Development and validation of a deep-learning model for the detection of non-displaced femoral neck fractures with anteroposterior and lateral hip radiographs.

Background: Hip fractures, including femoral neck fractures, are a significant cause of morbidity and mortality in the elderly population and are typically diagnosed using plain radiography. However, diagnosing non-displaced femoral neck fractures can be challenging due to their subtle appearance on hip radiographs. Previous deep-learning models have shown low accuracy in identifying these fractures on anteroposterior (AP) radiographs; however, no studies have used lateral radiographs. This study aimed to evaluate the potential of using deep-learning with both AP and lateral hip radiographs to automatically identify non-displaced femoral neck fractures. Methods: We conducted a retrospective analysis of patients with femoral neck fractures at The First Affiliated Hospital of Xiamen University. All the hip radiographs were reviewed, and cases of non-displaced femoral neck fractures were included in the study. Additionally, 439 participants with normal hip radiographs were also included in the study. A vision transformer (Vit) model was developed using 1,536 AP and lateral hip radiograph. The model's performance was compared to the performance of two groups of human observers: an expert group comprising orthopedic surgeons and radiologists, and a non-expert group, including emergency physicians and general practice doctors. We also carried out the external validation using two additional data sets to assess the generalizability of the model. Results: The Vit model showed exceptional performance in detecting non-displaced femoral neck fractures on paired AP and lateral hip radiographs, achieving a binary accuracy of 95.8% [95% confidence interval (CI): 94.9%, 96.8%] and an area under the curve (AUC) of 0.988. Compared to the human observers, the model had a higher accuracy of 96.7% (95% CI: 93.9%, 99.5%) on the paired AP and lateral hip radiographs, while the accuracy of the expert group was 90.5% (95% CI: 85.7%, 95.2%). Further, the model maintained good performance during the external validation, with an AUC of 0.959 on the paired AP and lateral views. Conclusions: Our Vit model showed expert-level performance in identifying non-displaced femoral neck fractures on paired AP and lateral hip radiographs. This model has the potential to enhance diagnosis accuracy and improve patient outcomes by reducing the need for additional examinations and preoperative time.

Comparison of Full Endoscopic Lumbar Diskectomy Using the Transforaminal Approach versus Interlaminar Approach for L5-S1 Lumbar Disk Herniation Treatment: A Meta-Analysis.

BACKGROUND: Numerous studies have examined the clinical effectiveness of transforaminal full endoscopic lumbar diskectomy (T-FELD) and interlaminar full endoscopic lumbar diskectomy (I-FELD) for L5-S1 lumbar disk herniation (LDH), with mixed findings. The goal of this systematic review and meta-analysis was to evaluate the perioperative outcomes, clinical results, and complications of T-FELD and I-FELD to determine their efficacy and safety for treating L5-S1 LDH and to examine the features of complications in depth. METHODS: Several databases were searched for articles that matched all of the inclusion criteria. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the clinical results. Information on perioperative outcomes and complications was gathered and analyzed. RESULTS: Eight studies with 756 participants were included. There were no significant differences in postoperative bed time (p = 0.44) and hospitalization time (p = 0.49) between T-FELD and I-FELD. When compared with I-FELD, T-FELD was associated with substantially longer fluoroscopy time (p < 0.0001) and operating time (p < 0.0001). There were no significant differences in the preoperative and postoperative VAS and ODI scores between T-FELD and I-FELD. The rates for overall complications, postoperative dysesthesia, postoperative lower extremity pain, incomplete decompression, recurrence, and conversion to open surgery were comparable for T-FLED and I-FELD. CONCLUSION: T-FELD and I-FELD had equal clinical results and safety for treatment of L5-S1 LDH. Fluoroscopy and operative times were shorter for I-FELD than for T-FELD.

Letter to the editor regarding "Full­endoscopic (bi­portal or uni­portal) versus microscopic lumbar decompression laminectomy in patients with spinal stenosis: systematic review and meta­analysis".

