Integration of Ultrasound in Image-Guided Adaptive Brachytherapy in Cancer of the Uterine Cervix.

Cervical cancer continues to be a public health concern, as it remains the second most common cancer despite screening programs. It is the third most common cause of cancer-related death for women, and the majority of cases happen in developing nations. The standard treatment for locally advanced cervical cancer involves the use of external beam radiation therapy, along with concurrent chemotherapy, followed by an image-guided adaptive brachytherapy (IGABT) boost. The five-year relative survival rate for European women diagnosed with cervical cancer was 62% between 2000 and 2007. Updated cervical cancer treatment guidelines based on IGABT have been developed by the Gynecological working group, which is composed of the Group Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology. The therapeutic strategy makes use of three-dimensional imaging, which can be tailored to the target volume and at-risk organs through the use of computed tomography or magnetic resonance imaging. Under anaesthesia, the brachytherapy implantation is carried out. Ultrasonography is utilised to assess the depth of the uterine cavity and to facilitate the dilation of the uterine canal during the application insertion. In this study, we examine data from the international literature regarding the application of ultrasound in cervical cancer brachytherapy.

Epidemiological and histopathological aspects of ocular melanomas in Northeastern Romania.

Ocular melanoma is a rare but complex disease in current medical practice. Our retrospective study spans over a period of 28 years and analyzed uveal and conjunctival melanomas that were consecutively admitted, diagnosed, and treated in the 2nd Ophthalmology Clinic of Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iasi, Romania. The patients were selected from the records of the Department of Pathology of our Hospital, being diagnosed by standard histopathological techniques. The aim of this study was to summarize the epidemiological and pathological aspects of uveal and conjunctival melanomas in Northeastern region of Romania. In our study, we did not notice a predilection of uveal and conjunctival melanoma to one particular gender. The most common histological subtypes of ocular melanomas were the heavily pigmented spindle cell subtype, followed by the epithelioid subtype. Our patients sought medical help in a timely manner, before the systemic invasion of the disease could develop.

Cerebellar Abscess Secondary to Cholesteatomatous Otomastoiditis-An Old Enemy in New Times.

Chronic otitis with cholesteatoma is a potentially dangerous disease that can lead to the development of intracranial abscesses. Although cerebellar abscess is half as common as cerebral abscess, it is known for its particularly difficult diagnosis, which requires the visualization of the pathological process continuity from the mastoid to the posterior fossa. In this article, we present an extremely rare case from the literature of cholesteatomatous otomastoiditis complicated with meningitis and cerebellar abscess, along with the description of technical surgical details for the plugging of the bony defect between the mastoid and posterior fossa with muscle and surgical glue. The particularity of this case lies in the late presentation to the doctor of an immunocompetent patient, through a dramatic symptomatology of life-threatening complications. We emphasize the importance of responsibly treating any episode of middle ear infection and considering the existence of underlying pathologies. In such cases, we recommend additional neuroimaging explorations, which can prevent potentially lethal complications. The treatment of such intracranial complications must be carried out promptly and requires collaboration between a neurosurgeon and an ENT surgeon.

Predictor factors for recurrence in atypical meningiomas.

BACKGROUND AND OBJECTIVES: Atypical meningiomas (AMs), World Health Organization (WHO) grade 2, are a group of tumors with uneven and unpredictable clinical behavior. Our aim was to analyze possible tumor recurrence predictors, and to identify factors that improve progression-free survival (PFS). PATIENTS, MATERIALS AND METHODS: Our retrospective study included 81 patients followed up in the Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iasi, Romania, between 1 January 2010 and 31 December 2020. The histopathological specimens were reviewed according to the WHO 2021 criteria. Analyses included clinical, imaging, pathological and surgical factors. RESULTS: The tumor recurred in 53.1% of the 81 cases within 60 months of surgery. Tumor location (p<0.000), tumor volume (p<0.010), extent of surgical resection (p<0.000) and dural sinus invasion (p<0.001) were predictive factors of recurrence. Gross total resection (Simpson grade I and II) was achieved in 59.2% of patients. Patients with the tumors located in the brain convexity and volume <26.4 cm³ had better survival rates up to recurrence. PFS showed a significant relationship between Simpson grade I-III and biopsy (p<0.000) and was statistically influenced by tumor volume and location, and dural sinus invasion. CONCLUSIONS: AMs are a heterogeneous group of tumors, and we identified posterior fossa location, volume ≥26.4 cm³, Simpson grade III and IV resection and dural sinus invasion as predictive factors for relapse and a shorter PFS. Whereas certain characteristics provide some prognostic value, future molecular characterizations of AMs are necessary, which will support the clinical decision-making process.

Clinicopathological characteristics and prognostic factors of atypical meningiomas with bone invasion: a retrospective analysis of nine cases and literature review.

