ARID1 and BRG1 Expression in Endometrial Cancer.

BACKGROUND/AIM: Endometrial cancer (EC) is the predominant malignancy among gynecologic cancers and ranks fourth among all types of cancer. Recently, researchers have focused on the development of new prognostic biomarkers. Subunits of the SWI/SNF protein complex, like the ARID1 and BRG1, have been associated with the development of endometrial cancer. The present study aimed to evaluate the expression patterns of ARID1A and BRG1 in a collection of endometrioid adenocarcinomas of the uterus using immunohistochemistry. PATIENTS AND METHODS: The study comprised a total of thirty-three individuals diagnosed with stage I endometrioid endometrial cancer, treated with radical hysterectomy. The histological material was then examined to assess the cytoplasmic and nuclear expression of the proteins. RESULTS: ARID1A exhibited expression in both the cytoplasm and nucleus of cancer cells, whereas BRG1 was mainly expressed in the nuclei. In addition, ARID1A exhibited a notable decrease in expression in grade 3 histology, with no significant correlation with the depth of myometrial invasion. The reduced expression was highly related to tumor expansion into the endocervix. The findings demonstrated a total absence of ARID1A expression in 27% of endometrioid carcinomas, with a significant reduction in expression in an additional 51% of cancer cells. These findings align with the most recent published data. In contrast, in the current study, BRG1 was rarely down-regulated and was extensively expressed in the majority of endometrioid carcinomas, preventing the possibility of statistical analysis. CONCLUSION: In summary, ARID1A expression loss can be used as a biomarker to guide post-operative therapy; however, further investigation is needed, especially for early-stage endometrial cancer.

Diffuse Tenosynovial Giant Cell Tumor Encircling the First Metatarsal Bone Remodeling after Resection. A Case Report.

Introduction: The term tenosynovial giant cell tumor encompasses a group of rare soft-tissue tumors. A new classification divides the group in localized and diffuse type, depending on the involvement of the surrounding tissues. Due to the unclear origin and heterogeneity in extend of the diffuse-type giant cell tumors, there is only limited evidence on the tumor-specific treatment. Thus, every case report has an added value toward setting disease-specific guidelines. Case Report: Presentation of a diffuse type tenosynovial giant cell tumor encircling the first metatarsal. The tumor had mechanically eroded the plantar aspect of the distal metaphysis, with no signs of tumor spread. After an open biopsy, resection of the mass was performed without debriding or resecting the first metatarsal. Repeat imaging postoperatively showed no recurrence at 4-year follow-up and a bony remodeling of the lesion. Conclusion: Bone remodeling is possible after complete resection of diffuse tenosynovial giant cell tumor when the erosion is caused by mechanical pressure and no intraosseous expansion of the tumor is present.

Advantages and Limitations of Ultrasound as a Screening Test for Ovarian Cancer.

Ovarian cancer (OC) is the seventh most common malignancy diagnosed among women, the eighth leading cause of cancer mortality globally, and the most common cause of death among all gynecological cancers. Even though recent advances in technology have allowed for more accurate radiological and laboratory diagnostic tests, approximately 60% of OC cases are diagnosed at an advanced stage. Given the high mortality rate of advanced stages of OC, early diagnosis remains the main prognostic factor. Our aim is to focus on the sonographic challenges in ovarian cancer screening and to highlight the importance of sonographic evaluation, the crucial role of the operator΄s experience, possible limitations in visibility, emphasizing the importance and the necessity of quality assurance protocols that health workers have to follow and finally increasing the positive predictive value. We also analyzed how ultrasound can be combined with biomarkers (ex. CA-125) so as to increase the sensitivity of early-stage OC detection or, in addition to the gold standard examination, the CT (Computed tomography) scan in OC follow-up. Improvements in the performance and consistency of ultrasound screening could reduce the need for repeated examinations and, mainly, ensure diagnostic accuracy. Finally, we refer to new very promising techniques such as liquid biopsies. Future attempts in order to improve screening should focus on the identification of features that are unique to OC and that are present in early-stage tumors.

