Clinical efficacy of Gamma Knife® combined with transarterial chemoembolization and immunotherapy in the treatment of primary liver cancer

BACKGROUND This study was designed to investigate the clinical efficacy and safety of Gamma Knife®combined with transarterial chemoembolization(TACE)and immunotherapy in the treatment of primary liver cancer.AIM To investigate the clinical efficacy and safety of Gamma Knife®combined with TACE and immune-targeted therapy in the treatment of primary liver cancer.METHODS Clinical data from 51 patients with primary liver cancer admitted to our hospital between May 2018 and October 2022 were retrospectively collected.All patients underwent Gamma Knife®treatment combined with TACE and immunotherapy.The clinical efficacy,changes in liver function,overall survival(OS),and progression-free survival(PFS)of patients with different treatment responses were evaluated,and adverse reactions were recorded.RESULTS The last follow-up for this study was conducted on October 31,2023.Clinical evaluation of the 51 patients with primary liver cancer revealed a partial response(PR)in 27 patients,accounting for 52.94%(27/51);stable disease(SD)in 16 patients,accounting for 31.37%(16/51);and progressive disease(PD)in 8 patients,accounting for 15.69%(8/51).The objective response rate was 52.94%,and the disease control rate was 84.31%.Alanine aminotransferase,aspartate aminotransferase,lactate dehydrogenase,and alpha-fetoprotein isoform levels decreased after treatment compared with pretreatment(all P=0.000).The median OS was 26 months[95%confidence interval(95%CI):19.946-32.054]in the PR group and 19 months(95%CI:14.156-23.125)in the SD+PD group,with a statistically significant difference(P=0.015).The median PFS was 20 months(95%CI:18.441-34.559)in the PR group and 12 months(95%CI:8.745-13.425)in the SD+PD group,with a statistically significant difference(P=0.002).Common adverse reactions during treatment included nausea and vomiting(39.22%),thrombocytopenia(27.45%),and leukopenia(25.49%),with no treatment-related deaths reported.CONCLUSION Gamma Knife®combined with TACE and immune-targeted therapy is safe and effective in the treatment of primary liver cancer and has a good effect on improving the clinical benefit rate and liver function of patients.

Emerging molecules,tools,technology,and future of surgical knife in gastroenterology

The 21^(st) century has started with several innovations in the medical sciences,with wide applications in health care management.This development has taken in the field of medicines(newer drugs/molecules),various tools and technology which has completely changed the patient management including abdominal surgery.Surgery for abdominal diseases has moved from maximally invasive to minimally invasive(laparoscopic and robotic)surgery.Some of the newer medicines have its impact on need for surgical intervention.This article focuses on the development of these emerging molecules,tools,and technology and their impact on present surgical form and its future effects on the surgical intervention in gastroenterological diseases.

CyberKnife系统技术评估和临床应用评价

介绍了Cyber Knife系统作为最新型的立体定向放射治疗设备之一的独有优势,同时提出了临床上其仍然存有一定局限性且有待被重新认识。最后对Cyber Knife系统的技术特点及临床应用情况进行了评估和总结,指出不断拓展治疗空间、提升引导图像中组织解剖信息是Cyber Knife系统未来发展的方向。

金标伪影对CyberKnife射野剂量学影响的计算与测量

目的:分析植入的金标在CT扫描时产生的金属伪影对Cyber Knife射野的剂量学影响。方法:用CT模拟机对固体水进行扫描以获取金标不同深度位置的CT图像,在计划系统中,分别制作以电离室收集极为等中心的单射野照射计划,并将相应计划移植到指定金标伪影密度覆盖值的CT图像并执行计划进行测量。结果:金标的植入对等中心剂量的影响在0.5%左右,而伪影对剂量及相同深度离轴点处吸收剂量影响达3%,并随金标植入深度的增加而降低;给伪影指定密度覆盖值后,其对剂量的影响可降低至1%;金标伪影使得金标后方的百分深度剂量(percentage depth dose,PDD)有明显跌落区,伪影密度值的覆盖可以减少对PDD的影响;金标对偏心比(off-center ratio,OCR)的影响较小,但使OCR曲线相对稍加平坦。结论:通过伪影覆盖可有效降低金标伪影对剂量的影响。

