Spine Surgery Assisted by Augmented Reality:Where Have We Been?

This present systematic review examines spine surgery literature supporting augmented reality (AR) technology and summarizes its current status in spinal surgery technology. Database search strategies were retrieved from PubMed, Web of Science, Cochrane Library, Embase, from the earliest records to April 1, 2021. Our review briefly examines the history of AR, and enumerates different device application workflows in a variety of spinal surgeries. We also sort out the pros and cons of current mainstream AR devices and the latest updates. A total of 45 articles are included in our review. The most prevalent surgical applications included are the augmented reality surgical navigation system and head-mounted display. The most popular application of AR is pedicle screw instrumentation in spine surgery, and the primary responsible surgical levels are thoracic and lumbar. AR guidance systems show high potential value in practical clinical applications for the spine. The overall number of cases in AR-related studies is still rare compared to traditional surgical-assisted techniques. These lack long-term clinical efficacy and robust surgical-related statistical data. Changing healthcare laws as well as the increasing prevalence of spinal surgery are generating critical data that determines the value of AR technology.

Do Obliquity and Position of the Oblique Lumbar Interbody Fusion Cage Influence the Degree of Indirect Decompression of Foraminal Stenosis?

Objective@#: Oblique lumbar interbody fusion (OLIF) is a surgical technique that utilizes a large interbody cage to indirectly decompress neural elements. The position of the cage relative to the vertebral body could affect the degree of foraminal decompression. Previous studies determined the position of the cage using plain radiographs, with conflicting results regarding the influence of the position of the cage to the degree of neural foramen decompression. Because of the cage obliquity, computed tomography (CT) has better accuracy than plain radiograph for the measurement of the obliquely inserted cage. The objective of this study is to find the correlation between the position of the OLIF cage with the degree of indirect decompression of foraminal stenosis using CT and magnetic resonance imaging (MRI). @*Methods@#: We review imaging of 46 patients who underwent OLIF from L2-L5 for 68 levels. Segmental lordosis (SL) was measured in a plain radiograph. The positions of the cage were measured in CT. Spinal canal cross-sectional area (SCSA), and foraminal crosssectional area (FSCA) measurements using MRI were taken into consideration. @*Results@#: Patients’ mean age was 69.7 years. SL increases 3.0±5.1 degrees. Significant increases in SCSA (33.3%), FCSA (43.7% on the left and 45.0% on the right foramen) were found (p<0.001). Multiple linear regression analysis shows putting the cage in the more posterior position correlated with more increase of FSCA and decreases SL correction. The position of the cage does not affect the degree of the central spinal canal decompression. Obliquity of the cage does not result in different degrees of foraminal decompression between right and left side neural foramen. @*Conclusion@#: Cage position near the posterior part of the vertebral body increases the decompression effect of the neural foramen while putting the cage in the more anterior position correlated with increases SL.

Patterns of Locoregional Recurrence after Radical Cystectomy for Stage T3-4 Bladder Cancer:A Radiation Oncologist’s Point of View

Purpose@#Adjuvant radiotherapy (RT) has been performed to reduce locoregional failure (LRF) following radical cystectomy for locally advanced bladder cancer; however, its efficacy has not been well established. We analyzed the locoregional recurrence patterns of post-radical cystectomy to identify patients who could benefit from adjuvant RT and determine the optimal target volume. @*Materials and Methods@#We retrospectively reviewed 160 patients with stage ≥ pT3 bladder cancer who were treated with radical cystectomy between January 2006 and December 2015. The impact of pathologic findings, including the stage, lympho-vascular invasion, perineural invasion, margin status, nodal involvement, and the number of nodes removed on failure patterns, was assessed. @*Results@#Median follow-up period was 27.7 months. LRF was observed in 55 patients (34.3%), 12 of whom presented with synchronous local and regional failures as the first failure. The most common failure pattern was distant metastasis (40%). Among LRFs, the most common recurrence site was the cystectomy bed (15.6%). Patients with positive resection margins had a significantly higher recurrence rate compared to those without (28% vs. 10%, p=0.004). The pelvic nodal recurrence rate was < 5% in pN0 patients; the rate of recurrence in the external and common iliac nodes was 12.5% in pN+ patients. The rate of recurrence in the common iliac nodes was significantly higher in pN2–3 patients than in pN0–1 patients (15.2% vs. 4.4%, p=0.04). @*Conclusion@#Pelvic RT could be beneficial especially for those with positive resection margins or nodal involvement after radical cystectomy. Radiation fields should be optimized based on the patient-specific risk factors.

