Objective:To evaluate the radiographic and clinical outcomes of pre-operative Halo-gravity traction (HGT) and posterior correction surgery in treating patients with neurological deficits secondary to severe focal angular kyphosis of the upper thoracic spine.Methods:A total of 16 patients (11 males, 5 females) with neurologic deficits secondary to severe focal angular kyphosis of the upper thoracic spine undergoing preoperative HGT and posterior correction operation from January 2010 to December 2019 were retrospectively analyzed. The average age was 12.9±5.6 years (range 6-27 years). The standing X-ray of whole spine was taken at pre-, post-traction and post-operation. The Cobb angles of main curve at both sagittal and coronal planes were measured accordingly. The neurologic function at pre-traction, post-traction and post-operation was assessed according to the American Spinal Injury Association (ASIA) grading. The complications during HGT, operation and post-operative follow-up were recorded for each patient.Results:The average values of focal kyphosis and scoliosis were 96.1°±16.0° (71°-128°) and 75.5°±20.5° (40°-107°) at pre-traction respectively. The spinal cord function graded by ASIA criteria at pre-traction was B in 1 patient, C in 6 and D in 9, respectively. The correction rates of focal kyphosis and scoliosis were 32.8%±15.0% (18.0%-65.9%) and 22.9%±8.0% (14.1%-38.6%) after traction, which were further improved to 45.4%±14.9% (29.0%-69.0%) and 33.6%±8.6% (23.3%-49.3%) at post-operation without significant correction loss during 35.6±14.2 (24-72) months follow-up. After traction, the spinal cord function improved to grade D in 4 patients and grade E in 12 patients. At the last follow-up, the spinal cord functions were grade E in 15 patients and grade C in 1 patient. No neurologic monitor events occurred during operation. One patient suffered from transient left brachial plexus after operation. Further, proximal hook loosening was observed in 2 patients during follow-up. The spinal cord function was ASIA grade C pre-operatively in one patient, who recovered to ASIA grade E after operation and significantly deteriorated to ASIA C at 4 years follow-up.Conclusion:The correction of spinal kyphoscoliosis was satisfactory in this cohort. Preoperative HGT followed by posterior spinal correction surgery is an effective and safe procedure in treating neurological deficits secondary to focal angular kyphosis in the upper thoracic spine.

Objective To evaluate the feasibility of sentinel lymph node(SLN) mapping with CT lymphography (CT-LG). Methods Twenty-five patients with confirmed breast cancer and no palpably axillary lymph node underwent CT-LG examination. The first one or more lymph nodes along the lymph duct draining from the injection sites to axilla were defined as SLNs, and then the LG results were compared with sentinel lymph node biopsy (SLNB). The over- and underestimation of LG were evaluated. The quality of LG imaging was classified Grade Ⅰ and Ⅱ according to lymph duct appearance on volume rendering (VR). The body mass index (BMI) ＞ 25 was considered obesity. Fisher exact test was used for the statistics. Results (1)Of 25 patients, 5 had local mastectomy history. BMI ＜ 25 was found in 20 cases, and ≥25 was in 5 cases. (2) All SLNs were showed by CT-LG, and Grade Ⅰ and Ⅱ imaging quality were achieved in 21 cases ( 84. 0% ) and 4 cases ( 16. 0% ), respectively. The obese patient tended to have a poor imaging quality ( P ＜ 0. 05 ). (3) Fifty-six SLNs and 45 lymph ducts in all 25 patients were identified on CT-LG. Compared with the results of SLNB, 7 cases ( 28. 0% ) and 9 cases ( 36. 0% ) were over- and underestimated respectively by CT-LG due to obesity and local mastectomy ( P ＜ 0. 05 ). (4) Fifty-two negative SLNs in 18 patients and 15 positive SLNs in 7 patients were confirmed by pathology through SLNB, while 56 SLNs were delineated on CT-LG with 43 negative and 13 positive. The shape in 32. 6% of the negative SLNs (14/43) and 76. 9% of the positive SLNs (10/13) was round,the difference was significant (P＜0. 05). The filling defect on the center in 9.3% of negative SLNs (4/43) and 23. 1% of positive SLNs (3/13) was demonstrated, and irregular filling defect on the margin was found only in 30.8% of positive SLNs (4/13). 3 SLNs in 2 patients combined with small satellite lymph nodes on CT-LG were also confirmed to have tumor infiltration. Conclusion CT-LG can clearly demonstrate the breast lymphatic pathway and may potentially be used for breast SLN mapping, while the imaging quality can be influenced by the obesity and local mastectomy.