CyberKnife等中心及非等中心立体定向治疗计划质量及效率评价

目的探讨并评价Cyber Knife(CK)系统利用等中心和非等中心两种计划模式立体定向治疗计划(SRT)的剂量学特性及差异。方法将18例肿瘤患者分为A、B两组:A为小体积组即肿瘤大小在3 cm以下;B为大体积组即肿瘤大小在3 cm以上。每组9例患者计划分别给予同一处方剂量条件40 Gy/5F。在相同的条件下,分别以等中心和非等中心两种布野方式立体定向治疗技术设计相应的计划,通过其靶区适形指数(CI)、非均匀指数(HI)、梯度指数(GI)和危及器官等剂量学参数,分析评估SRT计划优化质量及实施效率,从而实现评价两种治疗模式的剂量学差异。结果等中心组计划执行的平均治疗时间(P=0.002)及机器MUs(P<0.001)明显优于非等中心组;CI均值(A:P=0.027;B:P=0.007)和GI均值(A:P<0.001;B:P<0.001)分别小于非等中心组;HI均值则略高于非等中心组(A:P=0.029;B:P<0.001);A组平均剂量归一值(P=0.011)等中心组优于非等中心组,而B组(P=0.012)等中心组低于非等中心组。结论等中心治疗模式在治疗时间、MU数及GI上均优于非等中心,在CI和HI上略低于非等中心模式。小体积肿瘤可考虑等中心治疗模式,而大体积肿瘤则宜用非等中心治疗模式;但仍需更多的临床病例给予研究。

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. METHODS: Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. RESULTS: The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT- ESD group (57.6 ± 31.9 min vs 21.1 ± 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. CONCLUSION: IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. Thelong-term outcome needs to be evaluated in the future.

Treatment of over 20 mm gastric cancer by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM： To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife （IT-ESD） for the treatment of patients with over 20 mm early gastric cancer （EGC）. METHODS： A total of 112 patients with over 10 mm EGC were treated with IT-ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 5 year period from January 2002 to December 2006, including 40 patients with over 20 mm EGC. We compared patient backgrounds, the one-piece resection rate, complete resection （CR） rate, operation time, bleeding rate, perforation rate between patients with over 20 mm EGC [over 20 mm group （21-40 ram）] and the remaining patients （under 20 mm group）. RESULTS： We found no significant difference in the rate of underlying cardiopulmonary disease （over 20 mm group vs under 20 mm group, 5.0% vs 5.6%）, one- piece resection rate （95% vs 96%）, CR rate （85% vs 89%）, operation time （72.3 rain vs 66.5 rain）, bleeding rate （50 vs 4.2%）, and perforation rate （0% vs 1.4%） between the 2 groups. Three patients in each group had submucosal invasion and two in each groups underwent additional surgery. CONCLUSION： There was no significant difference in the outcome resulting from IT-ESD between the 2 groups. Our study proves that IT-ESD is a feasible treatment for patients with over 20 mm mucosal gastric cancer although the long-term outcome should be evaluated in the future.

Endoscopic submucosal dissection for early esophageal neoplasms using the stag beetle knife

AIM To determine short-and long-term outcomes of endoscopic submucosal dissection(ESD) using the stag beetle(SB) knife, a scissor-shaped device.METHODS Seventy consecutive patients with 96 early esophageal neoplasms, who underwent ESD using a SB knife at Kure Medical Center and Chugoku Cancer Center, Japan, between April 2010 and August 2016, were retrospectively evaluated. Clinicopathological characteristics of lesions and procedural adverse events were assessed. Therapeutic success was evaluated on the basis of en bloc, histologically complete, and curative or non-curative resection rates. Overall and tumor-specific survival, local or distant recurrence, and 3-and 5-year cumulative overall metachronous cancer rates were also assessed.RESULTS Eligible patients had dysplasia/intraepithelial neoplasia(22%) or early cancers(squamous cell carcinoma, 78%). The median procedural time was 60 min and on average, the lesions measured 24 mm in diameter, yielding 33-mm tissue defects. The en bloc resection rate was 100%, with 95% and 81% of dissections deemed histologically complete and curative, respectively. All procedures were completed without accidental incisions/perforations or delayed bleeding. During follow-up(mean, 35 ± 23 mo), no local recurrences or metastases were observed. The 3-and 5-year survival rates were 83% and 70%, respectively, with corresponding rates of 85% and 75% for curative resections and 74% and 49% for noncurative resections. The 3-and 5-year cumulative rates of metachronous cancer in the patients with curative resections were 14% and 26%, respectively.CONCLUSION ESD procedures using the SB knife are feasible, safe, and effective for treating early esophageal neoplasms, yielding favorable short-and long-term outcomes.

