nerves with partial denervation, amputation neuroma, or entrapment (secondary to recurrence or fibrosis) after resection or ECRRI with or without RadRx. One patient developed a posterior tibial artery pseudoaneurysm after ECRRI.

Conclusions

Follow-up of patients with benign and malignant bone tumors demonstrated the efficacy of DCE-MRI for distinguishing rapidly enhancing viable tumor from the slowly enhancing or non-enhancing benign processes after different therapies. Although recurrences, residual tumors, metastases and seromas were more common after resection, fractures, osteoporosis, infection, and muscular atrophy predominated in the ECRRI-treated patient. RadRx further predisposed post-resection and post-ECRRI patients to develop fractures, osteoporosis and infection and was the major cause of persistent muscle inflammation at MRI. Because complications can evolve and resolve years after treatment, the patients with bone tumors, particularly sarcomas, must receive life-time multimodal imaging for maximal diagnosis and treatment.     

Cochlear re-implantation: lessons learnt and the way ahead

Conclusion A cochlear re-implantation procedure is undesirable; however, the cochlear implant surgeon may have to perform a re-implantation procedure occasionally for various reasons. Following standard techniques, implant performance comparable with primary implantation may be achieved. Objective To study the causes and outcomes of cochlear re-implantation in an Asian Indian population. Study design Retrospective analysis of clinical charts over an 18-year period with prospective follow-up of patients. Methods The charts of 534 patients, who underwent cochlear implant, at an Otorhinolaryngology institutional Centre, from January 1997 to January 2015 were studied. Of these, the charts of 18 patients who underwent cochlear re-implantation were studied. The causes and audiological and speech outcomes were analysed. Results Eighteen patients (3.4%) underwent cochlear re-implantation for various reasons. The commonest indication was device failure in seven patients (39%), followed by electrode extrusion in five (28%), trauma in three (11%), electrode migration in two (11%) and improper electrode placement in one (6%) patient. The audiological performance tests and speech tests either remained the same or improved from those achieved for patients undergoing primary implantation, in 87% patients.     

Uretero-neocystostomy in a swine model of kidney transplantation: a new technique

BACKGROUND: Swine constitute a well-characterized large animal model for kidney transplantation (K-Tx) although the uretero-neocystostomy represents a crucial aspect because of the very small caliber of the ureter and the mucosal susceptibility to the edema during surgical management. Besides infectious and occlusive complications limited the employment of a stent and the peculiar anatomy of the species prevents its removal without an operative approach. These features find an equivalent in children (<4 year old) candidates to urological surgery. We investigated an uretero-neocystostomy technique to be applied in case of narrow caliber without using endoluminal device. MATERIALS AND METHODS: Thirty unrelated large-white piglets, divided into three equal groups (n = 10) on the basis of the uretero-neocystostomy technique used, underwent K-Tx while receiving a double immunosuppressive regimen. We developed a direct uretero-neocystostomy (Direct) technique and compare this with the gold standard Lich-Gregoir (LG) and Leadbetter-Politano (LP) techniques. RESULTS: After 60 days, the ureteral complication rates were: group 1 (LG): 60% (6/10, three early and three late strictures); group 2 (LP): 40% (4/10, two leakages, one early stricture, and one isolated ureteral dilatation); group 3 (Direct): 10% (1/10, one isolated ureteral dilatation). No bacterial cystitis or nephritis occurred; retrograde cystograms were negative for refluxes in every group. CONCLUSIONS: The comparison between the old techniques and the new one (LG and LP versus Direct) showed a lower incidence of complications among the animals that underwent the new direct technique (P < 0.05). This technique could be applied clinically in selected pediatric cases either of transplantation or reflux.     

Effect of enamel matrix proteins (Emdogain') on healing after re-implantation of "periodontally compromised" roots. An experimental study in the dog

OBJECTIVE: The present experiment was performed to assess whether Emdogain applied on the root surface of extracted teeth or teeth previously exposed to root planning can protect the tooth from ankylosis following re-implantation. MATERIAL AND METHODS: The experiment included two groups of dogs, including five animals each. The root canals of all mandibular third premolars (3 P 3) were reamed and filled with gutta-percha. A crestal incision was placed from the area of the second to the fourth premolar. Buccal and lingual full thickness flaps were elevated. With the use of a fissure bur, the crown and furcation area of 3 P 3 were severed in an apico-coronal cut. The distal and mesial tooth segments were luxated with an elevator and extracted with forceps. Group A: The mesial and distal segments of 3 P 3 were air dried on a glass surface for 60 min. The roots from the right side were conditioned and exposed to Emdogain application. The roots from the left side received the same treatment with the exception of Emdogain application. The mesial and distal tooth segments were re-implanted and the crown portions were severed with a horizontal cut and removed. The buccal and lingual flaps were mobilized and sutured to obtain complete coverage of the submerged roots. Group B: A notch was prepared in each root, 4-5 mm apical of the cemento-enamel junction. The area of the root that was located coronal to the notch was scaled and planned. The roots in the right side of the mandible were treated with Emdogain, while the roots in the left side served as controls. After 6 months of healing, the dogs were killed and blocks containing one root with surrounding tissues were harvested, and prepared for histological examination, which also included morphometric assessments. Thus, the proportions of the roots that exhibited signs of (i) replacement (ii) inflammatory and (iii) surface resorption were calculated. RESULTS AND CONCLUSION: It was demonstrated that healing of a re-implanted root that had been extracted and deprived of vital cementoblasts was characterized by processes that included root resorption, ankylosis and new attachment formation. It was also demonstrated that Emdogain treatment, i.e. conditioning with EDTA and placement of enamel matrix proteins on the detached root surface, failed to interfere with the healing process.     

