Search Results (192)

Treatment of locally advanced rectal cancer (LARC), clinical stages II–III, typically involves multimodal treatment options. Over the past decade, the role of radiation therapy as a neoadjuvant treatment for LARC has evolved and is currently a part of total neoadjuvant therapy (TNT). Some recently published studies advocate for the omission of radiation therapy entirely, while others report on a non-operative approach that emphasizes the use of higher radiation therapy doses. This review aims to evaluate the latest literature on the current role of radiation therapy in the management of LARC, with a discussion of how to best select the most appropriate treatment protocol based on individual patient and tumor characteristics, comorbidities, and personal needs and preferences. Full article

Background: The purpose of this study was to evaluate Achilles tendon ruptures (ATR) in NHL players and the effects on return to play and player performance metrics. The incidence, mechanism of injury, management strategy, return to play (RTP), and post-injury were assessed from official online sports databases. Methods: A retrospective review of NHL players who sustained a partial or complete tear of the Achilles tendon from 2008 to 2024 was performed. Data were collected from NHL injury databases and media reports, and included player demographics, injury mechanism, treatment, and post-injury performance metrics. A Wilcoxon signed rank test was used to compare pre-injury and post-injury performance metrics, with significance set at p < 0.05. Results: Here, 15 NHL players with a mean age of 27.8 years were identified, with a prevalence rate of 0.125 injuries per 10,000 athletic exposures. Overall, 73.3% of ATRs were non-contact in nature, with 60.0% of ATRs occurring during off-season training. Fourteen players were managed with non-operative treatment, with no re-ruptures reported. The RTP rate was 93.3%, with players missing a mean number of 45.7 games. However, there was a deterioration in post-injury performance metrics, including games played per season, plus/minus rating, and time on ice per game post-injury. Conclusions: This study found that Achilles tendon ruptures are an uncommon injury in NHL players, with a prevalence rate of 0.125 injuries per 10,000 athletic exposures. A high RTP rate of 93.3% was observed in this cohort. However, there was a deterioration in post-injury performance metrics, including games played per season, plus/minus rating, and time on ice per game post-injury, highlighting the potential devastating sequelae of ATRs in elite NHL athletes. Full article

Background/Objectives: Nonoperative management (NOM) of patients with locally advanced rectal cancer (LARC) who achieve a complete clinical response (cCR) to total neoadjuvant therapy (TNT) has been shown to be oncologically safe and is an attractive treatment option for patients. However, identifying responders to TNT that may benefit from nonoperative management is clinically challenging. Circulating tumor DNA (ctDNA) testing has shown promise in detecting minimal residual disease but has not yet been studied extensively within this clinical context. Methods: This is a single-institution retrospective case series study of LARC patients treated with TNT from 2019 to 2023 who underwent ctDNA testing as an adjunct to standard clinical response assessments. Results: A total of 28 patients had ctDNA testing as part of their response assessments after TNT. In total, 9 patients had positive ctDNA, and 19 patients had negative ctDNA during surveillance. Baseline characteristics of these two groups were not different. In this study, 6/9 (67%) patients who had positive ctDNA required surgery for residual rectal cancer, whereas only 4/19 (21%) patients who had negative ctDNA required surgery (p = 0.035). Conclusions: ctDNA testing has the potential to detect MRD in LARC patients treated with TNT. Full article

Locally advanced rectal cancer (LARC) remains a major clinical challenge due to its high risk of local recurrence and distant metastasis. Although total mesorectal excision (TME) has been established as the gold standard surgical approach, high recurrence rates associated with surgery alone have driven the development of multimodal preoperative strategies, such as radiotherapy and chemoradiotherapy. More recently, total neoadjuvant therapy (TNT)—which integrates systemic chemotherapy and radiotherapy prior to surgery—and non-operative management (NOM) for patients who achieve a clinical complete response (cCR) have further expanded treatment options. These advances aim not only to improve oncologic outcomes but also to enhance quality of life (QOL) by reducing long-term morbidity and preserving organ function. However, several unresolved issues persist, including the optimal sequencing of therapies, precise risk stratification, accurate evaluation of treatment response, and effective surveillance protocols for NOM. The advent of molecular biomarkers, next-generation sequencing, and artificial intelligence (AI) presents new opportunities for individualized treatment and more accurate prognostication. This narrative review provides a comprehensive overview of the current status of preoperative treatment for LARC, critically examines emerging strategies and their supporting evidence, and discusses future directions to optimize both oncological and patient-centered outcomes. By integrating clinical, molecular, and technological advances, the management of rectal cancer is moving toward truly personalized medicine. Full article

