Treatment of Multiple RT1 Gingival Recessions Using a Coronally Advanced Flap Associated with L-PRF or Subgingival Connective Tissue Graft from Maxillary Tuberosity: A Randomized, Controlled Clinical Trial.

The goal of plastic periodontal surgery is to obtain complete root coverage, increasing gingival thickness (GT), a positive prognostic factor for gingival margin stability over time. The aim of this study was to compare the effectiveness of the Coronally Advanced Flap (CAF) in RT1 (GR; gingival recession with no loss of interproximal attachment) when associated with a connective tissue graft from the maxillary tuberosity (tCTG) or with leukocyte and platelet-rich fibrin (L-PRF) membranes in obtaining root coverage and increasing the thickness and width of the keratinized tissue, along with aesthetic improvement, taking into account a number of patient-related outcomes. Thirty patients with two adjacent RT1 GRs (GRs with no loss of interproximal attachment) were each treated using CAF associated with tCTG (15 patients) or L-PRF. The main outcome was a GT increase; secondary outcomes were keratinized tissue width (KT), gingival recession (GR), probing depth (PD), clinical attachment level (CAL), root coverage percentage (RC%), complete root coverage (CRC), and root coverage esthetic score (RES). Patient-reported outcomes were discomfort (D), dentine hypersensitivity (DH), patient-related esthetic score (PRES), and overall treatment satisfaction (OTS). After 12 months, clinical and patient-reported parameters did not show significant differences between groups, with the only exception being a GT gain, which was significantly greater in the CAF + tCTG group. Our results showed that both techniques were effective in treating RT1 GRs, with comparable patient-related outcomes. However, the use of tCTG produces significantly thicker tissue, covering the exposed root surface.

Recurrent high-grade glioma surgery: a multimodal intraoperative protocol to safely increase extent of tumor resection and analysis of its impact on patient outcome.

OBJECTIVE: No consensus exists on the best treatment for recurrent high-grade glioma (HGG), particularly in terms of surgical indications, and scant data are available on the integrated use of multiple technologies to overcome intraoperative limits and pitfalls related to artifacts secondary to previous surgery and radiotherapy. Here, the authors report on their experience with the integration of multiple intraoperative tools in recurrent HGG surgery, analyzing their pros and cons as well as their effectiveness in increasing the extent of tumor resection. In addition, they present a review of the relevant literature on this topic. METHODS: The authors reviewed all cases in which recurrent HGG had been histologically diagnosed after a first surgery and the patient had undergone a second surgery involving neuronavigation with MRI, intraoperative CT (iCT), 11C-methionine-positron emission tomography (11C-MET-PET), 5-aminolevulinic acid (5-ALA) fluorescence, intraoperative neurophysiological monitoring (IONM), and intraoperative navigated ultrasound (iUS). All cases were classified according to tumor functional grade (1, noneloquent area; 2, near an eloquent area; 3, eloquent area). RESULTS: Twenty patients with recurrent HGG were operated on using a multimodal protocol. The recurrent tumor functional grade was 1 in 4 patients, 2 in 8 patients, and 3 in the remaining 8 patients. In all patients but 2, 100% EOTR was obtained. Intraoperative 5-ALA fluorescence and navigated iUS showed low specificity and sensitivity. iCT detected tumor remnants in 3 cases. Postoperatively, 6 patients (30%) had worsening neurological conditions: 4 recovered within 90 days, 1 partially recovered, and 1 experienced a permanent deficit. The median Karnofsky Performance Status remained substantially unchanged over the follow-up period. The mean progression-free survival after the second surgery was 7.7 months (range 2-11 months). The mean overall survival was 25.4 months (range 10-52 months), excluding 2 long survivors. Two patients died within 60 days after surgery, and 3 patients were still under follow-up at the end of this study. CONCLUSIONS: This is the first study reporting the integration of neuronavigation, 5-ALA fluorescence, iUS, iCT, 11C-MET-PET, and IOM during microsurgical resection of recurrent glioma. The authors believe that the proposed multimodal protocol is useful to increase the safety, effectiveness, and EOTR in patients with recurrent HGG and brain alterations secondary to radio- and chemotherapy.

High Grade Glioma Treatment in Elderly People: Is It Different Than in Younger Patients? Analysis of Surgical Management Guided by an Intraoperative Multimodal Approach and Its Impact on Clinical Outcome.

OBJECTIVE: Age is considered a negative prognostic factor for High Grade Gliomas (HGGs) and many neurosurgeons remain skeptical about the benefits of aggressive treatment. New surgical and technological improvements may allow extended safe resection, with lower level of post-operative complications. This opportunity opens the unsolved question about the most appropriate HGG treatment in elderly patients. The aim of this study is to analyze if HGG maximal safe resection guided by an intraoperative multimodal imaging protocol coupled with neuromonitoring is associated with differences in outcome in elderly patients versus younger ones. METHODS: We reviewed 100 patients, 53 (53%) males and 47 (47%) females, with median (IQR) age of 64 (57; 72) years. Eight patients were diagnosed with Anaplastic Astrocytoma (AA), 92 with Glioblastoma (GBM). Surgery was aimed to achieve safe maximal resection. An intraoperative multimodal imaging protocol, including neuronavigation, neurophysiological monitoring, 5-ALA fluorescence, 11C MET-PET, navigated i-US system and i-CT, was used, and its impact on EOTR and clinical outcome in elderly patients was analyzed. We divided patients in two groups according to their age: <65 and >65 years, and surgical and clinical results (EOTR, post-operative KPS, OS and PFS) were compared. Yet, to better understand age-related differences, the same patient cohort was also divided into <70 and >70 years and all the above data reanalyzed. RESULTS: In the first cohort division, we did not found KPS difference over time and survival analysis did not show significant difference between the two groups (p = 0.36 for OS and p = 0.49 for PFS). Same results were obtained increasing the age cut-off for age up to 70 years (p = 0.52 for OS and p = 0.92 for PFS). CONCLUSIONS: Our data demonstrate that there is not statistically significant difference in post-operative EOTR, KPS, OS, and PFS between younger and elderly patients treated with extensive tumor resection aided by a intraoperative multimodal protocol.