Salvage interstitial brachytherapy based on computed tomography for recurrent cervical cancer after radical hysterectomy and adjuvant radiation therapy: case presentations and introduction of the technique.

PURPOSE: Locally recurring cervical cancer after surgery and adjuvant radiotherapy remains a major therapeutic challenge. This paper presents a new therapeutic technique for such patients: interstitial brachytherapy (BT) guided by real-time three-dimensional (3D) computed tomography (CT). MATERIAL AND METHODS: Sixteen patients with recurrent cervical cancer after radical surgery and adjuvant external-beam radiotherapy (EBRT) were included in this study. These patients underwent high-dose-rate (HDR) interstitial BT with free-hand placement of metal needles guided by real-time 3D-CT. Six Gy in 6 fractions were prescribed for the high-risk clinical target volume (HR-CTV). D90 and D100 for HR-CTV of BT, and the cumulative D2cc for the bladder, rectum, and sigmoid, including previous EBRT and present BT were analyzed. Treatment-related complications and 3-month tumor-response rates were investigated. RESULTS: The mean D90 value for HR-CTV was 52.5 ± 3.3 Gy. The cumulative D2cc for the bladder, rectum, and sigmoid were 85.6 ± 5.8, 71.6 ± 6.4, and 69.6 ± 5.9 Gy, respectively. The mean number of needles was 6.1 ± 1.5, with an average depth of 3.5 ± 0.9 cm for each application. Interstitial BT was associated with minor complications and passable tumor-response rate. CONCLUSIONS: Interstitial BT guided by real-time 3D-CT for recurrent cervical cancer results in good dose-volume histogram (DVH) parameters. The current technique may be clinically feasible. However, long-term clinical outcomes should be further investigated.

Imaging and histologic features of traumatic temporomandibular joint ankylosis.

OBJECTIVE: We aimed to study the pathology underlying traumatic temporomandibular joint ankylosis (TMJA). STUDY DESIGN: Specimens from 10 patients with traumatic TMJA were categorized using the Sawhney classification and were decalcified and stained with hematoxylin-eosin, alcian blue/periodic acid-Schiff, alizarin red, and Masson stains. Immunostaining with anti-CD34 antibody was performed. Computed tomography and pathologic findings were compared. RESULTS: Ankylosed areas consisted of fibrocartilaginous tissues. Bone formation occurred by osteophyte extension from the osteochondral surface toward the mass center. Endochondral ossification and osteophyte proliferation, alone or simultaneously, participated in bony ankylosis. Sequestra in the cartilaginous ankylosis preferentially formed bony bridges. Newly formed capillaries participated in ossification from the bony surface of the bone-cartilage junction; bone formed around the capillaries. Osteoclasts were present at the capillary tips. CONCLUSIONS: Types II and III were cartilaginous-bony ankylosis, with similar components. Bony traumatic TMJA was formed by osteophyte proliferation and endochondral ossification.

A pilot trial on the molecular pathophysiology of traumatic temporomandibular joint bony ankylosis in a sheep model. Part I: Expression of Wnt signaling.

OBJECTIVE: To preliminarily investigate the temporal patterns of the endogenous mRNA expression for members of the Wnt signaling and a series of genes regulating bone formation during the development of traumatic temporomandibular joint (TMJ) bony ankylosis in a sheep model. METHODS: Six sheep were used for the induction of bony ankylosis of TMJ. We performed a condylar fracture, excision of the lateral 2/3 disc and serious injury to the glenoid fossa to induce bony ankylosis on the right TMJ. An isolated condylar fracture was performed on the left side. Two sheep were sacrificed at 1 month, 3 months, and 6 months after surgery, respectively. The specimens from the ankylosed joint and the condylar fracture were harvested for RNA extraction respectively. In this report (Part I), only the bony ankylosed samples were used for analysis of gene expressions. The specimens 1 month postoperatively were taken as the control, and the changes of expression of target genes over time were examined by real-time PCR. RESULTS: mRNA expression of Wnt1, Wnt2b, Wnt3a, ß-catenin, Sfrp1, Lrp6, Lef1, CyclinD1, and Runx2 was up-regulated at 3 and 6 months compared with 1 month. The expression of Wnt5a, Sox9, and Osterix was up-regulated with a peak at 3 months, and then fell back to the basal levels at 6 months. The expression of Ocn began to up-regulate until 6 month postoperatively. CONCLUSION: Our findings suggested that Wnt signaling was involved in the formation of traumatic TMJ bony ankylosis and thus may be a potential therapeutic target for the treatment of the disease in the future.

