Extra-Capsular Spread of Lymph Node Metastasis in Oral, Oropharyngeal and Hypopharyngeal Cancer: A Comparative Subsite Analysis.

BACKGROUND: The extra-capsular spread (ECS) of lymph node metastasis (LNM) is a hallmark of aggressive primary tumor phenotype in head and neck cancer (HNC); however, the factors influencing ECS are poorly understood. PATIENTS AND METHODS: This was a retrospective study, including 190 cases of oral tongue cancer (OTC), 148 cases of oropharyngeal cancer (OPC) (118 HPV-positive and 30 HPV-negative), and 100 cases of hypopharyngeal cancer (HPC). Tumor dimension, tumor biological variables (lymphovascular/perineural invasion and histologic grade), and LNM variables (LNM number and size) were analyzed according to the presence of ECS using multivariable logistic regression and receiver operating characteristic (ROC) curve analyses. RESULTS: LNM variables were significant factors for ECS in all subsites of HNC (p < 0.05), except HPV-positive OPC. In OTC, tumor dimensional variables were significantly related to ECS (p < 0.01). Meanwhile, in OPC and HPC, neither the primary tumor dimension nor the T status were significant factors for ECS occurrence. The predictability of ECS by ROC curve using multiple variables was 0.819 [95% confidence interval: 0.759-0.878] in OTC, 0.687 [0.559-0.815] in HPV-positive OPC, 0.823 [0.642-1.000] in HPV-negative OPC, and 0.907 [0.841-0.973] in HPC. CONCLUSION: LNM variables were correlated with ECS occurrence for most HNC subsites, and site-dependent primary tumor characteristics might contribute differentially to the ECS development of LNM in HNC.

Extracapsular extension of pN2 lymph node metastases is not prognostically significant in surgically resected patients with non-small cell lung cancer.

Objectives: In patients with non-small cell lung cancer (NSCLC) the pathologic lymph node status N2 is a heterogeneous entity, with different degrees of lymph node involvement representing different prognoses. It is speculated whether extra capsular nodal extension may help to define a subgroup with implications on long-term survival. Methods: We retrospectively identified 118 patients with non-small cell lung cancer (65 men, 53 women), who were treated between 2013 and 2018 and found to have pathologic N2 lymph node involvement. In all patients lung resection with systematic mediastinal and hilar lymph node dissection was performed with curative intent. In N2 lymph node metastases capsules of affected lymph nodes were examined microscopically as to whether extracapsular extension was present. Results: 51 patients (43 %) had extracapsular extension (ENE). Most of these patients (n=35) only had ENE in a single lymph node (69 %). The overall 5-year survival rate was 24.6 % and progression-free survival rate 17.8 %. In the multivariate analysis OS was worse for patients with multiple affected pN2 stations, concurrent N1 metastases, increasing age, and larger tumor size. For the percentage of lymph nodes affected with ENE (of total examined) only a non-significant trend towards worse OS could be observed (p=0.06). Conclusions: Although we could not demonstrate significant prognostic differences between N2 extra capsular nodal involvement within our patient population, other analyses may yield different results. However, clinicians should continue performing thorough lymph nodes dissections in order to achieve local complete resection even in patients with extra capsular tumor spread.

Prognostic significance of extra-nodal extension and positive surgical margins in HPV positive oropharyngeal squamous cell carcinoma.

BACKGROUND: Whether extra-nodal extension (ENE+) and surgical margin positivity (margin+) are poor prognostic factors in HPV-associated (HPV+) oropharyngeal carcinoma (OPC) remains uncertain. RESULTS: Our study evaluated if microscopic ENE+ and/or margin+ are associated poorer recurrence free survival (RFS) and overall survival (OS) in HPV+ OPC. Patients were classified as high risk (ENE+ and/or margin+) or low risk (ENE- and margins-). Of a total of 176 patients HPV+ OPC, 81 underwent primary surgery and dad data on ENE and margin status. There was no statistically significant difference in RFS (p = 0.35) or OS (p = 0.13) for high-risk versus low-risk groups. Ongoing smoking (p = 0.023), alcohol use (p = 0.044) and advanced stage (p = 0.019) were associated with higher risk of recurrence. Only advanced stage (p-value <0.0001) was associated poorer overall survival. CONCLUSIONS: The presence of ENE+ and/or margin+ was not an independent predictor of poor RFS or OS in HPV+ OPC.