Objective: To investigate the efficacy and safety of Ponte osteotomy and sequential correction technique with satellite rod construction in the treatment of severe rigid thoracic scoliosis. Methods: A total of 32 patients (12 male, 20 female) with severe rigid thoracic scoliosis (Cobb angle>100°) who underwent posterior Ponte osteotomy and sequential correction technique with satellite rod construction between October 2012 and October 2016 and with more than 2 years follow-up were retrospectively reviewed. Major curve Cobb angle, apex vertebral translation, trunk shift, thoracic kyphosis and lumbar lordosis were measured through standing posterior-anterior X-ray preoperatively, postoperatively and at the final follow-up. The duration of operation, blood loss and complications were recorded. SRS-22 questionnaire was used to evaluate the clinical outcomes. Results: The average age was 21.3±10.8 years (range from 17 to 46 years). The mean preoperative major curve Cobb angle was 117.8°±9.8°(range from 104° to 131°) with a mean flexibility of 13.9% and the mean thoracic kyphosis was 65.5°±18.7° (range from 48° to 87°). The mean duration of operation was 267.4±42.3 min and the mean blood loss was 895.4±103.1 ml. The mean fused levels ranged from T2 to L4 with a mean 13.3±2.4 fused segments. The mean implant density was 62.1%±8.8%. Ponte osteotomy was performed in 4-9 segments which was 6.1±1.9 segments in average. The coronal main curve was corrected to 54.4°±10.9° with a mean correction rate of 53.9%±9.3% and the mean thoracic kyphosis was corrected to 35.6°±12.0°, which were both significantly improved. The average follow-up time was 34.3±8.9 months. At the last follow-up, the mean coronal main curve was 53.1°±1.9° with a mean correction loss of 1.3° and the thoracic kyphosis was 36.7°±11.4°. There were no neurological deficit or implant failure postoperatively and follow-up. Conclusion Ponte osteotomy followed by sequential correction technique with satellite rods construction was safe and effective which could achieve satisfactory correction rate and less correction loss during the longitudinal follow-up in the treatment of severe rigid thoracic scoliosis.

Background and purpose:Along with the development of diagnosis and treatment technology, the disease free survival and overall survival of breast cancer have been extended. In order to improve the quality of life after mastectomy, more and more breast reconstructions were applied in breast cancer patients. We retrospectively reviewed 118 cases of free abdominal lfaps for breast reconstruction performed in Fudan University Shanghai Cancer Center. Clinical outcomes, reconstructive techniques and experiences are discussed. Methods:From November, 2006 to June, 2013, we used free abdominal lfaps to perform 118 cases of breast reconstruction on 117 female patients after mastectomy. We observed the surgery, complications and safety of this technic. Results:We performed 118 cases of lfaps based on deep inferior epigastric vessels. The average operation time was 7.72 h. The average time of ischemia was 78.74min. The average anastomosis time was 60.83min. The average number of perforators included in the lfap was 3. The internal thoracic vessels were preferred recipient vessels. Ten cases of vessel crisis occurred and 6 of them were venous thrombosis and 4 cases were venous kink. Seven of them were salvaged, and the other 3 failed, the success rate was 97.46%. Postoperative infection rate was 7.00%. Abdominal bulge occurred in 3.50%of patients. None of the patients developed abdominal hernia. The median interval between surgery and the ifrst cycle of adjuvant chemotherapy was 19 days. The median follow-up time was 12 months. One case of distant metastasis, but no local recurrence was observed. Conclusion: Although free abdominal flap breast reconstruction requires complicated microsurgical techniques, and the learning curve does exist, free abdominal lfap breast reconstruction has a high success rate with oncological safety and few complications.