A recent article entitled "Full­endoscopic (bi­portal or uni­portal) versus microscopic lumbar decompression laminectomy in patients with spinal stenosis: systematic review and meta­analysis" written by Pairuchvej et al. (Eur J Orthop Surg Traumatol 30(4):595-611, 2019) published in "European Journal of Orthopaedic Surgery & Traumatology" has aroused our great interest. The authors concluded that compared with minimally invasive decompression surgery, full endoscopic spinal surgery had better pain relief (back pain and leg pain) in the treatment of lumbar spinal stenosis and had a lower complication rate, but no statistical difference in oswestry disability index score and operative time between both groups. Comparing to minimally invasive spinal surgery, bi-portal endoscopic spinal surgery had better back pain relief in the early stage, while uni-portal full endoscopic spinal surgery had better pain relief in the leg and a lower rate of complications.

Research relating to three-dimensional (3D) printing in spine surgery: a bibliometric analysis.

PURPOSE: Although numerous publications on three-dimensional printing (3DP) in spine surgery have been published, bibliometric analysis studies are scarce. Thus, this study aimed to present a bibliometric analysis of the status, hot spots, and frontiers of 3DP in spine surgery and associated research disciplines. METHODS: All publications relating to the utilization of 3DP in spine surgery from 1999 to May 9, 2022, were retrieved from the Web of Science. The bibliometric analysis was performed using CiteSpace software, and information on the country, institution, author, journal, and keywords for each publication was collected. RESULTS: A total of 270 articles were identified. From 2016 onward, a significant increase in publications on spinal surgery was observed. China was the most productive and influential country (98 publications) and H-index (22), followed by the USA and Australia. The most productive institution was Capital Medical University (9 publications). P. S. D'urso (8 publications, 46 citations) and R. J. Mobbs (8 publications, 39 citations) were the most prolific authors. European Spine Journal contributed the highest number of publications. The eight main clusters were: "rapid prototyping" #0, "3D printed" #1, "spine fusion" #2, "scoliosis" #3, "spine surgery" #4, "patient-specific" #5, "nervous system" #6, and "neuronavigation" #7. The strongest keyword bursts in 3DP in spine surgery were "fixation," "drill template," "instrumentation," "fusion," "complication," and "atlantoaxial instability." CONCLUSION: This analysis provides information on research trends and frontiers in the application of 3DP in spine surgery, as well as research and collaboration partners, institutions, and countries.

Postoperative Pain Management after Full Endoscopic Lumbar Discectomy: An Observational Study.

Background: Surgical incision pain, rebound pain, and recurrence can manifest themselves in different forms of postoperative pain after full endoscopic lumbar discectomy (FELD). This study aims to evaluate various postoperative pains after FELD and summarize their characteristics. Methods: Data about the demographic characteristics of patients, pain intensity, and functional assessment results were collected from January 2016 to September 2019. Clinical outcomes including Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, were obtained. Results: A total of 206 patients were enrolled. ODI and VAS of the patients significantly decreased after FELD at 12-month follow-up. A total of 193 (93.7%) patients had mild surgical incision pain after FELD and generally a VAS < 4, and it mostly resolved on its own within 3 days. A total of 12 (5.8%) patients experienced rebound pain, which was typically characterized by pain (mainly leg pain with or without back pain), generally occurring within 2 weeks after FELD and lasting < 3 weeks. The pain levels of rebound pain were equal to or less than those of preoperative pain, and generally scored a VAS of < 6. The recurrence rate was 4.4%. Recurrence often occurs within three months after surgery, with the pain level of the recurrence being greater than or equal to the preoperative pain. Conclusions: Different types of postoperative pain have their own unique characteristics and durations, and treatment options are also distinct. Conservative treatment and analgesia may be indicated for rebound pain and surgical incision pain, but recurrence usually requires surgical treatment.

A meta-analysis of clinical effects of microscopic unilateral laminectomy bilateral decompression (ULBD) versus biportal endoscopic ULBD for lumbar canal stenosis.