Association between Expression of Connective Tissue Genes and Prostate Cancer Growth and Progression.

To find an association between genomic features of connective tissue and pejorative clinical outcomes on radical prostatectomy specimens. We performed a retrospective analysis of patients who underwent radical prostatectomy and underwent a Decipher transcriptomic test for localized prostate cancer in our institution (n = 695). The expression results of selected connective tissue genes were analyzed after multiple t tests, revealing significant differences in the transcriptomic expression (over- or under-expression). We investigated the association between transcript results and clinical features such as extra-capsular extension (ECE), clinically significant cancer, lymph node (LN) invasion and early biochemical recurrence (eBCR), defined as earlier than 3 years after surgery). The Cancer Genome Atlas (TCGA) was used to evaluate the prognostic role of genes on progression-free survival (PFS) and overall survival (OS). Out of 528 patients, we found that 189 had ECE and 27 had LN invasion. The Decipher score was higher in patients with ECE, LN invasion, and eBCR. Our gene selection microarray analysis showed an overexpression in both ECE and LN invasion, and in clinically significant cancer for COL1A1, COL1A2, COL3A1, LUM, VCAN, FN1, AEBP1, ASPN, TIMP1, TIMP3, BGN, and underexpression in FMOD and FLNA. In the TCGA population, overexpression of these genes was correlated with worse PFS. Significant co-occurrence of these genes was observed. When presenting overexpression of our gene selection, the 5-year PFS rate was 53% vs. 68% (p = 0.0315). Transcriptomic overexpression of connective tissue genes correlated to worse clinical features, such as ECE, clinically significant cancer and BCR, identifying the potential prognostic value of the gene signature of the connective tissue in prostate cancer. TCGAp cohort analysis showed a worse PFS in case of overexpression of the connective tissue genes.

Propensity score matching analysis of adjuvant external-beam radiotherapy for the treatment of papillary thyroid carcinoma with other organ invasions.

PURPOSE: The role of adjuvant external-beam radiotherapy (EBRT) in the treatment of locally advanced papillary thyroid carcinoma (PTC) remains controversial due to the lack of prospective data and the conflicting retrospective data. This study aimed to determine the benefits of adjuvant EBRT in patients with PTC and other organ invasions using propensity score matching to reduce the heterogeneity of the patient population. METHODS: Data from patients with PTC with other organ invasions but no distant metastases who underwent surgery and adjuvant radioactive iodine (RAI) alone (Non-EBRT group) or adjuvant EBRT plus RAI (EBRT group) were retrospectively reviewed. Propensity matching was used to reduce heterogeneity. Survival outcomes and toxicities associated with EBRT were evaluated. RESULTS: Between January 2005 and December 2019, 102 patients in the Non-EBRT group and 26 patients in the EBRT group were evaluated. In the 48 propensity score-matched patients, no significant differences in baseline characteristics between the Non-EBRT and EBRT groups were detected. The locoregional recurrence-free survival (LRRFS) and recurrence-free survival (RFS) rates were significantly higher in the EBRT group compared with the rates in the Non-EBRT group (5y-LRRFS: 100% vs. 74%, p = 0.003, 5y-RFS: 91% vs. 74%, p = 0.035). EBRT was well-tolerated, with no grade ≥ 3 toxicity, and all patients completed the therapy as planned. CONCLUSION: Adjuvant EBRT plus RAI exhibited acceptable toxicity and improved LRRFS and RFS in patients with PTC with other organ invasions compared with RAI alone.

