Surgical Challenges of Chronic Empyema and Bronchopleural Fistula

Chronic empyema has always been a clinical challenge for physicians. There is no standard procedure or treatment to deal with the situation, and multi-modality approach is often necessary. Surgical intervention plays a very crucial role in the treatment of chronic empyema. Since bronchopleural fistula is often seen in chronic empyema patients, therefore it should also be mentioned. In this chapter, the focus will be on the different treatment options, various surgical approaches, and the rationale behind every single modality. Certain specific entity will be included as well, such as tuberculosis infection, post lung resection empyema, and intrathoracic vacuum assisted closure system application. Even with the advancement of technology and techniques, chronic empyema management is still evolving, and we look forward to less traumatic ways of approach with better outcome in the future.

Examining the Feasibility of Quantifying Receptor Availability Using Cross-Modality Paired-Agent Imaging

Purpose The ability to noninvasively quantify receptor availability (RA) in solid tumors is an aspirational goal of molecular imaging, often challenged by the influence of non-specific accumulation of the contrast agent. Paired-agent imaging (PAI) techniques aim to compensate for this effect by imaging the kinetics of a targeted agent and an untargeted isotype, often simultaneously, and comparing the kinetics of the two agents to estimate RA. This is usually accomplished using two spectrally distinct fluorescent agents, limiting the technique to superficial tissues and/or preclinical applications. Applying the approach in humans using conventional imaging modalities is generally infeasible since most modalities are unable to routinely image multiple agents simultaneously. We examine the ability of PAI to be implemented in a cross-modality paradigm, in which the targeted and untargeted agent kinetics are imaged with different modalities and used to recover receptor availability. Procedures Eighteen mice bearing orthotopic brain tumors were administered a solution containing three contrast agents: (1) a fluorescent agent targeted to epidermal growth factor receptor (EGFR), (2) an untargeted fluorescent isotype, and (3) a gadolinium-based contrast agent (GBCA) for MRI imaging. The kinetics of all three agents were imaged for 1 h after administration using an MRI-coupled fluorescence tomography system. Paired-agent receptor availability was computed using (1) the conventional all-optical approach using the targeted and untargeted optical agent images and (2) the cross-modality approach using the targeted optical and untargeted MRI-GBCA images. Receptor availability estimates between the two methods were compared. Results Receptor availability values using the cross-modality approach were highly correlated to the conventional, single-modality approach (r = 0.94; p < 0.00001). Conclusion These results suggest that cross-modality paired-agent imaging for quantifying receptor availability is feasible. Ultimately, cross-modality paired-agent imaging could facilitate rapid, noninvasive receptor availability quantification in humans using hybrid clinical imaging modalities.

The impact of multimodality therapies in marginally inoperable soft tissue sarcomas (STS): The Toronto Sarcoma Program (TSP) experience.

