Long duration of immunotherapy before radiosurgery might improve intracranial control of melanoma brain metastases.

PURPOSE: Despite significant advances that have been made in management of metastatic melanoma with immune checkpoint therapy, optimal timing of combination immune checkpoint therapy and stereotactic radiosurgery is unknown. We have reported toxicity and efficiency outcomes of patients treated with concurrent immune checkpoint therapy and stereotactic radiosurgery. PATIENTS AND METHODS: From January 2014 to December 2016, we analyzed 62 consecutive patients presenting 296 melanoma brain metastases, treated with gamma-knife and receiving concurrent immune checkpoint therapy with anti-CTLA4 or anti-PD1 within the 12 weeks of SRS procedure. Median follow-up time was 18 months (mo) (13-22). Minimal median dose delivered was 18 gray (Gy), with a median volume per lesion of 0.219 cm3. RESULTS: The 1-year control rate per irradiated lesion was 89% (CI 95%: 80.41-98.97). Twenty-seven patients (43.5%) developed distant brain metastases after a median time of 7.6 months (CI 95% 1.8-13.3) after gamma-knife. In multivariate analysis, positive predictive factors for intracranial tumor control were: delay since the initiation of immunotherapy exceeding 2 months before gamma-knife procedure (P=0.003) and use of anti-PD1 (P=0.006). Median overall survival (OS) was 14 months (CI 95%: 11-NR). Total irradiated tumor volume<2.1 cm3 was a positive predictive factor for overall survival (P=0.003). Ten patients (16.13%) had adverse events following irradiation, with four grade≥3. Predictive factors of all grade toxicity were: female gender (P=0.001) and previous treatment with MAPK (P=0.05). CONCLUSION: A long duration of immune checkpoint therapy before stereotactic radiosurgery might improve intracranial tumor control, but this relationship and its ideal timing need to be assessed in prospective trials.

2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults.

These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.

Safety of middle-ear day-surgery in children: A STROBE observational study.

OBJECTIVE: The main objective of this pediatric study of otologic surgery was to analyze factors for success of outpatient management. The secondary objective was to study unscheduled postoperative consultations and readmissions. MATERIALS AND METHODS: This retrospective observational study analyzed clinical characteristics and procedures in consecutive children undergoing major ear surgery over a 3-year period in a teaching hospital. The study followed STROBE recommendations. RESULTS: We included 214 day-cases from a total population of 271 children. Median age was 109±44months (9years) [range: 8-196months (16years)]. In 57% of cases, the procedure was performed without mastoidectomy: 84 myringoplasties and 37 tympanoplasties. In 43% of cases, mastoidectomy was associated: 47 cochlear implants and 46 closed tympanoplasties for cholesteatoma. Ninety-five percent of day-surgeries were successful; in 5%, there was crossover to pediatric ENT department admission, for the following symptoms: postoperative nausea and vomiting in 3 cases, pain in 3, and late awakening in 5. Univariate analysis showed a relationship between failure and age under 36months (P=0.002). There were no readmissions. There were unscheduled consultations in 3% of cases: for minor otorrhagia in 5 cases and uncomplicated otorrhea in 2. CONCLUSION: Major otologic surgery in children is compatible with day-surgery. Younger patients, usually candidates for cochlear implantation, had greater risk of crossover to conventional admission. In this age group, scheduling should be earlier in the morning, with rigorous postoperative nausea and vomiting prophylaxis.

Spinal and cranio-cervical mycetoma: A difficult surgery, with poor prognosis.

BACKGROUND: Few central nervous systems (CNS) cases of actinomycetoma have been recorded in the literature, and most were reported in tropical and subtropical regions. The management of this invasive infection is difficult, especially when it affects the spine and the cranio-cervical regions. CASE: We report an unusual case of a cranio-cervical junction actinomycetoma, in a patient presenting a cerebellar syndrome from brainstem compression. The CT scan showed a compressive solid osteolytic lesion in the cranio-cervical junction. The patient underwent cranio-cervical decompression and lesion resection. The diagnosis of actinomycetoma was confirmed on immune-histochemistry and molecular analysis. At 4 months' follow-up, the patient presented a fatal recurrence disseminating within the cerebellum and the spine. CONCLUSION: The surgical treatment of CNS actinomycetoma presented poor prognosis and a disseminating recurrence. We believe that clinicians and surgeons must be informed about these "new" infectious pathologies that are so difficult to treat, especially with the arrival of migrant patients from endemic countries in conflict.