Long-term clinical outcomes and prognostic factors for patients with papillary thyroid carcinoma with other organ invasions after adjuvant radioactive iodine.

PURPOSE: Papillary thyroid carcinoma (PTC) with other organ invasions is directly related to patient prognosis and quality of life; however, studies on the clinical outcomes of adjuvant radioactive iodine (RAI) for PTC with other organ invasions are limited. This study aimed to clarify the clinical outcomes and prognostic factors for patients with PTC with other organ invasions after adjuvant RAI. METHODS: Patients with PTC with other organ invasions without distant metastases who underwent surgery and adjuvant RAI were retrospectively reviewed. We evaluated the initial responses based on the American Thyroid Association guidelines and survival rates. Prognostic factors for locoregional recurrence-free survival (LRRFS) were analyzed. RESULTS: Between January 2005 and December 2019, 102 patients were included in the study. Their median age was 55 years. The median follow-up duration was 92 months (range; 30-231 months). The excellent response rate after RAI was 42%. The 7-year overall survival, LRRFS, and recurrence-free survival rates were 100%, 75%, and 75%, respectively. Metastatic lymph node size, resection margin status, and post-RAI suppressed thyroglobulin level were the independent prognostic factors for LRRFS. CONCLUSION: We demonstrated that 75% of patients with PTC with other organ invasions could achieve long-term survival without recurrence after adjuvant RAI. Future development of effective treatment strategies for large metastatic lymph nodes, gross residual tumors, and high serum thyroglobulin levels is warranted.

Predictors of Occult Neck Metastasis and Extra Capsular Spread in Early Oral Cancers.

To investigate the incidence of occult neck metastasis and to determine the prognostic factors related to the occurrence of the cervical lymph nodal metastasis and extra capsular extension (ECE) in early oral cavity cancer patients. A retrospective review performed on 100 patients with node negative squamous cell carcinoma of oral cavity who underwent primary treatment between Jan 2015 and Dec 2018. Incidence of occult neck metastasis after the elective neck dissection in our study was 35%. Independent correlates of positive occult neck metastasis were lymphovascular Invasion (P-0.000)[CI 0.004-0.326] and depth of invasion(P-0.009)[CI 0.509-13.428] on univariate analysis and statistically significant factors associated with the incidence of the extracapsular extension were age(P-0.044), lymphovascular invasion(P-0.018)[CI 0.004-0.603] and lymph node ratio(P-0.000)[CI 4.570-158.45] on univariate analysis. Lymphovascular invasion and depth of invasion correlated significantly with occurrence of neck metastasis. Age and LVI were the prognostic factors for extra capsular spread.

Evolution of manual small-incision cataract surgery from 8 mm to 2 mm - A comprehensive review.

Cataract is the most common cause of reversible blindness worldwide, accounting for approximately 50% of blindness worldwide. Cataract surgery is the most common surgical procedure performed in routine ophthalmic practice. It has undergone tremendous evolution, and the incision size has progressively reduced from 10-12 mm in extracapsular cataract surgery (ECCE) to 6-8 mm for manual small-incision cataract surgery (MSICS) and 2.2-2.8 mm in phacoemulsification. In a developing country like India, with a massive backlog of cataract, everyone cannot afford private surgery like phacoemulsification. Moreover, annual maintenance of the machine, cost of foldable IOLs, need for greater skill, learning curve, and difficulty in performing the surgery in mature and brown cataracts are other barriers. Due to these factors, MSICS is the surgery of choice in the developing world, with profound societal and economic benefits and similar visual recovery compared to phacoemulsification. During the last two decades, MSICS gained popularity in developing countries and has undergone tremendous advances. This article aims to review the various techniques of MSICS and how the surgery has evolved over the years, particularly focusing on the current technique of 2-mm MSICS.

