Volume 104 · Issue 48 · 2024

Endoscopic ear surgery is currently widely applied in middle ear and lateral skull base procedures, driving the development of ear surgery towards minimally invasive approaches and function preservation. Endoscopic techniques offer many advantages. However, the learning curve is relatively steep, requiring surgeons to overcome challenges such as single-handed operation and a lack of spatial awareness. Through in-depth theoretical study, temporal bone dissection training, and gradual surgical practice, this technique can be gradually mastered. The combined use of endoscopy and microscopy further enhances the flexibility and precision of lateral skull base surgeries. Repeated cycles of anatomical study, observation, and practice, along with timely updates in knowledge and skills, lay the foundation for improving the outcomes of endoscopic ear surgery.

The current study aimed to understand the current status and problems of marginal zone lymphoma (MZL) in the diagnosis and treatment of hospitals at all levels in China. A multi-center questionnaire survey was conducted in a number of medical institutions across the country. A combination of online questionnaire survey and face-to-face interview was adopted. (1)Pathologists paid more attention than clinicians to distinguish MALT from chronic inflammation (86.3% vs 32.1%, P<0.01) and plasma cell tumor (51.8% vs 23.1%, P<0.01). A total of 21% pathologists never performed B-cell gene rearrangement, 67.6% of clinicians and 69.0% of pathologists would not recommend splenic puncture to diagnose SMZL.(2)In terms of treatment indications, 40.0% of clinicians mistakenly believed that stage Ⅲ-Ⅳ was also a treatment indication. Seventy percent of clinicians reported confusion about treatment indications. (3) In staging and efficacy evaluation, 63.3% of physicians performed PET-CT testing for patients, mainly for resolving clinical staging (89.0%), identifying histologically transformation (79.6%), and determining the site of radiotherapy or biopsy (66.2%). (4) In terms of treatment choice, only 32.2% of patients with indications were recommended for radiotherapy, and the proportion of hematologists choosing radiotherapy was significantly lower than that of oncologists (42.6% vs 71.7%, P<0.01); In the anti-HP indications, 53.1% of physicians will perform anti-HP therapy regardless of Hp positive or not; For advanced MZL, first-line immunochemotherapy was selected by 62.7% of clinicians, compared with 37.3% for targeted therapy. (5)15.3% of clinicians believed that the current prognostic evaluation system could not guide the selection of treatment options after initial treatment and recurrence. At present, there are still some cognitive deviations in the disease cognition and treatment indication of MZL among clinicians at all levels of hospitals in China. Likewise, there are still many unmet needs in MZL staging, efficacy evaluation, treatment selection and prognosis evaluation.

Pediatric middle ear cholesteatoma is an aggressive keratotic lesion caused by abnormal proliferation of keratinised squamous epithelium in the temporal bone, with the characteristics of high postoperative recurrence rate, poor hearing effect and poor quality of life. Endoscopic surgery is able to deal with the majority of pediatric middle ear cholesteatoma cases with the features of minimal trauma and wide surgical field. However, endoscopic surgical treatment still has problems in standardization. In order to facilitate the development of endoscopic surgery for pediatric middle ear cholesteatoma, experts of the Endoscopic Ear Surgery Expert Committee and the Youth Committee of the Otorhinolaryngology Professional Committee, Chinese Association of Integrative Medicine discussed and formulated recommendations for the selection of endoscopic surgical and functional reconstruction methods of pediatric middle ear cholesteatoma based on the classification of cholesteatoma location in line with the clinical research results and diagnosis and treatment experience at home and abroad, aiming to provide guidance for the development of endoscopic surgery in pediatric setting.

Targeted next-generation sequencing (tNGS) technology focuses on detecting pathogenic microorganisms and drug-resistant genes in clinical samples by designing specific primers or capture probes, providing evidence for the diagnosis, treatment and surveillance of infectious diseases. However, the current clinical application scenarios of tNGS and metagenomic next-generation sequencing (mNGS) are not clearly defined, and the tNGS systems from different manufacturers vary significantly in quality and results. There is an urgent need for consensus and standards regarding the clinical indications, laboratory processes, quality control, performance validation and interpretation of reports for this technology. In order to standardize the application and practice of tNGS in infectious diseases, experts in the fields of microbiology, infectious disease, respiratory disease, epidemiology and other fields from the Society of Clinical Microbiology of China International Exchange and Promotion Association for Medical and Healthcare discussed the above problems, wrote the expert consensus on the application and practice of tNGS in infectious diseases. This consensus summarizes the research on tNGS in infectious diseases, and proposes recommendations that are in line with clinical practice in China, so as to standardize the application and practice of tNGS in infectious diseases. The main contents include: consensus formulation process, clinical indications, technical points, wet and dry experiments, report and interpretation, and report template.