Background: Renal trauma accounts for approximately 3–5% of all trauma cases, predominantly affecting young males. The most common etiology is blunt trauma, particularly due to road traffic accidents, and it frequently occurs as part of polytrauma involving multiple organ systems. Management strategies are primarily dictated by hemodynamic stability, overall clinical condition, comorbidities, and injury severity graded according to the AAST classification. This study aimed to evaluate the effectiveness of non-operative management (NOM) in high-grade renal trauma (AAST grades III–V), beyond its established role in low-grade injuries (grades I–II). Secondary endpoints included the identification of independent prognostic factors for NOM failure and in-hospital mortality. Methods: We conducted a retrospective observational study including patients diagnosed with blunt renal trauma who presented to the Emergency Department of Policlinico Umberto I in Rome between 1 January 2013 and 30 April 2024. Collected data comprised demographics, trauma mechanism, vital signs, hemodynamic status (shock index), laboratory tests, blood gas analysis, hematuria, number of transfused RBC units in the first 24 h, AAST renal injury grade, ISS, associated injuries, treatment approach, hospital length of stay, and mortality. Statistical analyses, including multivariable logistic regression, were performed using SPSS v28.0. Results: A total of 244 patients were included. Low-grade injuries (AAST I–II) accounted for 43% (n = 105), while high-grade injuries (AAST III–V) represented 57% (n = 139). All patients with low-grade injuries were managed non-operatively. Among high-grade injuries, 124 patients (89%) were treated with NOM, including observation, angiography ± angioembolization, stenting, or nephrostomy. Only 15 patients (11%) required nephrectomy, primarily due to persistent hemodynamic instability. The overall mortality rate was 13.5% (33 patients) and was more closely associated with the overall injury burden than with renal injury severity. Multivariable analysis identified shock index and active bleeding on CT as independent predictors of NOM failure, whereas ISS and age were significant predictors of in-hospital mortality. Notably, AAST grade did not independently predict either outcome. Conclusions: In line with the current international literature, our study confirms that NOM is the treatment of choice not only for low-grade renal injuries but also for carefully selected hemodynamically stable patients with high-grade trauma. Our findings highlight the critical role of physiological parameters and overall ISS in guiding management decisions and underscore the need for individualized assessment to minimize unnecessary nephrectomies and optimize patient outcomes. Full article

Diabetic foot osteomyelitis (DFO) is a severe complication of diabetes mellitus and a leading cause of non-traumatic lower extremity amputation. Treatment remains clinically challenging with high recurrence rates despite standard antibiotic therapy and surgical debridement. This narrative review synthesizes current evidence on novel operative and nonoperative therapies for DFO, focusing on emerging biomaterials, local antibiotic delivery systems, innovative surgical techniques, and adjunctive topical agents. Studies examining bioabsorbable and nonabsorbable antibiotic carriers, such as calcium sulfate beads, collagen sponges, and bioactive glass, demonstrate promising infection resolution rates and a potential to reduce the surgical burden, though most are limited by small cohorts and observational designs. Similarly, alternative surgical approaches (i.e., cancelloplasty, conservative bone excision, and tibial cortex distraction) have shown early success in limb preservation. Nonoperative strategies, including adjunct antimicrobials, antimicrobial peptides, and topical oxygen, offer additional options, particularly for patients unfit for surgery. While initial outcomes are encouraging, the supporting evidence is heterogeneous and primarily limited to case series and small, noncomparative trials. Overall, these novel therapies show potential as adjuncts to established DFO management, but further prospective research is indicated to define their long-term efficacy, safety, and role in clinical practice. Full article

Background/Objectives: Achilles tendon pathologies, such as Achilles tendinitis, tendinosis, ruptures, and equinus contracture, cause pain and functional impairment. While surgical intervention is indicated in some cases, many patients are successfully managed with nonoperative treatment. The goal of this review was to evaluate the current evidence-based treatments for the nonoperative management of Achilles tendon disorders, focusing on indications and clinical outcomes. Methods: A scoping review of the literature was conducted from 2015 to 2025 from the PubMed database. Research published in the last ten years was included if it addressed nonoperative treatments for Achilles tendinopathy, acute ruptures, and/or equinus contracture. The outcome measures of interest included functional outcomes, re-rupture rates, and overall patient satisfaction. Results: Nonoperative management results in favorable outcomes for a wide range of Achilles tendon pathologies. Eccentric loading is supported for chronic tendinopathy, and functional rehabilitation programs with early mobilization have shown comparable outcomes to surgical repair for acute tendon ruptures. Combination therapy for the nonoperative management of equinus is favored. These therapies include stretching protocols, casting, and the botulinum toxin. Conclusions: The literature supports the notion that nonoperative management strategies for Achilles tendon pathologies provide symptom relief and functional improvement in patients. However, these treatment plans should be individualized and tailored to patient-specific goals. Full article