Modified iliotibial band tenodesis versus lateral extracapsular tenodesis, to augment anterior cruciate ligament reconstruction: a 2-year randomized controlled trial.

BACKGROUND: Residual instability following anterior cruciate ligament (ACL) reconstruction is associated with disruption of the anterolateral complex (ALC). Our goal was to conduct a randomized controlled trial comparing the effectiveness of modified Iliotibial tenodesis (MITBT) versus lateral extracapsular tenodesis (LET) to correct this residual instability. METHODS: Group 1 underwent MITBT, Group 2 LET, added to the ACL reconstruction. Outcomes of interest were Tegner activity Scores (TAS), international knee documentation committee score (IKDC), knee osteoarthritis outcome score (KOOS), ACL related quality of life (ACL QoL), recurrent ACL rupture and meniscal tears. Follow-up was 2 years. Statistical analysis used chi-squared tests, frequency statistics and generalized linear models. We have followed the guidelines outlined in the CONSORT statement. RESULTS: A total of 164 patients were randomized, 84 to Group 1, 80 to Group 2. Group 1 had higher TAS than Group 2, at 2 years (median 8, range 7-10 vs. median 7, range 5-9, P<0.001). Group 1 had higher ACL QoL scores at 1 and 2 years post-surgery (82.1, SD2.7 vs. 67.9, SD 4.0, P< 0.001 and 82.5, SD 2.6 vs. 68.8, SD 3.8, P<0.001, respectively), and higher KOOS Sport/recreation subscale at both 1 and 2 years (91.5, SD4.3 vs. 78.3, SD7.9, P<0.001 and 91.8, SD4.8 vs. 80.4, SD 9.5, P<0.001). Risk of recurrent ACL rupture (0% vs. 5%, P = 0.040-0.05) and medial meniscal tear (2.4% vs. 14%, P = 0.007-0.02) were lower in Group 1. CONCLUSION: Augmentation of ACL reconstruction with the MITBT, rather than the LET, was associated with improved outcomes, and lower risks of recurrent ACL rupture and medial meniscal tears.

Endoscopic extra-capsular resection of a giant pituitary adenoma: how I do it.

BACKGROUND: Giant pituitary adenomas are characterized by their large size and potential to invade parasellar and suprasellar regions leading to visual decline and hypopituitarism. Thus, they remain a significant surgical challenge, and gross total removal is only achieved in the minority of cases. METHOD: We aim to describe the key surgical steps for endoscopic extra-capsular resection of a giant pituitary adenoma with the aim of achieving complete tumor resection with description of the relevant surgical anatomy, indications and limitations. CONCLUSION: Endoscopic extra-capsular resection of giant pituitary tumors when feasible allows for complete tumor resection, early identification of the gland and avoidance of manipulation of the optic apparatus.

Comparison of outcomes after different methods of fixation for extracapsular hip fractures: An observational study.

OBJECTIVE: Optimal management of intertrochanteric fractures using either sliding hip screws (SHS) or Intramedullary nail (IMN) fixation has long been disputed and the optimal length of a 'short nail' has yet to be clarified. Our aim was to investigate functional outcomes in patients who have undergone either sliding hip screw fixation or intramedullary fixation using varied lengths of nails to assess potential superiority. DESIGN: We retrospectively reviewed data from consecutive patients with trochanteric hip fractures between January 2010 - July 2019. Fracture fixation was performed with four different devices; SHS, 220mm and 175mm Targon PFT nails or 180mm Short Affixus Hip Fracture Nails. There was no significant difference in the patient demographics in each treatment group. MAIN OUTCOME MEASURES: Patients were followed up for 1 year post operatively to determine if there were differences in mobility and pain with the different fixation methods. RESULTS: There was no significant difference in the overall complication rate between methods of fixation. Overall Intramedullary nail fixation resulted in an improved mean pain score compared to SHS (mean difference 0.25, 95% CI 0.11 - 0.39, p=0.0005). On sub-analysis this was only statistically significant in 220mm Targon nails (mean difference 0.35, CI 0.19-0.57, p=0.0010) and not for the other two nails. In addition, there was a significant difference in mobility score (mean difference 0.38, CI 0.12-0.63, p=0.0036). On sub-analysis this was only statistically significant favouring the for 220 mm Targon nail (mean difference 0.57, CI 0.27-0.87, p=0.0002). CONCLUSION: We advise caution in interpreting the results of studies between different nails and SHS, as not all nails appear to be the same. Design features of modern nails such as length, proximal diameter, the use of a compression screw, lag screw interface within the nail and valgus inclination may all play a role in functional outcomes.