Osbjective: Several studies have shown that both microscopic unilateral laminotomy bilateral decompression (ULBD) and unilateral biportal endoscopic (UBE) ULBD are effective for treating lumbar canal stenosis (LCS). However, there are different viewpoints as to which surgical technique is superior. Therefore, this meta-analysis investigated the clinical efficacy and side effects of microscopic ULBD and UBE ULBD for treating LCS. Methods: To identify relevant studies describing the clinical outcomes and complication rates of microscopic ULBD and UBE ULBD for LCS, several databases were systematically searched in the Internet. The visual analog scale score for back and leg pain and the Oswestry Disability Index were used to assess clinical outcomes. Furthermore, data about perioperative outcomes and complications were documented. Results: In total, six studies with 450 participants were included in this meta-analysis. The UBE ULBD was found to be superior to microscopic ULBD in terms of efficacy against early postoperative back and leg pain. However, there was no significant difference between the two procedures in terms of final clinical outcomes and complications. In addition, compared with microscopic ULBD, UBE ULBD was associated with a significant reduction in the length of hospital stay and C-reactive protein levels 2 days after surgery. Conclusion: UBE ULBD and microscopic ULBD for the treatment of LCS were similar in terms of final clinical outcomes and complications. However, UBE ULBD has several advantages over microscopic ULBE, including a shorter hospital stay and faster alleviation of postoperative back and leg pain.

Characteristics and hotspots of the 50 most cited articles in the field of pre-psoas oblique lumbar interbody fusion.

Purpose: In the past decade, the field of pre-psoas oblique lumbar interbody fusion (OLIF) has developed rapidly, and with it, the literature on OLIF has grown considerably. This study was designed to analyze the top 50 articles in terms of the number of citations through bibliometric research to demonstrate the research characteristics and hotspots of OLIF. Method: Searching the Web of Science database yielded the 50 most cited publications in the OLIF field as of July 10, 2022. The publications were ranked according to the number of citations. The following sources were evaluated: the year of publications, the number of citations, authors, countries, institutions, journals, research topics, and keyword hotspots. Results: The most productive period was from 2017 to 2020, with 41 articles. The number of citations varied from 10 to 140, with an average of 35.52, and 1,776 citations were found. World Neurosurgery published the most articles (12), China produced the most articles (16), and the Catholic University of Korea produced the most studies (6). The corresponding author who produced the most articles was J.S. Kim (5), and the first author who produced the most publications was S. Orita (3). The main research topics were anatomical morphology, surgical techniques, indications, outcomes, and complications. The top 10 most cited keywords were "complications," "decompression," "spine," "surgery," "outcomes," "transpsoas approach," "spondylolisthesis," "anterior," "disease," and "injury." Conclusions: Certain articles can be distinguished from others using citation analysis as an accurate representation of their impact due to their long-term effectiveness and peer recognition. With these publications, researchers are provided with research priorities and hotspots through influential literature in the field of OLIF.

Global research hotspots and trends in the field of spine surgery during the COVID-19 pandemic: A bibliometric and visual analysis.

Background: The Coronavirus disease-2019 (COVID-19) significantly affected the healthcare and research systems, including spine surgery, throughout the world. A bibliometric analysis allows graphical visualization of the development of an academic field and its frontiers. Since research concerning spine surgery during the COVID-19 pandemic is being constantly upgraded, we conducted a bibliometric analysis of this literature to investigate the current status, research hotspots, and trends in this field. Methods: We searched the Web of Science database for literature published (from December 1, 2019, to March 24, 2022) using the terms "COVID-19" OR "2019-nCoV" OR "SARS-CoV-2" AND "spine surgery" OR "spinal surgery" OR "discectomy" OR "decompression" OR "laminectomy" OR "interbody fusion" OR "pedicle screws." Detailed bibliometric and visual analysis of the number of publications, geographical distribution, institutions, journals, authors, and keywords was done using CiteSpace, VOSviewer, and R-Bibliometrix. Results: Of the initially screened 173 articles, we included 84 relevant articles-62 original articles, 10 editorial materials, 8 reviews, and 4 others. The United States, China, Egypt, and Argentina were most actively publishing in the field of spine surgery and COVID-19. The AOSpine International community contributed 7 articles (24 citations). The Hospital for Special Surgery (13.1%) and Johns Hopkins University (13.1%) were institutions with the most publications. Using the Law of Bradford, we found that World Neurosurgery, Global Spine Journal, and European Spine Journal are the core journals in this field, with P. K. Louie being the most influential author. "Elective surgery," "intensive care," "telehealth," "patient satisfaction," and "follow-up" had the strongest citation bursts. Conclusions: During the COVID-19 pandemic, spine surgeons were more concerned with surgical timing, care, treatment, and patient's quality of life. Accordingly, research hotspots in spine surgery during the pandemic shifted from "early healthcare" to "virus management" and "experience and education."

