[Value of surgery combined chemotherapy and radiation therapy in locally advanced neuroendocrine carcinoma of the cervix: a single-center retrospective cohort study].

Objective: To evaluate the surgery combined chemotherapy and radiation in locally advanced neuroendocrine carcinoma of the cervix (NECC) . Methods: This is a single-center retrospective cohort study. Locally advanced NECC patients admitted to Peking Union Medical College Hospital, Chinese Acadmy of Medical Sciences from January 2011 to April 2022 were enrolled. They were divided into concurrent chemoradiotherapy group, and surgery combined with chemotherapy and radiation group. The Kaplan-Meier method was used to analyze the progression free survival (PFS), overall survival (OS), recurrence rate, and mortality rate. Results: (1) Forty-six cases were included, 22 in concurrent chemoradiotherapy group, 24 in surgery combined chemotherapy and radiation group. With 16 patients (35%, 16/46) received neoadjuvant chemotherapy (NACT), the NACT effective rate was 15/16. (2) The median follow-up time was 27.5 months (range: 10-106 months), with 26 (57%, 26/46) experienced recurrences. There were 4 (9%, 4/46) pelvic recurrences and 25 (54%, 25/46) distant recurrences, and 3 (7%, 3/46) both pelvic and distant recurrences. Compared with concurrent chemoradiotherapy group, surgery combined chemotherapy and radiation group had lower pelvic recurrence rate [14% (3/22) vs 4% (1/24); χ2=1.296, P=0.255] but without statistic difference. Both groups had similar distant recurrence rate [55% (12/22) vs 54% (13/24); χ2=0.001, P=0.979] and overall recurrence rate [59% (13/22) vs 54% (13/24); χ2=0.113, P=0.736]. (3) During the follow-up period, 22 cases (48%, 22/46) died, with 11 cases (50%, 11/22) in concurrent chemoradiotherapy group and 11 cases (46%, 11/24) in surgery combined chemotherapy and radiation group, without significant difference (χ2=0.080, P=0.777). The postoperative 3-year and 5-year OS rates were 62.3% and 36.9%. Compared with concurrent chemoradiotherapy group, the patients in surgery combined chemotherapy and radiation group showed an extended trend in PFS (17.0 vs 32.0 months) and OS (37.0 vs 50.0 months) but without statistic differences (P=0.287, P=0.125). Both groups had similar 3-year OS rate (54.2% vs 69.9%; P=0.138) and 5-year OS rate (36.1% vs 38.8%; P=0.217). Conclusions: Our study supports the multi-modality treatment strategy (including surgery, chemotherapy and radiation) as an important component in the treatment of locally advanced NECC. The combination of surgery, chemotherapy and radiation seems to have advantages in the treatment of locally advanced NECC, but needs to be confirmed by further multicenter studies.

[Swyer syndrome with gonadal non-dysgerminoma malignant germ cell tumors: a report of 15 cases in a national medical center].

Objective: To evaluate the incidence, treatment, and survival outcomes of Swyer syndrome with gonadal non-dysgerminoma malignant germ cell tumor (MGCT-NDG). Methods: A retrospective study was performed on Swyer syndrome patients with MGCT-NDG between January 2011 and December 2022 in Peking Union Medical College Hospital to investigate their characteristics and outcomes. Results: A total of 15 patients (4.9%, 15/307) with Swyer syndrome were identified in 307 MGCT-NDG patients. The average age at diagnosis of MGCT-NDG and Swyer syndrome were (16.8±6.7) and (16.7±6.6) years, respectively. Six cases were preoperatively diagnosed as Swyer syndrome, of which 4 cases received bilateral gonadectomy with or without hysterectomy, while the other 2 cases underwent removal of gonadal tumor and unilateral gonadectomy with hysterectomy, respectively. Of the 9 patients postoperatively diagnosed as Swyer syndrome, unilateral gonadectomy, removal of gonadal tumor, and unilateral gonadectomy with hysterectomy were performed in 6 patients, 2 patients, and 1 patient, respectively. Mixed malignant germ cell tumor (MGCT;10 cases), yolk sac tumor (4 cases), and immature teratoma (1 case) were the pathological subtypes, in the descending order. There were International Federation of Gynecology and Obstetrics (FIGO) stage Ⅰ in 6 cases, stage Ⅱ in 3 cases, stage Ⅲ in 5 cases, and stage Ⅳ in 1 case, respectively. Eleven patients received reoperation for residual gonadectomy after a average delay of (7.9±6.2) months, including 8 MGCT-NDG patients and 1 gonadoblastoma patient, no tumor involved was seen in the remaining gonads in the other 2 cases. Ten patients experienced at least one recurrence, with a median event free survival of 9 months (5, 30 months), of which 2 patients received surgery only at the time of initial treatment. All patients with recurrence received surgery and combined with postoperative chemotherapy. After a median follow-up of 25 months (15, 42 months), 10 patients were disease-free, 3 patients died of the tumor, 1 died of side effects of leukemia chemotherapy, and 1 survived with disease. Conclusion: The incidence rate of Swyer syndrome in patients with MGCT-NDG is about 4.9%; timely diagnosis and bilateral gonadectomy should be emphasized to reduce the risk of reoperation and second carcinogenesis in this population.

[Clinical effects of scalp flaps pedicled with superficial temporal artery parietal branch in repairing facial destructive burn wounds].