Intraocular pressure variation after conventional extracapsular cataract extraction, manual small incision cataract surgery and phacoemulsification in an indigenous black population.

INTRODUCTION: intraocular pressure changes have been reported following the various cataract surgical technique. This study aims to compare the intra-ocular pressure (IOP) variation following conventional extra-capsular cataract extraction (ECCE), manual small incision cataract surgery (MSICS) and phacoemulsification in an indigenous black population. METHODS: a comparative cross-sectional study of adult patients aged 40 years and above who had pressure was measured with Goldman's applanation tonometer pre-operatively and 1st day, 1st week, 1st month as well as 3rd month post-operative periods and recorded. Data was analyzed using SPSS version 21. Mean IOP changes between study groups were compared using ANOVA. P-value of < 0.05 was taken as statistically significant. RESULTS: total of 82 patients consisting of 20(24.4%) ECCE, 32(39%) MSICS and 30(36.6%) phacoemulsification with mean preoperative 13.4mmHg, 13.5mmHg and 14.1 mmHg (p = 0.657) respectively was studied. Mean IOP increased from baseline at 1st day post-operative period in the ECCE and MSICS groups (13.4 ± 3.0mmHg to 13.7 ± 4.5mmHg (p = 0.84) and 13.5 ± 3.1mmHg to 15.3 ± 5.1mmHg (P = 0.48) respectively), and decrease in the phacoemulsification group (14.1 ± 2.6mmHg to 13.9 ± 3.5mmHg (p = 0.378). There was a decline in IOP in all the 3 study groups by one week post-operative period; the difference was significant only in the ECCE group (p = 0.032). By 3rd month postoperatively, there was a reduction in mean IOP when compared with pre-operative IOP the difference being greatest in the ECCE group. CONCLUSION: ECCE, MSICS, and Phacoemulsification cause a decline in IOP below preoperative levels at 3rd month postoperatively in the MSICS group.

Extracapsular Lymph Node Involvement in Ovarian Carcinoma.

Ovarian cancer (OC) spread to retro-peritoneal lymph nodes is detected in about one out of two patients at primary diagnosis. Whether the histologic pattern of lymph node involvement i.e., intra-(ICG) or extracapsular (ECG) cancer growth may affect patients' prognosis remains unknown. The aim of the current study was to analyze the prevalence of ECG and ICG in lymph node positive ovarian cancer. We further investigated whether ECG may be related to patients' prognosis and whether biomarkers expressed in the primary tumor may predict the pattern of lymph node involvement. Lymph node samples stemming from 143 OC patients were examined for presence of ECG. Capsular extravasation was tested for statistical association with clinico-pathological variables. We further tested 27 biomarkers that had been determined in primary tumor tissue for their potential to predict ECG in metastatic lymph nodes. ECG was detected in 35 (24.5%) of 143 lymph node positive patients. High grade (p = 0.043), histologic subtype (p = 0.006) and high lymph node ratio (LNR) (p < 0.001) were positively correlated with presence of ECG. Both ECG (p = 0.024) and high LNR (p = 0.008) were predictive for shortened overall survival. A four-protein signature determined from the primary tumor tissue was associated with presence of concomitant extracapsular spread in lymph nodes of the respective patient. This work found extracapsular spread of lymph node metastasis to be a common feature of lymph node positive ovarian cancer. Since ECG was positively associated with grade, LNR and shortened overall survival, we hypothesize that the presence of ECG may be interpreted as an indicator of tumor aggressiveness.