Pain phenomena and sensory recovery following brachial plexus avulsion injury and surgical repairs

Seventy-six patients with severe brachial plexus avulsion injuries were studied using pain questionnaires and quantitative sensory testing. There was significant correlation between pain intensity and the number of roots avulsed prior to surgery (P=0.0004) and surgical repairs were associated with pain relief. Sensory recovery to thermal stimuli was observed, mainly in the C5 dermatome. Allodynia to mechanical and thermal stimuli was observed in the border zone of affected and unaffected dermatomes in 18% of patients assessed early (<6 months) and 37% patients at later stages. Pain and sensations referred to the original source of afferents occurred at a later stage (>6 months) in 12% of patients and were related to nerve regeneration. By contrast, "wrong-way" referred sensations (e.g. down the affected arm while shaving or drinking cold fluids) were reported by 44% of patients and often occurred early, suggesting CNS plasticity. Understanding sensory mechanisms will help develop new treatments for severe brachial plexus injuries.     

21例合并气管狭窄肺动脉吊带患儿的治疗

目的：回顾性分析合并气管狭窄的肺动脉吊带患儿的治疗和预后,探讨单纯左肺动脉移植,避免气管成形术治疗策略的可行性。方法2009年4月至2015年11月,共有21例合并气管狭窄肺动脉吊带患儿在本单位接受手术治疗。其中6例患儿采用左肺动脉移植加气管干预手术策略。另外15例患儿采用左肺动脉移植、避免气管成型手术,术后采用早期拔管,无创CPAP过渡治疗策略。对所有患儿病例资料进行收集分析。结果21例合并气管狭窄患儿,男12例,女9例,年龄1个月~10岁,体重2.9~25.0 kg,术前均有中度至重度呼吸道症状,其中5例为重度,需要机械通气辅助呼吸。左肺动脉移植加气管干预手术患儿6例,存活出院1例,存活率16.7％;其中3例接受Slide气管成形术,2例气管吻合口肉芽组织增生,呼吸衰竭死亡;另外3例接受气管支架植入术,无存活。左肺动脉移植手术患儿共15例,采用经胸骨正中切口行左肺动脉移植术,存活出院13例,存活率86.7％;另外2例撤离呼吸机失败,体外膜肺辅助下行Slide气管成形术,术后气管吻合口愈合不良死亡。结论中、重度气管狭窄的肺动脉吊带患儿,采取左肺肺动脉移植,避免气管成形手术,术后早期拔除气管插管改无创CPAP过渡的治疗策略是可行的,预后也比较好,可以成为此类患儿的理想治疗策略。     

Tubular proteinuria in reflux nephropathy: post ureteric re-implantation

We studied urine protein excretion in 55 adults with reflux nephropathy (median age 26.9 years) who had had normal blood pressure, renal function and ureteric re-implantation in childhood. Urine retinol binding protein (RBP), N-acetyl-β-D-glucosaminidase (NAG), albumin, bacteriuria, systolic blood pressure, glomerular filtration rate (GFR), peripheral plasma renin activity (PRA) and the degree of renal scarring were measured in each subject; 20 had bilateral and 35 unilateral renal scarring; 5 were hypertensive and none were in renal failure. Urinary NAG and RBP excretions were significantly greater in the study group than in 34 healthy controls (median age 29.7 years). Within the study group, NAG excretion significantly correlated with PRA (P = 0.02). RBP excretion correlated with PRA, systolic blood pressure and the laterality (bilateral vs. unilateral) of scarring (P<0.01). Urinary albumin excretion correlated with systolic blood pressure (P = 0.03). We conclude that increased urinary protein, especially NAG and RBP excretion, occur late after ureteric re-implantation in reflux nephropathy independent of GFR. Its association with PRA supports the concept of segmental perfusion and filtration as an important mechanism that may explain the above findings. Received June 26, 1995; received in revised form and accepted March 6, 1996     

A retrospective clinical and radiologic study of teeth re-implanted following traumatic avulsion

Abstract Re-implantation is the recommended therapeutic procedure following traumatic exarticulation of teeth though its long-term prognosis remains controversial. The purpose of the following study was to evaluate the periodontal healing of 33 reimplanted incisors lost after trauma. The sample, which included 24 upper and 9 lower incisors, was divided in two groups: 15 teeth were reimplanted within 1 hour (=Group A) and 21 teeth after 3 hours or more (=Group B). The reimplanted teeth were followed for different radiographic evaluation periods up to 5 years (mean = 2–9 years). The results showed a high rate of periodontal healing in Group A (66.7%), while Group B demonstrated a high percentage (83.3%) of both inflammatory and replacement resorption. Thus, even if the whole sample was prevented from drying before reimplantation, the teeth were affected by different rates of root resorption. Among the various prognostic factors suggested by the literature, bacterial contamination during extra-alveolar storage seemed the most critical.