Objective: To explore the clinical effects of scalp flaps pedicled with superficial temporal artery parietal branch in repairing facial destructive burn wounds. Methods: A retrospective observational study was conducted. From January 2016 to December 2021, 15 patients with facial destructive burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, including 11 males and 4 females, aged 22 to 79 years. Two patients were complicated with unilateral eyeball destructive burns, two patients were complicated with unilateral auricle defects, eight patients were complicated with lip and cheek defects, and three patients were complicated with lip, cheek, and unilateral nasal alar defects. The burn wound areas ranged from 9 cm×6 cm to 13 cm×10 cm. The scalp flaps pedicled with superficial temporal artery parietal branch, with the area of 10 cm×7 cm to 15 cm×11 cm, were designed, excised, and transferred for repairing burn wounds. The secondary wounds at the donor sites were repaired with medium-thickness scalp grafts. According to patient's needs, the hairs grew at the facial transplanted flap were removed by laser at 2 weeks after the flap was completely viable, or the expanded scalp flap was used to treat the secondary alopecia in the flap donor area of the head at 3 months after the primary wound repair. The survival of the flap/skin graft and the wound healing of the donor and recipient areas after the primary wound repair were recorded. During the follow-up, the appearance of the flap, the scar hyperplasia at the suture site, the repair effect of facial functional parts, the treatment effects of laser hair removal and secondary alopecia treatment at the flap donor site were observed; the patient's satisfaction with the overall repair effect was inquired. Results: After the primary wound repair, all the flaps transplanted to the burn wounds and the skin grafts transplanted to the secondary wounds of the flap donor sites survived well, and the wounds at the donor and recipient sites of flap healed well. The color, texture, and thickness of flap were basically the same as those of normal facial skin, and the scar at the suture site was slight during 3 to 18 months of follow-up period after the primary wound repair. In 11 patients complicated with lip defects, the oral integrity, and the opening and closing functions of mouth were restored with the mouth opening being 2.0-2.5 cm and no microstomia; all the patients could carry out basic language communication, 8 of them could take regular food, and 3 of them could take soft food. The wounds in two patients with unilateral eyeball destructive burns were repaired. In 2 patients complicated with auricle defects, the wounds were repaired, and the external auditory canals were normal. In 3 patients complicated with unilateral nasal alar defects, their noses had poor appearance with reduced nostrils. No hair growth was observed in the facial flap sites after treatment of laser hair removal in 8 patients. Five patients were successfully treated with expanded scalp flaps for secondary alopecia in the flap donor area of the head. The patients were all satisfied with the overall repair effect. Conclusions: The scalp flap pedicled with superficial temporal artery parietal branch has abundant blood supply and is suitable for repairing the wounds in facial destructive burns. It is easy to transfer and can better restore the appearance and function of the recipient area with minimal damage to the flap donor area, which is worthy of clinical promotion.

[Effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with wrist electric burn].

Objective: To explore the effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with severe wrist electric burn. Methods: A retrospective observational study was conducted. From January 2017 to December 2020, 4 patients with wrist high-voltage electric burn admitted to the Department of Burns of the First People's Hospital of Zhengzhou and 4 patients with wrist high-voltage electric burn admitted to the Department of Hand Surgery of Beijing Jishuitan Hospital met the inclusion criteria, including 6 males and 2 females, aged 12 to 52 years. They were all classified as type Ⅱ wrist high-voltage electric burns with median nerve defect. In the first stage, the wounds were repaired with free anterolateral thigh femoral myocutaneous flap. In the second stage, the free gracilis muscle flap combined with sural nerve transplantation was used to reconstruct the digital flexion and sensory function of the affected hand in 3 to 6 months after wound healing. The cut lengths of muscle flap and nerve were 32 to 38 and 28 to 36 cm, respectively. The muscle flap donor area and nerve donor area were both closed and sutured. The survival condition of gracilis muscle flap and sural nerve, the wound healing time of recipient area on forearm, the healing time of suture in muscle flap donor area and nerve donor area were observed and recorded after operation, and the recovery of donor and recipient areas was followed up. In 2 years after operation, the muscle strength of thumb and digital flexion and finger sensory function after the hand function reconstruction were evaluated with the evaluation criteria of the hand tendon and nerve repair in the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association. Results: All the gracilis muscle flap and sural nerve survived successfully after operation. The wound healing time of recipient area on forearm was 10 to 14 days after operation, and the healing time of suture in muscle flap donor area and nerve donor area was 12 to 15 days after operation. The donor and recipient areas recovered well. In the follow-up of 2 years after operation, the muscle strength of thumb and digital flexion was evaluated as follows: 4 cases of grade 5, 3 cases of grade 4, and 1 case of grade 2; the finger sensory function was evaluated as follows: 4 cases of grade S3+, 2 cases of grade S3, and 2 cases of grade S2. Conclusions: For patients with hand dysfunction caused by severe wrist electric burn, free gracilis muscle flap combined with sural nerve transplantation can be used to reconstruct the digital flexion and sensory function of the affected hand. It is a good repair method, which does not cause great damage to thigh muscle flap donor area or calf nerve donor area.

[Value of postoperative radiotherapy and analysis of prognostic factors in early-stage neuroendocrine carcinoma of cervix].

