Predicting Patterns of Distant Metastasis in Breast Cancer Patients following Local Regional Therapy Using Machine Learning.

Up to 30% of breast cancer (BC) patients will develop distant metastases (DM), for which there is no cure. Here, statistical and machine learning (ML) models were developed to estimate the risk of site-specific DM following local-regional therapy. This retrospective study cohort included 175 patients diagnosed with invasive BC who later developed DM. Clinicopathological information was collected for analysis. Outcome variables were the first site of metastasis (brain, bone or visceral) and the time interval (months) to developing DM. Multivariate statistical analysis and ML-based multivariable gradient boosting machines identified factors associated with these outcomes. Machine learning models predicted the site of DM, demonstrating an area under the curve of 0.74, 0.75, and 0.73 for brain, bone and visceral sites, respectively. Overall, most patients (57%) developed bone metastases, with increased odds associated with estrogen receptor (ER) positivity. Human epidermal growth factor receptor-2 (HER2) positivity and non-anthracycline chemotherapy regimens were associated with a decreased risk of bone DM, while brain metastasis was associated with ER-negativity. Furthermore, non-anthracycline chemotherapy alone was a significant predictor of visceral metastasis. Here, clinicopathologic and treatment variables used in ML prediction models predict the first site of metastasis in BC. Further validation may guide focused patient-specific surveillance practices.

Drivers of Emergency Department Use Among Oncology Patients in the Era of Novel Cancer Therapeutics: A Systematic Review.

BACKGROUND: Patients diagnosed with cancer are frequent users of the emergency department (ED). While many visits are unavoidable, a significant portion may be potentially preventable ED visits (PPEDs). Cancer treatments have greatly advanced, whereby patients may present with unique toxicities from targeted therapies and are often living longer with advanced disease. Prior work focused on patients undergoing cytotoxic chemotherapy, and often excluded those on supportive care alone. Other contributors to ED visits in oncology, such as patient-level variables, are less well-established. Finally, prior studies focused on ED diagnoses to describe trends and did not evaluate PPEDs. An updated systematic review was completed to focus on PPEDs, novel cancer therapies, and patient-level variables, including those on supportive care alone. METHODS: Three online databases were used. Included publications were in English, from 2012-2022, with sample sizes of ≥50, and reported predictors of ED presentation or ED diagnoses in oncology. RESULTS: 45 studies were included. Six studies highlighted PPEDs with variable definitions. Common reasons for ED visits included pain (66%) or chemotherapy toxicities (69.1%). PPEDs were most frequent amongst breast cancer patients (13.4%) or patients receiving cytotoxic chemotherapy (20%). Three manuscripts included immunotherapy agents, and only one focused on end-of-life patients. CONCLUSION: This updated systematic review highlights variability in oncology ED visits during the last decade. There is limited work on the concept of PPEDs, patient-level variables and patients on supportive care alone. Overall, pain and chemotherapy toxicities remain key drivers of ED visits in cancer patients. Further work is needed in this realm.

Bony Canal Method of Dexamethasone Injections in Aggressive Form of Central Giant Cell Granuloma-Case Series.

Central Giant Cell Granuloma constitutes approximately 7% of benign tumors of the jaws. The aggressive form of CGCG clinically behaves like a classic semi-malignant neoplasm. In the literature, the suggested method of treatment of aggressive forms of CGCG is curettage or resection with the margin of 0.5 cm. Surgical treatment, especially in the developmental age, entails disturbances in the growth and differentiation of tissues and deforms and disturbs the functioning of the stomatognathic system. Alternative treatment methods of the CGCG presented in this article lead to the patient avoiding a mutilating procedure and improve their quality of life. The aim was to present alternative method of treatment of aggressive forms of Central Giant Cell Lesion of the jaws-injections of dexamethasone into the tumor mass through drilled bony canals. Here, we present the three cases of aggressive forms of CGCG of jaws treated with dexamethasone injections into the tumor mass. Two cases resulted in regression of the tumor, which was confirmed in histologic evaluation after remodeling surgery. Those two patients were uneventful and showed no signs of tumor recurrence at 8 and 9 years of thorough follow-up, respectively. The third patient was qualified for the mandible resection due to the enlargement of the lesion and destruction of the cortical bone. According to our observations, if the proper patient discipline, and thorough, careful clinical and radiological examinations are provided, the dexamethasone injections could be a recommended method of treatment of intraosseous giant cell granuloma. The indication is restricted to the cases with preserved bony borders despite deformation. Additionally, leaving vital teeth in the lesion is also possible.