Combined with the concept and technique of plastic surgery,breast reconstruction has become an important development direction in the field of breast surgery on the premise of ensuring tumor safety.Breast reconstruction can be performed at the same time as mastectomy or partial mastectomy,or it can be delayed until the appropriate time after the completion of adjuvant therapy.The former is called immediate breast reconstruction,and the latter is called delayed breast reconstruction.Clinically,the timing of reconstruction is determined by the stage of disease and the patients ' needs.Delayed-immediate breast reconstruction was used in some patients to reduce the adverse effects of adjuvant radiotherapy and the occurrence of serious postoperative complications.Breast reconstruction also includes autologous flap breast reconstruction,implant-based breast reconstruction and autologous combined implant breast reconstruction.Implant based reconstruction is the most commonly used technique in immediate breast reconstruction.For delayed breast reconstruction,autologous flapbased breast reconstruction or two-step implant-based reconstruction is more frequently.

Objective: To evaluate the efficiency of preoperative Halo-gravity traction (HGT) in the treatment of severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ (NF1). Methods: A retrospective review was conducted on patients with severe kyphoscoliosis secondary to NF1 at Department of Spinal Surgery, Drum Tower Hospital, Medical School of Nanjing University between July 2007 and May 2016. A total of 29 patients including 17 males and 12 females were finally enrolled and the age was (13.7±2.9) years. The Cobb angle of major coronal curve and global kyphosis were measured before and after HGT. The forced vital capacity (FVC)and forced expiratory volume in 1 second (FEV₁) before and after traction were also recorded. The paired t test was used for comparison analysis. Results: The average maximum traction weight of HGT was (12.2±2.8) kg and the traction duration was (10.2±6.6) weeks. The coronal Cobb angle before HGT was (87.5±36.5)°, which improved to (68.4±25.9)° after HGT with a correction rate of (21.9±12.1)% (t=9.14, P<0.001); the average global kyphosis before HGT was (79.1±27.1)°, which improved to (59.9±19.4)° after HGT and the correction rate was (20.2±14.1)% (t=8.55, P<0.001). One patient had transient brachial plexus palsy which resolved completely after reducing the traction weight. After HGT treatment, FVC increased from (0.83±0.16) L to (0.89±0.19) L (t=1.48, P=0.12) and FEV₁ increased from (0.72±0.16) L to (0.78±0.20) L (t=0.49,P=0.63). FVC predicted and FEV₁ predicted improved from (42.9±20.1)% and (40.6±19.6)% to (46.9±20.5)% (t=0.98,P=0.33) and (43.6±25.8)% (t=1.24,P=0.22), respectively. Conclusion Preoperative HGT in the treatment of severe kyphoscoliosis secondary to NF1 can improve spinal deformity and pulmonary function to some extent, which can further benefit the patients by improving their surgical tolerance.