To evaluate the effectiveness of CT-MRI image fusion technology in the preoperative assessment of middle ear cholesteatoma.

The clinical data of patients with middle ear cholesteatoma who underwent surgery at Guangdong Provincial People′s Hospital from September 2018 to January 2020 were retrospectively analyzed. Preoperative CT and MRI of the patients were automatically fused using the open-source software 3D Slicer, followed by 3D reconstruction of the fused inner ear structures. The degree of overlap was assessed and scored to evaluate the image fusion quality, with manual adjustments made for cases with poor fusion. The value of CT-MRI image fusion technology in the preoperative assessment of middle ear cholesteatoma was then analyzed.

A total of 27 patients (12 males and 15 females) aged (40.0±16.2) years were included. The fusion effect was satisfactory (score≥3) in 21 cases and poor (score<3) in 6 cases. After manual adjustments, all 6 cases achieved a satisfactory fusion effect (score≥3). The area under the receiver operating characteristic curve (AUC) values for diagnosing the extent of invasion of middle ear cholesteatoma in the retrotympanic and mastoid regions using CT, MRI, and CT-MRI fused images were 0.621 (95%CI: 0.404-0.838), 0.803 (95%CI: 0.638-0.969), and 0.841 (95%CI: 0.693-0.990), respectively, with the sensitivity of 94.1%, 70.6% and 88.2%, the specificity of 30.0%, 90.0% and 80.0%, and the accuracy of 70.4%, 77.8% and 85.2%, respectively.

The 3D reconstruction of inner ear structures can be used to assess and refine the fusion quality of CT-MRI images. This CT-MRI image fusion technology is valuable for the preoperative localization assessment of middle ear cholesteatoma.

To explore the effect of hydroxyapatite (HA) combined with concentrated growth factor (CGF) on the cavity filling during endoscopic mastoidectomy in patients with middle ear cholesteatoma.

The data of patients with middle ear cholesteatoma who underwent endoscopic canal wall down (CWD) mastoidectomy and mastoid obliteration with hydroxyapatite in Huazhong University of Science and Technology Union Shenzhen Hospital from December 2017 to October 2023 were retrospectively analyzed. The patients were divided into observational group (HA+CGF) and control group (HA) according to whether CGF was used. The postoperative follow-up time was not less than 6 months.The otoendoscopy results of the two groups were collected, and the excretion incidence of hydroxyapatite bone powder exposure was observed. The degree of epithelialization of the mastoid cavity and the time required for complete epithelialization were compared between the two groups using a subjective epithelialization scoring scale at one month post-operation.

A total of 58 patients (36 males and 22 females) aged (39.4±13.4) years were collected, including 26 left ears and 32 right ears. There were 30 cases in HA group and 28 cases in HA+CGF group, respectively. No statistically differences in gender, location and age were detected between the two groups (all P>0.05). The excretion incidence of bone powder exposure was 3.4% (2/58), with 1 case in HA group and 1 case in HA+CGF group, respectively. The median (Q₁, Q₃) subjective epithelialization score at one month post-operation was 1 (1, 2) in the HA+CGF group and 2(1, 2) in the HA group, with no statistically significant difference between the two groups (P=0.032). The results of 60-day follow-up after otoendoscopy showed that the proportion of complete epithelialization was 74.1% (20/27) in HA+CGF group and 48.3% (14/29) in HA group, and there was a statistically significant difference between the two groups (P=0.048).

HA combined with CGF has a better effect on the cavity filling during endoscopic mastoidectomy in patients with middle ear cholesteatoma.

To compare the surgical time, auditory outcomes and safety between microdrill and diode laser in endoscopic stapedotomy.

The data of patients with otosclerosis who underwent endoscopic stapedotomy in Eye and ENT Hospital of Fudan University from January 2020 to December 2023 were retrospectively analyzed. The patients were divided into microdrill group and laser group according to treatment method. Surgical time, hearing level and complications were compared between the two groups.