Association between Laterality and Location of Deep Vein Thrombosis of Lower Extremity and Pulmonary Embolism

Purpose@#The aim of this study was to investigate the relationship between the anatomical location of thrombi in the lower extremities and the development of pulmonary embolism (PE). @*Materials and Methods@#We collected and analyzed the data of patients diagnosed with deep vein thrombosis (DVT) of the lower extremities between 2006 and 2015, and included those whose computed tomography (CT) data were available for PE identification. We evaluated the relationship between the laterality and the proximal/distal location of the thrombi in lower extremites and the location of PE. @*Results@#CT images were available for 388/452 patients with DVT. After excluding 32 cases with bilateral involvement, 356 cases were included for analysis in this study. The ratio of DVT in the left:right leg was 232:124. PEs developed in 121 (52.2%) patients with left-sided DVT and in 78 (62.9%) with right-sided DVT (P=0.052). PEs in the main pulmonary arteries developed in 36 (15.5%) patients with left leg DVT and in 30 (24.2%) with right leg DVT (P=0.045). The most frequent site of thrombosis associated with the development of PE was the left iliac vein (59/199, 29.6%). According to the anatomical segment of the leg affected by DVT, patients with DVT in the right femoral vein (50/71, 70.4%; P=0.016) had the highest rate of occurrence of PE. @*Conclusion@#PE develops more frequently in patients with right-sided DVT than in those with left-sided DVT. Therefore, careful observation for the possible development of PE is recommended in cases with right-sided DVT of the lower extremity.

Potential benefit of a screening tool in selecting head-injured children aged 36 months or younger who can cooperate in computed tomography

Purpose@#We aimed to investigate the benefit of a screening tool in selecting head-injured children who can potentially cooperate with computed tomography (CT). @*Methods@#The study population consisted of head-injured children aged 36 months or younger who visited the emergency department (ED) and underwent CT from January 2013 through December 2020. Procedural sedation and analgesia (PSA) using per os chloral hydrate or per rectal thiopental was implemented to children presumed less cooperative for CT as per a clinical screening tool for cooperative candidates for CT (e.g., ability to lie still on bed for 10 seconds without a guardian). According to the PSA and the first attempt success of CT, we compared baseline characteristics, CT findings, clinically important traumatic brain injury, ED length of stay (EDLOS), and ED disposition. @*Results@#Among the 247 children, PSA was used in 102 (41.3%). The PSA group showed a higher proportion of 3-36 months of age (PSA, 96.1% vs. non-PSA, 82.8%; P = 0.001) and longer median EDLOS (PSA, 127.0 [interquartile range, 101.0-172.0] vs. non-PSA, 85.0 minutes [63.0-130.0]; P < 0.001). The number of children undergoing the first attempt success was 213 (86.2%) without a difference in both groups (PSA, 84.3% vs. non-PSA, 87.6%; P = 0.645). In the 213 children, the implementation of PSA was associated with longer median EDLOS (PSA, 121.0 [99.0-156.0] vs. non-PSA, 77.0 minutes [60.0-122.0]; P < 0.001). In the non-PSA group (n = 145), the first attempt failure was associated with the presence of skull fracture (success, 7.1% vs. failure, 27.8%; P = 0.009). @*Conclusion@#This study suggests a potential benefit of the screening tool in selecting cooperative candidates for CT, i.e., those who could forgo PSA using oral chloral hydrate or per rectal thiopental, in young children with head injury.

Unilateral Bi-portal Endoscopic Decompression via the Contralateral Approach in Asymmetric Spinal Stenosis: A Technical Note

We discuss the technical details and operative advantages of approaching pathologies from the contralateral side in cases of asymmetric spinal stenosis. The contralateral approach offers better manipulative freedom and a more accessible target approach along the plane of the pathology, allowing safer decompression and facet preservation; further, this approach is ergonomic for surgeons. We recommend the adoption of this approach in decompressing asymmetric spinal stenosis.