Mapping knowledge structure and themes trends in unilateral biportal endoscopic spine surgery: A bibliometric analysis.

Background: The numerous benefits of unilateral biportal endoscopic (UBE) spine surgery have attracted the attention of many researchers, and a considerable number of relevant clinical studies have been published. However, global research trends in the field of UBE have received little attention. The purpose of this study was to apply bibliometric method to analyze the UBE-related publications to obtain an overview of the research trends in the field of UBE, as well as research hotspots and trends. Methods: Web of Science database was searched for articles published until January 31, 2022. CiteSpace was used to analyze the data, which provided graphical knowledge maps. The following factors were applied to all literature: number of publications, distribution, h-index, institutions, journals, authors, and keywords. Results: Seventy-three articles were identified. Since 2019, there has been a significant increase in the number of UBE-related publications. The country with the largest number of articles was South Korea (72.6%), followed by China (9.6%), Japan (4.1%), and Egypt (4.1%). South Korea had the highest h-index (16), followed by China (2), Japan (1), and Egypt (1). Leon Wiltse Memorial Hospital was the organization that produced the most papers (12 publications). Heo DH was the most productive author (16 papers) and was the most cited author (35 times). World Neurosurgery published the most papers on UBE (23.3%). The main research hotspots were spinal diseases, decompression, complications, learning curve, and interbody fusion. In addition, the recent concerns were "learning curve," "interbody fusion," "management," and "dural tear." Conclusions: The quantity of publications on UBE research will increase, and South Korea being the major contributor and most prominent country in this field. The findings of our study will provide researchers with practical information on the field of UBE, and identification of mainstream research directions and recent hotspots.

Current Status and research hotspots in the field of full endoscopic spine surgery: A bibliometric analysis.

Purpose: We aimed to comprehensively analyze the current status, hotspots, and trends in full endoscopic spine surgery (FESS) research using bibliometric analysis and knowledge domain mapping. Methods: The Web of Science database was used to screen FESS-related articles published between January 1, 1993 and June 10, 2022. The evaluation involved the following criteria: total number of articles; H-index; and contributions from countries/regions, institutions, journals, and authors. Results: A total of 1,064 articles were included. Since 2016, there have been a significant number of publications in the field of FESS. The country/region contributing the largest number of articles was China (37.8%), followed by South Korea (24%), the United States (16.1%), Japan (5.7%), and Germany (5.1%). South Korea (35) had the highest H-index, followed by the United States (27), China (22), Japan (21), and Germany (20). World Neurosurgery (15.7%) published the largest number of FESS-related articles. However, among the top 10 most cited articles, six were published in Spine. The author who contributed the most was S.H. Lee (5.4%), and the largest number of contributions in this field originated from Wooridul Spine Hospital (South Korea; 6.1%). Notably, six of the 10 most published authors in this field were from South Korea. Of the top five productive institutions, three were from South Korea. The keywords with the strongest citation bursts in the field of FESS were "lumbar spine," "discectomy," "interlaminar," "surgical technique," "follow-up," "excision," "thoracic spine," and "endoscopic surgery." The 10 clusters generated in this study were: "endoscopic discectomy" (#0), "thoracic myelopathy" (#1), "recurrent lumbar disc herniation" (#2), "low back pain" (#3), "cervical vertebrae" (#4), "lumbar spinal stenosis" (#5), "transforaminal lumbar interbody fusion" (#6), "radiation exposure" (#7), "management" (#8), and "lumbar spine" (#9). Conclusion: Global research on FESS is mostly concentrated in a few countries/regions and authors. South Korea has made the largest contribution to the field of FESS. Based on the most cited keyword bursts and clusters, the focus of FESS research was found to include its indications, management, and applications.

Does the application of expandable cages in TLIF provide improved clinical and radiological results compared to static cages? A meta-analysis.