Added value of MRI tractography of peri-prostatic nerve plexus to conventional T2-WI in detection of extra-capsular extension of prostatic cancer.

PURPOSE: To evaluate the role of DTI (with fibretracking) and T2-weighted imaging (T2-WI) used together for predicting extra-capsular extension in patients with localized prostate cancer. METHOD AND MATERIALS: Thirty-six patients with biopsy-proven diagnosis of prostatic neoplasia performed MRI and underwent radical prostatectomy. Histopathological analysis showed ECE in 15/36 and capsule sparing in 21/36. By means of T2-WI, ECE was evaluated in a qualitative manner, according to PI-RADS v.2 (two groups with low and high risk of ECE); sensitivity and specificity were calculated for both groups. We performed a quantitative analysis on two tractographic parameters, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) and computed the ratio between the lesion quadrant and its contralateral (L/H ratio). We compared L/H ratios of patients with and without ECE; ROC analyses were performed to determinate ECE cut-off values of tractographic parameters. These cut-off values were used in association with T2-WI to reassess patients and to evaluate whether specificity and sensitivity of ECE detection change. RESULTS: T2-WI showed a sensitivity of 80% and a specificity of 71% in detection of ECE. Tractography displayed a significant difference in L/H ratio for FA and ADC between patients with and without ECE. The simultaneous use of T2-WI and tractography revealed high sensitivity (100%) on patients with low suspect of ECE (on T2-WI) and high specificity (83%) on patients with high suspect of ECE (on T2-WI). CONCLUSION: The morphologic component of T2-weighted imaging and functional aspect of DTI should be interpreted together to more successfully assess the presence of ECE.

Extracapsular excision of hepatic hemangioma: A single centre experience.

BACKGROUNDS/AIMS: Hepatic hemangioma is a common non-epithelial neoplasm of the liver. Presence of symptoms and uncertainty in diagnosis are the most common indications for surgery. METHODS: Eighteen patients with hepatic hemangioma, operated on from January 2011 to December 2016 at the Hepato-pancreato-biliary surgical unit of Tata Memorial Hospital, were retrospectively analyzed. RESULTS: Main indications for operation were presence of symptoms, the most common being pain and diagnostic uncertainty. The median size of hemangioma was 9.9 cm (range 3.2 to 24 cm). All patients underwent extra-capsular excision of hemangioma. The median operating time was 180 minutes (range 75 to 460 minutes) and median blood loss was 950 ml (range 100 to 3,500 ml). Median post-operative stay was 5.5 days (range 3 to 10 days). One (5.6%) patient required re-exploration for post-operative hemorrhage, Clavien Dindo (CD) grade IIIb, and one (5.6%) had postoperative purulent intra-abdominal collection requiring percutaneous cutaneous drainage CD grade IIIa. There was no postoperative mortality. Postoperative day 3 liver function tests were within normal limits. Size of the tumor did not correlate significantly with postoperative complications (p=0.135). CONCLUSIONS: Surgical treatment of hemangioma should be guided by presence of symptoms or by the presence of diagnostic uncertainty, not by size alone. The size had no correlation with perioperative complications. The technique of extra-capsular excision is safe and technically feasible in most of the hemangiomas. This technique preserves maximum liver parenchyma, resulting in early postoperative recovery with minimal morbidity.

Primary Squamous Cell Carcinoma of Submandibular Salivary Gland: A Case Report.

