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We report two cases of proximal endograft collapse with an almost complete aortic occlusion after endovascular tube-graft treatment of thoracic aortic disease (thoracic aneurysm after a type B dissection, traumatic blunt aortic rupture) using the TAG Gore system. Oversizing of endografts is known to cause this complication. In our two cases, however, the oversizing was between 12% and 21.7%, which is less than the allowed oversizing of 25% that is recommended by the manufacturer. This endograft-related complication might be due to a poor alignment of the currently available endografts in highly angulated and tight aortic arches. In the first case, a combined endovascular and open emergent repair procedure achieved a reopening of the proximal endograft by proximal extension (TAG Gore). In the second case, proximal extension was not considered owing to a precise positioning of the endograft distal to the left carotid artery. A balloon-expanding Palmaz stent was therefore placed interventionally in the proximal part of the TAG graft to expand the endograft and to avoid another collapse of the device. This proximal endograft collapse has to be acknowledged as a potentially hazardous complication. We therefore recommend that the proximal part of thoracic endografts in the aortic arch should be closely monitored and we offer two possible endovascular solutions for resolving the problem of proximal endograft collapse.

In a prospective and randomised clinical study, acetabular cups were implanted free-hand (control group n=22) or with computer assistance using an image-free navigation system (study group n=23). The cup position was determined postoperatively on pelvic CT. An average inclination of 42.3°(range: 30°-53°; SD±7.0°) and an average anteversion of 24.0°(range: −3°to 51°; SD±15.0°) were found in the control group, and an average inclination of 45.0°(ranage: 40°-50°; SD±2.8°) and an average anteversion of 14.4°(range: 5°-25°; SS±5.0°) in the computer-assisted study group. The deviations from the desired cup position (45°inclination, 15°anteversion) were significantly lower in the computer-assisted study group (p<0.001 each). While only 11/22 of the cups in the control group were within the Lewinnek safe zone, 21/23 of the cups in the study group were placed in this target region (p=0.003).Résumé Dans un étude clinique prospective et randomisé, les cupules acétabulaires ont été implantées de façon habituelle (n=22; groupe témoin) ou avec assistance d'un ordinateur qui utilise un système de navigation imagelibre (n=23; groupe d'étude). La place de la cupule a été déterminée après l'opération sur un scanner pelvien. Une inclinaison moyenne de 42,3°(30°à 53°; ±7.0°) et une antéversion moyenne de 24,0°(−3°à 51°; ±15.0°) ont été trouvées dans le groupe témoin et une inclinaison moyenne de 45,0°(40°à 50°; ±2.8°) et une antéversion moyenne de 14,4°(5°à 25°; ±5.0°) dans le groupe de l'étude assistée par ordinateur. Les déviations par rapport à la position désirée de la cupule (45°d'inclinaison, 15°d'antéversion) étaient notablement inférieures dans le groupe de l'étude assistée par ordinateur (p<0.001 chacun). Alors que seulement 11 des 22 cupules du groupe témoin étaient dans la zone sûre de Lewinnek, 21 des 23 cupules du groupe d'étude ont été placées dans cette région cible (p=0.003).

These results demonstrate that IA SIJ injections remain technically challenging despite ultrasound guidance. However, peri-articular deposition of triamcinolone appears sufficient for pain and symptom control in patients suffering from active sacroiliitis.