Ovarian Cancer and Glutamine Metabolism.

Cancer cells are known to have a distinct metabolic profile and to exhibit significant changes in a variety of metabolic mechanisms compared to normal cells, particularly glycolysis and glutaminolysis, in order to cover their increased energy requirements. There is mounting evidence that there is a link between glutamine metabolism and the proliferation of cancer cells, demonstrating that glutamine metabolism is a vital mechanism for all cellular processes, including the development of cancer. Detailed knowledge regarding its degree of engagement in numerous biological processes across distinct cancer types is still lacking, despite the fact that such knowledge is necessary for comprehending the differentiating characteristics of many forms of cancer. This review aims to examine data on glutamine metabolism and ovarian cancer and identify possible therapeutic targets for ovarian cancer treatment.

Cancer Treatment and Immunotherapy during Pregnancy.

BACKGROUND/AIM: Immunotherapy has, in recent years, witnessed an expansion in its indications for the treatment of cancer. Coupled with the fact that, nowadays, even more women choose to postpone parenthood, thus increasing their chances of having some kind of malignancy during pregnancy, more and more women are eligible for receiving immunotherapy during this period of their lives. The cases of cancer diagnosed during pregnancy is an ever-increasing trend nowadays. MATERIALS AND METHODS: The oncologists and clinicians treating women often face a range of ethical and therapeutic dilemmas due to the particularity of the patient's conditions. The primary concern is the protection of the mother, firstly, and then the fetus (through adjustments to the various treatment regimens) if possible. RESULTS AND CONCLUSIONS: Oncological drugs, radiation therapy, surgery, or a combination of all the above methods are selected, depending on the case. In this project, we studied the oncology drugs used for various types of gestational cancer, their appropriateness and timing, as well as their possible effects on the parent and embryo upon their administration. Various studies have shown that the administration of oncological drugs should be postponed until at least after the first trimester of pregnancy.

The Significance of Peritoneal Washing as a Prognostic Indicator for Ovarian Cancer Patients.

BACKGROUND/AIM: During ovarian cancer (OC) debulking surgery, the surgeon can examine the peritoneal cavity for malignant cancer cells with peritoneal washing (PW) cytology. The goal of this study was to examine the significance of peritoneal washing as a prognostic indicator for ovarian cancer patients. PATIENTS AND METHODS: Information considering the prognostic factors of OC and their impact in PW's result was collected, compared, and combined. RESULTS: Omental metastasis, tumor type, tumor invasion, tumor size, tumor grade/ stage, tumor's cytoreduction, and recurrence affect both the peritoneal washing result and the patient's prognosis. The correlation that most of the above factors have with a positive PW and dismal prognosis, led us to the assumption that PW has a significance as a prognostic indicator. CONCLUSION: The significance of PW as a prognostic indicator remains an assumption.

A Brief Overview of Oncogenes and Signal Transduction Pathways in Gynecological Cancer.

Gynecological cancer is the cancer that originates in the female reproductive system. According to the anatomical location of the cancer, it is distinguished into cervical, uterine, vaginal, ovarian, and vulvar cancer. Oncogenes and tumor catalytic genes play a key role in the genesis and development of gynecological cancer. This article presents the signaling pathways and expression of oncogenes that take place in the carcinogenesis of the female reproductive system.

The Prognostic Role and Significance of Dll4 and Toll-like Receptors in Cancer Development.

The Notch signaling pathway regulates the development of embryonic and tissue homeostasis of various types of cells. It also controls cell proliferation, variation, fate and cell death because it emits short-range messages to nearby cells. The pathway plays an important role in the pathophysiology of various malignancies, controlling cancer creation. It also limits cancer development by adjusting preserved angiogenesis and cellular programs. One of the Notch signaling ligands (in mammals) is Delta-like ligand 4 (Dll4), which plays a significant role in the overall malignancies' advancement. Particularly, sequencing Notch gene mutations, including those of Dll4, have been detected in many types of cancers portraying information on the growth of particular gynecological types of tumors. The current research article examines the background theory that implies the ability of Dll4 in the development of endometrial and other cancer types, and the probable therapeutic results of Dll4 inhibition.