Primary Squamous Cell Carcinoma (PSCC) of submandibular salivary gland is a rare occurrence. Careful clinical and histopathological examination is must to diagnose it. The treatment protocol of this rare disease is not clearly defined. Though surgery is primary treatment, role of adjuvant treatment is not clear. A 40-year-old male presented to us with asymptomatic upper neck swelling. Triple endoscopy, cross-sectional investigation and FNAC suggested primary squamous cell carcinoma of right submandibular salivary gland. He was treated with bilateral modified neck dissection and wide excision of sub mandibular gland with surrounding muscles. Post surgery, he had undergone interval chemotherapy followed by radiotherapy. The patient is still on regular follow up at an interval of three months without any evidence of disease recurrence. Though difficult to diagnose and treat this kind of rare variant of salivary neoplasms, awareness of the disease and aggressive treatment depending on histopathology report, can help patient to achieve health.

Lymph Node Central Necrosis on the Computed Tomography as the Predictor of the Extra Capsular Spread in Metastatic Head and Neck Squamous Cell Carcinoma.

The aim of this study is to investigate the relationship between the presence of the cervical lymph node with central necrosis as on the preoperative imaging and postoperative histopathological identification of the lymph node extra capsular spread. This study is a prospective study conducted at J.L.N. Hospital and Research Centre, Bhilai (C.G), from August 2011 to January 2014. Thirty patients with metastatic head and neck squamous cell carcinoma were enrolled. All candidates were subjected to a detailed history taking and clinical examination. Their preoperative computed tomography (CT) scans were assessed with attention to the presence and absence of lymph node, lymph node size, shape, level, presence or absence of the lymph node central necrosis and other signs of the ECS such as thick walled enhancing nodal margin, loss of margin definition, alteration of adjacent fat planes. These patients then underwent surgery which included resection of the primary with the neck dissection. The preoperative records of the lymph node size and location were observed radio-graphically and analyzed with the resected lymph node histopathologically. These data was used for finding out correlation. Of the total 30 patients studied, 24 patients were male and 6 patients female with ratio of 4:1. The most common group of the patients were of malignancy of gingivobuccal sulcus. Out of the 30 patients 19 patients had the radiographic evidence of the central necrosis, out of which 11 had the extra capsular spread on the histological analysis. In no patients did we found histopathology extra capsular spread without central necrosis. Thus the central necrosis on the CT has the high sensitivity for detection of the extra capsular spread. Out of the 19 lymph node without extra capsular spread, 11 lymph nodes had no central necrosis on the preoperative CT, remaining 8 lymph node were having central necrosis on CT whereas post op histopathology of these 8 lymph nodes showed metastatic deposit, indicating the low specificity of the central necrosis in detection of the ECS. Lymph node central necrosis on pre-operative CT is sensitive indicator with a high negative predictive value for lymph node extra capsular spread. Future studies focusing on identifying molecular mediator involved in ECS to determine targets for adjuvant therapies in this subset of patients are recommended.

A retrospective cohort study of concomitant ipsilateral extra-capsular and intra-capsular fractures of the proximal femur. Are they casual findings or an undervalued reality?

BACKGROUND: Fractures of the proximal femur constitute a major public health problem, with an annual incidence in Spain of 7.6 cases per 1000 inhabitants over 65 years of age. Hip fractures are frequent in elderly patients, related to osteoporosis and with low energy trauma, which means that they can be considered a geriatric syndrome. Simultaneous ipsilateral extra- and intra-articular hip fractures are considered as very rare are, and generally speaking, classified as extra- or intra-capsular fractures. Moreover, there is no consensus with regard to treatment of these concomitant fractures. AIM: To estimate the incidence of concomitant ipsilateral extra- and intra-capsular fractures of the proximal femur, and to describe the diagnostic process and the clinical characteristics of these concomitant fractures. PATIENTS AND METHODS: Retrospective cohort study of patients with hip fractures. The incidence of combined extra- and intra-capsular fractures was estimated, a confidence interval of 95% (95%CI) was calculated and a descriptive analysis was drawn up. RESULTS: Between May 2010 (the date on which the Orthopaedic and Trauma Surgery Department of our new Hospital began the surgical activity) and December 2016, 33 (median age, 86 years-old) of the 2625 hip fractures were classified as simultaneous extra- and intra-capsular ipsilateral fractures. The overall cumulative incidence was of 1.3% (95%CI:0.9-1.8%). In 32 (97%) of the patients, the fracture was a consequence of a low energy trauma (ground level fall), while the remainder was due to a medium energy trauma (skating). In all cases the two fracture lines seem to be independent of each other, which suggests different mechanisms of injury from that of isolated subcapital or intrertrochanteric fracture. CONCLUSION: The incidence of concomitant ipsilateral extra- and intra-capsular fractures of the proximal femur must be taken into account in patients over 65 years of age. It is clinically relevant to identify these concomitant fractures in order to arrive at a correct diagnosis, which will facilitate preoperative planning and the choice of the best treatment to achieve a better outcome. Misdiagnosis may cause further problems, such as fixation failures, disability and, in a worst case scenario, an increased risk of death. Therefore, a good and complete preoperative study is important, along with both good quality X-ray projections and 2D and 3D Ct-Scans in case of doubt.