Intracranial primary synovial sarcoma mimicking a spontaneous cerebral hematoma-a case report and review of the literature.

BACKGROUND: Synovial sarcoma is a soft tissue sarcoma, of uncertain histological origin, usually located near large joints and concerning mainly young adults. Intracranial presentation in the form of metastasis from a primitive body sarcoma has been rarely reported. However, intracranial primitive synovial sarcoma (IPSS) is extremely rare and only a few cases have been reported in the literature. CASE DESCRIPTION: We present the case of a 48-year-old man, with no particular medical history, that was referred to our hospital for severe headache with a normal neurological exam and a CT cerebral scan showing a left frontal lobe hematoma. The initial cerebral CT scan didn't show any vascular malformation and the body CT scan was negative for a primitive lesion. A close follow-up with a cerebral MRI three months later, demonstrated a T1 enhanced lesion with an important volume progression. The patient underwent a complete surgical removal of this lesion and the first pathology diagnosis was compatible with a meningioma. After further proofreading by an expert and molecular analysis, the diagnosis of monophasic synovial sarcoma was confirmed. Nine months after the first surgery, the follow-up MRI showed the progressive recurrence of the lesion and in this context the patient underwent a second surgery with total resection of the tumor and frontal thin margin excision. Afterwards, the patient was treated with adjuvant radiotherapy, with a good clinical evolution, and till now the follow-up shows no recurrence. CONCLUSION: IPSS is an extremely rare sarcoma, with challenging diagnosis and difficult management. Specific molecular analysis is necessary. Complete resection followed by radiotherapy seem to be the most appropriate therapeutic approach. However, the prognosis is still poor. Our case is even rarer because of the initial presentation as a cerebral hematoma.

Thoracolumbar spinal fracture in children: Conservative or surgical treatment?

PURPOSE: Spinal thoracolumbar fractures represent 10-14% of pediatric fractures. Most children concerned by such fractures are above 10 years of age. No guidelines presently exist. Analysis of spine pathophysiology and of the various common therapeutic attitudes led us to conduct a review of the different therapeutic approaches in pediatric thoracolumbar fracture. METHODS: A review of the literature was carried out using the Medline and Embase databases with the search-term "pediatric thoracic lumbar spine fractures". RESULTS: The systematic review identified 44 studies, 24 of which were selected, and 19 were included for analysis. Physiological age was categorized on Risser's classification. In Risser 1 with Magerl A1 fracture, surgical treatment was not necessary and functional (rest and analgesics) or conservative treatment (bracing for 6 weeks) was sufficient. In Risser 1 with Magerl A2, A3 or B fracture, conservative treatment (bracing for 3 months) was the first-line option. In Risser 2-4, conservative treatment with bracing for 3 months was possible in the absence of instability, with kyphosis>20° and canal compression>33%; otherwise, treatment should be surgical. Subsequently, in case of onset of secondary instability, surgical treatment can be proposed. We highlight the importance of MRI assessment for diagnosis of thoracolumbar fracture and associated lesions of the intervertebral discs and posterior ligament complex. Children classified as Risser 5 can undergo the same treatment as adults. CONCLUSION: Two main parameters should be assessed in treatment decision-making for thoracolumbar fracture: the Risser scale and the Magerl classification.

Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Metallic implants and CT artefacts in the CTV area: Where are we in 2020?