Objective: To evaluate the effect of postoperative radiotherapy and high-risk pathological factors on the prognosis of early-stage neuroendocrine carcinoma of cervix (NECC). Methods: A single-center retrospective cohort study of early-stage NECC in Peking Union Medical College Hospital from January 2011 to April 2022 were enrolled. The patients were treated with radical hysterectomy±adjuvant treatment. They were divided into postoperative non-radiation group and postoperative radiation group. The possible postoperative recurrence risk factors identified by univariate analysis were assessed using multivariate logistic regression. The Kaplan-Meier method was used to analyze the progression free survival (PFS), overall survival (OS), recurrence rate, and mortality rate. Results: (1) Sixty-two cases were included in the study, including 33 cases in postoperative non-radiation group and 29 cases in postoperative radiation group. (2) The median follow-up time was 37 months (ranged 12-116 months), with 23 cases (37%) experienced recurrences. There were 7 cases (11%) pelvic recurrences and 20 cases (32%) distant recurrences, in which including 4 cases (6%) both pelvic and distant recurrences. Compared with postoperative non-radiation group, the postoperative radiation group had a lower pelvic recurrence rate (18% vs 3%; P=0.074) but without statistic difference, a slightly elevated distant recurrence rate (24% vs 41%; P=0.150) and overall recurrence rate (33% vs 41%; P=0.513) without statistically significances. Univariate analysis showed that lymph-vascular space invasion and the depth of cervical stromal invasion≥1/2 were risk factors for postoperative recurrence (all P<0.05). Multivariate analysis showed lymph-vascular space invasion was an independent predictor for postoperative recurrence (OR=23.03, 95%CI: 3.55-149.39, P=0.001). (3) During the follow-up period, 18 cases (29%, 18/62) died with tumor, with 10 cases (30%, 10/33) in postoperative non-radiation group and 8 cases (28%, 8/29) in postoperative radiation group, without significant difference (P=0.814). The postoperative 3-year and 5-year survival rate was 79.2%, 60.8%. The depth of cervical stromal invasion≥1/2 was more common in postoperative radiation group (27% vs 64%; P=0.011), and postoperative radiation in such patients showed an extended trend in PFS (32.3 vs 53.9 months) and OS (39.4 vs 73.4 months) but without statistic differences (P=0.704, P=0.371). Compared with postoperative non-radiation group, the postoperative radiation did not improve PFS (54.5 vs 37.3 months; P=0.860) and OS (56.2 vs 62.4 months; P=0.550) in patients with lymph-vascular space invasion. Conclusions: Postoperative radiation in early-stage NECC patients has a trend to reduce pelvic recurrence but not appear to decrease distant recurrence and overall recurrence, and has not improved mortality. For patients with the depth of cervical stromal invasion≥1/2, postoperative radiation has a trend of prolonging OS and PFS but without statistic difference. Lymph-vascular space invasion is an independent predictor for postoperative recurrence, but postoperative radiation in such patients does not seem to have any survival benefits.

[Effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns].

Objective: To explore the effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns. Methods: A retrospective observational study was conducted. From January 2015 to December 2020, 18 male children with cervical scar contracture deformity after burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 4 to 12 years, including 10 cases with degree Ⅱ cervical scar contracture deformity and 8 cases with degree Ⅲ scar contracture deformity, and were all reconstructed with expanded frontal-parietal pedicled flap. The surgery was performed in 3 stages. In the first stage, a cylindrical skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 300 to 500 mL was placed in the frontal-parietal region. The expansion time was 4 to 6 months with the total normal saline injection volume being 2.1 to 3.0 times of the rated capacity of expander. In the second stage, expander removal, scar excision, contracture release, and flap transfer were performed, with the flap areas of 18 cm×9 cm to 23 cm×13 cm and the secondary wound areas of 16 cm×8 cm to 21 cm×11 cm after scar excision and contracture release. After 3 to 4 weeks, in the third stage, the flap pedicle was cut off and restored. The rated volume of placed expander, total normal saline injection volume, type of vascular pedicle of flap, survival of flap and reconstruction of scar after the second stage surgery were recorded. The neck range of motion and cervico-mental angle were measured before surgery and one-year after surgery. The appearance of neck, occurrence of common complications in the donor and recipient sites of children, and satisfaction of children's families for treatment effects were followed up. Data were statistically analyzed with paired sample t test. Results: All the patients successfully completed the three stages of operation. The rated volume of implanted expander was 300 mL in 6 children, 400 mL in 9 children, and 500 mL in 3 children, with the volume of normal saline injection being 630 to 1 500 mL. The type of vascular pedicle of flap was double pedicle in 13 cases and was single pedicle in 5 cases. All the flaps in 17 children survived well, and the secondary wounds after neck scar excision and contracture release were all reconstructed in one procedure. In one case, the distal blood supply of the single pedicled flap was poor after the second stage surgery, with necrosis of about 2.5 cm in length. The distal necrotic tissue was removed on 10 days after the operation, and the wound was completely closed after the flap was repositioned. In the follow-up of 6 months to 3 years post operation, the cervical scar contracture deformity in 18 children was corrected without recurrence. The flap was not bloated, the texture was soft, and the appearances of chin and neck were good. The range of motion of cervical pre-buckling, extension, left flexion, and right flexion, and cervico-mental angle in one year after operation were improved compared with those before operation (with t values of 43.10, 22.64, 27.96, 20.59, and 88.42, respectively, P<0.01). The incision in the frontal donor site was located in the hairline, the scar was slight and concealed. No complication such as cranial depression was observed in expander placement site, and the children's families were satisfied with the result of reconstruction. Conclusions: Application of expanded frontal-parietal pedicled flap in reconstructing the cervical scar contracture deformity in children after burns can obviously improve the appearance and function of neck, with unlikely recurrence of postoperative scar contractures, thus it is an ideal method of reconstruction.

[GnRH-a combined fertility-sparing re-treatment in women with endometrial carcinoma or atypical endomertial hyperplasia who failed to oral progestin therapy].