Clinical outcomes following salvage Gamma Knife radiosurgery for recurrent glioblastoma

Glioblastoma multiforme(GBM) is the most common malignant primary brain tumor with a survival prognosis of 14-16 mo for the highest functioning patients. Despite aggressive, multimodal upfront therapies, the majority of GBMs will recur in approximately six months. Salvage therapy options for recurrent GBM(r GBM) are an area of intense research. This study compares recent survival and quality of life outcomes following Gamma Knife radiosurgery(GKRS) salvage therapy. Following a Pub Med search for studies usingGKRS as salvage therapy for malignant gliomas, nine articles from 2005 to July 2013 were identified which evaluated rG BM treatment. In this review, we compare overall survival following diagnosis, overall survival following salvage treatment, progression-free survival, time to recurrence, local tumor control, and adverse radiation effects. This report discusses results for rG BM patient populations alone, not for mixed populations with other tumor histology grades. All nine studies reported median overall survival rates(from diagnosis, range:16.7-33.2 mo; from salvage, range:9-17.9 mo). Three studies identified median progression-free survival(range:4.6-14.9 mo). Two showed median time to recurrence of GBM. Two discussed local tumor control. Six studies reported adverse radiation effects(range:0%-46% of patients). The greatest survival advantages were seen in patients who received GKRS salvage along with other treatments, like resection or bevacizumab, suggesting that appropriately tailored multimodal therapy should be considered with each rG BM patient. However, there needs to be a randomized clinical trial to test GKRS for rG BM before the possibility of selection bias can be dismissed.

Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife

AIM to compare the efficacy and safety of a hook knife(HO) with a hybrid knife(HK) during endoscopic submucosal tunnel dissection(EStD) procedure.METHODS Between August 2012 and December 2015, the ESt D procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups.RESULTS there were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. EStD was successfully completed in all the patients, and no case was converted to laparoscopy. the mean procedure time was significantly shorter in the HK group than in the HO group(41.3 ± 20.3 min vs 57.2 ± 28.0 min, p = 0.004). the mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group(p < 0.001). the differences in tumor size and histopathological diagnoses were not significant between the two groups(p = 0.813, p = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups(p = 0.901). During the follow-up, no recurrence occurred in either group.CONCLUSION We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.

Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model

AIM: To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model. METHODS: The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy. RESULTS: Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels. CONCLUSION: The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.

Diagnostic and Therapeutic Cold Knife Conization for Cervical Intraepithelial Neoplasia

OBJECTIVE of using cold （CIN）. METHODS To evaluate the diagnostic and therapeutic efficacy knife conization for cervical intraepithelial neoplasia We retrospectively analyzed 186 cases with CIN diagnosed and treated in our hospital; compared the histologic diagnoses from cervical conization and from colposcopic multiple punch biopsies, and then evaluated their postoperative histologic findings and clinical outcomes. RESULTS Of the 186 cases, there was a correlation in histologic findings between cervical conization and colposcopic multiple punch biopsies in 138 cases （74.2%）, and there was no correlation in the other 48 cases （25.8%）. Incomplete excision was performed in 8 cases （4.3%）, but the failure rate was only 1.1%; the cure rate was 98.9%. Five cases with early invasive cancer were found. Eleven patients underwent subsequent hysterectomy. The main complications associated with conization were hemorrhage and cervical stenosis. Bleeding occurred in 8 （4.3%） of the patients, and cervical stenosis occurred in 3 （1.6%）. CONCLUSION Cervical intraepithelial neoplasia was diagnosed more accurately using conization than by colposcopic multiple punch biopsies. Conization can also play an important role in the treatment for CIN. If properly performed, the procedure has a low risk of complications. It can provide an accurate histologic representation of the disease process, and be curative in most cases.

A novel device for endoscopic submucosal dissection,the Fork knife

AIM： To introduce and evaluate the efficacy and technical aspects of endoscopic submucosal dissection （ESD） using a novel device, the Fork knife. METHODS： From March 2004 to April 2008, ESD was performed on 265 gastric lesions using a Fork knife （Endo FS） （group A） and on 72 gastric lesions using a Flexknife （group B） at a single tertiary referral center. We retrospectively compared the endoscopic characteristics of the tumors, pathological findings, and sizes of the resected specimens. We also compared the en b/oc resection rate, complete resection rate, complications, and procedure time between the two groups. RESULTS： The mean size of the resected specimens was 4.27 ± 1.26 cm in group A and 4.29 ± 1.48 cm in group B. The en b/oc resection rate was 95.8% （254/265 lesions） in group A and 93.1% （67/72） in group B. Complete ESD without tumor cell invasion of the resected margin was obtained in 81.1% （215/265） of group A and in 73.6% （53/72） of group B. The perforation rate was 0.8% （2/265） in group A and 1.4% （1/72） in group B. The mean procedure time was 59.63 ± 56.12 min in group A and 76.65 ± 70.75 min in group B （P 〈 0.05）. CONCLUSION： The Fork knife （Endo FS） is useful for clinical practice and has the advantage of reducing the procedure time.