Background/Objectives: Treatment of locally advanced rectal cancer (LARC) very often requires a neoadjuvant multimodal approach. Neoadjuvant treatment (NAT) encompasses treatments like chemoradiotherapy (CRT), short-course radiotherapy (SCRT), radiotherapy (RT) or a combination of either of these two with additional induction or consolidation chemotherapy, namely total neoadjuvant treatment (TNT). In case of complete radiological and clinical response, the non-operative watch-and-wait strategy can be adopted in selected patients. This strategy is impacted by a regrowth rate of approximately 30%. Predicting biomarkers of tumor response to NAT could improve guidance of clinicians during clinical decision making, improving treatment outcomes and decreasing unnecessary treatment exposure. To this day, there is no validated biomarker to predict tumor response to any NAT strategies in clinical use. Most research focused on CRT neglects the study of other regimens. Methods: We conducted a narrative literature review which aimed at summarizing the status of biomarkers predicting tumor response to NAT other than CRT in LARC. Results: Two hundred and fourteen articles were identified. After screening, twenty-one full-text articles were included. Statistically significant markers associated with improved tumor response pre-treatment were as follows: low circulating CEA levels; BCL-2 expression; high cellular expression of Ku70, MIB-1(Ki-67) and EGFR; low cellular expression of VEGF, hPEBP4 and nuclear β-catenin; the absence of TP53, SMAD4, KRAS and LRP1B mutations; the presence of the G-allel of LCS-6; and MRI features such as the conventional biexponential fitting pseudodiffusion (Dp) mean value and standard deviation (SD), the variable projection Dp mean value and lymph node characteristics (short axis, smooth contour, homogeneity and Zhang et al. radiomic score). In the interval post-treatment and before surgery, significant markers were as follows: a reduction in the median value of circulating free DNA, higher presence of monocytic myeloid-derived suppressor cells, lower presence of CTLA4+ or PD1+ regulatory T cells and standardized index of shape changes on MRI. Conclusions: Responders to neoadjuvant SCRT and RT tended to have a tumor microenvironment with an immune–active phenotype, whereas responders to TNT tended to have a less active tumor profile. Although some biomarkers hold great promise, scarce publications, inconsistent results, low statistical power, and low reproducibility prevent them from reliably predicting tumor response following NAT. Full article

Rectal cancer management necessitates a rigorous multidisciplinary strategy, emphasizing precise staging and detailed risk stratification to inform optimal therapeutic decision-making. Obtaining an accurate histological diagnosis before initiating treatment is essential. Comprehensive staging integrates clinical evaluation, thorough medical history analysis, assessment of carcinoembryonic antigen (CEA) levels, and computed tomography (CT) imaging of the abdomen and thorax. High-resolution pelvic magnetic resonance imaging (MRI), utilizing dedicated rectal protocols, is critical for identifying recurrence risks and delineating precise anatomical relationships. Endoscopic ultrasound further refines staging accuracy by determining the tumor infiltration depth in early-stage cancers, while preoperative colonoscopy effectively identifies synchronous colorectal lesions. In early-stage rectal cancers (T1–T2, N0, and M0), radical surgical resection remains the standard of care, although transanal local excision can be selectively indicated for certain T1N0 tumors. In contrast, locally advanced rectal cancers (T3, T4, and N+) characterized by microsatellite stability or proficient mismatch repair are optimally managed with total neoadjuvant therapy (TNT), which combines chemoradiotherapy with oxaliplatin-based systemic chemotherapy. Additionally, tumors exhibiting high microsatellite instability or mismatch repair deficiency respond favorably to immune checkpoint inhibitors (ICIs). The evaluation of tumor response following neoadjuvant therapy, utilizing MRI and endoscopic assessments, facilitates individualized treatment planning, including non-operative approaches for patients with confirmed complete clinical responses who comply with rigorous follow-up. Recent advancements in molecular characterization, targeted therapies, and immunotherapy highlight a significant evolution towards personalized medicine. The effective integration of these innovations requires enhanced interdisciplinary collaboration to improve patient prognosis and quality of life. Full article