A pilot trial on the molecular pathophysiology of traumatic temporomandibular joint bony ankylosis in a sheep model. Part II: The differential gene expression among fibrous ankylosis, bony ankylosis and condylar fracture.

OBJECTIVE: The purpose of the study was to preliminarily explore the differential expressions of a series of genes regulating bone formation in temporomandibular joint (TMJ) fibrous ankylosis, bony ankylosis and condylar fracture healing. METHODS: The cDNA from either the bony ankylosed callus or fracture callus of the 6 sheep, as described in the part I, were both used in the study. The differences of gene expressions between bony ankylosis and condylar fracture at 1, 3, and 6 months postoperatively were measured by real-time PCR, with 2 samples at each time point. In addition, another 2 sheep were added to have fibrous ankylosis induced on the right TMJ, and 1 sheep was sacrificed at 3 and 6 months after surgery, respectively. The differences of gene expressions between fibrous and bony ankylosis at 3 and 6 months postoperatively were measured by real-time PCR. RESULTS: Bony ankylosis showed higher mRNA expression trends in Wnt2b, Wnt5a, ß-Catenin, Lef1, CyclinD1, Runx2, Osterix, Sox9, Col10a1, Alp, Ocn, Bmp2, and Bmp7 compared to fibrous ankylosis, although no statistical analysis was performed due to the very small sample size. Whereas bony ankylosis showed a significant lower expression of Wnt5a, ß-Catenin, Lef1, Runx2, Osterix, Sox9, Col10a1, Alp, Ocn and Bmp4 compared to condylar fracture at several time points (P < 0.05). CONCLUSION: Our data provided a preliminary molecular evidence for the hypothesis that the development of traumatic TMJ bony ankylosis was the course of delayed bone healing or hypertrophic nonunion, and deserved to be further studied.

Surgical induction of TMJ bony ankylosis in growing sheep and the role of injury severity of the glenoid fossa on the development of bony ankylosis.

OBJECTIVE: The purpose of this paper is to summarize our experiences in creating an animal model of TMJ bony ankylosis based on 2 sequential experiments. METHODS: Two sequential experiments were performed with the aim of creating a model of TMJ bony ankylosis. Seven growing sheep were used in the first experiment, in which 1 was served as a control animal. Condylar fracture with disc preservation was performed on the control side. On the contralateral side, condylar fracture, excision of the lateral 2/3 disc and injury to the glenoid fossa were performed to induce bony ankylosis. Three animals were sacrificed respectively at 3 and 6 months after surgery. In the second experiment, 7 growing sheep were used. The only difference of modeling between the 2 experiments was that more serious injury to the glenoid fossa was made in the ankylosis-induced side in experiment 2. Three, 2, and 2 animals were sacrificed respectively at 1, 3, and 6 months postoperatively. The TMJ complexes were examined by computed tomography (CT) and histological evaluation. RESULTS: In experiment 1, only fibrous ankylosis was observed in the ankylosis-induced side both at 3 and 6 months postoperatively. In experiment 2, CT and histological evaluation showed that the outcomes of the ankylosis-induced side were fibrous-bony ankylosis, fibrous-bony ankylosis, and bony ankylosis respectively at 1, 3, and 6 months after surgery. CONCLUSION: Through summarizing the differences of the modeling and the different outcomes in the 2 experiments, we concluded that severe damage to the glenoid fossa played an important role in the development of TMJ bony ankylosis.

Ankylosing spondylitis associated with bilateral ankylosis of the temporomandibular joint.

