Injuries to the rigid spine have a distinguished position in the broad spectrum of spinal injuries due to altered biomechanical properties. The rigid spine is more prone to fractures. Two ...ossification bone disorders that are of particular interest are Ankylosing Spondylitis (AS) and Diffuse Idiopathic Skeletal Hyperostosis (DISH).
DISH is a non-inflammatory condition that leads to an anterolateral ossification of the spine.
AS on the other hand is a chronic inflammatory disease that leads to cortical bone erosions and spinal ossifications. Both diseases gradually induce stiffening of the spine.
The prevalence of DISH is age-related and is therefore higher in the older population. Although the prevalence of AS is not age-related the occurrence of spinal ossification is higher with increasing age. This association with age and the aging demographics in industrialized nations illustrate the need for medical professionals to be adequately informed and prepared.
The aim of this narrating review is to give an overview on the diagnostic and therapeutic measures of the ankylosed spine.
Because of highly unstable fracture configurations, injuries to the rigid spine are highly susceptible to neurological deficits. Diagnosing a fracture of the ankylosed spine on plain radiographs can be challenging. Moreover, since 8% of patients with ankylosing spine disorders (ASD) have multiple non-contagious fractures, a CT scan of the entire spine is highly recommended as the primary diagnostic tool.
There are no consensus-based guidelines for the treatment of spinal fractures in ASD. The presence of neurological deficit or unstable fractures are absolute indications for surgical intervention. If conservative therapy is chosen, patients should be monitored closely to ensure that secondary neurologic deterioration does not occur. For the fractures that have to be treated surgically, stabilization of at least three segments above and below the fracture zone is recommended. These fractures mostly are treated via the posterior approach.
Patients with AS or DISH share a significant risk for complications after a traumatic spine injury. The most frequent complications for patients with thoracolumbar burst fractures are respiratory failure, pseudoarthrosis, pneumonia, and implant failure.
•AS and DISH cause spinal rigidity, elevating fracture risk.•CT essential for fracture diagnosis MRI helps identifying occult fractures.•No consensus on treatment; tailored approach necessary.•Post-trauma complications high in AS and DISH patients.•Aging demographics increase prevalence of spinal rigidity.
The OligoMetastatic Esophagogastric Cancer (OMEC) project aims to provide clinical practice guidelines for the definition, diagnosis, and treatment of esophagogastric oligometastatic disease (OMD).
...Guidelines were developed according to AGREE II and GRADE principles. Guidelines were based on a systematic review (OMEC-1), clinical case discussions (OMEC-2), and a Delphi consensus study (OMEC-3) by 49 European expert centers for esophagogastric cancer. OMEC identified patients for whom the term OMD is considered or could be considered. Disease-free interval (DFI) was defined as the time between primary tumor treatment and detection of OMD.
Moderate to high quality of evidence was found (i.e. 1 randomized and 4 non-randomized phase II trials) resulting in moderate recommendations. OMD is considered in esophagogastric cancer patients with 1 organ with ≤ 3 metastases or 1 involved extra-regional lymph node station. In addition, OMD continues to be considered in patients with OMD without progression in number of metastases after systemic therapy. 18F-FDG PET/CT imaging is recommended for baseline staging and for restaging after systemic therapy when local treatment is considered. For patients with synchronous OMD or metachronous OMD and a DFI ≤ 2 years, recommended treatment consists of systemic therapy followed by restaging to assess suitability for local treatment. For patients with metachronous OMD and DFI > 2 years, upfront local treatment is additionally recommended.
These multidisciplinary European clinical practice guidelines for the uniform definition, diagnosis and treatment of esophagogastric OMD can be used to standardize inclusion criteria in future clinical trials and to reduce variation in treatment.
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•Multidisciplinary European clinical practice guidelines were developed.•One organ with ≤ 3 metastases is considered OMD.•One extra-regional lymph node station is considered OMD.•Patients with OMD undergo systemic therapy followed by restaging.•Patients without progression at 18F-FDG PET/CT restaging undergo local treatment.
In esophageal cancer (EC) patients who are not eligible for surgery, definitive chemoradiation (dCRT) with curative intent using cisplatinum with 5-fluorouracil (5-FU) is the standard chemotherapy ...regimen. Nowadays carboplatin/paclitaxel is also often used. In this study, we compared survival and toxicity rates between both regimens.
This multicenter study included 102 patients treated in five centers in the Northeast Netherlands from 1996 till 2008. Forty-seven patients received cisplatinum/5-FU (75 mg/m
and 1 g/m
) and 55 patients carboplatin/paclitaxel (AUC2 and 50 mg/m
).
Overall survival (OS) was not different between the cisplatinum/5-FU and carboplatin/paclitaxel group {P = 0.879, hazard ratio (HR) 0.97 confidence interval (CI) 0.62-1.51}, with a median survival of 16.1 (CI 11.8-20.5) and 13.8 months (CI 10.8-16.9). Median disease-free survival (DFS) was comparable P = 0.760, HR 0.93 (CI 0.60-1.45) between the cisplatinum/5-FU group 11.1 months (CI 6.9-15.3) and the carboplatin/paclitaxel group 9.7 months (CI 5.1-14.4). Groups were comparable except clinical T stage was higher in the carboplatin/paclitaxel group (P = 0.008). High clinical T stage (cT4) was not related to OS and DFS in a univariate analysis (P = 0.250 and P = 0.201). A higher percentage of patients completed the carboplatin/paclitaxel regimen (82% versus 57%, P = 0.010). Hematological and nonhematological toxicity (≥grade 3) in the carboplatin/paclitaxel group (4% and 18%) was significantly lower than in the cisplatinum/5-FU (19% and 38%, P = 0.001).