Novel endoscopic management of buried bumper syndrome in percutaneous endoscopic gastrostomy: The Olympus Hook Knife

Buried bumper syndrome(BBS) is an uncommon but serious complication of percutaneous endoscopic gastrostomy. It involves the internal fixation device, or "bumper", migrating into the gastric wall and subsequent mucosal overgrowth. We described a case series of four patients with BBS treated with a novel endoscopic technique using a Hook Knife between June 2016 and February 2017. The Hook Knife is a rotating L-shaped cutting wire designed for hooking tissue and pulling it away from the gastric wall towards the lumen. The technique was successful in all four cases with no complications. Each patient was discharged on the day of treatment. The Hook Knife is a manoeuvrable, safe and effective device for endoscopic removal of buried bumpers and could avoid surgery in a high risk group of patients. To our knowledge this technique has not been described previously. We suggest that this technique should be added to the treatment algorithms for managing BBS.

Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma

AIM:To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.METHODS:In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory.RESULTS:Between January 2008 and December 2010,38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients.Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy.There were 8(61.5%)males and 5(38.5%)females.The most common presenting symptom was jaundice(100%),followed by fever(46.2%),melena(38.5%),abdominal pain(30.8%)and weight loss(30.8%).All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of(11.2 ± 1.9)mg/dL(normal value <1 mg%)and the mean ± SD serum alkaline phosphatase was(288.0 ± 94.3)IU/L(normal value < 129 IU/L).Serum CA 19.9 level estimation was done in 11 patients;it was elevated(cut off value > 70.5 IU/L)in all of them with a median of 1200 IU/L(inter quartile range 274-3500).Side viewing endoscopy showed a bulky papilla in all of them.Adequate tissue was obtained in all of the 13 patients for histological evaluation;12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma.There were no complications from the needle knife papillotomy in any of the patients.CONCLUSION:Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.

Endoscopic sphincterotomy with needleshaped knife: report of 476 cases

Objectives: To evaluate endoscopic duodenal sphinc- terotomy and improve its success rate. Methods: Needle-shaped knife was used for endoscop- ic sphincterotomy (EST) in 476 patients with biliary or pancreatic diseases from March 1995 to October 2000. Results: Direct incision was made in 243 patients, papillary fenestration in 89, and opposite incision in 144. The papilla located beside and in the diverticu- lum in 56 and 12 patients, respectively. EST emer- gency was made in 147 patients. ERCP after EST be- cause of the difficulty in intubation was made suc- cessfully in 62 patients. Mild complications occurred in 14 patients (2.94%), all of whom were cured af- ter symptomatic treatment. Conclusions: EST with needle-shaped knife has such advantages as safety in operation and convenience in incision. It is suitable for the papilla with different shape, with a higher success rate.

Clutch Cutter knife efficacy in endoscopic submucosal dissection for early gastric neoplasms

AIM To compare the outcomes of endoscopic submucosal dissection(ESD) for gastric neoplasms using Clutch Cutter(ESD-C) or other knives(ESD-O).METHODS This was a single-center retrospective study. Gastric neoplasms treated by ESD between April 2016 and October 2017 at Kitakyushu Municipal Medical Center were reviewed. Multivariate analyses and propensity score matching were used to reduce biases. Covariates included factors that might affect outcomes of ESD, including age, sex, underlying disease, anti-thrombotic drugs use, tumor location, tumor position, tumor size, tumor depth, tumor morphology, tumor histology, ulcer(scar), and operator skill. The treatment outcomes were compared among two groups. The primary outcome was ESD procedure time. Secondary outcomes were en bloc, complete, and curative resection rates, and adverse events rates including perforation and delayed bleeding.RESULTS A total of 155 patients were included in this study; 44 pairs were created by propensity score matching. Background characteristics were quite similar among two groups after matching. Procedure time was significantly shorter for ESD-C(median; 49 min) than for ESD-O(median; 88.5 min)(P < 0.01). However, there was no significant difference in treatment outcomes between ESD-C and ESD-O including en bloc resection rate(100% in both groups), complete resection rate(100% in both groups), curative resection rate(86.4% vs 88.6%, P = 0.730), delayed bleeding(2.3% vs 6.8%, P = 0.62) and perforation(0% in both groups).CONCLUSION ESD-C achieved shorter procedure time without an increase in complication risk. Therefore, ESD-C could become an effective ESD option for gastric neoplasms.