BACKGROUND: Meningiomas are the most common primary neoplasms of the central nervous system in adults, arising from the arachnoid cap cells. Thus, grade 2 meningiomas are situated on the border between benignity and malignancy. Among the many prognostic factors that have been investigated in these tumors, bone invasion is one of them. OBJECTIVE: The aim of our study was to identify whether bone invasion influences tumor recurrence and progression-free survival (PFS) in patients with atypical meningiomas (AMs). PATIENTS, MATERIALS AND METHODS: Out of 81 patients with AMs followed over a period of five years, we identified nine patients with bone invasion. We analyzed their demographic, clinical, imaging, and pathological characteristics, such as age, gender, radiological aspects, morphological features, extent of resection, recurrence rate, and PFS over a follow-up period of 60 months. Bone invasion was determined based on preoperative, surgical, and pathological reports. RESULTS: Out of the nine patients with bone invasion, four had convexity meningiomas, four had parasagittal meningiomas and one had a falcine meningioma. Regarding tumor recurrence∕progression, most patients (n=6) recurred within the first 24 months after surgery. Our study showed that the early recurrence/progression of tumor (at 12 months) correlated with extensive presence of malignancy criteria, especially with the presence of 15-18 mitoses∕10 high-power fields, as well as with large foci of spontaneous necrosis, but also with tumor bone infiltration, extensive bone lamellae destruction, and tumor infiltration of adjacent muscle with its atrophy due to tumor compression. Patients with bone invasion had a PFS of 29.3 months, compared to patients without invasion who had a higher PFS (49.3 months). Significant statistical associations were observed between bone invasion and tumor recurrence (p=0.002) and PFS (p=0.004). CONCLUSIONS: Our study emphasizes the importance of a thorough histopathological examination of the surgical specimen, which can provide significant data for the assessment of the progression of an AM [World Health Organization (WHO) grade 2] with bone invasion. AM infiltration in adjacent bone and muscle increases the rate of tumor recurrence and decreases PFS over a follow-up period of 60 months.

Humps and bumps of head: review of meningiomas of the scalp.

Meningiomas are a type of tumor that arises from meningothelial cells and primarily develops in intracranial space, being some of the most common benign tumors of the central nervous system. However, meningiomas can rarely occur on the scalp and are called primary cutaneous meningiomas. Since the pathogenesis of these lesions is still uncertain, these tumors still pose challenges in terms of histopathological diagnosis. In this review, we will discuss the main cases of scalp meningiomas in the literature, their classification, pathological and immunohistochemical diagnosis, differential diagnosis with other scalp lesions and the most effective treatment. This study highlights the importance of immunohistochemistry in the differential diagnosis of skin lesions located on the scalp.

Autoimmune myasthenia gravis after COVID-19 in a triple vaccinated patient.

Despite a well characterized mechanism, myasthenia gravis (MG) remains a dilemma in terms of etiology. Several case reports and series of cases suggest a potential cause-effect relation between SARS-CoV-2 infection or vaccination and MG. We present the case of an autoimmune MG occurring post Covid-19 in an elderly male, vaccinated with three doses of the BNT162b2/Pfizer-BioNTech vaccine. The 78-year-old male was admitted in the Neurology Clinic in early November 2021 with double vision, bilateral ptosis, dysphonia and dysphagia, 16 days after receiving a third dose of the BNT162b2/Pfizer-BioNTech SARS-CoV-2 vaccine and 12 days after testing positive for SARS-CoV-2 infection. The symptoms began to emerge at 9 days after COVID-19 diagnosis. Clinical neurological examination included ice-pack test and intramuscular neostigmine, both with positive results. Myasthenia gravis positive diagnosis was confirmed by slow repetitive nerve stimulation and abnormally increased serum levels of antibodies against acetylcholine receptors. Due to patient's refusal of further hospitalization, he was discharged with therapy recommendations. Under treatment with oral pyridostigmine, but no oral corticosteroid due to therapeutic noncompliance, the patient was readmitted two months later with aggravated symptoms. The myasthenic crisis was successfully treated with intravenous immunoglobulins, corticosteroid therapy and oral pyridostigmine. The novelty of the current case resides in the fact that, to the best of our knowledge, appears to be the first case of MG clinically manifested after COVID-19 infection in a fully vaccinated patient.

Oxaliplatin-induced neuropathy and colo-rectal cancer patient's quality of life: Practical lessons from a prospective cross-sectional, real-world study.

