Abscopal effect in radioimmunotherapy

Abscopal effect is an interesting phenomenon in radiobiology that causes activation of immune system against cancer cells. Traditionally, this phenomenon was known as a suppressor of non-irradiated tumors or metastasis. However, it can be used as a stimulator of the immune system against primary tumor during radiotherapy. Immunotherapy, a novel tumor therapy modality, also triggers immune system against cancer. To date, some immunotherapy types have been developed. However, immune checkpoint blockade is a more common modality and some drugs have been approved by the FDA. Studies have shown that radiotherapy or immunotherapy administered alone have low efficiency for tumor control. However, their combination has a more potent anti-tumor immunity. For this aim, it is important to induce abscopal effect in primary tumors, and also use appropriate drugs to target the mechanisms involved in the exhaustion of cytotoxic CD8+T lymphocytes (CTLs) and natural killer (NK) cells. Among the different radiotherapy techniques, stereotactic body radiation therapy (SBRT) with some few fractionations is the best choice for inducing abscopal effect. On the other hand, programmed cell death 1 (PD-1) is known as one of the best targets for triggering anti-tumor immunity. This combination is known as the best choice among various strategies for radioimmunotherapy. However, there is the need for other strategies to improve the duration of immune system’s activity within tumor microenvironment (TME). In this review, we explain the cellular and molecular mechanisms behind abscopal effect by radiotherapy and evaluate the molecular targets which induce potent anti-tumor immunity.     

Fluoroscopy: An essential diagnostic modality in the age of high-resolution cross-sectional imaging

The importance of fluoroscopy as an imaging modality has been minimized relative to other cross-sectional modalities, including high-resolution computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Fluoroscopy examinations have decreased in clinical practice due to reduced appreciation of its usefulness, insufficient training of residents, fewer staff with adequate expertise, and poor reimbursements relative to other modalities. We revisit and build upon the prior literature and history of this decreased utilization. We then seek to prove continued value, through categorized examples and within multiple subspecialties, wherein fluoroscopy plays an integral part toward clinical diagnoses as well as optimizing patient outcomes. This is particularly true for motility and esophageal disorders, where structure and function with real-time evaluation is essential.  We additionally show several post-operative cases where the synergy of fluoroscopy with CT and endoscopy is apparent.  The fluoroscopic radiologist also has the unique ability to vary patient positioning, as opposed to traditional CT or MRI, where orthogonal views are employed without positional or temporal changes. We turn attention to the modern era, with synergistic and novel cases demonstrating that fluoroscopy remains instrumental toward achieving a diagnosis alongside other modalities. Our cases stress the need to maintain expertise in fluoroscopy skill, and underline its continued importance in residency training programs.  We conclude that fluoroscopy is a relatively inexpensive modality that is often under-appreciated in diagnostic radiology. We suggest that competency in fluoroscopy is crucial for future generations of radiologists to both work with their peers, as well as to aid clinicians in the optimal treatment of patients.     

Results of more than 11,000 scans with weightbearing CT — Impact on costs,radiation exposure,and procedure time

BackgroundWeightbearing CT (WBCT) has been proven to more precisely measure bone position than conventional weightbearing radiographic series (R) and conventional CT (CT). The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT as the standard imaging modality, evaluating image acquisition time, radiation dose, and cost-effectiveness.MethodsAll patients who obtained a WBCT as part of standard of care from July 1, 2013 until March 15, 2019 were included in the study. Image acquisition time (T), radiation dose (RD) per patient, and cost-effectiveness were analyzed and compared between the time period using WBCT (yearly average) and the parameters from 2012, i.e. before the availability of WBCT (RCT group).Results11,009 WBCT scans were obtained from 4987 patients (4,987 scans (45%) before treatment; 6,022 scans (55%) at follow-up). On a yearly average, 1,957 WBCTs (bilateral scans) and an additional 10.6 CTs (bilateral feet and ankles) were obtained (WBCT group). In 2012, 1,850 Rs (bilateral feet, dorsoplantar and lateral, metatarsal head skyline view) and 254 CTs were obtained from 885 patients (RCT group). The mean yearly RD was 4.3/4.8uSv for the WBCT/RCT groups (mean difference of .5 uSv; a decrease of 10% for the WBCT group; p < .01). Yearly mean T was 114/493 h in total (3.3/16.0 min per patient) for WBCT/RCT groups (mean difference of 379 h; a 77% decrease for the WBCT group; p < .01). Yearly cost-effectiveness was a mean profit of 43,959/−723 Euros for WBCT/RCT groups.Conclusions11,009 WBCT scans from 4,987 patients over a period of 5.6 years at a foot and ankle department resulted in 10% decreased RD, 77% decreased T, and increased financial profit (51 Euros per patient) for the institution.     