RapidArc与Novalis Knife在多发脑转移瘤SRS中的剂量学比较

目的:比较基于多叶准直器的RapidArc与基于圆形限光筒的Novalis Knife在多发脑转移瘤立体定向放射外科(SRS)中的剂量学差异。方法:选取10例已进行Novalis Knife治疗的多发脑转移瘤患者(转移瘤3~5个/人),共37个转移瘤。重新设计单中心、非共面4弧的RapidArc SRS计划,靶区处方剂量统一为16 Gy。比较Novalis Knife计划和RapidArc SRS计划中靶区的剂量适形度指数和均匀性指数、靶区周围剂量梯度指数、正常脑组织等剂量线体积(V16、V12、V9、V6、V3)以及治疗所需的机器跳数。结果:RapidArc SRS计划相较于Novalis Knife计划,适形度指数更接近于1(0.79±0.10 vs 0.50±0.22,P=0.000),均匀性指数更接近于0(0.07±0.01 vs 0.15±0.07,P=0.000),但靶区周围剂量梯度指数较大(15.92±12.43 vs 5.05±3.53,P=0.000)。对于正常脑组织等剂量线体积,RapidArc SRS计划中V16明显小于Novalis Knife计划(P=0.005);两计划的V12、V9无明显差异(P=0.445,0.059);而RapidArc SRS计划中V6、V3明显大于Novalis Knife计划(P=0.005,0.005)。RapidArc SRS计划的机器跳数明显少于Novalis Knife计划(P=0.005)。结论:RapidArc SRS计划通过设置单一治疗等中心可实现颅内多个转移瘤的同步放射外科治疗,具有更高的靶区剂量适形度及均匀性;但靶区周边剂量跌落陡度不及Novalis Knife计划,正常脑组织低剂量受照范围较大。治疗依从性较差的多发脑转移患者可考虑选择治疗效率更高的RapidArc技术,并根据临床实际情况调整剂量分割模式,以减少放射损伤风险。

Current gamma knife treatment for ophthalmic branch of primary trigeminal neuralgia

AIM: To probe into problems existing in gamma knife treatment of ophthalmic branch of primary trigeminal neuralgia (TN), and propose a safe and effective solution to the problem. METHODS: Through sorting the literature reporting gamma knife treatment of refractory TN in recent years, this article analyzed the advantages and problems of gamma knife treatment of primary TN, and proposed reasonable assessment for existing problems and the possible solution. RESULTS: Gamma knife treatment of TN has drawn increasing attention of clinicians due to its unique non-invasion, safety and effectiveness, but there are three related issue; to be considered. The first one is the uncertainty of the optimal dose (70-90GY); the second one is the difference in radiotherapy target selection (using a single isocenter or two isocenters); and the third one is the big difference of recurrent pains (specific treatment methods need to be summarized and improved). CONCLUSION: For patients with refractory TN, gamma knife treatment can be selected when the medical treatment fails or drug side effects emerge. The analysis of a large number of TN patients receiving gamma knife treatment has shown that this is a safe and effective treatment method.

Spontaneous Resolution of Traumatic AV Malformation of the Uterus Following Hysteroscopic Cold Knife Evacuation of Retained Products of Conception

Uterine myometrial arteriovenous malformations (AVM) are reported on color doppler ultrasonography as mosaic pattern of blood flow with different peak systolic velocities (PSV) at different places. High PSV within the AVM may require arterial embolization as treatment. However, we present a case of traumatic AVM with incomplete abortion managed by hysteroscopic cold knife evacuation. This case report is of a young patient with off and on vaginal bleeding for 3 1/2 months following 2nd trimester spontaneous abortion. She had undergone dilation and evacuation (D & E) for incomplete abortion. Now the bleeding was heavy and intermittent not responding to medications. The subsequent TVS examination shows incomplete abortion with myometrial AVM with high PSV. Hysteroscopic cold knife removal of products of conception resulted in immediate resolution of Uterine AVM.