In this study, we showed comparable outcome, in terms of DFS and OS for carboplatin/paclitaxel compared with cisplatinum/5-FU as dCRT treatment in EC patients. Toxicity rates were lower in the carboplatin/paclitaxel group together with higher treatment compliance. Carboplatin/paclitaxel as an alternative treatment of cisplatinum/5-FU is a good candidate regimen for further evaluation.
Adequate prediction of tumor response to neoadjuvant chemoradiotherapy (nCRT) in esophageal cancer (EC) patients is important in a more personalized treatment. The current best clinical method to ...predict pathologic complete response is SUV
in
F-FDG PET/CT imaging. To improve the prediction of response, we constructed a model to predict complete response to nCRT in EC based on pretreatment clinical parameters and
F-FDG PET/CT-derived textural features.
From a prospectively maintained single-institution database, we reviewed 97 consecutive patients with locally advanced EC and a pretreatment
F-FDG PET/CT scan between 2009 and 2015. All patients were treated with nCRT (carboplatin/paclitaxel/41.4 Gy) followed by esophagectomy. We analyzed clinical, geometric, and pretreatment textural features extracted from both
F-FDG PET and CT. The current most accurate prediction model with SUV
as a predictor variable was compared with 6 different response prediction models constructed using least absolute shrinkage and selection operator regularized logistic regression. Internal validation was performed to estimate the model's performances. Pathologic response was defined as complete versus incomplete response (Mandard tumor regression grade system 1 vs. 2-5).
Pathologic examination revealed 19 (19.6%) complete and 78 (80.4%) incomplete responders. Least absolute shrinkage and selection operator regularization selected the clinical parameters: histologic type and clinical T stage, the
F-FDG PET-derived textural feature long run low gray level emphasis, and the CT-derived textural feature run percentage. Introducing these variables to a logistic regression analysis showed areas under the receiver-operating-characteristic curve (AUCs) of 0.78 compared with 0.58 in the SUV
model. The discrimination slopes were 0.17 compared with 0.01, respectively. After internal validation, the AUCs decreased to 0.74 and 0.54, respectively.
The predictive values of the constructed models were superior to the standard method (SUV
). These results can be considered as an initial step in predicting tumor response to nCRT in locally advanced EC. Further research in refining the predictive value of these models is needed to justify omission of surgery.
Abstract
Background
Proximal oesophageal cancer is commonly treated with definitive chemoradiation (CRT). The radiation dose and type of chemotherapy backbone in CRT are still under debate. The ...objective of this study is to compare the treatment benefit of four contemporary CRT regimens.
Methods
In this retrospective observational cohort study, we included patients with locally advanced squamous cell cancer of the proximal oesophagus, from 11 centers in the Netherlands, treated with definitive CRT between 2004-2014. Each center had a preferential CRT regimen, based on cisplatin (Cis) or carboplatin/paclitaxel (CP) combined with low (≤50.4 Gy) or high (>50.4 Gy) dose radiotherapy (RT). Differences in overall survival (OS) between CRT regimens were assessed using a fully adjusted Cox proportional hazards and propensity score (PS) model. Safety profiles were compared using the Chi-square test.
Results
Two-hundred patients were included. Fifty-four, 39, 95, and 12 patients were treated with Cis-low-dose RT, Cis-high-dose RT, CP-low-dose RT, and CP-high-dose RT, respectively. Median follow-up was 62.6 months (95% CI 47.9-77.2 months). Median OS (21.9 months; 95% CI 16.9-27.0 months) was comparable between treatment groups (logrank P = 0.88), confirmed in the fully adjusted and PS weighted model (P > 0.05). Grade 3-5 acute adverse events were less frequent in patients treated with CP-low-dose RT (P = 0.01).
Conclusions
Our study results suggest that carboplatin and paclitaxel combined with RT at a dose of 50.4 Gy is the preferred CRT regimen in patients with locally advanced proximal oesophageal squamous cell cancer, showing comparable OS and a significantly more favourable safety profile when compared with cisplatin-based or higher RT dose regimens.
Legal entity responsible for the study
The authors.
Funding
Has not received any funding.
Disclosure
J. de Vos-Geelen: Travel / Accommodation / Expenses: BTG; Research grant / Funding (institution), Travel / Accommodation / Expenses: Servier; Advisory / Consultancy: Shire. B.T.A. de Greef: Research grant / Funding (institution): Prinses Beatrix Spierfonds (W.OR12-01). H.W.M. van Laarhoven: Advisory / Consultancy, Research grant / Funding (institution): BMS; Advisory / Consultancy, Research grant / Funding (institution): Celgene; Advisory / Consultancy, Research grant / Funding (institution): Lilly; Advisory / Consultancy, Research grant / Funding (institution): Nordic; Research grant / Funding (institution): Bayer; Research grant / Funding (institution): Merck Serono; Research grant / Funding (institution): MSD; Research grant / Funding (institution): Philips; Research grant / Funding (institution): Roche. V.E.P.P. Lemmens: Research grant / Funding (institution): Roche. V.C.G. Tjan-Heijnen: Honoraria (self), Research grant / Funding (institution), Travel / Accommodation / Expenses: Roche; Honoraria (self), Research grant / Funding (institution), Travel / Accommodation / Expenses: Novartis; Honoraria (self), Research grant / Funding (institution), Travel / Accommodation / Expenses: Pfizer; Honoraria (self), Research grant / Funding (institution), Travel / Accommodation / Expenses: Lilly; Honoraria (self), Travel / Accommodation / Expenses: Accord Healthcare; Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): Eisai. All other authors have declared no conflicts of interest.
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