Purpose: This study aimed to provide a direct meta-analysis of the evidence comparing outcomes between expandable cages and static cages in patients with transforaminal lumbar interbody fusion (TLIF). Methods: A search of relevant materials from databases was performed from inception to March 7, 2022. Clinical and radiological outcomes were included. Results: Ten studies (1,440 patients) were included. The anterior disc height and foraminal height for expandable cages were substantially higher than those for static cages at the final follow-up (P < 0.0001; P = 0.05). In comparison with static cages, although not statistically significant, expandable cages showed beneficial results, including an increase in posterior disc height and segmental lordosis. There were no statistically significant differences in segmental lordosis, lumbar lordosis, pelvic parameters, cage subsidence, or fusion rates (P > 0.05). Oswestry disability index scores for expandable cages were substantially lower than those for static cages at the final follow-up (P = 0.0007). Interestingly, although the preoperative visual analog scores for back and leg pain were significantly higher in the expandable group than in the static group (P < 0.0001; P = 0.008), there was no significant difference between the static and expandable groups during the final follow-up (P = 0.51; P = 0.85). Conclusions: Expandable cages are associated with improved functional outcomes and restored postoperative disc and foraminal heights in patients with TLIF. In addition, no statistically significant differences were observed in segmental lordosis, lumbar lordosis, pelvic parameters, cage subsidence, or fusion rate.

Bibliometric analysis and visualization of research trends on oblique lumbar interbody fusion surgery.

PURPOSE: To determine trends and hot subjects in the field of oblique lumbar interbody fusion (OLIF) research during the last decade using bibliometric analysis and visualization tools, in order to assist researchers in exploring new directions for future research in that field. METHODS: Articles published from January 1, 2012, to August 15, 2021, were screened in the Web of Science database. The data were analyzed with CiteSpace software, which generated visualization knowledge maps. All literature was assessed for the following parameters: the number of total publications, distribution, h-index, institutions, journals, authors, co-occurrence state, and research hotspots. RESULTS: A total of 173 articles were identified. The country with the largest number of articles was China (41.04%), followed by South Korea (20.81%), the USA (15.61%), Japan (9.83%), and Thailand (2.89%). South Korea and the USA had the highest h-index (9), followed by China (8), Japan (7), and Thailand (2). Catholic University of Korea was the organization that produced the most literature. World Neurosurgery published the most papers about OLIF (12.50%), but articles in Spine were most frequently cited (151). Kim JS was the most productive author, whereas Silvestre C was the most cited author. The main research hotspots are anatomy, discectomy, approach, injure, and diseases. CONCLUSIONS: The number of publications in the field of OLIF has increased considerably in recent years. The USA, China, South Korea, and Japan have made substantial contributions to this field. Anatomy, complications, decompression surgery, and application in various degenerative lumbar diseases have been the research hotspots in recent years.

Evaluation of the Outcomes of Biportal Endoscopic Lumbar Interbody Fusion Compared with Conventional Fusion Operations: A Systematic Review and Meta-Analysis.

OBJECTIVE: In recent years, biportal endoscopic lumbar interbody fusion (BE-LIF) has been increasingly used in the treatment of lumbar degenerative diseases. BE-LIF combines the benefits of minimally invasive fusion with endoscopic spine surgery. However, there is little evidence on whether BE-LIF is superior to posterolateral lumbar interbody fusion (PLIF). The purpose of this meta-analysis is to compare the clinical outcomes, complications, and fusion rates of BE-LIF and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF)/PLIF in treating lumbar degenerative diseases. METHODS: A comprehensive assessment of the literature was conducted, and the quality of the retrieved studies was evaluated using the Newcastle-Ottawa Scale. Clinical parameters were investigated using a visual analog scale (VAS) for pain levels and the Oswestry Disability Index for disability levels. The operative times, estimated blood loss, fusion rates, and complications were also analyzed. RESULTS: This meta-analysis comprised 5 studies with a total of 444 participants. No significant differences between the techniques were seen in VAS scores for legs, Oswestry Disability Index, complications, or fusion rates. There were significantly lower VAS scores for back pain in the BE-LIF group than the MI-TLIF/PLIF group, postoperatively. In addition, BE-LIF resulted in significantly less blood loss but required a longer operative time than did MI-TLIF/PLIF. CONCLUSIONS: The benefits of BE-LIF and MI-TLIF/PLIF were approximately equivalent in terms of clinical outcomes and achievement of fusion, and complication rates were similar in both groups. However, BE-LIF reduced postoperative back pain and blood loss, despite longer operative times.

Osteochondroma Arising From the Inferior Articular Process of the Lumbar Spine in a Geriatric Patient: A Case Report and Literature Review.