Physical and Biological Characteristics of Particle Therapy for Oncologists / Journal of the Korean Cancer Association, 대한암학회지

Particle therapy is a promising and evolving modality of radiotherapy that can be used to treat tumors that are radioresistant to conventional photon beam radiotherapy. It has unique biological and physical advantages compared with conventional radiotherapy. The characteristic feature of particle therapy is the “Bragg peak,” a steep and localized peak of dose, that enables precise delivery of the radiation dose to the tumor while effectively sparing normal organs. Especially, the charged particles (e.g., proton, helium, carbon) cause a high rate of energy loss along the track, thereby leading to high biological effectiveness, which makes particle therapy attractive. Using this property, the particle beam induces more severe DNA double-strand breaks than the photon beam, which is less influenced by the oxygen level. This review describes the general biological and physical aspects of particle therapy for oncologists, including non-radiation oncologists and beginners in the field.

Mammography with a fully automated breast volumetric software as a novel method for estimating the preoperative breast volume prior to mastectomy

Purpose@#Increasing interest in maintaining a positive body image following breast cancer surgery has become an important aspect of reconstruction surgery. Volume matching of the reconstructed breast to natural breasts is the most important consideration. This study aimed to explore the feasibility of using mammography with a fully automated breast volumetric software to measure the preoperative breast volume in patients with breast cancer. @*Methods@#We evaluated patients who underwent a total mastectomy between July 2016 and February 2021. The specimen volume following total mastectomy was compared with breast volume estimates using a fully automated volumetric software (Quantra ver. 2.1.1) and 4 other previously described mammography-based prediction methods. The association between the estimates and mastectomy specimen volume was assessed using Pearson correlation and Bland-Altman analysis. @*Results@#Sixty-six patients were included. Compared with previously described mammography-based methods, Quantra estimates were more strongly correlated with mastectomy specimen volume in the entire, fatty, and dense breast groups (r = 0.920, 0.921, and 0.915, respectively; P < 0.001). In applying Quantra estimates for measuring preoperative breast volume, we adjusted a simple equation: mastectomy specimen volume = Quantra estimate × 0.8. @*Conclusion@#Mammography with a fully automated breast volumetric software can be useful for measuring preoperative breast volume in patients with breast cancer who undergo reconstruction surgery.

Patterns of Locoregional Recurrence after Radical Cystectomy for Stage T3-4 Bladder Cancer:A Radiation Oncologist’s Point of View

Purpose@#Adjuvant radiotherapy (RT) has been performed to reduce locoregional failure (LRF) following radical cystectomy for locally advanced bladder cancer; however, its efficacy has not been well established. We analyzed the locoregional recurrence patterns of post-radical cystectomy to identify patients who could benefit from adjuvant RT and determine the optimal target volume. @*Materials and Methods@#We retrospectively reviewed 160 patients with stage ≥ pT3 bladder cancer who were treated with radical cystectomy between January 2006 and December 2015. The impact of pathologic findings, including the stage, lympho-vascular invasion, perineural invasion, margin status, nodal involvement, and the number of nodes removed on failure patterns, was assessed. @*Results@#Median follow-up period was 27.7 months. LRF was observed in 55 patients (34.3%), 12 of whom presented with synchronous local and regional failures as the first failure. The most common failure pattern was distant metastasis (40%). Among LRFs, the most common recurrence site was the cystectomy bed (15.6%). Patients with positive resection margins had a significantly higher recurrence rate compared to those without (28% vs. 10%, p=0.004). The pelvic nodal recurrence rate was < 5% in pN0 patients; the rate of recurrence in the external and common iliac nodes was 12.5% in pN+ patients. The rate of recurrence in the common iliac nodes was significantly higher in pN2–3 patients than in pN0–1 patients (15.2% vs. 4.4%, p=0.04). @*Conclusion@#Pelvic RT could be beneficial especially for those with positive resection margins or nodal involvement after radical cystectomy. Radiation fields should be optimized based on the patient-specific risk factors.