A comparison of weekly versus 3-weekly cisplatin during adjuvant radiotherapy for high-risk head and neck cancer.

OBJECTIVES: To compare cumulative cisplatin dose and toxicity between patients who received 3-weekly versus weekly cisplatin during adjuvant radiotherapy for high-risk head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS: Consecutive HNSCC patients with involved resection margins and/or extra-capsular extension in two tertiary cancer centers with different institutional practices were identified. Cumulative cisplatin dose was calculated and information on toxicity reviewed and compared between patients who received 3-weekly versus weekly cisplatin. RESULTS: Of 270 high risk patients, 60 received 3-weekly 100mg/m(2) and 48 received weekly 50mg/m(2) cisplatin during adjuvant radiotherapy (60-66Gy in 30-33 fractions). Fourteen patients received other chemotherapy schedules and 148 received no chemotherapy. Mean cumulative cisplatin dose was 199.4mg/m(2) (standard error (SE) 5.4) in 3-weekly versus 239.8mg/m(2) (SE 11.0, P=0.001) in weekly treated patients. Cumulative cisplatin ⩾200mg/m(2) was given to 67.7% of patients in the 3-weekly cohort and 85.2% (P=0.039) in the weekly cohort. The rate of feeding tube dependency 6months after treatment, osteoradionecrosis, neutropenic fever, and persistent renal function decline were not statistically different. CONCLUSIONS: About one half of high-risk HNSCC patients are not eligible for cisplatin during postoperative radiotherapy. Patients treated with weekly 50mg/m(2) cisplatin received a higher cumulative dose with comparable toxicity as patients who received 3-weekly 100mg/m(2) cisplatin. Efficacy and applicability to the frequently used weekly 40mg/m(2) schedule remains to be evaluated.

Invasive benign meningioma: Clinical characteristics, surgical strategies and outcomes from a single neurosurgical institute.

The aim of the present study was to improve the prognosis for patients with invasive benign meningioma by increasing the precision of pre-operative evaluation and refining the surgical resection strategy. A retrospective review of all the cases of invasive benign meningioma admitted to a single institute from 2005 to 2010 was conducted. The clinical characteristics, magnetic resonance imaging (MRI) findings, refined surgical strategies and outcomes were summarized and analyzed. There were 19 cases of invasive benign meningioma among 254 cases of meningioma. Of the earliest 4 cases, a traditional extra-capsular surgical removal approach was applied, which resulted in permanent neurological deficits for all cases. A modified surgical strategy combining intra- and extra-capsular resection techniques was employed for the subsequent 15 cases, which lead to mild neurological impairment in only 1 case. Pre-operative recognition of this unique sub-type of meningioma maybe facilitated by its typical MRI study findings, and the combination of intra- and extra-capsular resection techniques may be of critical importance in achieving complete tumor removal while maintaining intact neurological functions.