Radiation therapy (RT) is one of the main modalities of cancer treatment worldwide with computed tomography (CT), as the most commonly used imaging method for treatment planning system (TPS). Image reconstruction errors may greatly affect all the radiation therapy planning process, such as target delineation, dose calculation and delivery, particularly with particle therapy. Metallic implants, such as hip and spinal implants, and dental filling significantly deteriorate image quality. These hardware structures are often very complex in geometry leading to geometric complex artefacts in the clinical target volume (CTV) area, rendering the delineation of CTV challenging. In our review, we focus on the methods to overcome artefact consequences on CTV delineation: 1- medical approaches anticipating issues associated with imaging artefacts during preoperative multidisciplinary discussions while following standard recommendations; 2- common metal artefact reduction (MAR) methods such as manually override artefact regions, ballistics avoiding beam paths through implanted materials, megavoltage-CT (MVCT); 3- prospects with radiolucent implants, MAR algorithms and various methods of dual energy computed tomography (DECT). Despite substantial and broad evidence for their benefits, there is still no universal solution for cases involving implanted metallic devices. There is still a high need for research efforts to adapt technologies to our issue: "how do I accurately delineate the ideal CTV in a metal artefact area?"

Cylindroma spine metastasis: Long-term follow-up is required.

BACKGROUND: Adenoid cystic carcinoma (ACC), or cylindroma, is a rare malignancy believed to arise from epithelial cells of salivary glands. It is a slow-growing but aggressive tumor with a propensity for perineural invasion. Metastases are common to the lung, but rare to the spine. The natural history of ACC spine metastases is unknown and progression is unpredictable. METHODS: (1) A case report was described for a patient diagnosed with spine ACC metastasis of the T6/T7 vertebrae. (2) A literature search was conducted on Medline via PubMed and the Cochrane databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles from 1973 to March 2019 using following keywords: adenoid cystic carcinoma, cylindroma, metastasis, salivary glands. RESULTS/CASE REPORT: We report an unusual case of spine ACC metastasis of the T6/T7 vertebrae in a patient suffering from progressive radiculopathy and thoracic pain. Based on these findings, the patient underwent T6/T7 laminectomy. The diagnosis was confirmed by the pathology results. The primary parotid tumor had been resected 35 years before spine metastasis. A review of literature encompassing 40 years identified 16 patients treated for ACC spine metastases. Mean time to spine metastases was 4.1 years after primary treatment of ACC. Spine metastases were isolated, without local recurrence at the neck. CONCLUSION: This case highlights the critical importance of long follow up of ACC patients, due to late spine metastases. Diagnosis spinal metastasis of salivary carcinoma should be considered, to guide management, especially in clinical follow-up.

Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery!

BACKGROUND: With recent advances in oncologic treatments, there has been an increase in patient survival rates and concurrently an increase in the number of incidence of symptomatic spinal metastases. Because elderly patients are a substantial part of the oncology population, their types of treatment as well as the possible impact their treatment will have on healthcare resources need to be further examined. PURPOSE: We studied whether age has a significant influence on quality of life and survival in surgical interventions for spinal metastases. STUDY DESIGN: We used data from a multicenter prospective study by the Global Spine Tumor Study Group (GSTSG). This GSTSG study involved 1,266 patients who were admitted for surgical treatments of symptomatic spinal metastases at 22 spinal centers from different countries and followed up for 2 years after surgery. PATIENT SAMPLE: There were 1,266 patients recruited between March 2001 and October 2014. OUTCOME MEASURES: Patient demographics were collected along with outcome measures, including European Quality of Life-5 Dimensions (EQ-5D), neurologic functions, complications, and survival rates. METHODS: We realized a multicenter prospective study of 1,266 patients admitted for surgical treatment of symptomatic spinal metastases. They were divided and studied into three different age groups: <70, 70-80, and >80 years. RESULTS: Despite a lack of statistical difference in American Society of Anesthesiologists (ASA) score, Frankel neurologic score, or Karnofsky functional score at presentation, patients >80 years were more likely to undergo emergency surgery and palliative procedures compared with younger patients. Postoperative complications were more common in the oldest age group (33.3% in the >80, 23.9% in the 70-80, and 17.9% for patients <70 years, p=.004). EQ-5D improved in all groups, but survival expectancy was significantly longer in patients <70 years old (p=.02). Furthermore, neurologic recovery after surgery was lower in patients >80 years old. CONCLUSIONS: Surgeons should not be biased against operating elderly patients. Although survival rates and neurologic improvements in the elderly patients are lower than for younger patients, operating the elderly is compounded by the fact that they undergo more emergency and palliative procedures, despite good ASA scores and functional status. Age in itself should not be a determinant of whether to operate or not, and operations should not be avoided in the elderly when indicated.