Objective: To analyze the clinical efficacy and pregnancy outcomes of gonadotropin-releasing hormone agonist (GnRH-a) based fertility-sparing re-treatment in women with endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) who failed with oral progestin therapy. Methods: Forty cases with EC or AEH who failed to respond to oral progestin were included from January 2012 to December 2020 at Peking Union Medical College Hospital. Combination of GnRH-a with levonorgestrel-releasing intrauterine system (group GLI: a subcutaneous injection of GnRH-a every 4 weeks and LNG-IUS insertion constantly) or the combination of GnRH-a with aromatase inhibitor (group GAI: a subcutaneous injection of GnRH-a every 4 weeks and oral letrozole 2.5 mg, daily) were used for these patients. Histological evaluation were performed at the end of each course (every 3-4 months) by hysteroscopy and curettage. After the complete remission (CR), all patients were followed up regularly. Results: (1) Clinical characteristics:among the 40 patients with EC or AEH, the median age at diagnosis was 31 years (range: 22-40 years) and the median body mass index was 24.7 kg/m2 (range: 18.9-39.5 kg/m2). (2) Efficacy of fertility-sparing re-treatment: 37 (92%, 37/40) patients achieved CR, 6 (6/7) in AEH and 31 (94%, 31/33) in EC patients. The CR rate was 93% (26/28) and 11/12 in group GLI and GAI, respectively. The median time to CR was 5 months (range: 3-12 months). At the end of the first therapy course, the CR rates in AEH and EC were 5/7 and 42% (14/33), at the second course, the CR rates were 6/7 and 82% (27/33), respectively. (3) Recurrence: after 25 months of median follow-up duration (range: 10-75 months), 8 (22%, 8/37) women developed recurrence, 1/6 in AEH and 7 (23%, 7/31) in EC patients, with the median recurrence time of 18 months (range: 9-26 months). Among them, two cases who had completed childbirth chose to receive hysterectomy directly. Six patients met the criteria of fertility-preserving therapy and received conservative treatment again and 5 (5/6) of them achieved CR. (4) Pregnancy: of the 37 patients with CR, 33 desired to conceive. Ten women attempted to get pregnancy spontaneously and 23 cases with assisted reproductive technology. Fourteen (42%, 14/33) patients became pregnant, including 9 (27%, 9/33) live births, 3 (9%, 3/33) missed abortions, and 2 (6%, 2/33) miscarriages at the second trimester. Conclusions: GnRH-a based fertility-sparing re-treatment in AEH or EC patients who failed with oral progestin therapy achieved good treatment effect and reproductive outcomes. It is an encouraging alternative regime for patients who failed with oral progestin therapy.

[Clinical effects of single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region in reconstruction of large scar deformities in the face and neck].

Objective: To explore the clinical effects of single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region in reconstruction of large scar deformities in the face and neck. Methods: From January 2016 to August 2019, 10 male patients, aged from 20 to 52 years with post-burn facial and cervical scar deformities, were admitted to the First People's Hospital of Zhengzhou, with the size of scar ranging from 15 cm×7 cm to 23 cm×11 cm. In the first stage, a cylindrical skin and soft tissue expander with rated capacity ranging from 400 to 600 mL was placed in the frontal-parietal region. Another cylindrical expander with rated capacity ranging from 50 to 100 mL was placed in the temporal region of the patient with scars in front of the ear and in cheek. The injection time was 3 to 5 months with the total injection volume being 1.5 to 2.5 times of the rated capacity of expander. In the second stage, the superficial temporal artery frontal branch and its branches were explored, the expander was removed, the scars in the face and neck were conducted resection and contracture relaxation, and the single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region for reconstruction was performed. When the branches of the superficial temporal vessels were difficult to be detected by Doppler ultrasonic blood stream detector, the patient underwent computed tomography (CT) angiography and three-dimensional reconstruction. The donor site in frontal-parietal region was directly sutured, and the wound of the exposed donor site at the pedicle and temporal region was temporarily covered with scar skin. After the suture wound was healed and the hair in expanded flap grew out, hair removal and laser hair removal were performed. Three to four weeks after transplantation of expanded flap, the flap pedicle was cut off, restored, and trimmed in the third stage. The status about the completion of operation, the implantation of expander in the temporal region, CT angiography and three-dimensional reconstruction were recorded. The effective resection area of expanded flap, the length across the midline and the length of the pedicle, and the survival status of the expanded flap and complications after operation were observed. The appearance of donor and recipient sites, the scar recurrence, the appearance and function improvement of patients, and the satisfaction degree of patients were followed up. Results: All the 10 patients successfully completed three stages of operation, of which 6 patients had an auxiliary expander placement in the temporal region, and 5 patients underwent CT angiography and three-dimensional reconstruction. The effective resection area of expanded flap ranged from 18 cm×8 cm to 25 cm×13 cm. The distal end of the flap across the midline extended 4-6 cm to the opposite side, and the length of pedicle was 2-6 cm. All the expanded flaps of patients survived well after formation and transfer. The venous reflux disorder and obvious swelling occurred in 6 patients at the distal end of the flap after operation, and the blood supply recovered after acupuncture bloodletting, etc. Follow-up of 6 to 24 months showed that the color, texture, and thickness of the expanded flaps were similar to those of the facial skin, and no recurrence of scar was observed; the incision in the donor site of the frontal-parietal region was concealed, the hair growth of the temples and head was normal, and the reconstructed hairline was natural; compared with those before operation, the appearance, head-up, mouth-opening, and other functions of patients were significantly improved; the patients were satisfied with the effect of reconstruction. Conclusions: Clinical application of single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region in reconstruction of large scar deformities in the face and neck can achieve a good appearance and function, and the donor site shows good shape, which enriches the application range of the trans-regional blood supply flap. It is a reliable method for reconstruction of large scar deformities in the face and neck.

[Clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound on the wrist].