Single incision, minimally invasive fasciotomy of the anterior and lateral leg compartments with decompression of the superficial peroneal nerve.

BACKGROUND: There is a considerable overlap of symptoms between chronic exertional compartment syndrome (CECS) of the anterior and lateral compartments of the lower leg and entrapment neuropathy of the superficial peroneal nerve (SPN). We describe a minimally invasive, single incision surgical technique for release of both the compartments and the SPN in the same setting. The operative technique involves a minimal anterolateral approach at the level where the SPN pierces the subcutaneous fascia. METHODS: Nineteen patients were operated with the method and 24 anterolateral compartments (5 cases with bilateral CECS) were released. Anterior and lateral, proximal and distal fasciotomies were performed sequentially with the use of a specific instrument designed for carpal tunnel release (KnifeLight®, Stryker). This is a modification of a fasciotome with an intergrated light source which allows for transillumination of the subcutaneous tissues. The SPN and its main branches with their anatomical variations were explored and decompressed at the same setting. RESULTS: Patients who met the inclusion criteria were reviewed at one year postoperatively with a Numeric Analog Pain Scale (NAS) and the Linkert satisfaction scale. There were 5 men and 10 women, aged 35.7 (21-60) years. The NAS scores improved by a mean 6 points (p<0.0001) postoperatively and 86.6% (13/15) of the patients were either satisfied or very satisfied with the operation. There were no intraoperative complications. There were two patients with SPN neuropathy symptoms postoperatively, one of whom required revision surgery. One patient had recurrence of less intense symptoms in the first postoperative year with no need for reoperation. CONCLUSIONS: The simultaneous release of the anterolateral compartment of the leg and decompression of the SPN with the described technique was safe and effective. It combined the advantages of a single, minimally invasive approach with the subcutaneous transillumination, and had a high patient satisfaction and a low recurrence rate. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Arthroscopic os trigonum en-bloc removal outcomes at 6-month follow-up are better compared to Stieda's process resection in patients with posterior ankle impingement syndrome: a prospective comparative study.

OBJECTIVE: To evaluate the potential differences in American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Foot Function Index (FFI) at 6-month and 12-month postoperative follow-up of arthroscopic treatment for posterior ankle impingement (PAIS) between os trigonum (OT) and Stieda's process (SP) patients. METHODS: Thirty consecutive patients (32 ankles) treated in our Institution for PAIS with posterior arthroscopy were prospectively enrolled in the study from December 2012 to July 2019. Indications were patients with PAIS with persistent symptoms following conservative management. Exclusion criteria were the coexistence of concomitant pathologies and patients who underwent additional surgical procedures. An independent investigator interviewed and evaluated the patients according to the AOFAS hindfoot score and FFI preoperatively, at 6-month and 12-month follow-up. RESULTS: Except for AOFAS scores in the SP group (MD (mean difference) 11.28, p=0.08), patients undergoing arthroscopic treatment for bony PAIS had an overall significant improvement in AOFAS score (OT MD 22.29, p<0.05) and FFI (OT MD -70.07, p<0.05; SP MD -50.96, p<0.05) from their preoperative scores at 6-month follow-up. Similarly, a significant improvement in AOFAS score (OT MD 5.78, p=0.01; SP MD 12.14, p<0.05) and FFI (OT MD -9.36, p=0.04; SP MD -26.43, p<0.05) was observed from the 6-month to 12-month follow-up in all groups. At 6-month follow-up, the OT group had significantly better FFI outcomes (MD -33.57, p=0.04) compared with the SP group. No differences were found by group when comparing AOFAS score and FFI score at 12-month follow-up. CONCLUSIONS: When comparing patients undergoing OT excision or SP resection, better FFI outcomes were observed in the OT group at 6-month follow-up. LEVEL OF EVIDENCE: Prospective comparative study. Level II.