Extrinsic thoracic spinal cord compression related to supine position: from diagnosis to the creation of a spinal protection shield.

BACKGROUND: Rapidly progressing extrinsic spinal cord compression syndromes are rare, especially when the compression is associated with the supine position. PURPOSE: This work presents a case of extrinsic thoracic spinal cord compression related to the supine position and describes our approach from diagnosis to the technical therapeutic creation of a spinal protection shield. STUDY DESIGN: One case of a patient suffering from extrinsic spinal cord compression syndrome is reported. PATIENT SAMPLE: We report the case of a Coptic priest patient who, as a result of Pott disease sequelae, underwent several decompressive and stabilizing surgeries for major kyphoscoliosis. Consequently, he developed extrinsic thoracic spinal cord compression caused by the supine position. OUTCOME MEASURES: After each instrumentation device removal, we noticed progressive severe paraparesis when the patient was supine. Imaging assessment confirmed spinal dynamic and intermittent compressions triggered by the supine position, which was facilitated by the exposure and vulnerability of the thoracic spine cord. METHODS: We implanted a tailored titanium mesh spinal protection shield and a trapezius flap for spine coverage. This work presents the diagnostic aspects as well as several surgical technique options. RESULTS: At the 6-year follow-up, the patient's neurologic conditions were significantly improved. We report neurologic improvements, no sphincter disorder, persistent spasticity, and lower limbs weakness not affecting full ambulation. CONCLUSIONS: To our knowledge, no other case of spinal protection shield in compressions caused by the supine position have been studied. The surgical and technical management therefore remains innovative.

Expert-validated CSF segmentation of MNI atlas enhances accuracy of virtual glioma growth patterns.

Biomathematical modeling of glioma growth has been developed to optimize treatments delivery and to evaluate their efficacy. Simulations currently make use of anatomical knowledge from standard MRI atlases. For example, cerebrospinal fluid (CSF) spaces are obtained by automatic thresholding of the MNI atlas, leading to an approximate representation of real anatomy. To correct such inaccuracies, an expert-revised CSF segmentation map of the MNI atlas was built. Several virtual glioma growth patterns of different locations were generated, with and without using the expert-revised version of the MNI atlas. The adequacy between virtual and radiologically observed growth patterns was clearly higher when simulations were based on the expert-revised atlas. This work emphasizes the need for close collaboration between clinicians and researchers in the field of brain tumor modeling.

Experimental measure of the tensile strength of biological sealant-collagen association after hepatectomy in dogs.

Fibrin sealants are commonly used in liver surgery. The aim of this study was to test the adhesive properties of a biological sealant-collagen bonding, using an experimental model. After hepatectomy in dogs, we measured the rupture stress point of a fibrin clot on the liver cross-section. The tensile strength was 0.28 N, 5 times higher than the force of arterial pressure in a 2-mm-diameter vessel. These results indicate that the adhesion of fibrin sealants is effective to prevent hemorrhage from the liver cross-section after hepatectomy.

Measuring the rupture stress point of biological sealant-collagen bonding: validation of a technique used after hepatectomy.

The aim of this experimental study was to measure the rupture stress point of a fibrin clot situated on a liver, in realistic surgical conditions. The experimental method was carried out with a machined wooden cylinder bonded on the liver, connected with a wire to a setup and pulled at a constant speed, and a sensor was placed on the wire measuring the applied strength. This method, realized in the dog, made it possible to validate a precise and reproducible method designed for testing the adhesive characteristics of biological sealant-collagen bonding on the liver.