OBJECTIVE: Spinal osteochondromas are rare, and approximately less than 5% occur as spinal lesions. We report the case of a solitary osteochondroma of the spine and review and update the literature on spinal osteochondroma, including surgical treatment and subsequent results. CASE DESCRIPTION: A 73-year-old female patient complained of a 10-year history of back pain and a 4-year history of right-side lower extremity radiating pain with paresthesia. Computed tomography and magnetic resonance imaging (MRI) revealed a bony mass arising from the inferior articular process (IAP) of L3, presenting with features of compressive spinal stenosis at the L3-L4 level. The treatment strategy included the complete marginal excision of the lesion through the posterior approach, as well as complete decompression of the spinal canal and nerve roots. The patient's symptoms resolved after surgery, and histopathological examination identified the lesion as an osteochondroma. REVIEW RESULTS: This review study included 168 solitary osteochondroma cases. The most commonly involved spinal level was cervical (51.8%), and the most frequent spinal anatomic column involved was the posterior column (70.8%). Radiculopathy accounted for 30.3% of all cases, myelopathy accounted for 31.0%, and 7.7% exhibited both symptoms simultaneously. The recurrence rate was 6.0%. CONCLUSION: Computed tomography and MRI can effectively diagnose spinal osteochondroma, and surgical treatment can effectively improve clinical outcomes. In almost all symptomatic cases, the best treatment is marginal excision of the tumor. Complete resection of the cartilaginous cap of the tumor is especially important to prevent recurrence.

A Pilot Study of Radiculopathy Following Osteoporotic Vertebral Fracture in Elderly Patients: An Algorithmic Approach to Surgical Management.

Background: Osteoporotic vertebral compression fractures (OVCF) due to severe and refractory back pain or neurological complications require surgical treatment. In this study, patients with radiculopathy due to foraminal stenosis following OVCF were surgically managed by performing transforaminal full-endoscopic lumbar foraminoplasty and/or discectomy (FELFD). Methods: From May 2015 to November 2019, fifteen patients underwent transforaminal FELFD. Patient data, Charlson comorbidity index (CCI), and American Society of Anesthesiologists (ASA) score were collected. Clinical outcomes, including pre- and postoperative Visual Analog Scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria of response to surgical treatment, were evaluated. Results: Mean of age, bone mineral density (T-score), CCI, ASA, and follow-up duration were 69.5 ± 6.6 years, -2.6 ± 0.8, 5.2 ± 2.3, 2.4 ± 0.5, and 24.5 ± 8.8 months, respectively. Mean VAS for leg pain significantly decreased from 6.9 ± 0.8 preoperatively to 2.9 ± 1.1 (P < .05). Mean ODI decreased from 39.9 ± 3.2 preoperatively to 19.3 ± 4.6 postoperatively (P < .05). The satisfaction rate is 86.7% (based on Macnab criteria), showed six patients had excellent outcomes and seven had good outcomes. Conclusions: Transforaminal FELFD is an effective treatment option for patients with radiculopathy due to lumbar OVCF, including those with severe osteoporosis and elderly patients.

Combination of the neutrophil to lymphocyte ratio and the platelet to lymphocyte ratio as a useful predictor for recurrence following radiofrequency ablation of hepatocellular carcinoma.

The aim of the present study was to investigate the prognostic potential of a novel inflammation-based system, the combination of the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) (CNP), for predicting the survival time of patients with hepatocellular carcinoma (HCC) who had received radiofrequency ablation (RFA). A total of 287 HCC patients treated with RFA were enrolled in the study. Patients with an elevated NLR (>2.58) and an elevated PLR (>131.78) were allocated a score of 2, and patients exhibiting one or neither of these characteristics were allocated a score of 1 or 0, respectively. The association between the CNP and various HCC clinicopathological factors, patterns of recurrence and prognoses were analyzed. The CNP was associated with liver cirrhosis (P=0.015), Child-Pugh class (P=0.024), total bilirubin level (P=0.028), neutrophil count (P<0.001), lymphocyte count (P<0.001) and platelet count (P<0.001). Compared with their low-CNP counterparts, patients with an elevated CNP were more likely to develop distant intrahepatic recurrence [52.3% (CNP 2) vs. 33.9% (CNP 0) and 34.6% (CNP 1), P=0.015; CNP 0 vs. CNP 1, P=0.922; CNP 1 vs. CNP 2, P=0.020] and extrahepatic metastasis [25.0% (CNP 2) vs. 7.6% (CNP 0) and 18.5% (CNP 1), P=0.003; CNP 0 vs. CNP 1, P=0.020; CNP 1 vs. CNP 2, P=0.309], and had shorter overall survival (OS) time (CNP 0 vs. CNP 1, P<0.001; CNP 1 vs. CNP 2, P<0.001) and recurrence-free survival (RFS; CNP 0 vs. CNP 1, P=0.012; CNP 1 vs. CNP 2, P=0.004). Moreover, multivariate analysis revealed that the CNP was superior to the NLR and the PLR as an independent prognostic marker of OS and RFS. Therefore, it was concluded that the CNP may represent a useful predictor for recurrence and prognosis in patients with HCC treated with RFA.