A total of 148 patients (41 males and 107 females) aged (42.8±7.7) years were included. There were 81 cases in the microdrill group and 67 cases in the laser group, respectively. No statistically significant differences in age, gender, duration of disease and surgical side were detected between the two groups (all P>0.05). Preoperative air-bone gap (ABG) was (27.0±5.5) decibel hearing level (dB HL) in microdrill group and (25.0±5.1) dB HL in laser group, with no statistically significant difference (P=0.191). Postoperative ABG was (14.0±2.6) dB HL and (12.1±2.7) dB HL in microdrill group and laser group, respectively, and there was no statistically significant difference between the two groups (P=0.595). Compared with preoperative results, postoperative ABG decreased in both groups (both P<0.05). Postoperative vertigo was observed in 7 patients (8.6%) in the microdrill group and 6 patients (9.0%) in the laser group, respectively (P=0.947). The surgical time in microdrill group [(53.0±9.0) min] was shorter than that in laser drilling group [(59.3±12.8) min] (P<0.001).

Postoperative improvement in hearing level after microdrill is similar to diode laser, but microdrill has shorter surgical time.

To explore the efficacy and safety of toripalimab combined with platinum-based chemoradiotherapy in the treatment of locally advanced cervical cancer.

A total of 82 patients diagnosed as locally advanced cervical cancer who received toripalimab combined with platinum-based concurrent chemoradiotherapy at Tianjin Medical University Cancer Institute and Hospital from May 24^th 2019 to August 31^st 2022 were enrolled prospectively. After undergoing concurrent chemoradiotherapy, the patient received six cycles of treatment with toripalimab in combination with paclitaxel and platinum-based agents. The primary endpoint of the study was the objective response rate (ORR), and the secondary endpoints included disease control rate (DCR), safety, progression-free survival, and overall survival. Kaplan-Meier curves were used to depict the cumulative incidence of progression-free survival (PFS) and overall survival (OS) for patients with different expression levels of programmed death-ligand 1 (PD-L1) and genetic mutation burdens, and log-rank tests were used to compare the difference between groups.

The median age of the patients was 53.6 (45.5,58.7) years, and 76 patients (92.7%) had squamous cell carcinoma. The overall ORR and DCR for the 82 patients were both 87.8% (72 patients, 95%CI: 78.7%-94.0%). Among the 82 patients, 64 (78.0%) achieved complete remission, 8 (9.8%) had partial remission, 8 (9.8%) had disease progression, and 2 (2.4%) were not evaluable. During the treatment, 37 patients (45.1%) experienced treatment-related adverse events, of which 17 patients (20.7%) had grade 3 or higher adverse reactions. The most common grade 3 or higher treatment-related adverse reaction was radiation enteritis (n=5, 6.1%). The median follow-up time was 20.6 (14.0, 27.9) months. The median progression-free survival (mPFS) and median overall survival (mOS) were not reached. The 2-year PFS rate was higher in patients with PD-L1 combined positive score (CPS)≥10 compared to those with CPS<10 (92.4% vs 81.2%, χ²=0.68, P=0.409), and higher in patients with low tumor mutation burden (TMB-L) compared to those with high tumor mutation burden (TMB-H) (95.2% vs 83.3%, χ²=1.91, P=0.167).

Patients with locally advanced cervical cancer can achieve favorable objective response rates when treated with toripalimab in combination with platinum-based concurrent chemoradiotherapy and consolidative chemotherapy.

The current study summarized the surgical key points and technique advantages of endoscope holder in revision tympanoplasty. Fifteen patients who underwent revision tympanoplasty using the endoscope holder between January 2023 and April 2024 at the Department of Otorhinolaryngology, Peking Union Medical College Hospital were retrospectively collected. There were 6 males and 9 females, with an average age of (37.1±13.4) years. All patients successfully completed the revision tympanoplasty under the endoscope holder. The median follow-up time was 8 months (range: 2-16 months). Postoperative otoendoscopic examinations within 2-3 weeks revealed that all patients had dry ears, with well-healed ear canal flaps and tympanic membranes. Pure tone audiometry demonstrated significant improvements in pure tone air conduction thresholds [preoperative level: (54.3±18.0) dB HL; postoperative level: (37.4±18.4) dB HL; P=0.002]. The air-bone gap (ABG) decreased from (36.7±13.9) dB HL to (22.3±13.1) dB HL after surgery, indicating a marked improvement (P=0.003). The current study suggests that the endoscope holder technique has good application effects in revision tympanoplasty.