Objective: To explore the clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound of type Ⅱ and Ⅲ on the wrist. Methods: From May 2016 to February 2019, 25 patients with deep high-voltage electrical burn wounds on the wrist were admitted to Zhengzhou First People's Hospital, including 23 males and 2 females, aged 11-63 years. Among them, 4 cases had bilateral electrical burns on the wrist, and 21 cases had unilateral electrical burns on the wrist. There were 29 wounds in 29 affected limbs with depth of full-thickness to full-thickness with tendon and bone exposure, and 17 wounds were type Ⅱ and 12 wounds were type Ⅲ. Twenty-four patients underwent CT angiography of the upper extremities before surgery, while the other one patient did not undergo the examination due to seafood allergy. There were no obvious injury to the ulnar and radial arteries in 7 affected limbs, simple ulnar artery injury in 6 affected limbs, simple radial artery injury in 7 affected limbs, and both ulnar and radial arteries injury in 9 affected limbs. The wound areas after debridement were 10 cm×7 cm-36 cm×17 cm, and the free anterolateral thigh flaps were obtained with area of 11 cm×8 cm-37 cm×18 cm for repairing the wounds. For patients with no damage of ulnar artery and radial artery, the trunk of descending branch of lateral circumflex femoral artery of the flap or combined with the thick muscle perforating branch or lateral branch was anastomosed with the ulnar or radial artery of the wound. For patients with simple ulnar artery or radial artery injury, the trunk, lateral branch, or medial branch was anastomosed with the ulnar artery or radial artery of the wound. For patients with long injury of ulnar artery and radial artery, the ulnar artery or radial artery of the wound was reconstructed with one of the above-mentioned methods, the injured artery that was not anastomosed was reconstructed with great saphenous vein, and the transplanted blood vessel was embedded in the lateral femoral muscle. The accompanying vein of the descending branch of the lateral circumflex femoral artery of the flap was anastomosed with the accompanying vein of the ulnar artery or radial artery of the wound and/or the cephalic vein. The donor sites of flaps were sutured directly or repaired with split-thickness skin graft from the thigh. The survival condition of flap and affected limb after operation and during follow-up was observed, and hand function of the affected limb during follow-up was evaluated according to the evaluation standard after repair of peripheral nerve injury in upper limbs. Results: Fifteen affected limb wounds had tissue liquefaction but healed after second debridement on 14-28 days after flap repair operation. All 29 flaps survived in the end. One patient had long ulnar artery and radial artery injuries in affected limbs and the hand was necrotic due to second embolism of the blood vessel in 1 week post operation, and the remaining affected limbs survived. During the follow-up of 6 to 30 months after operation, the flaps were slightly bloated, the affected limbs were warm with normal blood flow, and finger flexion, wrist flexion, and sensory function of hand recovered to varying degrees. The functions of the survived affected limbs were evaluated as excellent in 8 affected limbs, good in 9 affected limbs, medium in 5 affected limbs, and poor in 6 affected limbs, with an excellent and good rate of 60.71%. Conclusions: The clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction is good for repairing high-voltage electrical burn wound on the wrist, and the patency restoration of the ulnar artery and/or radial artery of the upper limb in stage Ⅰ is helpful for improving the success rate of limb salvage.

[Clinicopathological features and prognosis of patients in endometrial cancer with bone metastases].

Objective: To analyze the clinicopathological features and prognosis of patients in endometrial cancer with bone metastases. Methods: A retrospective review of medical records was performed to analyze patients with endometrial cancer who developed bone metastases at Peking Union Medical College Hospital (PUMCH) from January 2004 to December 2017, including patients with bone metastases at the diagnosis of endometrial cancer and at recurrence of endometrial cancer. The patient's clinicopathological features, bone metastasis characteristics, treatment process and prognoses were also analyzed. Results: The incidence of bone metastasis of endometrial cancer in PUMCH from 2004 to 2017 was 0.57% (14/2 458). (1) General clinical pathological features: the median age of the 7 patients with bone metastases diagnosed at the time of initial diagnosis was 50 years old, and the main pathological type was endometrioid carcinoma (n=5). The median age of the other 7 patients was 57 years old, with no significant difference comparing to the former groups (P=0.559). (2) The majority site of bone metastasis in endometrial cancer were discovered in pelvic bones, followed by the tibia. (3) Treatment: according to the staging of endometrial cancer, a comprehensive treatment based on surgery was performed, and one patient with isolated bone metastases underwent resection of bone metastasis. (4) Prognosis: nine out of the 14 patients died during the follow-up period. The median over all survival time was 25.5 months (range: 7.7-258.0 months). The median survival of population after diagnosis of bone metastases was 15.0 months (range: 3.0-51.0 months). The survival rate of endometrial cancer at 1-year after diagnosis of bone metastasis was 71.4%. The 2-year survival rate was 40.8%. (5) No independent prognostic factors affecting survival was found (P>0.05). Conclusions: The incidence of bone metastasis in endometrial cancer is less than 1%. Bone metastasis could occur at the diagnosis of endometrial cancer or recurrence of endometrial cancer. Bone metastasis suggests a poor prognosis. There is no standard follow-up and treatment protocols so that individualized treatment is needed.

[Effects of free anterolateral femoral or medial calf flaps in the repair of severe facial burns].