Background: The rectal cancer treatment paradigm is rapidly changing with the advent of total neoadjuvant therapy and non-operative management approaches in responders. A good clinical response to neoadjuvant treatment documented by magnetic resonance imaging, endoscopy and clinical examination corresponds, to a large extent, to a pathologic complete response, as assessed in surgical specimens. Methods: We undertook a systematic review and meta-analysis on the MRI-based omics approach to predicting pathologic complete responses. Results: A total of 29 studies with relevant data available reporting on a total of 4486 patients were eligible for meta-analysis. The calculated values for the area under the curve in receiver operator curves of diagnostic accuracy for radiomics-only and radiomics-combined-with-clinical-data models were 0.80 and 0.88, respectively, for studies incorporating baseline imaging data only. The value for studies using delta radiomic data was 0.86, and those for studies using data from the post-neoadjuvant setting were 0.75 and 0.83, respectively, for the radiomics-only and radiomics-combined-with-clinical-data models. Conclusions: Radiomics-based prediction models for pathologic complete response assessment might further enable individualized treatment decisions to be made in patients with rectal cancer. Full article

Background/Objectives: Distal radius fractures (DRFs) are among the most common fractures in the elderly, with increasing incidence due to population aging. Recent evidence questions the benefits of operative treatment, particularly in elderly patients. The present study aimed to assess post-traumatic osteoarthritis (OA) and patient-reported outcome measures (PROMs) after a minimum of two years of follow-up of the previously published VOLCON randomized controlled trial (RCT), which compared operative and non-operative treatments of unstable DRFs in patients aged ≥ 65 years. Methods: This study presents a minimum two-year follow-up of a single-center, assessor-blinded RCT. A total of 100 patients with unstable DRFs were randomized to either operative treatment with volar locking plating or non-operative treatment with cast immobilization. The primary outcome was post-traumatic OA, assessed using the Knirk and Jupiter classification. Secondary outcomes included PROMs (Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH)) and Patient-Rated Wrist/Hand Evaluation (PRWHE), complications, pain, grip strength, and range of motion (ROM). Statistical analyses were performed using two-way ANOVA. Results: After a median follow-up of 3.0 years, 60 patients (28 non-operative and 32 operative) were available for analysis. There was no significant difference in OA between the groups (p = 0.57). PROMs (Quick-DASH, PRWHE), pain, grip strength, and ROM were time-dependent (p < 0.001) but not treatment-dependent. Complications were more frequent in the operative group, including hardware-related issues requiring reoperation. Conclusions: At a minimum of two years of follow-up, no correlation was found between treatment choice and post-traumatic OA. Functional outcomes were similar between groups, suggesting that non-operative treatment remains a viable option for elderly patients with unstable DRFs. Full article

Background: Triangular fibrocartilage complex (TFCC) tears are a common source of ulnar-sided wrist pain. Surgery has to be performed in case of instability, pain, or if non-operative treatment fails. Overall, the results are very good. However, some patients still suffer from pain after surgery. Post-operative MR imaging can reveal potential pathologies but it needs to be assessed whether depicted changes are normal or whether these findings have a clinical significance. Therefore, the purpose of this study was to evaluate postoperative MR imaging and the function of the patients’ wrists in order to assess which postoperative changes are correlated with pain. Patients and Methods: All patients with a TFCC lesion who were treated arthroscopically at our hospital between January 2012 and December 2016 were retrospectively enrolled. Seventeen patients with complete data sets were enrolled. Post-operative MRI examinations needed to be performed within 24 months after arthroscopy. The mean magnet resonance imaging (MRI) follow-up was 22 months. The average clinical follow-up was 27.3 months. Age, gender, pain level, PROM scores (Munich Wrist Questionnaire, MWQ), follow-up interval, and TFCC classification (Palmer) were documented. The patients underwent a clinical examination and MR imaging. Results: Ten patients (59%) had scar tissue at the triangular fibrocartilaginous complex (TFCC) and nine (53%) had an effusion in the ulnar recess. These findings were not necessarily associated with pain, as six patients without pain and four with pain had scar tissue at the TFCC and six patients without pain and three with pain showed an effusion in the ulnar recessus. Bone marrow edema could be found in the lunate of five patients (29%) (three with pain, two without pain) and in the distal radial ulnar joint (DRUJ) of one patient (6%) with pain. However, typical degenerative changes were not necessarily associated with pain. Conclusions: This present study is the first study correlating postoperative MRI findings after arthroscopic assisted TFCC surgery with both pain and function. Bone edema seems to be associated with pain, whereas scarring at the TFCC is visible on MRI but is not necessarily associated with pain. Full article