Radiosynoviorthesis after Surgery in the Treatment of Patients with Ankle Pigmented Villonodular Synovitis: A Case Series.

Pigmented villonodular synovitis (PVNS) of the ankle is a very rare, locally aggressive, proliferative disorder. Although surgical excision represents the standard curative treatment, the PVNS relapse rate is high. We present our study of five young athletes (range 20-36 years) with a histopathological diagnosis of PVNS of the ankle, who were treated by surgery and adjuvant radiosynoviorthesis (RSO). The operation involved either arthroscopic (four patients) or open (one patient) debridement, followed by intraarticular RSO with the radiopharmaceutical erbium-169 (169Er). They were evaluated with the Foot Function Index (FFI) and a visual analog scale (VAS) for pain. At a median follow up period of 47 months (range 36-54 months), all five patients reported marked pain relief with improvements in their daily activities. In particular, the median FFI decreased from 77% (range 71.0%-84.5%) pre-treatment, to 0.5% (range 0%-6%) after treatment. The median VAS score decreased from 4 (range 3-7) to 0 (range 0-1), respectively. Throughout the follow-up period, there were no major complications regarding either therapeutic intervention (arthroscopic or open debridement, RSO). Based on these results, it can be concluded that adjuvant RSO with 169Er following surgical excision is effective and safe in the treatment of PVNS of the ankle.

Talonavicular Dislocation-What Lies Beneath?

BACKGROUND: The talonavicular joint is a rare site of dislocation. Its etiology varies and can be the result of either acute trauma or a chronic degenerative process that most commonly occurs in patients with rheumatoid arthritis or Charcot arthropathy. Our aim is to highlight the relationship between the underlying pathology of talonavicular dislocations and the final outcome in the case of operative management. METHODS: We present three cases of talonavicular dislocation with the dislocation itself as the only common denominator, and a completely different etiology, natural history, treatment, and prognosis among them. RESULTS: There was one case of a traumatic talocalcaneonavicular dislocation in a healthy individual, one case in a rheumatoid arthritis patient, and one case in a patient with diabetes mellitus. All patients were treated surgically. The outcomes were excellent, fair, and poor, respectively. CONCLUSIONS: Among many factors that influence prognosis, it is equally critical to evaluate the overall background in which the dislocation occurs so as to apply the suitable treatment. The surgeon not only needs to treat the local incident but also appreciate the general medical condition to provide the best final outcome to the patient.

Minimal resection interposition arthroplasty of the first metatarsophalangeal joint.

BACKGROUND: Interposition arthroplasty of the first metatarsophalangeal (MTP) joint is a viable alternative to fusion in patients with advanced hallux rigidus. The purpose of this study is to evaluate the midterm results of a modification of the technique. METHODS: Case series of 18 interposition arthroplasties were performed on 13 female patients with Grade III-IV hallux rigidus. The technique included cheilectomy, bunionectomy when needed, minimal resection of the base of the proximal phalanx and interposition of a fascia lata allograft in the first metatarsophalangeal joint. Mean follow up was nine years (range 75-136 months). Patients were evaluated according to the AOFAS score, the ability to tip toe and their subjective satisfaction. RESULTS: There was a significant difference between preoperative (mean 43.2, range 15-83) and postoperative (mean 77.3, range 40-100) AOFAS scores (p<0.001). The patients were able to tip toe on 12 of the 18 operated feet and 9 of the 13 patients were satisfied from the operation. All dissatisfied patients had a coexistent hallux valgus deformity. CONCLUSIONS: The technique had satisfactory midterm outcomes in older patients with advanced hallux rigidus without hallux valgus. Advantages of the method are the preservation of tip toe function in most patients and a technically easy conversion to fusion when needed.