Objective: To explore the effects of free anterolateral femoral or medial calf flaps in the repair of severe facial burns. Methods: From January 2014 to October 2017, 18 patients with severe facial burns were admitted to Zhengzhou First People's Hospital, including 12 males and 6 females, aged 15-78 years. Autologous intermediate split-thickness skin grafts were transplanted to replace oral mucosa in 4 patients with perforating cheek defects, and 8 patients underwent early vacuum sealing drainage and autologous intermediate split-thickness skin grafting to reduce the wound area to 14 cm×6 cm-22 cm×14 cm before flap transplantation. The wounds of 15 patients were repaired with free anterolateral femoral flaps, and the wounds of the other 3 patients were repaired with free medial calf flaps. The area of flaps ranged from 16 cm×7 cm to 24 cm×17 cm. The facial artery or superficial temporal artery was anastomosed end-to-end with lateral femoral circumflex artery or posterior tibial artery under microscope routinely and manually, and the two accompanying veins were anastomosed end-to-end by Coupler microvascular anastomat. The donor site was sutured or transplanted with autologous intermediate split-thickness skin graft. The anastomosis time of veins was recorded. The patency rate of vascular was calculated. The survival status of flaps were observed. The recovery of recipient area was observed during follow-up. Results: The anastomosis time of two veins in this group was 6-10 minutes, with an average of 8.5 minutes. The patency rates of veins and arteries were 100%. There was no vascular crisis due to the anastomosis problem. The free flaps survived well in 16 patients; one patient had hemorrhage under the flap 6 hours after operation, and the blood circulation of flaps turned well after hemostasis by surgical exploration; the other patient had 3 cm necrosis at the distal end of flap after operation, and the wound was closed after dressing change and autologous intermediate split-thickness skin grafting. The patients were followed up for 2 to 24 months after discharge. Most of the five senses function recovered. The color and texture of the flaps were not consistent with those of the normal facial skin. Some flaps were slightly swollen. Oral integrity was restored in 4 patients with perforating cheek defect with mouth opening of 2.2-3.5 cm. Conclusions: Free anterolateral thigh flaps or medial calf flaps can repair severe facial burn wounds. It takes less time to anastomose venous vessels by microvascular anastomat during operation and can ensure the quality of venous anastomosis.

[Clinical effect of free anterolateral thigh flap in repairing large annular soft tissue defect of lower leg after burn].

Objective: To explore the clinical effect of free anterolateral thigh flap in repairing large annular soft tissue defect of lower leg after burn. Methods: From January 2014 to December 2018, 9 patients with large annular soft tissue defects of lower legs after burns were hospitalized in Zhengzhou First People's Hospital, including 1 case with wounds on both legs. After debridement, area of wounds was 16 cm×11 cm-38 cm×21 cm, and the burn wounds were repaired with free anterolateral thigh flaps in the area of 18 cm×12 cm-32 cm×24 cm. End-to-end anastomosis of posterior tibial vessels or anterior tibial vessels with lateral circumflex femoral vessels was performed in manual way or by microvascular stapler. For the affected legs without condition for anastomosis, the sound medial lower leg flaps with areas of 10 cm×8 cm-15 cm×10 cm were excised and made into skin tubes, the posterior tibial vessels of the flaps were anastomosed with the vessels of free anterolateral femoral flaps, and the wounds of the injured lower legs were repaired by bridge-type cross-over free transplantation of anterolateral thigh flaps. The pedicles were broken 4 to 5 weeks later. The donor site was transplanted with autologous intermediate split-thickness skin graft from thigh. The outcome of the treatment, the number of perforators included in the flaps, and the anastomotic vessel in the recipient area of patients were recorded. The anastomosis time between manual way and microvascular staplers was recorded and compared. The patency of blood vessels, methods of free transplantation, and follow-up condition were recorded. Data were processed with Wilcoxon rank sum test for two independent samples. Results: All the 10 free flaps and skin grafts of 9 patients survived, and all the wounds were closed by primary operation. Seven flaps contained two perforators each, and three flaps contained three perforators each. The anastomotic vessels were posterior tibial vessels in 6 recipient areas and anterior tibial vessels in 4 recipient areas. Microvascular stapler was used to anastomose 12 veins, while 8 veins and 10 arteries were anstomosed manually. The time consumed by the former method was 4.00 (3.55, 4.38) min, significantly shorter than 12.80 (12.13, 13.40) min of the latter (W=78.00, P<0.01). The patency rates of veins and arteries were 100%. There was no vascular crisis due to vascular anastomosis. Three patients underwent bridge-type cross-over free transplantation, while the others underwent conventional free transplantation. Follow-up for 3 to 30 months showed that the donor site of the thigh had good motor function, without numbness or pain, but hypertrophy of scar could be seen. Four patients had slightly overstaffed flaps transplanted in the recipient area of the lower legs, while the other patients were satisfied with their appearance, and the walking function of the affected limbs gradually recovered. Conclusions: Free anterolateral thigh flap transplantation is a safe and reliable clinical limb salvage method for the repair of large annular soft tissue defect of lower leg after burn. Intraoperative application of microvascular stapler for venous anastomosis can shorten the time of vascular anastomosis and has great clinical application value.

[Clinicopathologic and survival analysis of synchronous primary endometrial and ovarian cancer].

Objective: To demonstrate the clinicopathological characteristics and determine the prognostic factors for women with synchronous primary endometrial and ovarian cancer (SEOC) . Methods: A retrospective analysis of 63 pathologically proven cases of SEOC diagnosed in Peking Union Medical College Hospital from January 2000 to May 2018 was carried out. Results: (1) Clinical features: mean age at diagnosis was (48.3±10.0) years, and the mean body mass index (BMI) was (23.4±3.7) kg/m(2). The most common presenting symptom was abnormal uterine bleeding with a ratio of 73% (46/63). Forty-three patients (68%, 43/63) were premenopausal, and 30% (19/63) were nulliparous. (2) Pathological features: for the endometrial cancer, 90% patients were diagnosed at stage Ⅰ, and 81% were low grade tumors (G(1)-G(2)). The histological type of endometrial cancer was mainly endometrioid carcinoma (86%) and majority (81%) of patients were proved without or with superficial myometrial invasion. For the ovarian cancer, 70% patients were diagnosed at stage Ⅰ and 65% were low grade tumors (G(1)-G(2)). Sixty-two percent of ovarian cancers were endometrioid carcinoma and 68% of patients had unilateral involvement of the ovaries. (3) Treatment and prognosis: all patients underwent surgery, of which 56 (89%) underwent staging surgery including retroperitoneal lymphadenectomy, and 57 (90%) received postoperative adjuvant therapy. The median follow-up time was 48.0 months (range, 2-176 months) , and 13% of the patients experienced tumor recurrence during the follow-up period. The median time to recurrence was 38.5 months, and 6 patients (10%) died of tumor recurrence. The 5-year progression-free survival (PFS) and 5-year overall survival (OS) for all patients were 69% and 80%, respectively. (4) Prognostic factors: univariate analysis showed that the presence of lymphovascular space invasion (LVSI) , non-endometrioid histology of ovarian cancer and stage of ovarian cancer above stage Ⅰ were associated with significantly worse PFS (P<0.05). LVSI, high grade of endometrial cancer, and above stage Ⅰ of ovarian cancer were associated with significantly worse OS (P<0.05). On multivariate analysis, LVSI, non-endometrioid type ovarian cancer and stage of ovarian cancer above stage Ⅰwere associated with significantly worse PFS (P<0.05). In addition, LVSI and stage of ovarian cancer above stage Ⅰ were also associated with significantly worse OS (P<0.05) . Conclusions: Women with SEOC are young, premenopausal and have a favorable overall prognosis. Presence of LVSI, non-endometrioid type ovarian cancer and stage of ovarian cancer above stage Ⅰ are independent prognostic factors for PFS, and stage of ovarian cancer above stage Ⅰare independent prognostic factors for OS.