An improved strategy to detect the epithelial-mesenchymal transition process in circulating tumor cells in hepatocellular carcinoma patients.

PURPOSE: We adopted a new strategy to explore the relationship between the EMT process of CTCs and hepatocellular carcinoma (HCC). Furthermore, we intend to illustrate the potential diagnostic value of CTCs of distinct phenotypes in HCC. METHODS: The clinical data of 33 HCC patients and 10 healthy volunteers were collected retrospectively. By using the optimized CanPatrol CTC enrichment technique, patient blood samples of about 5 ml were collected, and CTCs were identified and characterized. The first step of this detection process was to isolate CTCs via a filter-based method; then, an RNA in situ hybridization (RNA-ISH) technique based on the branched DNA signal amplification technology was used to classify the CTCs according to EMT markers. The relationships between HCC CTCs and clinical characteristics were analyzed. RESULTS: The number of epithelial CTCs was related to tumor size (r = 0.456, p = 0.008), epithelial-mesenchymal-mixed CTCs were related to tumor number (r = 0.421, p = 0.015), and mesenchymal CTC was associated with metastasis (r = 0.375, p = 0.032). There was no significant correlation between CTC number and other clinicopathological factors, such as age, serum AFP level or cirrhosis. CONCLUSIONS: Epithelial-mesenchymal-mixed CTCs seem to play an important role in EMT transition in HCC, mixed CTCs might be a vital factor for intrahepatic metastasis, and mesenchymal CTCs had the potential to be a predictor of extrahepatic metastasis.

Single-Agent versus Combination Doxorubicin-Based Transarterial Chemoembolization in the Treatment of Hepatocellular Carcinoma: A Single-Blind, Randomized, Phase II Trial.

OBJECTIVES: It was the aim of this study to find an optimal therapeutic regimen of transarterial chemoembolization (TACE) by comparing the efficacy of chemoembolization with different anticancer agents in hepatocellular carcinoma (HCC) patients. METHODS: A single-blind, three-group parallel, randomized trial was conducted in Guangdong General Hospital, Guangzhou, China, with patients with biopsy-confirmed HCC. Group 1 received single-drug (doxorubicin) chemoembolization, while group 2 received double-drug (doxorubicin and mitomycin C) chemoembolization. Patients in group 3 were treated with triple-drug (doxorubicin, mitomycin C, and gemcitabine) chemoembolization. Lipiodol was used as embolization agent in all protocols. We compared the overall survival (OS), time to progression (TTP), and objective response rate (ORR) between groups. Response assessment was performed according to modified RECIST (Response Evaluation Criteria In Solid Tumors) criteria. RESULTS: Between January 2008 and January 2011, 162 patients (group 1, n = 50; group 2, n = 59; group 3, n = 53) were recruited. The OS and TTP in groups 1, 2, and 3 were 14.9 and 6.4, 13.2 and 6.4, and 20.5 and 6.8 months, respectively. OS and TTP were statistically significant among groups (p = 0.002 and p = 0.037). The ORR was 22.0, 40.7, and 56.6%, respectively. The ORR was significantly different across the three groups (p < 0.002). CONCLUSIONS: TACE with multiple chemotherapeutic agents might significantly increase survival and tumor response; additionally, gemcitabine was likely to have an advantage in improving the prognosis of HCC patients. © 2015 S. Karger AG, Basel.