Association between Laterality and Location of Deep Vein Thrombosis of Lower Extremity and Pulmonary Embolism

Purpose@#The aim of this study was to investigate the relationship between the anatomical location of thrombi in the lower extremities and the development of pulmonary embolism (PE). @*Materials and Methods@#We collected and analyzed the data of patients diagnosed with deep vein thrombosis (DVT) of the lower extremities between 2006 and 2015, and included those whose computed tomography (CT) data were available for PE identification. We evaluated the relationship between the laterality and the proximal/distal location of the thrombi in lower extremites and the location of PE. @*Results@#CT images were available for 388/452 patients with DVT. After excluding 32 cases with bilateral involvement, 356 cases were included for analysis in this study. The ratio of DVT in the left:right leg was 232:124. PEs developed in 121 (52.2%) patients with left-sided DVT and in 78 (62.9%) with right-sided DVT (P=0.052). PEs in the main pulmonary arteries developed in 36 (15.5%) patients with left leg DVT and in 30 (24.2%) with right leg DVT (P=0.045). The most frequent site of thrombosis associated with the development of PE was the left iliac vein (59/199, 29.6%). According to the anatomical segment of the leg affected by DVT, patients with DVT in the right femoral vein (50/71, 70.4%; P=0.016) had the highest rate of occurrence of PE. @*Conclusion@#PE develops more frequently in patients with right-sided DVT than in those with left-sided DVT. Therefore, careful observation for the possible development of PE is recommended in cases with right-sided DVT of the lower extremity.

Physical and Biological Characteristics of Particle Therapy for Oncologists / Journal of the Korean Cancer Association, 대한암학회지

Particle therapy is a promising and evolving modality of radiotherapy that can be used to treat tumors that are radioresistant to conventional photon beam radiotherapy. It has unique biological and physical advantages compared with conventional radiotherapy. The characteristic feature of particle therapy is the “Bragg peak,” a steep and localized peak of dose, that enables precise delivery of the radiation dose to the tumor while effectively sparing normal organs. Especially, the charged particles (e.g., proton, helium, carbon) cause a high rate of energy loss along the track, thereby leading to high biological effectiveness, which makes particle therapy attractive. Using this property, the particle beam induces more severe DNA double-strand breaks than the photon beam, which is less influenced by the oxygen level. This review describes the general biological and physical aspects of particle therapy for oncologists, including non-radiation oncologists and beginners in the field.

Mammography with a fully automated breast volumetric software as a novel method for estimating the preoperative breast volume prior to mastectomy

Purpose@#Increasing interest in maintaining a positive body image following breast cancer surgery has become an important aspect of reconstruction surgery. Volume matching of the reconstructed breast to natural breasts is the most important consideration. This study aimed to explore the feasibility of using mammography with a fully automated breast volumetric software to measure the preoperative breast volume in patients with breast cancer. @*Methods@#We evaluated patients who underwent a total mastectomy between July 2016 and February 2021. The specimen volume following total mastectomy was compared with breast volume estimates using a fully automated volumetric software (Quantra ver. 2.1.1) and 4 other previously described mammography-based prediction methods. The association between the estimates and mastectomy specimen volume was assessed using Pearson correlation and Bland-Altman analysis. @*Results@#Sixty-six patients were included. Compared with previously described mammography-based methods, Quantra estimates were more strongly correlated with mastectomy specimen volume in the entire, fatty, and dense breast groups (r = 0.920, 0.921, and 0.915, respectively; P < 0.001). In applying Quantra estimates for measuring preoperative breast volume, we adjusted a simple equation: mastectomy specimen volume = Quantra estimate × 0.8. @*Conclusion@#Mammography with a fully automated breast volumetric software can be useful for measuring preoperative breast volume in patients with breast cancer who undergo reconstruction surgery.

Modified Book Binding Technique (MBBT) for Intracorporeal Gastroduodenostomy in Totally Laparoscopic Distal Gastrectomy: Initial Experience

Totally laparoscopic distal gastrectomy (TLDG) frequently involves the use of delta shaped gastroduodenostomy (DSG) for intracorporeal anastomosis. However, DSG has some drawbacks, and the book binding technique (BBT) was developed as a new technique to overcome these drawbacks. Subsequently, this technique was further improved with the development of modified book binding technique (MBBT). This study evaluated the safety and feasibility of MBBT in patients undergoing TLDG. Thirty-three patients who underwent TLDG with MBBT were retrospectively evaluated. The mean operation time was 277.6±37.1 minutes, including 51.9±15.7 minutes for reconstruction. Two patients had anastomosis-related complications, one patient with stricture after leakage and 1 patient with stenosis. The former patient was treated with endoscopic balloon dilatation, and the latter was managed conservatively; neither required re-operation. MBBT is a safe and feasible technique, with acceptable surgical outcomes. It may be a good alternative option for the treatment of intracorporeal anastomosis in patients undergoing TLDG.