BACKGROUND: Colon cancer is one the most common forms of cancer in both sexes. Due to important progress in the field of early detection and effective treatment, colon and rectal cancer survivors currently account for 10% of cancer survivors worldwide. However, the effects of anti-cancer treatments, especially oxaliplatin-based chemotherapy, on the quality of life (QoL) have been less evaluated. Although the incidence of severe chemotherapy-induced neuropathy (CIPN) in clinical studies is below 20%, data from real-world studies is scarce, and CIPN is probably under-reported due to patient selection and the patients' fear that reporting side-effects might lead to treatment cessation. AIM: To determine the impact of CIPN on QoL in colorectal cancer patients with a recent history of oxaliplatin-based chemotherapy. METHODS: We performed a prospective cross-sectional study in two major Romanian oncology tertiary hospitals-the Regional Institute of Oncology Iași (Iasi, Romania) and the Fundeni Clinical Oncology Institute (Bucharest, Romania). All consecutive patients with colon or rectal cancer, undergoing Oxaliplatin-based chemotherapy that consented to enroll in the study, were assessed by means of two questionnaires-the EORTC QQ-CR29 (quality of life in colon and rectal cancer patients) and the QLQ-CIPN20 (assessment of neuropathy). Several demographical, social, clinical and treatment data were also collected. Statistical analysis was performed by means of SPSS v20. The student t test was used to assess the relationship between the QLQ-CIPN20 and QLQ-CR29 results. Kaplan Meyer-curves were used to report 3-year progression-free survival (PFS) in patients that discontinued chemotherapy vs those that completed the recommended course. RESULTS: Of the 267 patients that fulfilled the inclusion criteria in the pre-specified time frame, 101 (37.8%) agreed to participate in the clinical study. At the time of the enrolment in the study, over 50% of the patients had recently interrupted their oxaliplatin-based chemotherapy, most often due to neuropathy. Almost 85% of the responders reported having tingling or numbness in their fingers or hands, symptoms that were associated with pain in over 20% of the cases. When comparing the scores in the two questionnaires, a statistically significant relationship (P < 0.001) was found between the presence of neuropathic symptoms and a decreased quality of life. This correlation was consistent when the patients were stratified by sex, disease stage, comorbidities and the presence of stoma or treatment type, suggesting that neuropathy in itself may be a reason for a decreased quality of life. At the 3 year final assessment, median recurrence-free survival in stage III patients was 26.88 mo. When stratified by completion of chemotherapy, median recurrence free-survival of stage III patients that completed chemotherapy was 28.27 mo vs 24.33 mo in patients that discontinued chemotherapy due to toxicity, a difference that did not reach statistical significance. CONCLUSION: CIPN significantly impacts QoL in colorectal cancer patients. CIPN is also the most frequent reason for treatment discontinuation. Physicians should actively assess for CIPN in order to prevent chronic neuropathy.

HOXB13 and TFF3 can contribute to the prognostic stratification of prostate adenocarcinoma.

Homeobox B13 (HOXB13) and trefoil factor 3 (TFF3) are novel candidates for the classification of prostate cancer (PC) in molecular subtypes that could predict the clinical evolution of patients. The aim of our study was to analyze the possible associations between HOXB13 and TFF3 immunohistochemical (IHC) expression in sporadic prostate adenocarcinoma (PAC), the potential prognostic value in relation to the classical clinico-pathological parameters, as well as their role in defining distinct molecular subtypes of this malignancy. The study group comprised 105 patients diagnosed with PAC who underwent radical prostatectomy. IHC exam was performed using anti-HOXB13 and anti-TFF3 antibodies and a scoring system that permit the separation of the cases into two subgroups, with low and high immunoexpression, respectively. The statistical analysis evaluated the relationship between the two immunomarkers and clinico-pathological parameters. The Kaplan-Meier curves and log-rank Mantel-Cox test were used for assessing the prostate-specific antigen (PSA)-progression free survival. Four subgroups of PAC were defined based on the IHC overexpression and low immunoexpression of HOXB13 and TFF3. High HOXB13 and TFF3 immunoexpression was commonly identified in cases characterized by a Gleason score over 7, a G4 or G5 dominant pattern, a grade group of 3 or 4 and a preoperatory PSA serum level over 20 ng/mL. HOXB13 overexpression was also associated with pathological tumor-node-metastasis (pTNM) stage. The subgroup with both low HOXB13 and TFF3 immunoexpression had the highest PSA-progression free interval, whereas the subgroup with high HOXB13 immunoexpression and low TFF3 immunoexpression presented the lowest rate, but no statistically significant differences were registered. Our results sustain the role of HOXB13 and TFF3 in the stratification of PAC. Further investigations in larger cohorts are imposed to validate the clinical significance of these subgroups in the diagnostic and prognostic of PAC.

Challenges in management of male breast adenomioepithelioma with malignant behavior: Case report.

RATIONALE: Male adenomyoepithelioma of the breast with malignant features is a rare tumor with only one previous case reported in the literature over 25 years ago. PATIENT CONCERNS: We report the case of a 63-year-old man admitted to our Oncology Institute with a painless tumor mass of 6 cm in the left breast with no additional regional lymph nodes. Ultrasound revealed a complex cystic tumor mass of 60 mm in the left breast, with both anechoic (cystic) and echogenic (solid) components, with ill-defined margin. DIAGNOSES: Extemporaneous assessment showed a solid (invasive) papillary intracystic carcinoma. Definitive pathology examination revealed the presence of a breast malignant adenomyoepithelioma. INTERVENTIONS: Based on the extemporaneous assessment, wide tumor excision was performed. The tumor board decided to continue treatment with adjuvant anthracycline-based chemotherapy. OUTCOMES: After 6 years of follow-up, the patient is cancer-free. No chronic side effects were noted. LESSONS: Because this pathology is extremely rare, no guidelines are available for its therapeutic approach. All decisions regarding patient management should be made by a multi-disciplinary team and can only be based on clinical experience and the few cases reported in female patients.