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital coronary anomaly, with an uncertain prevalence and often diagnosed incidentally. This case report presents a 62-year-old male with ARCAPA diagnosed during an evaluation for chest surgery. The patient had a history of colon cancer and active tuberculosis, complicating the clinical management. He reported chest pain, shortness of breath, and palpitations, with atrial fibrillation observed on a 24 h Holter ECG. Coronary angiography revealed robust collateral circulation and a suspected anomalous origin of the right coronary artery, confirmed by CT imaging. The patient’s stress MRI showed mildly reduced left and right ventricular ejection fractions and perfusion deficits in the apical segments (2/17) of the septal and inferior walls. Given the patient’s comorbidities, including active tuberculosis, the Heart team decided on a non-operative management approach, focusing on careful monitoring and pharmacological management rather than immediate surgery. This case emphasizes the complexity of managing ARCAPA in the context of significant comorbidities, highlighting the importance of individualized, multidisciplinary treatment strategies. Early diagnosis using advanced imaging techniques is crucial, and a non-operative approach can be considered in patients with preserved left ventricular function and no significant ischemia, as demonstrated in this case. Full article

Objectives: The current study aimed to evaluate the effect of denosumab on patients with impending instability due to spinal metastasis, including whether it can improve spinal instability neoplastic score (SINS) and reduce the need for surgical treatment. Methods: This study retrospectively reviewed patients initially treated non-operatively for metastatic spinal lesions with intermediate SINS (7–12 points) between January 2017 and December 2023 in a single tertiary cancer hospital. Patients were divided into two groups based on the use of denosumab for the intermediate SINS lesion: D-group and N-group. Propensity score matching (PSM) was conducted with a caliper width of 0.025 for the covariates (age, sex, and primary cancer). The study outcomes were (1) the rate of conversion to surgery, (2) the change in SINS, and (3) the change in HU (Hounsfield unit) during the follow-up period. Results: A total of 286 patients (male 151, female 135) with a mean age of 68.0 ± 12.6 years and a mean follow-up period of 37.1 ± 26.5 months were included. Forty-one (14.3%) patients received denosumab (D-group), whereas 245 (85.7%) did not receive denosumab (N-group). Before PSM, 9.8% (4/41) in the D-group and 18.8% (46/245) in the N-group underwent surgical treatment. The rate of conversion to surgery was similar after PSM: the D-group, 8.3% (3/36) vs. the N-group, 16.6% (6/36). Survival analysis using Kaplan–Meier curves also showed that the D-group had a significantly lower probability of conversion to surgery before and after PSM (p = 0.015 and p = 0.023, respectively). In addition, the D-group showed significant improvements in the SINS (total score, pain, and bone lesion scores) and HU after denosumab treatment. Conclusions: In this study, denosumab lowered the rate of conversion to surgery in patients with impending instability (intermediate SINS) due to spinal metastasis. Patients who received denosumab treatment showed significant improvements in the SINS and HU for their metastatic spinal lesions. Full article

Background: Fragility fractures of the pelvic ring (FFPs) represent a fast-growing entity in geriatric traumatology with increasing incidence worldwide. This study aimed to analyze the epidemiology, treatment concepts, and surgical strategies for FFPs based on data collected by the German Pelvic Multicenter Study Group documented in the German Pelvic Fracture Registry. It is the largest cohort study of its kind. Methods: This retrospective cohort study included patients aged 65 years or older after FFPs, as classified according to the Rommens and Hofmann classification. Data were collected from July 2018 onward and analyzed for demographics; fracture classifications; treatment modalities (operative vs. non-operative); and details of surgery, including timing and choice of implants. Patients after high-energy trauma were excluded. Statistical analyses included descriptive metrics and subgroup comparisons. Results: Among 1242 patients (84% female; median age 83.4 years), FFP Type II was the most common fracture type (50.8%), followed by Type IV (21.1%). Non-operative management was employed in 68.8% of cases, while 30.9% underwent surgery. Surgical intervention was more frequent in higher-grade FFPs (e.g., 72.1% in Type IV). The most common surgical technique for the posterior pelvic ring was percutaneous screw fixation (61.3%), with navigation used in 47.4% of cases. Conclusions: This study highlights the variability in treatment strategies for FFPs, with conservative management predominating in lower-grade fractures and surgical approaches increasingly utilized for more complex cases. The findings underscore the need for standardized, evidence-based guidelines and further research to optimize treatment and long-term outcomes for geriatric patients with FFPs. Full article