Clinical Characteristics and Outcomes of Patients with Culture-Negative Pyogenic Spondylitis according to Empiric Glycopeptide Use / 감염과화학요법

BACKGROUND@#The optimal choice of antibiotics is challenging in culture-negative pyogenic spondylitis (PS). The empiric use of glycopeptides is suggested depending on various risk factors, although clinical data are sparse. This study aimed to analyze the clinical characteristics and outcomes of patients with culture-negative PS and evaluate the effect of empiric glycopeptide use on clinical outcomes in these patients.@*MATERIALS AND METHODS@#Data on the characteristics, treatment, and outcomes of 175 patients diagnosed with PS were retrospectively obtained from the electronic database of a tertiary referral hospital from 2009 to 2016. Patients with negative culture results were grouped by the duration of glycopeptide treatment: glycopeptide therapy <28 days (Group A) and glycopeptide therapy ≥28 days (Group B).@*RESULTS@#Of 89 patients with negative culture results, 78 were included in the analysis (Group A, n = 66; Group B, n = 12). The mean age of patients with negative culture results was 65.5 years, and 52.6% were male. The median follow-up duration was 573 (interquartile range [IQR], 83 – 1,037) days. The duration of intravenous glycopeptide therapy was 0.0 (IQR, 0.0 – 0.0) days and 55.5 (IQR, 37.0 – 75.7) days for Groups A and B, respectively. Patients who used glycopeptide longer empirically (Group B) had more commonly undergone a previous spinal procedure, including surgery (P = 0.024). The length of hospitalization, erythrocyte sedimentation rate, and C-reactive protein level were significantly higher in Group B compared with those in Group A (P <0.001, P <0.001, and P = 0.006, respectively). Regarding treatment modalities, patients in Group B underwent surgery more frequently (P = 0.017). The duration of parenteral antibiotic treatment was longer in Group B (P <0.001). Recurrence was noted in 7 patients (9.0%), and the recurrence rate was not significantly different between the 2 groups (Group A, 5/66 [7.6%]; Group B, 2/12 [16.7%]; P = 0.293).@*CONCLUSION@#The recurrence rate among patients with culture-negative PS was not different based on the duration of empiric glycopeptide use. However, considering the small sample size and heterogeneity of our study population, we suggest that it is reasonable to administer glycopeptide antibiotics in these patients depending on clinical risk factors. Further large-scale prospective studies are needed to obtain more evidence for appropriate antibiotic treatment.

Diagnosis of Nerve Root Compromise of the Lumbar Spine: Evaluation of the Performance of Three-dimensional Isotropic T2-weighted Turbo Spin-Echo SPACE Sequence at 3T

OBJECTIVE: To explore the performance of three-dimensional (3D) isotropic T2-weighted turbo spin-echo (TSE) sampling perfection with application optimized contrasts using different flip angle evolution (SPACE) sequence on a 3T system, for the evaluation of nerve root compromise by disc herniation or stenosis from central to extraforaminal location of the lumbar spine, when used alone or in combination with conventional two-dimensional (2D) TSE sequence. MATERIALS AND METHODS: Thirty-seven patients who had undergone 3T spine MRI including 2D and 3D sequences, and had subsequent spine surgery for nerve root compromise at a total of 39 nerve levels, were analyzed. A total of 78 nerve roots (48 symptomatic and 30 asymptomatic sites) were graded (0 to 3) using different MRI sets of 2D, 3D (axial plus sagittal), 3D (all planes), and combination of 2D and 3D sequences, with respect to the nerve root compromise caused by posterior disc herniations, lateral recess stenoses, neural foraminal stenoses, or extraforaminal disc herniations; grading was done independently by two readers. Diagnostic performance was compared between different imaging sets using the receiver operating characteristics (ROC) curve analysis. RESULTS: There were no statistically significant differences (p = 0.203 to > 0.999) in the ROC curve area between the imaging sets for both readers 1 and 2, except for combined 2D and 3D (0.843) vs. 2D (0.802) for reader 1 (p = 0.035), and combined 2D and 3D (0.820) vs. 3D including all planes (0.765) for reader 2 (p = 0.049). CONCLUSION: The performance of 3D isotropic T2-weighted TSE sequence of the lumbar spine, whether axial plus sagittal images, or all planes of images, was not significantly different from that of 2D TSE sequences, for the evaluation of nerve root compromise of the lumbar spine. Combining 2D and 3D might possibly improve the diagnostic accuracy compared with either one.

