Is corticosteroid coinjection necessary for radiosynoviorthesis of patients with hemophilia?

PURPOSE: Radiation synovectomy is frequently combined with intraarticular corticosteroid injection in the treatment of rheumatoid arthritis to reduce local inflammation and lymphatic clearance of radiocolloid. However, this practice is not universally accepted because corticosteroids have local and systemic toxicity such as osteonecrosis and cartilage damage and whether simultaneous corticosteroid injection together with radiocolloids is necessary in other forms of chronic synovitis like patients with hemophilia remains to be determined. MATERIALS AND METHODS: In this study, we performed radiosynoviorthesis in 14 joints of 12 patients with hemophilia with chronic knee synovitis without corticosteroid coadministration and measured radiocolloid leakage from the joint space. Five mCi Y-90 radiocolloid was injected under local anesthesia and the needle was flushed with additional lidocaine injection instead of corticosteroid. The joint was then manipulated through a full range of extension and flexion to distribute the particles homogeneously throughout the joint space. The joint was then splinted for 48 hours to minimize leakage from the joint space. After the immobilization period, radiocolloid leakage was evaluated using a gamma camera with a 20% window centered over the maximum Bremsstrahlung photopeak of Y-90. Regions of interest were drawn to the injection site on the knee joint and to the ipsilateral inguinal lymph node area. Leakage of radiocolloid was calculated by dividing the background-corrected counts/pixel at the inguinal region by the counts/pixel at the injection site. RESULTS: One of 12 patients who had knee arthroplasty was previously found to have a high amount of leakage. In this patient, 70% of radiocolloid at the injection site drained into the pelvic lymph nodes. In the remaining 11 patients, no lymph nodes were visualized in the groin area and the measured average leakage for these patients was 2.3% (range, 0-13). CONCLUSION: We concluded that in cases of appropriate particle size and strict immobilization of knee joints, leakage of radiocolloid was minimal and steroid coinjection might not be necessary for radiosynoviorthesis of patients with hemophilia with chronic knee synovitis.     

Is postoperative exercise therapy necessary in patients with degenerative meniscus? A randomized controlled trial with one year follow-up

Purpose

There is no consensus on a postoperative rehabilitation regimen for patients who have undergone surgery for medial meniscus damage. The aim of this investigation was to evaluate two rehabilitation approaches after arthroscopic surgery in patients with degenerative meniscus: supervised medical exercise therapy versus no treatment.

Methods

A prospective randomized controlled clinical trial. Over 4 months, 70 participants were randomly assigned into either a medical exercise therapy group (n = 36) or a control group (n = 34). Pain was a composite score of a visual analogue scale (VAS), and function was measured with a functional assessment questionnaire (KOOS), while anxiety and depression were measured with the Hospital Anxiety and Depression Scale. Function was also measured with tests of quadriceps femoris strength and a one-leg jump test.

Results

Prognostic variables were similar between the groups at baseline, with five (7 %) patients dropping out during the treatment period and another six (8 %) before the one-year follow-up. After 3 months, the medical exercise therapy group achieved significantly better outcome effects than the control group for pain and function. The results after the 12-month follow-up indicated the same results as at posttest, whereas Hospital Anxiety and Depression Scale, fiveRM and the one-leg hop test also demonstrated a significant difference between the groups from pre- to posttest to follow-up.

Conclusion

In patients with surgery for degenerative meniscus damage, postoperative medical exercise therapy is an efficient treatment alternative compared to no treatment.

Level of evidence

I.     

Is standardised 18F-FDG uptake value an outcome predictor in patients with stage III non-small cell lung cancer?

PURPOSE: Recent studies have demonstrated the relevance of (18)F-FDG uptake as an independent prognostic factor for recurrence of operable non-small cell lung cancer (NSCLC). This corresponds with the experimental finding that FDG uptake correlates with the proliferative activity of tumour cells (Higashi et al., J Nucl Med 2000;41:85-92). On the basis of these observations, we studied the influence of FDG uptake on prognosis and occurrence of distant metastases in patients with advanced NSCLC. METHODS: One hundred and fifty-nine patients with NSCLC of UICC stage IIIA or IIIB were included in the study. In all patients, neoadjuvant treatment was planned to achieve operability. FDG PET was performed as an additional staging procedure prior to the initiation of therapy. Clinical outcome data in terms of overall survival, disease-free survival and incidence of distant metastases could be obtained for 137 patients and were correlated with the average standardised uptake value of the tumour (SUV(avg)). Furthermore, other factors influencing SUV(avg) and patient outcome (histological tumour type, grading, UICC stage, tumour size) were analysed. RESULTS: SUV(avg) was significantly influenced by tumour histology, UICC stage and tumour size. No significant difference could be shown for grading. In 38 out of the 159 patients (24%), FDG PET revealed previously unsuspected distant metastases. The incidence of distant metastases significantly correlated with SUV(avg). Overall survival tended to decrease with increasing SUV(avg); however, significance was only reached when a cut-off of 12.0 was applied (p=0.05). CONCLUSION: FDG uptake is an independent prognostic factor in patients with UICC stage III NSCLC, although less distinctively so than has been reported for stage I/II tumours.     