Improving patient and staff safety by minimising radiation exposure during trauma surgery: A simple and validated predictive model

IntroductionMinimising radiation exposure, from fluoroscopic equipment during trauma surgery is crucial to safe-guarding patients and staff. This aim of this study was to identify variables associated with increased radiation exposure for 3 of the most common trauma procedures. Secondly, we aimed to derive an internally and externally validated mathematical model for predicting radiation exposure for these procedures.Materials and methodsWe prospectively recorded radiation exposure from 270 sliding hip screw (SHS), ankle and wrist fixation procedures. Patient demographics, fracture severity, surgeon and radiographer grade were assessed using univariate and multivariate analyses. A mathematical model was then created and externally assessed for validity from another unit.ResultsWith regards to the analysis of radiation exposure when fixing wrist fractures, a significant regression equation was found (F (3, 86) = 62.2, p < 0.001), with an adjusted R² of 0.69. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 81.916(Fracture severity) + 43.426(Surgical grade) + 23.490 (radiographer grade)-203.89.With regards to the analysis of radiation exposure when fixing ankle fractures, a significant regression equation was found, (F (3, 83) = 15.49, p < 0.001), with an adjusted R² of 0.34. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 39.541(Fracture severity) + 51.937(Surgical grade) + 37.702 (radiographer grade)-124.558 SHS (F (3, 89) = 25.29, p < 0.001), R² of 0.44.61.338(Fracture severity) + 60.945(Surgical grade) + 35.491 (radiographer grade)-105.501. These predictive models were successfully externally validated.ConclusionThis study has demonstrated a workable and externally validated model for accurately predicting the likely radiation exposure using common and easily collectable variables. These models could be used to modify practuce and minimise the radiation exposure to patients and staff.     

独活的临床应用及其用量探究

通过搜集古医籍及现代医家临床经验,总结出独活具有以下特点:首先,临床用量多为6~60 g。其次,独活临床用量应综合考虑病证及配伍等多种因素,随病施量、因证施量、因配伍施量。独活配伍羌活、防风等,治疗风寒湿引起的风湿免疫、骨科系统疾病,常用剂量9~60 g;配伍川芎、细辛、虫类药等,治疗神经官能症、阿尔兹海默症等多种神经系统疾病,常用剂量9~15 g;配伍黄芪、桂枝、女贞子等,治疗月经失调、产后身痛等妇产科疾病,临床常用9~12 g。     

Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

IntroductionAdverse events in radiology are quite rare, but they do occur. Radiation safety regulations and the law obligate organizations to report certain adverse events, harm and near misses, especially events related to patients' health and safety. The aim of this study was to describe and analyse incidents related to radiation safety issues reported in Finland.MethodsThe data were collected from incident reports documented by radiology personnel concerning notifications of abnormal events in medical imaging made to the Radiation and Nuclear Safety Authority between 2010 and 2017. During these eight years, 312 reports were submitted. Only events reported from radiology departments were included; nuclear medicine, radiotherapy and animal radiology cases were excluded. The final number of reports was 293 (94%).ResultsThe majority of the 293 approved reports were related to computed tomography (CT, 68.3%) and to X-ray examinations (27.6%). Altogether 82.9% of those irradiated were adults, most of whom were exposed to unnecessary radiation through CT (86.5%), 5.5% were children, and 4.4% pregnant women. The most common effective dose of unnecessary radiation was 1 mSv or less (89.7% of all examinations). The highest effective doses were reported in CT (from under 1 mSv–20 mSv and above). The reasons for the adverse events were incorrect identification (32%), incorrect procedure, site or side (30%); and human errors or errors of knowledge (20%).ConclusionAdverse events occurred especially in CT examinations. It is important to collect and analyse incident data, assess the harmful events, learn from them and aim to reduce adverse events.Implications for practiceThis study emphasizes the need for radiological personnel to obtain evidence-based information on adverse events and focus on training to improve patient safety.     

Adult parameningial alveolar rhabdomyosarcoma: Case report and literature review

Alveolar rhabdomyosarcoma (ARMS) represents the most common childhood soft tissue sarcoma, but they are rarely seen among adults. Most of the protocols for adults are adapted from pediatric protocols. Here we report a case of a 53-year-old woman diagnosed with a nasal alveolar rhabdomyosarcoma, stage IV at diagnosis, treated by chemotherapy (a regimen inspired from the pediatric protocole pEpSSG RMS 2005) which led to partial response followed by chemo-radiotherapy. We performed a systematic review of adult head and neck ARMS and found 29 cases. Primary chemotherapy with different protocols (VAC, VAI or VIE) should be done followed by surgery and/or external beam radiotherapy (preferably with IMRT). EBRT seems beneficial to every ARMS with a dose around 50 Gy in a conventional fractionation, eventually completed with a boost on residual tumor. The target volume must be defined on pre-chemotherapy imaging. Brachytherapy and proton therapy are under evaluation.