Analysis of Pediatric Tendon Injuries in the Hand in Comparison with Adults

BACKGROUND: The purpose of this study was to identify the epidemiologic characteristics of hand tendon injuries in children and to compare these with those of adults. METHODS: This retrospective study was conducted on acute traumatic tendon injuries of the hand treated at our institution from 2005 to 2013, based on medical records and X-ray findings. Age, sex, hand injured, mechanism of injury, tendons and zones injured, number of affected digits, and comorbidities and complications were analyzed. Patients were divided into 2 groups: a pediatric group (≤15 years) and an adult group (>15 years). RESULTS: Over the 9-year study period, 533 patients were surgically treated for acute traumatic tendon injuries of the hand. In the pediatric group (n=76), being male, the right hand, the extensor tendon, complete rupture, the middle finger, and glass injury predominated in hand tendon injuries. In the adult group (n=457), results were similar, but injury to the index finger and knife injury were the most common. An accompanying fracture was more common in the adult group and complication rates were non-significantly different. CONCLUSIONS: This comparative analysis revealed no significant epidemiologic intergroup differences. The belief that pediatric tendon injuries tend to be less severe is misplaced, and careful physical examination and exploration should be conducted in pediatric cases of hand injury.

Carotid-Sparing TomoHelical 3-Dimensional Conformal Radiotherapy for Early Glottic Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to investigate the dosimetric benefits and treatment efficiency of carotid-sparing TomoHelical 3-dimensional conformal radiotherapy (TH-3DCRT) for early glottic cancer. MATERIALS AND METHODS: Ten early-stage (T1N0M0) glottic squamous cell carcinoma patients were simulated, based on computed tomography scans. Two-field 3DCRT (2F-3DCRT), 3-field intensity-modulated radiation therapy (3F-IMRT), TomoHelical-IMRT (TH-IMRT), and TH-3DCRT plans were generated with a 67.5-Gy total prescription dose to the planning target volume (PTV) for each patient. In order to evaluate the plan quality, dosimetric characteristics were compared in terms of conformity index (CI) and homogeneity index (HI) for PTV, dose to the carotid arteries, and maximum dose to the spinal cord. Treatment planning and delivery times were compared to evaluate treatment efficiency. RESULTS: The median CI was substantially better for the 3F-IMRT (0.65), TH-IMRT (0.64), and TH-3DCRT (0.63) plans, compared to the 2F-3DCRT plan (0.32). PTV HI was slightly better for TH-3DCRT and TH-IMRT (1.05) compared to 2F-3DCRT (1.06) and 3F-IMRT (1.09). TH-3DCRT, 3F-IMRT, and TH-IMRT showed an excellent carotid sparing capability compared to 2F-3DCRT (p < 0.05). For all plans, the maximum dose to the spinal cord was < 45 Gy. The median treatment planning times for 2F-3DCRT (5.85 minutes) and TH-3DCRT (7.10 minutes) were much lower than those for 3F-IMRT (45.48 minutes) and TH-IMRT (35.30 minutes). The delivery times for 2F-3DCRT (2.06 minutes) and 3F-IMRT (2.48 minutes) were slightly lower than those for TH-IMRT (2.90 minutes) and TH-3DCRT (2.86 minutes). CONCLUSION: TH-3DCRT showed excellent carotid-sparing capability, while offering high efficiency and maintaining good PTV coverage.