The clinical data of 47 children (52 ears) with middle ear cholesteatoma at Eye & ENT Hospital, Fudan University from January 2021 to February 2024 were prospectively collected. There were 30 males and 17 females, with a mean age of (8.5±2.8) years. Surgical procedures included endoscopic tympanoplasty (29 ears), combined endoscopic/microscopic tympanoplasty (8 ears) and microscopic tympanoplasty (15 ears). After endoscopic surgeries, the mean air conduction hearing threshold, mean bone conduction hearing threshold and air bone gap were (28.4±10.4) dB HL, (12.4±5.9) dB HL and (16.0±6.3) dB HL, respectively, which were significantly improved compared with preoperative indicators [(40.2±14.0) dB HL, (16.3±6.8) dB HL and (23.9±9.8) dB HL, respectively] (all P<0.05). There were statistically significant differences in the postoperative mean air conduction hearing threshold and air bone gap among three surgical groups, and the value of endoscope group was lower than those of microscope group and endoscope combined with microscope group (all P<0.05). After a follow-up of 5.6 (1.2, 11.5) months, no statistically significant differences were observed in the rate of successful tympanic membrane healing between endoscope group and microscope group (P=0.747). One ear in the endoscope group experienced recurrence three years after surgery, and no intracranial and extracranial complications occurred. The current study indicates that endoscopic surgery for pediatric cholesteatoma improves hearing with good results.

This study aimed to investigate the surgical efficacy of middle ear cholesterol granuloma using otoendoscopy. A total of 23 patients (9 males and 14 females) aged (38±18) years who were diagnosed with middle ear cholesterol granuloma at the Otology Medical Center, the First People′s Hospital of Foshan from May 2020 to August 2023 were retrospectively analyzed. Based on clinical characteristics of the lesions, the patients were categorized into retention type and granulation type; the latter was further subdivided into localized and extensive types. Endoscopic intervention was performed on four patients with retention-type lesions. Nineteen cases presented as granulation type, among which eleven were classified as localized type and successfully treated via endoscopy. Among eight patients with extensive-type lesions, five adult patients underwent open endoscopic surgery for tympanic sinus and mastoid process reconstruction, and three children received endoscopic surgery along with microscopic closure techniques. During follow-up for at least one year, post-extubation fluid accumulation occurred in one patient, and no recurrence was observed in others. The current study suggests that endoscopic treatment for middle ear cholesterol granuloma yields favorable outcomes.

Exploring the clinical and pathological characteristics and prognostic factors of diffuse large B-cell lymphoma (DLBCL) patients with TP53 mutation. Data of 86 DLBCL patients with TP53 mutation treated with R-CHOP and 19 DLBCL patients with TP53 mutation treated with R-CHOP like regimen as first-line treatment at the Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) and the Cancer Hospital of the CAMS in Shenzhen, China, from January 2006 to June 2023 were retrospectively analyzed. Multivariate Cox analysis was applied to assess the effects of the factors on survival. Among the 105 DLBCL patients with TP53 mutation, 56 were male (53.3%); the median age was 59 years. There were 54 cases with stage Ⅰ-Ⅱ and 51 cases with stage Ⅲ-Ⅳ diseases. The proportion of B-cell lymphoma 2 (BCL2) gene amplification was 9.5% (10/105). The complete response rate in the whole group of patients treated with the R-CHOP regimen was 28.6% (30/105). The median progression-free survival (PFS) was 10.1 (95%CI: 7.3-13.0) months, and the median overall survival (OS) was not reached. Stage Ⅲ-Ⅳ was a risk factor for OS (HR=2.80, 95%CI: 1.04-7.54), and elevated lactic dehydrogenase (LDH) was a risk factor for PFS (HR=2.86, 95%CI: 1.56-5.26) and OS (HR=2.90, 95%CI: 1.08-7.69). The median PFS was lower in patients with BCL2 amplification than in patients without amplification [4.0 (95%CI: 2.7-5.3) vs 11.3 (95%CI: 8.5-14.1) months, P=0.011]. Thirty-one of the 54 (57.4%) patients with stage Ⅰ-Ⅱ disease received combination therapy based on the R-CHOP protocol. In conclusion, stage Ⅲ-Ⅳ and elevated LDH were associated with poor prognosis in TP53 mutation DLBCL patients, and patients with BCL2 amplification had a poor prognosis. For TP53 mutation DLBCL patients with stage Ⅰ-Ⅱ disease, combination of therapeutic modalities based on the R-CHOP may improve the prognosis.

The current study aimed to investigate the feasibility and safety of robot-assisted laparoscopic resection of the isthmus in patients with symptomatic horseshoe kidney. A retrospective analysis of clinical data from four patients with symptomatic horseshoe kidney treated between January 1, 2021 and December 31, 2023 at Guizhou Provincial People′s Hospital was conducted. The main surgical procedures included robot-assisted laparoscopic resection of the isthmus, kidney fixation, pyeloplasty, and pyelolithotomy. All four patients underwent successful surgery. One patient had concomitant calculi. The mean operative time was 179.8 minutes, with an average blood loss of 49.5 ml. In patients followed up for 3 months, 6 months, 1 year, and 2 years postoperatively, renal anatomy remained normal, significant improvement in hydronephrosis was observed compared to preoperative status, serum creatinine levels returned (maintained) to normal status, and no surgery-related complications occurred during the perioperative period. This study reports the safety and feasibility of robot-assisted laparoscopic resection of the isthmus in patients with symptomatic horseshoe kidney. This surgical approach effectively restores the abnormal anatomical structure of the horseshoe kidney, reestablishes the natural course of the ureter, and prevents compression of the ureter by the isthmus of the horseshoe kidney.

