Background Sinonasal cancers frequently involve the orbit with resulting controversies on whether to remove or preserve the orbital contents. Methods Retrospective review of patients with primary sinonasal cancer involving the orbit, treated according to a multidisciplinary protocol tailored to tumor histology and extent of orbital invasion in two tertiary care referral centers over a 20‐year period. Results The oncological and functional outcomes of 163 patients were analyzed. The degree of orbital involvement significantly affected both overall (P < .0001) and disease‐free (P < .0001) survival. Orbital apex invasion was an independent negative prognostic factor (5‐year overall survival, 14.6% ± 7.5%), with dismal prognosis regardless of the treatment adopted. An appropriate use of induction chemotherapy and endoscopic‐assisted surgery allowed for orbital preservation in 76.6% of cases; 96% of patients treated using an orbit‐sparing approach maintained a functional eye after treatment. Conclusion The multimodal treatment algorithm herein proposed was able to maximize orbital preservation rates with acceptable oncological and functional outcomes.

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Background-In patients with heart failure (HF), during maximal cardiopulmonary exercise test, anaerobic threshold (AT)is not always identified. We evaluated whether this finding has a prognostic meaning. Methods and Results-We recruited and prospectively followed up, in 14 dedicated HF units, 3058 patients with systolic (left ventricular ejection fraction <40%) HF in stable clinical conditions, New York Heart Association class I to III, who underwent clinical, laboratory, echocardiographic, and cardiopulmonary exercise test investigations at study enrollment. We excluded 921 patients who did not perform a maximal exercise, based on lack of achievement of anaerobic metabolism (peak respiratory quotient ≤1.05). Primary study end point was a composite of cardiovascular death and urgent cardiac transplant, and secondary end point was all-cause death. Median follow-up was 3.01 (1.39-4.98) years. AT was identified in 1935 out of 2137 patients (90.54%). At multivariable logistic analysis, failure in detecting AT resulted significantly in reduced peak oxygen uptake and higher metabolic exercise and cardiac and kidney index score value, a powerful prognostic composite HF index (P<0.001). At multivariable analysis, the following variables were significantly associated with primary study end point: peak oxygen uptake (% pred; P<0.001 T he anaerobic threshold (AT) concept is based on the principle that energy production shifts from an aerobic metabolism to a metabolism that combines both anaerobic and aerobic patterns during a progressively increasing workload exercise.1,2 According to the concept of threshold, the shift of metabolic pathway during incremental exercise must be more or less simultaneous among active muscular fibers. Therefore, the distribution of blood flow during exercise to and into muscles, the resistance to O 2 flow between capillaries and mitochondria, the type of muscular fibers, and their metabolic capability must be relatively homogeneous.3 This is not always the case in patients with heart failure (HF) who have an uneven distribution of blood flow to muscles and an uneven use of O 2 , so that, for example, an important percentage of subjects with HF increase their capillary PO 2 toward the end of exercise.4-7 Inhomogeneity of blood flow distribution, of O 2 flow resistance, and of O 2 use should widen the time frame where anaerobiosis starts to develop among the muscular fibers, in few cases making the threshold indefinable. If this hypothesis is correct, then AT should be more frequently undetectable in patients with a more severe disease. Clinical Perspective on p 987From a clinical point of view, the value of oxygen uptake (VO 2 ) at AT is used for grading the severity of HF or the effects of therapy, or to assess cardiovascular risk in case of surgery, 9-18 and it has been proposed as an alternative to peak VO 2 , being it independent of patients' motivation, exercise protocol, and exercise duration. 19 However, even in the presence of anaerobic metabolism, AT is not identified in a large num...