Urachal cancer (UrC) is a rare but aggressive malignancy often diagnosed in advanced stages requiring systemic treatment. Although cytotoxic chemotherapy is of limited effectiveness, prospective clinical studies can hardly be conducted. Targeted therapeutic treatment approaches and potentially immunotherapy based on a biological rationale may provide an alternative strategy. We therefore subjected 70 urachal adenocarcinomas to targeted next-generation sequencing, conducted in situ and immunohistochemical analyses (including PD-L1 and DNA mismatch repair proteins [MMR]) and evaluated the microsatellite instability (MSI) status. The analytical findings were correlated with clinicopathological and outcome data and Kaplan-Meier and univariable/multivariable Cox regression analyses were performed. The patients had a mean age of 50 years, 66% were male and a 5-year overall survival (OS) of 58% and recurrence-free survival (RFS) of 45% was detected. Sequence variations were observed in TP53 (66%), KRAS (21%), BRAF (4%), PIK3CA (4%), FGFR1 (1%), MET (1%), NRAS (1%), and PDGFRA (1%). Gene amplifications were found in EGFR (5%), ERBB2 (2%), and MET (2%). We detected no evidence of MMR-deficiency (MMR-d)/MSI-high (MSI-h), whereas 10 of 63 cases (16%) expressed PD-L1. Therefore, anti-PD-1/PD-L1 immunotherapy approaches might be tested in UrC. Importantly, we found aberrations in intracellular signal transduction pathways (RAS/RAF/PI3K) in 31% of UrCs with potential implications for anti-EGFR therapy. Less frequent potentially actionable genetic alterations were additionally detected in ERBB2 (HER2), MET, FGFR1, and PDGFRA. The molecular profile strengthens the notion that UrC is a distinct entity on the genomic level with closer resemblance to colorectal than to bladder cancer.

ContextAnaplastic thyroid carcinoma (ATC) represents one of the most aggressive carcinomas with no consistent survival benefit when treated with conventional radiochemotherapy. Approaches targeting “oncogene addiction” of ATC are increasingly explored and first promising results have been reported in single case studies.ObjectiveTo determine the prevalence of mutations in known thyroid oncogenes and signalling pathways amendable to targeted therapy in a large cohort of ATC.ResultsIn 118 ATC (57 male/ 61 female) a total of 165 mutations were found. Genes involved in the MAPK/ERK and PI3K pathway (BRAF 11.0%, HRAS 4.2%, KRAS 7.6%, NRAS 7.6%, PI3KCA 11.8%) were altered in 33%. Targetable receptor tyrosine kinases were mutated in 11%. The most frequently altered genes were TERT in 86/118 (73%) and p53 in 65/118 (55%) cases. No mutations were found analysing ALK, KIT, MET and mTOR.Materials and MethodsNext generation sequencing (NGS) was performed in FFPE samples from 118 ATC using MiSeq (Illumina) and CLC Cancer Research Workbench (CLCbio; Qiagen) for mutation analysis in: ALK, BRAF, CDKN2A, EGFR, ERBB2, HRAS, KIT, KRAS, MET, mTOR, NRAS, PDGFRA, PI3KCA, p53, RB1, RET and TSC2. Sanger sequencing was used to detect TERT promotor mutations.ConclusionsTo our knowledge this is the largest study analysing mutations for targeted therapy of ATC. We found that 33% of ATC harbour mutations in pathways amendable to targeted therapy. Molecular screening in ATC is suggested for targeted therapies since current conventional treatment for ATC proved mainly futile.

Urachal cancer (UrC) is a rare but aggressive cancer. Due to overlapping histomorphology, discrimination of urachal from primary bladder adenocarcinomas (PBAC) and adenocarcinomas secondarily involving the bladder (particularly colorectal adenocarcinomas, CRC) can be challenging. Therefore, we aimed to give an overview of helpful (immunohistochemical) biomarkers and clinicopathological factors in addition to survival analyses and included institutional data from 12 urachal adenocarcinomas. A PubMed search yielded 319 suitable studies since 1930 in the English literature with 1984 cases of UrC including 1834 adenocarcinomas (92%) and 150 nonadenocarcinomas (8%). UrC was more common in men (63%), showed a median age at diagnosis of 50.8 years and a median tumor size of 6.0 cm. No associations were noted for overall survival and progression-free survival (PFS) and clinicopathological factors beside a favorable PFS in male patients (p = 0.047). The immunohistochemical markers found to be potentially helpful in the differential diagnostic situation are AMACR and CK34βE12 (UrC versus CRC and PBAC), CK7, β-Catenin and CD15 (UrC and PBAC versus CRC), and CEA and GATA3 (UrC and CRC versus PBAC). Serum markers like CEA, CA19-9 and CA125 might additionally be useful in the follow-up and monitoring of UrC.

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