Patient-Based Long-Term Results of the Surgical Treatment of Congenital Talipes Equinovarus.

UNLABELLED: Long-term results of surgical treatment for congenital talipes equinovarus are documented in the literature but mainly in correlation with clinical and radiographic objective criteria. We present a retrospective study of 48 patients who underwent surgical correction (extended Cincinnati type "a la carte" approach) in our department with an average of 17 years' follow-up. Patients were interviewed and completed a validated disease specific instrument, which evaluates foot function as well as patients' satisfaction, the use of orthotics, shoe size, and the impact of this operation in their adult life. Parameters such as gender, age at first surgery, side affected, and the number of procedures were also studied. According to our findings, the greater the age at last surgery, the worse the outcome. Quality-of-life issues were expressed at a higher rate among women and by patients that underwent multiple surgeries. Unilateral correction has a correlation with the shoe size. Even if a "successful" surgical correction is achieved, residual symptoms may alter walking ability, self-image, and shoe wearing in adult life. It would be valuable to continue to follow these patients up over time. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Surgical management of hallux valgus and hallux rigidus: an email survey among Swiss orthopaedic surgeons regarding their current practice.

BACKGROUND: Various clinical and radiological criteria have been suggested to choose one of the numerous techniques in surgical treatment of hallux valgus and rigidus. We hypothesized that the surgeons' professional background will influence that choice depending on specialization, age, type and institution of training as well as his orthopaedic cultural orientation. Since Switzerland is characterized by regional languages (the most important being German and French), we were interested to learn if the linguistic differences had an influence on the orientation of the surgeons towards e.g. Anglo-American or French surgical traditions and/or sources of literature on the subject. METHODS: A survey was e-mailed to all members of the Swiss Orthopaedic Society (SGOT-SSOT). Questions were asked regarding respondents' demographics as well as their preferred treatment for 3 separate cases of (1) moderate and (2) severe hallux valgus and (3) hallux rigidus. The responses were collected and statistically analyzed. RESULTS: Two hundred thirty of 322 respondents completed the survey(response rate 46 %). as they perform foot surgery on a regular base; 39 % were members of the Swiss Orthopaedic Foot and Ankle Society (SFAS). Selected surgical treatments differed as follows: in joint sparing procedures older and busier surgeons were more likely to use Chevron osteotomies, however more than 50 % preferred a Scarf-type of osteotomy. Along the so-called "Rösti-Graben" separating the French from the German speaking part of Switzerland no significant difference was found in the choice of operation technique. Nevertheless the fact being a member of SFAS showed significant differences in technical choice in case 2 and 3. CONCLUSIONS: There are significant associations between the surgeons' age, expertise and training and their preferred operative intervention. Considerable differences in the surgical management were found in the practice of the general orthopaedic surgeons 72 and the foot and ankle specialists. The cultural background and training is not mirroring the classical Swiss east west discrepancy. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons.

A simple method of skin mapping for planning the operative approach in peripheral nerve injuries.

BACKGROUND: The operative treatment of post-traumatic neuromas includes open exploration, excision of adhesions and/or neurectomy. Apart from the anatomical variations of the peripheral nerves and their branches' routes, nerves may be further deviated from their expected anatomical locations due to scar tissue formation. We describe a simple and reproducible method of preoperative skin marking which aids the development of an accurate surgical exposure for the localisation of a lesion. METHOD: Skin marking is based on clinical assessment and is performed by the bedside on the day of the operation. It consists of mapping the skin with permanent marker by repeatedly using three symbols, namely √, O or X. These refer respectively to areas of normal sensation, numbness (decreased or no sensation without paraesthesia) and pain/dysaesthesia. Points with a positive Tinel sign were marked with an "X in a square". Fourteen patients, aged 21-55 years old, with post-traumatic neuromas, were marked with the method. A total of 18 neuromas were successfully located in the upper and lower limbs. RESULTS: In all cases the preoperative skin marking corresponded to the course of the nerve and/or its branches. All patients were improved with a good to excellent clinical outcome. CONCLUSIONS: Planning the surgical approach according to the skin marking enabled limited operative exposures and corresponded to atypical locations and branching of the peripheral nerves.