Objectives: To examine the influence factors on axillary evaluation in ductal carcinoma in situ (DCIS) patients, and the prognosis of different choices of axillary evaluation in a single-center retrospective study. Methods: Totally 1 557 DCIS patients admitted in Department of Breast Surgery, Fudan University Shanghai Cancer Center from January 2006 to November 2016 were retrospectively enrolled. All patients were female. The median age was 49 years (range: 21 to 85 years). Surgical methods included modified radical mastectomy, simple mastectomy (with or without axillary evaluation) and breast conservation surgery (with or without axillary evaluation). Axillary evaluation included axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB). T tests, χ² test and Logistic regression analysis was used to analyze influence factors on axillary evaluation, respectively. Kaplan-Meier curve and Log-rank analysis were used to evaluate recurrence-free survival (RFS) and loco-regional recurrence-free survival (LRRFS) in patients with different surgical methods. Results: Among the 1 557 DCIS patients, there were 1 226 cases received axillary evaluation, while 331 cases not received axillary evaluation. Patients were separated into 3 groups by different axillary evaluation choices: SLNB group (957 cases, 61.46%), ALND group (197 cases, 12.65%) and no evaluation group (403 cases, 25.88%). The patients in SLNB group increased significantly (P=0.000), from 3.85% (60/1 557) in 2006 to 75.19% (1 170/1 557) in 2016. The independent influence factors of receiving axillary evaluation were high nuclear grade (OR=3.191, 95%CI: 1.722 to 5.912, P=0.001) and tumor size>15 mm (OR=1.698, 95%CI: 1.120 to 2.573, P=0.012). Also, patients received breast conservation surgery were more likely to refuse axillary evaluation (OR=0.155, 95%CI: 0.103 to 0.233, P=0.000). There were no significant differences in RFS and LRRFS in patients with different axillary evaluation choices. Conclusions The investigation in trends and influence factors of different axillary evaluation choices provided basis on surgical precision medicine in DCIS patients. Patients received SLNB increased significantly. The independent influence factors of axillary evaluation were nuclear grade, tumor size and surgical methods. There was no significant differences in prognosis among the groups receiving different axillary evaluations.

Objective To evaluate the influence factors on surgical methods in DCIS (Ductal carcinoma in situ) patients,and the prognosis of different surgical methods in a 10-year single-center retrospective study.Methods We retrospectively included 1557 DCIS patients who received treatments in our center from Jan.2006 to Nov.2016.T tests,Chi-square analysis and logistic regression analysis were used to analyze influence factors on surgical methods.Kaplan-Meier and Log-rank analysis were used to evaluate recurrence-free survival(RFS) and loco-regional recurrence-free survival (LRRFS) in patients with different surgical methods.Results Of the enrolled 1557 DCIS patients,surgical methods included modified radical mastectomy,simple mastectomy (with or without axillary evaluation) and breast conservation surgery (with or without axillary evaluation).The number of DCIS cases in our center increased (P＜0.001),so did the percentage of DCIS in annual malignant surgery cases (P=-0.026).Significant decrease was found in modified radical mastectomy (P=0.012).More than half of the patients received simple mastectomy after 2010,and more than one fifth of the patients received breast conservation surgery after 2008.About 13.99％ patients who received mastectomy had breast reconstruction.The independent influence factors of refusing breast conservation surgery were age ≥ 50(P＜0.001),medium nuclear grade (P=0.044),tumor size ＞ 15mm (P＜0.001) and spontaneous discharge (P＜0.001).Patients with smaller tumor size (≤ 15mm) and no spontaneous discharge had 4.18-fold and 7.04-fold greater preference for breast conservation surgery,respectively(OR=0.232,P＜0.001;OR=0.144,P＜0.001).There were no significant differences in RFS and LRRFS in patients with different surgical methods.Conclusion The evaluation in trends and influence factors of different surgical methods provides basis on surgical precision medicine in DCIS patients.