11548 Background: The mainstay therapy of operable STS remains surgery, which may include (neo)adjuvant therapies. Within the TSP, marginally inoperable STS are often treated with sequential chemo (CTX) and radiation (RT) therapy, followed by surgery (SX). Herein we present our experience of multi-modality therapies for marginally inoperable STS patients (pts). Methods: This was a dual-center, single program, retrospective review. Pts were included if deemed to have marginally inoperable primary or recurrent STS, as determined at the TSP tumor board. Pts included must have had CTX with the intent of having RT and SX after. Pts demographics, treatment details and clinical outcomes data were collected. Relapse free survival (RFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Multivariate analysis of the influence of disease characteristics and treatment on outcomes was assessed using Cox regression. Results: From June 2005 to May 2019, 75 pts were identified. Median age was 52 years (range 16-72). Pts were predominantly male (55%). Histological subtypes included dedifferentiated liposarcoma (29%), leiomyosarcoma (27%), synovial sarcoma (19%) and others (25%). Primary tumor was located in the retroperitoneum (48%), extremity (23%), pelvis (12%), thorax (9%), and other sites (8%). All pts had doxorubicin and ifosfamide CTX (median 4 cycles; range 1-6), while RT dose delivered was 50.4Gy/28 fractions in 58 (77%) of cases. Twenty three pts (31%) achieved partial response, 40 pts (53%) had stable disease and 12 pts (16%) had progression of disease (PD) on CTX, of which half (8%) did not undergo further treatment. Nine pts (12%) underwent CTX followed by SX due to significant response, 9 pts (12%) underwent CTX and RT without SX due to persistent tumor unresectability or PD. The final 50 pts (67%) completed multi-modality treatment (CTX, RT & SX). Overall, 59 pts (79%) had SX; negative margins were achieved in 53 (71%). 19 pts (25%) had postoperative complications, causing death in 2 pts (2.7%). With a median follow-up of 72 months, median RFS and OS were 26.9 months (95% CI: 0-86.0), and 65 months (95% CI: 13.5-116.4). Extremity location was associated with superior RFS (median not reached [NR], HR 0.28 95% CI 0.09-0.83, p = 0.022), and OS (median NR, HR 0.29 95% CI 0.09-0.90, p = 0.032). Receipt of RT was associated with superior RFS (median NR, HR 0.23 95% CI 0.10-0.52, p < 0.001); and OS (median NR, HR 0.21 95% CI 0.09-0.50, p < 0.001). Pts who had PD after CTX were associated with poor outcomes - RFS (median 4.7 months, HR 2.03 95% CI 0.61-6.76, p = 0.24); and OS (median 21.9 months, HR 2.48 95% CI 0.73-8.47, P = 0.144). Conclusions: Multi-modality approach resulted in successful resection for most pts with marginally inoperable STS. Extremity location and RT administration were associated with better RFS and OS, while progression on CTX confers worse survival outcomes.

Facial Rejuvenation With Fat Grafting and Fillers

Facial rejuvenation requires a multi-modality approach to address the sun damage, volume loss, and thinning of skin that occurs with aging. With age, the collagen fibrils that provide strength become fragmented and fibroblasts connections become weak, leading to skin laxity and loss of youthful skin. Fillers can lead to a more youthful appearance by providing volumetric support. Synthetic fillers such as hyaluronic acid products, calcium hydroxyapatite, polylactic acid, and polymethylmethacralate have bio-stimulatory affects, ranging from small effects on fibroblast production to prolonged stimulatory effects on dermal thickness and blood supply. Fat grafting is also an ideal technique for facial rejuvenation because it is readily available, natural, and has regenerative effects. This review describes a new technique of fat grafting for the face called Injectable Tissue Replacement and Regeneration that specifically addresses the different anatomic compartments of the face with volume loss. With this brief review, we aim to evaluate the currents trends of fat grafting and fillers in the management of facial rejuvenation, including the cellular changes that occur with facial aging, the bio-stimulatory effects of fillers, and the anatomic replacement of tissue with fat grafting. &gt;Level of Evidence: 4

Effectiveness and safety of a combination of sun protection and depigmentation agent in the treatment of epidermal hyperpigmentation

<p class="Default"><strong>Background: </strong>Medication adherence is recognized as a worldwide public health problem. As a multi-modality approach with sun protection and depigmentation is quintessential in patients with epidermal hyperpigmentation, a combination of day and night cream may be prudent for long-term improvement and compliance. Aim of the current investigation was to assess treatment outcomes and medication compliance in patients with epidermal hyperpigmentation using day and night cream in a combi-kit packaging (Melaglow day and night^TM combi-kit).</p><p><strong>Methods: </strong>Sixty patients (18-45 years) with epidermal pigmentation were enrolled in this 12-week study. Treatment effectiveness was determined by melanin index/erythema measure (dermacatch), extent, depth and density of pigmentation (fotofinder), and clinical/dermoscopic aspects (grade-1: &lt;25%; grade-2: 25%-50%; grade-3: 50%-75%; grade-4: &gt;75% reduction in the amount of epidermal pigment), safety, satisfaction, and compliance were assessed.</p><p><strong>Results: </strong>Out of 60 patients, 52 completed the study. The overall percentage of melanin and erythema improvement was 22.51% and 13.85%, respectively. Based on fotofinder images, 36.54% had grade-2, 34.62% had grade-3, 15.38% had grade-1, and 13.46% patients had grade-4 improvement. Based on the photographic images, 40.38% had grade-2, 32.69% had grade-3, 17.31% had a grade-1, and 9.62% had grade-4 improvement in skin color. All patients agreed that combi-kit helped in remembering and adhering to treatment. Most patients were satisfied with the treatment (84.62%), with compliance rate of 97.72%. No adverse events were reported.</p><p><strong>Conclusions:</strong> Combi-kit containing day and night cream (Melaglow day and night^TM combi-kit) was safe and effective in the treatment of epidermal pigmentation, ensuing treatment compliance, and patient satisfaction. <strong></strong></p>