Common pitfalls in syndesmotic rupture management: a clinical audit.

BACKGROUND: Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes. MATERIALS AND METHODS: This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients' notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period. RESULTS: There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient. CONCLUSIONS: The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Perioperative variations of the intracompartmental pressures of the paraspinal muscles.

STUDY DESIGN: Study of the influence of thoracolumbar spinal surgery through a posterior approach to the intercompartmental pressure of the paraspinal muscles. OBJECTIVE: To create waveforms according to the pressure variations up to 24 hours postoperatively and relate these measurements to independent parameters. SUMMARY OF BACKGROUND DATA: The existence of a paraspinal anatomic compartment and a relevant compartment syndrome has been supported theoretically, proven experimentally, and confirmed in clinical cases. The perioperative variations of the intercompartmental pressures remain largely unknown. METHODS: Five measurements were taken from both paraspinal compartments in each operated patient: preoperatively, intraoperatively, immediately after wound closure, and at 6 and 24 hours postoperatively. The recorded pressures were grouped as normal, elevated, or suggestive of a paraspinal compartment syndrome. Abnormal pressures were correlated with patient-related and operation-related parameters. Forty-two patients participated in the study, 21 male and 21 female patients aged 13 to 83 years (mean age 51 y). Seventy compartments were included in the final analysis. RESULTS: Forty-two compartments developed abnormally elevated pressures postoperatively and in 22 of these, pressures suggestive of a compartment syndrome were recorded. In no case was there a clinical presentation of a true compartment syndrome. Different waveforms were created for the normal and elevated pressures group. In compartments with high measurements, pressures were likely to continue to rise at 6 and 24 hours postoperatively. The body mass index was greater in both the elevated pressures and compartment pressures groups. Procedures lasting >2 hours, extended approaches, and instrumented posterior interbody fusion operations were related with lower postoperative pressures. CONCLUSIONS: A large percentage of patients develop increased paraspinal muscle pressures up to 24 hours after posterior thoracolumbar spine surgery. These increases are related to patient-related and operation-related factors and may not present clinically as a compartment syndrome.

Prevalence of interdigital nerve enlargements in an asymptomatic population.

BACKGROUND: Morton's neuroma is a common primary diagnosis for referral to foot and ankle surgeons. On presentation, many patients have had an ultrasound reporting the presence of Morton's neuroma, which may not correlate with the clinical examination findings. The prevalence of such sonographic findings in the general population remains unknown. METHODS: In this observational prospective study, patients with asymptomatic forefeet who were seen by two foot and ankle surgeons for unrelated mid- or hind foot pathology were examined clinically and sonographically for the presence of interdigital nerve thickening. Forty-eight volunteers participated in the study (96 feet). For the purpose of this study, asymptomatic thickenings greater than 5 mm in diameter were termed sonographic neuromas. Ultrasound examination was performed by two specialist musculoskeletal radiologists. RESULTS: Fifty-four percent of the volunteers (26 of 48) had sonographic nerve thickening and in 17 cases (35.4%) enlarged nerves were found bilaterally. Differences for gender, original diagnosis or side of original pathology were not significant. Older subjects were more likely to have a sonographic neuroma (p = 0.018). Feet with a positive Mulder's click were more likely to have a sonographic neuroma (p = 0.015). CONCLUSION: Ultrasound, even in highly skilled hands, has a high rate of incidental finding of an asymptomatic interdigital nerve enlargement, which can lead to a false diagnosis of a Morton's neuroma. Sonographic evidence of Morton's neuroma per se is unreliable unless it is correlated with an equivocal clinical examination. Clinical examination is still the gold standard for the diagnosis of a Morton's neuroma.