Significance of Pseudomeningocele After Decompressive Surgery for Chiari I Malformation.

Background: Pseudomeningoceles (PMCs) as abnormal collections of cerebrospinal fluid are quite common findings on follow-up MRI after Chiari decompression surgery (CDS). However, the importance of their identification has not been truly determined, especially when PMCs are described occasionally in the process of radiological follow-up. We retrospectively analyzed surgical outcomes and imaging findings after CDS depending upon the occurrence and thickness of PMCs. Methods: A total of 76 adult patients who underwent CDS were analyzed. The clinical and radiological outcomes of patients with a pseudomeningocele (wPMC) were evaluated and compared to those of patients without a pseudomeningocele (w/oPMC). Radiological morphometric measurements were performed and compared between groups. Comparisons of the maximal PMC thickness were made within the wPMC group. Results: PMCs were recognized in 27 (35.5%) patients, of whom 3 (11.1%) required reoperation. Differences in satisfactory result rates regarding gestalt assessment and Chicago Chiari Outcome Scale were statistically insignificant between the w/oPMC and wPMC groups (p = 1 and p = 0.56, respectively). The postoperative syringomyelia decrease and cerebellar tonsil elevation were similar between the groups (p = 1 and p = 0.74, respectively) in the long-term follow-up. Additionally, the clinical or radiological outcomes with radiological details were not related to PMC thickness in the long-term follow-up. However, radiological details showed the cooccurrence of PMCs with a postsurgical of cerebello-tentorial distance increase (p < 0.05), basion-pontomedullary sulcus distance decrease (p < 0.05) and tonsillo-graft distance decrease (p < 0.05). Conclusions: We found no significant relationships between PMC presence or thickness and clinical or radiological outcomes. However, postoperative changes within the posterior fossa associated with PMCs resemble brain sagging, which occurs in intracranial hypotension. Therefore, extradural cerebrospinal fluid escape may also be responsible for symptoms in some patients with PMCs after CDS.

Long-Term Clinical Results with Radiological Correlations After Posterior Foraminotomy for Unilateral Cervical Discopathy.

BACKGROUND: In lateral cervical disc herniations, posterior foraminotomy (PF) provides direct nerve root decompression and maintains segmental mobility. However, partial facetectomy can cause instability. This study evaluated long-term clinical outcomes related to cervical sagittal alignment after PF. METHODS: The study included 48 consecutive patients with lateral cervical disc herniations who underwent PF. Pain and mobility were evaluated using the Numeric Rating Scale and Neck Disability Index (NDI), respectively. Sagittal alignment was evaluated using the modified Toyama method. RESULTS: Median Numeric Rating Scale arm, Numeric Rating Scale neck, and NDI scores improved by 7, 4.5, and 24 points, respectively. Corresponding mean minimal clinically important differences were achieved in 94%, 77%, and 98% of patients at a mean follow-up of 8.4 years. Of patients, 82% showed favorable radiological results (i.e., retained or developed lordosis or had straight spine), while 18% showed unfavorable radiological results (i.e., retained or changed toward kyphosis). The latter group had multilevel cervical degenerative disc disease (mcDDD) before PF. Nevertheless, the risk of developing kyphosis was only 2.6%, and the potential for improving sagittal balance was 43%. Follow-up median NDI scores, but not minimal clinically important differences, were significantly worse in patients with preoperative kyphosis (21 vs. 8; P = 0.03) or mcDDD (20 vs. 8; P = 0.024) compared with other patients. CONCLUSIONS: Patients with preoperative kyphosis or mcDDD had worse NDI outcomes but also benefited from PF. Sagittal alignment improved in >40% of patients, but coexisting mcDDD was a main risk factor for kyphosis persistence.

Clinical and radiological results of treating lumbar spondylosis with cortical bone trajectory screws.

ABSTRACT: The cortical bone trajectory screws technique (CBTT) is a popular minimally invasive spine surgery. Few studies have reported long-term outcomes. We aimed to evaluate the complication profile and long-term follow-up results of patients with lumbar degenerative disease treated with the CBTT.This retrospective analysis included the first 40 consecutive patients that underwent the CBTT. The indication for surgery was critical stenosis of the intervertebral foramen, which required removal of the entire intervertebral joint, on at least 1 side, during decompression.The last follow-up showed minimal clinically important differences in the numerical rating scale of leg pain, the numerical rating scale of back pain, and the Oswestry Disability Index, in 97%, 95%, and 95% of patients, respectively. Thirty-nine patients completed long-term radiological follow-up. Computed tomography demonstrated solid bone union on 47 (92%) operated levels, collapsed union on 2 (4%) levels, nonunion on 1 (2%) level, and 1 (2%) patient was lost to follow-up. Seven patients experienced complications (4 hardware-related). Three patients required 4 revision surgeries.The CBTT effectively achieved spinal fusion; over 90% of patients achieved clinical improvement at a mean follow-up of 4.4 years (range: 3-5.75 years).

Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery.

Suboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.

Lateral approach for recurrent unilateral cervical radiculopathy after anterior discectomy with fusion. Report of two cases.

Recurrent radiculopathy after anterior cervical discectomy with fusion (ACDF) occurs in approximately 4% of cases. The main obstacles of revision surgery after ACDF via the same approach are scar tissue and arthrodesis. We present two patients with recurrent symptoms after ACDF who underwent revision surgery using an alternative, less invasive lateral approach (LA). These two patients both presented with recurrent unilateral cervical radiculopathy due to progression of intervertebral foraminal stenosis. The second patient also presented with paraparesis of the lower limbs and central stenosis. Anterior foraminotomy in the first case and oblique corpectomy in the second were performed via the LA. The previously implanted interbody cages were left intact and no new fusion procedures were needed. No spinal instability or symptom relapse was observed in follow-up. The lateral approach to the cervical spine enables direct and effective decompression of neural structures without violation of previously achieved interbody fusion.

Morphometric Analysis for Surgical Treatment of Cervical Discopathy by Posterior Laminoforaminotomy: Radiologic Study and Technical Note.

BACKGROUND: The main concern with the posterior approach is the risk of postoperative segmental instability. The most commonly cited rule is that removal of the medial half of the articular facet provides adequate surgical exposure and has no effect on stability. The aim of this study was to define the areas of the articular processes in the cervical spine that can be safely removed. METHODS: Computed tomography scans of 50 cervical spines were analyzed. Measurements were analyzed for bone removal assuming the standard technique of posterior laminoforaminotomy. The width of the facet was measured at the level of the widest dimension. The height of the articular process was taken from the bottom (in the case of inferior process) or top (in the case of superior process) of the process. RESULTS: The mean width of the articular process ranged from 11.8 ± 1.5 mm (range, 8.3-15.7 mm) at the C2-C3 level to 14.6 ± 1.7 mm at the C6-C7 level. At the cervicothoracic junction (C7-T1 level), the mean width decreased to 14.0 ± 1.7 mm. The mean value for both sides when the inferior articular process was measured at all levels was 5.0 ± 1.4 mm (range, 4.5-5.8 mm). The mean height of the superior articular process was 7.7 ± 1.5 mm (range, 6.8-8.3 mm). CONCLUSIONS: Based on our findings, our "5-5-7 mm rule" corresponds to the amount of bone removal for each step of the laminoforaminotomy.

Midline lumbar fusion using cortical bone trajectory screws. Preliminary report.

INTRODUCTION: Midline lumbar fusion (MIDLF) using cortical bone trajectory is an alternative method of transpedicular spinal fusion for degenerative disease. The new entry points' location and screwdriving direction allow the approach-related morbidity to be reduced. AIM: To present our preliminary experience with the MIDLF technique on the first 5 patients with lumbar degenerative disease and with follow-up of at least 6 months. MATERIAL AND METHODS: Retrospective analysis was performed on the first 5 patients with foraminal (4) or central (1) stenosis operated on between December 2014 and February 2015. Three patients were fused at L4-L5 and two at the L5-S1 level. RESULTS: No intra- or post-operative complications occurred with this approach. An improvement regarding the leading symptom in the early postoperative period (sciatica 4/4, claudication 1/1) was achieved in all patients. The mean improvements in the visual analogue scale for low back and leg pain were 2.2 and 4.8 respectively. The mean Oswestry Disability Index scores were 52% (range: 16-82%) before surgery and 33% (range: 12-56%) at 3-month follow-up (mean improvement 19%). At the most recent follow-up, 4 patients reported the maintenance of the satisfactory result. The early standing and follow-up X-rays showed satisfactory screw placement in all patients. CONCLUSIONS: In our initial experience, the MIDLF technique seems to be an encouraging alternative to traditional transpedicular trajectory screws when short level lumbar fusion is needed. Nevertheless, longer observations on larger groups of patients are needed to reliably evaluate the safety of the method and the sustainability of the results.