OBJECTIVE: The objective of this study was to analyze the clinical and laboratory features, treatments, and prognosis of ankylosing spondylitis (AS) associated with bilateral temporomandibular joint ankylosis (TMJA). METHODS: A PubMed search was conducted from 1966 to date, and the references of published studies were also checked to identify additional cases. Information from these reports and our report were compared and analyzed. RESULTS: Published literature in the past 36 years, which included 8 cases, were reviewed. The mean (SD) age at diagnosis of AS and bilateral TMJA was 21.00 (6.35) and 32.50 (13.43) years, respectively. Ankylosis of cervical vertebra was described in all patients. Total alloplastic joints and artificial condyle replacements were also reported in recent years. The slices of ankylotic mass showed the marrow was infiltrated by eosinophilic granulocytes. CONCLUSION: Evaluating temporomandibular joint (TMJ) function is strongly recommended in patients who have a long history of AS, particularly in cases involving cervical vertebrae disease.

[Experimental establishment of animal model of temporomandibular joint ankylosis secondary to condylar sagittal fracture].

OBJECTIVE: To experimentally develop an animal model of traumatic temporomandibular joint ankylosis secondary to condylar fracture in small Tail Han sheep. METHODS: Four sheep were used to make sagittal fracture of condyles. The cartilage layer of articular surface was damaged and lateral half of articular disc was removed in the right side and conserved in the left side as a control. All animals were sacrificed at the end of 6 months postoperatively. CT observation and histological examination were carried out to evaluate the formation of ankylosed joints. RESULTS: All of the animals showed a change of mixed ankylosis on the right sides. On the CT image, the joint space became narrow and the articular surfaces became irregular with high-density callus formation. Histological observation validated that the bone-like and the cartilage-like matrix scattered between the condyle and temporal fossa. The ankylosis bone bridge could be figured out in some slices. CONCLUSION: This study has successfully simulated the formation of temporomandibular joint ankylosis resulting from condylar fractures. The established ankylosis model is allowed to duplicate at a high successful rate.

[Application of 3-D skull models and guide plates in the treatment of unilateral orbitozygomatic deformity after fracture].

OBJECTIVE: To discuss the application of 3-D skull models and guide plates in treatment of unilateral orbitozygomatic deformity after fracture. METHODS: Each patient underwent CT scan and DICOM data was obtained preoperatively. Two 3-D resin skull models were produced by rapid prototyping technique. The first model was produced based on the patient's original data and the second was the reshaped model by mirroring the unaffected facial side to the traumatic side. The original model was used for measurement of the fracture displacement in three directions and model surgery. On the second model, one 2.0 mm miniplate (Synthes Inc) was bended along the orbital rim as the repositioning guide plate. During the operation, osteotomy and reduction of zygomatic and the periorbital fractures was guided by prepared repositioning guide plate, following by orbital wall reconstruction and bone grafting. RESULTS: From March 2007 to February 2009, 7 cases (6 males and 1 female) were treated successfully with no infection or graft extrusion. One week after operation, the patient received CT examination again. The shape and location of zygomatic bone and arch was good. Three cases were followed up for 3 months. Among them, facial symmetry was achieved in 2 cases. Cicatricial contracture and temporal soft tissue atrophy occurred in one case. CONCLUSIONS: Reliable therapeutic effect can be achieved by application of rapid prototyping technique and repositioning guide plate in the treatment of complicated posttraumatic orbitozygomatic deformity.

[Prosthetic replacement of condylar head for management of traumatic temporomandibular joint ankylosis].

OBJECTIVE: To preliminarily evaluate the method of using titanium condylar protheses in management of traumatic temporomandibular joint ankylosis. METHODS: Between August 2006 and April 2008, titanium condylar replacement was performed in 5 male patients. Preoperative CT datum of patient was obtained and a resin model was then produced and used as a reference to select a suitable titanium condyle for reconstruction of the joint. In the operation, the bony ankylosis was removed. According to the preoperation planning, the selected prosthesis was inserted and fixed to the distal mandibular segment. The results were assessed by means of examinations and measurements postoperatively and during follow-up. RESULTS: The 5 patients received alloplastic replacement of 6 condyles. Three patients were under follow-up and follow-up time ranged from 8 months to 2 years and 6 months. The mean mouth opening was 30 mm. Two patients had good occlusion and one patient developed a slight open bite. CONCLUSIONS: Prosthetic condylar replacement can provide a choice for management of traumatic temporomandibular joint ankylosis.