Three patients with biphasic squamous acinar renal cell carcinoma diagnosed in the Department of Pathology of Sir Run Run Shaw Hospital affiliated to Zhejiang University from 2021 to 2023 were collected. The surgically resected specimens were examined for histology, immunohistochemistry, fluorescence in situ hybridization and molecular genetics, and followed up. Partial nephrectomy was performed in all 3 patients. The maximum diameter of the tumor is 3~10 cm, and the boundary is clear. Tumors are composed of two types of cells. The outer layer is composed of small cells with less cytoplasm, and the large cells with abundant cytoplasm surrounding the acinar center, similar to "squamous cells". Immunohistochemistry showed that both types of cells co-expressed methyl acyl-CoA racemase (P504S), succinate dehydrogenase B (SDHB), β-catenin, transcription factor PAX-8, cytokeratin 7 (CK7), vimentin (VM), CD57 and CK, with "squamous cells" expressing Cyclin D1 and CD10 alone. The results of fluorescence in situ hybridization showed trisomy changes on chromosomes 7 and 17. Until August 2024, no adjuvant radiotherapy or chemotherapy was received after follow-up surgery, and no recurrence or metastasis was seen. Biphasic squamous acinar renal cell carcinoma is a papillary renal cell carcinoma with special morphological characteristics, which has a good prognosis, but is easily missed.

Venous thromboembolism (VTE) is a common disease in hospitalized patients, and its high incidence, disability and mortality have attracted widespread attention in the medical community. However, the effective management of VTE prevention and treatment process is still a serious problem faced by China's medical system. The traditional VTE management mode relies on the personal ability and diagnosis and treatment experience of medical workers, and it is difficult to ensure the standardized practice of each link. In recent years, with the development of information technology, the popularization of big data and artificial intelligence, clinical decision support system (CDSS) can accurately and efficiently assist doctors and nurses to make the best clinical decisions, providing an important guarantee for the prevention and treatment of VTE. This paper mainly introduces the practical application of CDSS in the prevention and treatment of VTE, including the prevention, diagnosis, control, treatment and prevention of VTE, so as to provide theoretical support for further improving the standardized prevention and management of VTE.

The 15-year-old male came to the Second Hospital of Lanzhou University for "repeated cough and expectoration for 8 years". The patient began to have repeated cough and expectoration without obvious trigger at the age of 7, accompanied by repeated pus and bloody discharge. He was treated in the local hospital for symptomatic treatment many times, and the patient's cough and expectoration symptoms were repeated. The patient's parents were not consanguineous. Family history of chronic respiratory disease denied. High-resolution CT and three-dimensional reconstruction of the chest after admission showed that the proximal bronchiectasis of both lungs was accompanied by diffuse bronchial tree bud sign in both lungs, showing bronchiectasis and bronchiolitis (Figures 1 and 2). CT of paranasal sinuses showed: bilateral maxillary sinus and ethmoid sinus mucosa were thickened, and bilateral maxillary sinuses were filled with uneven density shadows, suggesting bilateral maxillary sinusitis and ethmoid sinusitis (shown by arrows, Figure 3). Pulmonary function tests showed: severe mixed pulmonary ventilatory dysfunction, negative bronchodilation test; There were no abnormalities in cardiac color Doppler ultrasound and abdominal color Doppler ultrasound; Chest CT and abdominal color Doppler ultrasound showed no visceral inversion; autoantibody negative; IgE negative; Bronchoscopy showed that a large amount of purulent secretion accumulated in the bilateral bronchial lumen, and no obvious abnormalities were found in the bronchial lumen and mucosa after microscopic aspiration. According to the onset age, clinical manifestations and auxiliary examination results of the patients, considering the primary ciliary dyskinesia disease, the whole exome sequencing of peripheral blood gene was performed with the consent of family members. Two mutations of CCNO gene were detected. The nucleotides (exons) were c.666 (exon3) del and c.258 (exon1) _c, respectively. The related disease was primary ciliary dyskinesia (PCD) type 29.