Effect of Radiation Therapy Techniques on Outcome in N3-positive IIIB Non-small Cell Lung Cancer Treated with Concurrent Chemoradiotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study was conducted to evaluate clinical outcomes following definitive concurrent chemoradiotherapy (CCRT) for patients with N3-positive stage IIIB (N3-IIIB) non-small cell lung cancer (NSCLC), with a focus on radiation therapy (RT) techniques. MATERIALS AND METHODS: From May 2010 to November 2012, 77 patients with N3-IIIB NSCLC received definitive CCRT (median, 66 Gy). RT techniques were selected individually based on estimated lung toxicity, with 3-dimensional conformal RT (3D-CRT) and intensity-modulated RT (IMRT) delivered to 48 (62.3%) and 29 (37.7%) patients, respectively. Weekly docetaxel/paclitaxel plus cisplatin (67, 87.0%) was the most common concurrent chemotherapy regimen. RESULTS: The median age and clinical target volume (CTV) were 60 years and 288.0 cm3, respectively. Patients receiving IMRT had greater disease extent in terms of supraclavicular lymph node (SCN) involvement and CTV > or = 300 cm3. The median follow-up time was 21.7 months. Fortyfive patients (58.4%) experienced disease progression, most frequently distant metastasis (39, 50.6%). In-field locoregional control, progression-free survival (PFS), and overall survival (OS) rates at 2 years were 87.9%, 38.7%, and 75.2%, respectively. Although locoregional control was similar between RT techniques, patients receiving IMRT had worse PFS and OS, and SCN metastases from the lower lobe primary tumor and CTV > or = 300 cm3were associated with worse OS. The incidence and severity of toxicities did not differ significantly between RT techniques. CONCLUSION: IMRT could lead to similar locoregional control and toxicity, while encompassing a greater disease extent than 3D-CRT. The decision to apply IMRT should be made carefully after considering oncologic outcomes associated with greater disease extent and cost.

Surgical Outcomes of Anterior Cervical Fusion Using Deminaralized Bone Matrix as Stand-Alone Graft Material: Single Arm, Pilot Study

OBJECTIVE: To investigate the safety and efficacy of demineralized bone matrix (DBM) as a bone graft substitute for anterior cervical discectomy and fusion (ACDF) surgery. METHODS: Twenty consecutive patients treated with ACDF using stand-alone polyestheretherketone (PEEK) cages (Zero-P) with DBM(CGDBM100) were prospectively evaluated with a minimum of 6 months of follow-up. Radiologic efficacy was evaluated with a 6-point scoring method for osseous fusion using plain radiograph and computed tomogrpahy scans. Clinical efficacy was evaluated using the visual analogue scale (VAS), Owestry disability index (ODI), and short-form health questionnaire-36. The safety of the bone graft substitute was assessed with vital sign monitoring and a survey measuring complications at each follow-up visit. RESULTS: There were significant improvements in VAS and ODI scores at a mean 6-month follow-up. Six months after surgery, solid fusion was achieved in all patients. Mean score on the 6-point scoring system was 5.1, and bony formation was found to score at least 4 points in all patients. There was no case with implant-related complications such as cage failure or migration, and no complications associated with the use of CGDBM100. CONCLUSION: ACDF using CGDBM100 demonstrated good clinical and radiologic outcomes. The fusion rate was comparable with the published results of traditional ACDF. Therefore, the results of this study suggest that the use of a PEEK cage packed with DBM for ACDF is a safe and effective alternative to the gold standard of autologous iliac bone graft.

Impact of the Endoscopic Submucosal Dissection on Early Postoperative Outcome after Additional Gastric Resections for Early Gastric Cancer

PURPOSE: The aim of this study was to compare ESD only and subsequent Laparoscopy-assisted gastrectomy (LAG) patients for EGC through propensity score matching analysis. METHODS: This study was a retrospective review of the records of 46 consecutive patients with gastric cancer who underwent LAG after ESD from 2009, September to 2014, September, and propensity matching analysis was performed with 92 patients who underwent LAG without ESD as a control group. Subgroup analysis was performed with the interval of subsequent laparoscopic gastrectomy and endoscopic resection (within 2 weeks, 2~4 weeks, above 4 weeks). RESULTS: There were no significant differences in age, gender, body mass index, comorbidity, previous abdominal surgery, and location of the lesion or clinical stage between the two groups. Early postoperative outcomes including postoperative complications and postoperative hospital stay were not significantly different between the two groups. According to subgroup analysis with the interval of laparoscopic gastrectomy and endoscopic resection, there were no significant differences in early outcomes in three groups. However, only early postoperative complication rate was significantly higher in patients who received LAG more than 4 weeks after ESD (0 versus 4.76 versus 40 per cent; p=0.0032). CONCLUSION: We analyzed the influence of ESD on subsequent LAG using propensity score matching to reduce the bias. However, we found that ESD might induce inflammation for a significant duration, but ESD had little influence on early postoperative outcome of LAG.