Study of toxicities of Intensity Modulated Radiotherapy (IMRT) in post-operative patients of carcinoma cervix and endometrium

Background Various studies have shown a clinical benefit of pelvic IMRT but included a significant number of patients with intact cervix and uterus. Therefore we proposed a prospective study to evaluate the toxicity, feasibility, and tolerance of IMRT in post-operative patients with carcinoma cervix and endometrium. Methods and Material: This was a prospective, single-arm study, conducted from August 2015 to October 2018 including a total of 30 patients (23 cervical and 7 endometrial cancer) who had undergone a total hysterectomy and required adjuvant pelvic irradiation. These patients were treated with pelvic IMRT using a dose of 45-50.4 Gray (Gy) at 1.8-2 Gy per fraction given as 5 fractions per week with/without concurrent chemotherapy (using injection cisplatin 35–40 mg/m2 per week) as per indications. Acute toxicities were recorded at weekly intervals during the treatment followed by the assessment of late toxicities at the time of each follow-up visits using RTOG radiation morbidity criteria. Results Maximum on treatment skin, lower gastrointestinal (LGI), genitourinary (GU), and hematological toxicities were grade 1, 2, 2, and 2, occurring in 38%, 31%, 14%, and 3.4% of the cases, respectively. No late skin and GU toxicities were observed. Maximum late LGI toxicity was grade 1, occurring in 6.67% of the cases. Five (out of 30) patients developed treatment failures (2 distant and 3 local). At a median follow-up of 35 months, the 3 year progression free survival (PFS) and overall survival (OS) were 83.3% (all stages included). Conclusion Considering acute and late adverse events in the form of skin, LGI, GU, and hematological toxicities, IMRT is well tolerated and has an acceptable toxicity profile even in the setting of an aggressive tri-modality approach.

A case of recurrent chondroblastic osteosarcoma mandible

<p class="abstract">Osteosarcoma is an uncommon primary malignant tumor of bone. Craniofacial osteosarcomas constitute only about 6.5–7% of all osteosarcomas. The most common histopathologic type is chondroblastic type in head and neck group and osteoblastic in extremity group. We present a case report of 21 year old male patient with chondroblastic osteosarcoma with two episodes of recurrence. The tumour was dealt with left hemimandibulectomy followed by radiochemotherapy. After first recurrence he underwent right hemimandibulectomy. During second recurrence excision of growth followed by radiochemotherapy was done. Thus an aggressive multi-modality approach was adopted for treatment. Osteosarcoma is an uncommon primary malignant tumor of bone. Craniofacial Osteosarcomas are considered a separate category in view of their low histologic grade, less frequent metastases and better prognosis. The most common presentation is local swelling with or without pain. Aggressive surgical approach with post-surgical radiochemotherapy can be an effective tool.</p>

The multi-modality approach in a case of fracture of the humerus with an ipsilateral floating knee: A case report

Ipsilateral fractures of humerus, femur and tibia is a rare entity. The number of fractures resulting due to road traffic accidents is on the rise. These Type of injuries usually occur due to high-velocity road traffic accidents. High-velocity road traffic accidents are associated with multiple bony injuries as well as injuries to various internal organs. These injuries are often difficult to manage due to their complex nature. Mostly multiple fractures are produced in ipsilateral limbs. This condition makes the management even more difficult. Hence a multi-modality approach is often required. A 55-year-old male sustained floating knee with ipsilateral shaft humerus fracture. After a three-staged surgical approach with three modalities for treating the compound injury, the patient had an excellent result with the full range of motion in the knee and complete coverage of wound. Compound floating injuries should be treated with simultaneous fixation of femur and tibia fractures to achieve early full range of knee motion with Vacuum-assisted closure followed by skin grafting for complete wound coverage.