[Application effects of CT angiography and three-dimensional reconstruction technique in repairing scar around the mouth and chin with expanded forehead axial flap].

Objective: To explore application effects of CT angiography (CTA) and three-dimensional reconstruction technique in repairing scar around the mouth and chin with expanded forehead axial flap. Methods: From June 2013 to October 2017, 9 patients with hyperplastic scar around the mouth and chin after deep burns on face were admitted to our unit. The sizes of scars of patients ranged from 8 cm×7 cm to 13 cm×8 cm. One cylindrical skin soft-tissue dilator with nominal volume of 400 to 500 mL was implanted in forehead area of each patient. Five to six months after the dilator was implanted, scar around the mouth and chin was resected, and the dilator was removed. The secondary wound after scar resection was repaired by expanded forehead axial flap with bilateral superficial temporal vessel pedicles. Three of the nine patients received microstomia diorthosis at the same time. Before the operation, CTA and three-dimensional reconstruction were applied to obtain three-dimensional images of superficial temporal arteries and the branches in the donor site, which could identify the travel, adjacent location, and vascular anastomosis of the above-mentioned vessels to guide flap design. The sizes of flaps of patients ranged from 25 cm×9 cm to 30 cm×8 cm. Two to three weeks after the operation, flap pedicles were cut off, restored, and trimmed. The donor site was sutured directly. Ten to twelve days after the flap repair operation, the flap site received depilation treatment with semiconductor freezing point laser once a month for 4 to 6 times. Results: Flaps of all patients survived well, with no blood circulation disorder. The flaps of three patients were slightly bulky, while they were with natural appearance after flap thinning operation in 3 months post flap repair operation. During follow-up of 6 months to 2 years after the operation, color, texture, and thickness of the flaps were close to normal skin around scars. The appearance of perioral and mental region, and opening function of mouth improved significantly, with no recurrence of scar. Frontotemporal incision was hidden, hair on head grew normally, and reconstructed hairline was natural. Conclusions: Scar around the mouth and chin repaired with expanded forehead axial flap were with good appearance and function in operation area and good shape in donor site. CTA and three-dimensional reconstruction technique can provide clear three-dimensional images of superficial temporal arteries and the branches in expanded forehead axial flaps, which can provide reliable basis for preoperative designing of flap, reduce operative risk, and improve survival rate of flap, thus having clinical application value.

Extracellular signal-regulated kinase activation in the spinal cord contributes to visceral hypersensitivity induced by craniofacial injury followed by stress.

BACKGROUND: We previously developed an animal model to examine mechanisms that underlie the emergence of visceral hypersensitivity modeling pain characteristics of temporomandibular disorder (TMD) patients with comorbid irritable bowel syndrome (IBS). In ovariectomized (OVx) rats with estradiol (E2) replacement, visceral hypersensitivity developed subsequent to masseter muscle inflammation followed by repeated forced swim (FS) stress. The purpose of this study was to investigate whether activation of extracellular signal-regulated kinase (ERK) in the spinal cord contributes to visceral hypersensitivity in this overlapping pain model. METHODS: In OVx with E2 replacement rats masseter muscle inflammation was followed by 3 day FS (comorbid condition). Depression-like behaviors were assessed by sucrose preference and in the elevated plus maze, and visceral sensitivity was measured by the visceromotor response (VMR) to colorectal distention. The protein level of ERK1/2 and phosphorylated ERK1/2 (p-ERK1/2) in the L6-S2 dorsal spinal cord was analyzed by western blot. KEY RESULTS: FS stress decreased sucrose consumption in E2 replaced rats in sucrose preference test. The expression of p-ERK1/2 in the L6-S2 dorsal spinal cord increased significantly in E2 with comorbid rats. Intrathecal injection of mitogen-activated protein kinase (MAPK) kinase (MEK) inhibitor PD98059 blocked the visceral hypersensitivity induced by masseter muscle inflammation combined with FS stress. CONCLUSIONS & INFERENCES: These data indicate that ERK1/2 activation contributes to the visceral hypersensitivity evoked by craniofacial inflammation pain combined with stress. The results may provide a new therapeutic avenue for alleviating overlapping pain conditions.

[Clinical effects of repair of wounds in fingers after electrical burn with wrist perforator free flaps].