Objective: To evaluate the radiographic and clinical outcomes of Scoliosis Research Society(SRS)-Schwab Grade IV osteotomy in type I congenital kyphosis. Methods: All of 28 patients with type I congenital kyphosis who underwent SRS-Schwab Grade 4 osteotomy from June 2015 to June 2017 were retrospectively reviewed,including 21 males and 7 females aged 10 to 28 years old, with an average of 13.6±8.5 years. On standing wholespinal X-rays at pre-operation, post-operation and each follow-up, global kyphosis(GK), thoracic kyphosis(TK), lumbar lordosis(LL) and sagittal vertical axis(SVA) were measured. The intra-operative and post-operative complications were recorded for each patient. The Scoliosis Research Society-22 questionnaires(SRS-22) and visual analog scale(VAS) for back pain were collected from patients elder than 12 years old at pre-operation and last follow-up. The comparison analysiswasperformed by paired samples t test. Results: At pre-operation, the GK, TK, LL and SVA were 47.0°±4.9°, 16.8°±3.7°, 36.6°±7.7°, (-31.9±13.6) mm, respectively. At 3 months post-operation, the average values improved to 3.7°±2.3°, 36.8°±4.0°, 46.5°±4.4°, 4.0±19.1 mm, respectively. Significant differences were found in all parametersbetween pre- and post-operation. The post-operative follow-up was 12 to 24 months, with an average of 13.2±5.2 months. At the last follow-up, the GK, TK, LL and SVA were 4.0°±2.4°, 38.0°±6.0°, 45.9°±5.4°, 7.6±15.3 mm, and no significant correction loss was found during follow-up. The scores of each domain of SRS-22 questionnaire improved at different level during follow-up, of which the improvement in self-imagewas statistically significant (P<0.001). The scores of VAS for back pain improved significantly after operation (P<0.001). One patient hadabnormal intra-operative monitoringwhile no neurological defectwas detected at post-opera tion. Proximal junctional kyphosis occurred in 2 patients at 3 months follow-up while no patients needed revision surgery. There wereno implant-related complicationsduring follow-up. Conclusion The SRS-Schwab Grade 4 osteotomycould provide satisfying correction with relatively low rates of complications in type I congenital kyphosis. Thus, the SRS-Schwab Grade IV osteotomy is a safe strategy for type I congenital kyphosis.

Objective:To compare the incidence of intraoperative neurological complications during correction surgery of spinal deformities in patients with or without rotatory subluxation (RS), and to analyze the correlation between RS and intraoperative neurological complications.Methods:From January 2012 to August 2017, a total of 37 patients with RS undergoing correction surgery, whom was excluded with preoperative spinal traction or three-column osteotomy during operation were retrospectively reviewedin our hospital. Thirty-seven patients without RS undergoing correction surgery were included asthe control group. The radiographic parameters included Cobb angle of main curve, coronal trunk balance (CTB) which was the distance between C 7 plumb line and center sacral vertical line, global kyphosis (GK), sagittal vertical axis (SVA), RS at coronal plane (CRS), RS at sagittal plane (SRS) and axial rotation (AR). The abnormal intraoperative neurophysiological monitoring events and positive wake-up test were recorded. Results:The mean age was 42.4±17.9 years (12-74 years) in the RS group and 42.7±18.3 years (12-74 years) in the control group( t=0.0713, P=0.943). The mean preoperative Cobb angle of main curve, CTB, GK, and SVA was 75.4°±29.7°, 38.4±28.4 mm, 52.8°±25.2°, and 40.3±36.8 mm respectively in the RS group, which was 75.1°±27.6°( t=0.045, P=0.964), 34.8±24.4 mm( t=0.584, P=0.560), 49.8°±22.5°( t=0.540, P=0.591), and 38.7±25.3 mm ( t=0.219, P=0.828) respectively in the control group. There was no significant difference between the two groups among the above preoperative index. Significant improvements in Cobb angle of main curve, CTB, GK, SVA,CRS, SRS and ARA were found between preoperation and postoperation ( P<0.05 for all), while no significant correction loss was observed during follow-up ( P>0.05 for all). There were 6 patients (16.2%) in the RS group and 4 patients (10.8%) in the control group with preoperative neurological deficit of Frankel grade D ( F=0.463, P=0.496). The abnormal intraoperative neurophysiological monitoring events were observed in 5 patients (13.5%) of the RS group and 1 patient (2.7%) of the control group ( F=2.902, P=0.088). Positive wake-up test was found in 2 patients of RS group (5.4%) ( F=2.056, P=0.493). Conclusion:Patients with RS had higher risks of preoperative neurological deficit, abnormal intraoperative neurophysiological monitoring events and deteriorative neurological deficit at postoperation. The RS at preoperation may be a risk factor for intraoperative neurological deficit.