Objective: To explore the clinical effects of repair of wounds in the fingers after electrical burn with wrist perforator free flaps. Methods: Twelve patients (13 fingers) with electrical burn were hospitalized in our burn ward from January 2016 to January 2017. After radical debridement, the size of wounds ranged from 5.0 cm×2.0 cm to 10.0 cm×7.0 cm. Wounds with size below or equal to 6.0 cm ×2.5 cm were repaired with free flaps based on the superficial palmar branch of radial artery, with flap area ranging from 2.5 cm×2.2 cm to 6.0 cm×4.5 cm. The superficial palmar branch of radial artery, subcutaneous vein, and palmar cutaneous branch of the median nerve underwent end-to-end anastomosis with digital proper artery, dorsal superficial vein, and digital proper nerve in the finger, respectively. The donor sites were sutured directly. Wounds with size larger than 6.0 cm×2.5 cm were repaired with free flaps based on the dorsal carpal branch of ulnar artery, with flap area ranging from 4.5 cm×3.0 cm to 12.0 cm×8.5 cm. The dorsal carpal branch of ulnar artery, subcutaneous vein, and medial antebrachial cutaneous nerve underwent end-to-end anastomosis with digital proper artery, dorsal superficial vein, and digital proper nerve in the finger, respectively. The donor sites were sutured directly or covered by full-thickness skin graft from abdomen. Results: Five free flaps based on the superficial palmar branch of radial artery and 8 free flaps based on the dorsal carpal branch of ulnar artery were used in the patients. In one week after surgery, 12 flaps survived completely, while one free flap based on the dorsal carpal branch of ulnar artery suffered from slight infection, after depressing change, it survived in the end. After the follow-up of half a year, the flaps were full in shape and the distance of two-point discrimination of ranged from 4.0 to 7.0 mm. The fingers showed good functional recovery and no deformity. The grade of function of the fingers was excellent in 10 cases and good in 3 cases. There were small incision scars in donor sites. Conclusions: The wrist perforator free flap is safe and reliable for repairing electrical burn wound of finger. The wounded finger shows good appearance and function after operation.

[Effects of Meek skin grafting on patients with extensive deep burn at different age groups].

Objective: To investigate the effect of Meek skin grafting on patients with extensive deep burn at different age groups. Methods: Eighty-four patients with extensive deep burns conforming to the study criteria were hospitalized in our unit from April 2011 to April 2015. Patients were divided into children group (C, with age less than 12 years old), young and middle-aged group (YM, with age more than 18 years and less than 50 years old), and old age group (O, with age more than 55 years old) according to age, with 28 patients in each group. All patients received Meek skin grafting treatment. The use of autologous skin area, operation time, wound healing time, and hospitalization time were recorded. The survival rate of skin graft on post operation day 7, complete wound healing rate in post treatment week 2, and the mortality were calculated. Data were processed with one-way analysis of variance, t test, and χ(2) test. Results: The use of autologous skin area of patients in group C was (5.1±1.0)% total body surface area (TBSA), significantly less than (8.3±1.0)%TBSA and (8.3±1.4)%TBSA in groups YM and O, respectively (with t values 32.900 and 52.624, respectively, P values below 0.05). The operation time, wound healing time, and hospitalization time of patients in group C were (1.368±0.562) h, (9.6±0.6) and (32±11) d, significantly shorter than those in group YM [(3.235±0.011) h, (16.9±2.6) and (48±12) d, respectively] and group O [(3.692±0.481) h, (17.3±2.6) and (46±13) d, respectively, with t values from 4.350 to 21.160, P values below 0.05]. The survival rate of skin graft of patients on post operation day 7 in group C was (92±15)%, significantly higher than (81±10)% and (72±12)% in groups YM and O, respectively (with t values 5.509 and 3.229, respectively, P values below 0.05). The above indexes in groups YM and O were similar (with t values from 0.576 to 22.958, P values above 0.05). Complete wound healing rate in post treatment week 2 and the mortality of patients in group C were similar to those in groups YM and O (with χ(2) values 0.365 and 0.122, respectively, P values above 0.05). Conclusions: Meek skin grafting can be used in the treatment of patients with extensive deep burns at different age groups, compared with the young and middle-aged and old patients, the effect in children was better.

[Clinical-based study of ovarian cancer patients with and without BRCA1/2 genes mutation: clinical features and pedigree analysis].

Objective: To compare the clinical and histological features and prognosis of patients with ovarian cancer from different genetic background, and to make further understanding of the genetic model of BRCA genes used pedigree analysis. Methods: There were 71 patients from 67 independent families enrolled in our study from Apr. 2000 to Jun. 2009 in Peking Union Medical College Hospital. All exons of BRCA1/2 genes were analyzed using denaturing high-performance liquid chromatography(DHPLC) followed by direct sequencing, and clinical features of patients were compared by statistical analysis. Pedigree analysis of two families with BRCA genes mutation were performed. Results: The mutation rate of BRCA genes was 28% (20/71). The frequency of BRCA1 and BRCA2 gene mutation was 23% (16/71) and 6% (4/71), respectively (P=0.004). Histology types of patients with and without BRCA genes mutation were different. The onset age between patients with and without BRCA genes mutation was similar (52.6 versus 54.6 years old, P=0.393), and tend to be early-onset breast or ovarian cancer in high-risk group. There was no significant difference of platinum-resistant rate, disease free survival and overall survival rate between patients with and without BRCA genes mutation (all P>0.05). According to the pedigree analysis, up to 100% of female offspring inherited pathogenic mutations, and male offspring could be a mutation carrier. Conclusions: The genetic screening and clinical intervention should be performed as early as possible for the members from families at risk of hereditary ovarian cancer. Genetic consulting is important for patients with high-grade papillary serous adenocarcinoma of ovary. It is still unknown that whether the patients with BRCA gene mutations have better prognosis than sporadic ones, and further perspective, randomized controlled trial is still needed.