Is rural radiation oncology practice quality as good as the big smoke? Results of the Australian radiotherapy single machine unit trial

Radiotherapy utilization rates in rural Australia are suboptimal, with one solution being the building of single machine units (SMUs). One concern raised with such an approach is the quality of care delivered in SMUs. The Australian and Victorian governments have established two SMUs in the state of Victoria, with each SMU operated as a satellite service of a major 'hub' site. We report on the planned evaluation of practice quality. Radiation oncologist (RO) clinical practice was externally audited using the Royal Australian and New Zealand College of Radiologists Peer Review Audit instrument. This tool splits RO clinical practice into documentation/quality assurance (QA) criteria and decision-making criteria. Over the four sites, 130 patients were randomly selected for audit. At hub sites, 79.6% of all criteria audited were adequate, compared with 84.4% of criteria audited at SMUs (P = 0.0002). This difference was largely because of better adherence to documentation/QA criteria at the SMU sites. RO decision-making and protocol adherence were routinely very high and consistent with other clinical practice audits. There were no significant differences between hubs and SMUs for adherence to decision-making criteria; however, the few potential deficiencies in patient care identified occurred only at the hub sites. In at least one of these cases, potential suboptimal management was as a direct result of inadequate documentation. This audit found that SMUs provide as high a standard of radiotherapeutic care as larger hub departments. The findings also emphasize the need for all departments to target clinical documentation.     

Once-daily radiotherapy to ≥59.4 Gy versus twice-daily radiotherapy to ≥45.0 Gy with concurrent chemotherapy for limited-stage small-cell lung cancer: a comparative analysis of toxicities and outcomes

Purpose  

The aim of this study was to compare toxicities, disease control, survival outcomes, and patterns of failure between groups of limited-stage small-cell lung cancer patients treated with once-daily versus twice-daily radiotherapy and concurrent chemotherapy.     

Is the lateral radiograph necessary for the management of intra-capsular proximal femoral fractures?

AimsTo investigate if a lateral hip radiograph is always needed in the management of intra-capsular proximal femoral fractures. Furthermore, we sought to evaluate if a radiographer could accurately identify cases in which the lateral radiograph is not required.MethodsAll patients who underwent surgical management of an intra-capsular proximal femoral fracture over a 3 month period at our unit were identified. Radiographs were reviewed by 6 observers: 2 consultant orthopaedic surgeons, 2 registrars, and 2 radiographers. Initially the observers viewed the AP radiographs alone and classified the fractures into displaced, undisplaced, or unclear categories. They were then shown the lateral view and asked for a diagnosis and management plan. Comparison of diagnosis and management based on AP views alone, and AP in-combination with a lateral view was made.Results90 patients were included; the mean age was 80.8 years with a range of 42–100 years. 73 underwent arthroplasty and 17 had internal fixation. All observers, including the radiographer were able to make a surgical decision in 90% of the cases based on AP views alone. Lateral radiographs improved the diagnostic accuracy by 6%. The availability of the lateral view did not alter the management in patients where the AP clearly demonstrated a displaced fracture.ConclusionElderly patients with a displaced intra-capsular fracture identifiable on the AP do not require a lateral radiograph. Such patients can be accurately identified by the radiographer. Patient discomfort experienced during positioning for the lateral view would be avoided, and a financial saving made.     

Is the identification of in-transit sentinel lymph nodes in malignant melanoma patients really necessary?

The sentinel lymph node (SLN) is the first node in a nodal basin to receive the direct lymphatic flow from a malignant melanoma. However, in some patients, lymphoscintigraphic study reveals the presence of lymphatic nodes in the area between the primary melanoma and the regional basin. These nodes are called in-transit nodes or interval nodes and, by definition, are also SLNs. The purpose of this study was to determine the incidence and location of in-transit SLNs in patients with malignant melanoma and to assess whether it is really necessary to harvest them. The evaluation involved 600 consecutive malignant melanoma patients. Lymphoscintigraphy was performed on the day before surgery following intradermal injection of 74–111 MBq of ^99mTc-nanocolloid in four doses around the primary melanoma or the biopsy scar. Dynamic and static images were obtained and revealed SLNs in 599 out of 600 patients. The SLN was intraoperatively identified with the aid of patent blue dye and a hand-held gamma probe. Lymphoscintigraphy showed in-transit SLNs in 59/599 patients (9.8%). During surgery, all these in-transit SLNs were harvested, with those in the popliteal and epitrochlear regions being the most difficult to identify and excise. Metastatic cell deposits were subsequently identified in ten (16.9%) of these in-transit SLNs. In conclusion, lymphoscintigraphy has a key role in the identification of in-transit SLNs. Although the incidence of these nodes is relatively low in malignant melanoma patients, such SLNs present metastatic deposits in a significant percentage of cases and therefore the identification of in-transit SLNs in these patients is really necessary.     

Is intravenous contrast necessary for detection of clinically significant extracolonic findings in patients undergoing CT colonography?

Objective:

To determine whether intravenous contrast (IVC) is necessary for detection of extracolonic findings (ECFs) in patients undergoing CT colonography (CTC).

Methods:

We performed a retrospective review of CT findings in 179 cases of CTC studies performed over 18 months where both pre-contrast (NECT) and post-contrast (CECT) scans were performed in the prone and supine positions, respectively, in the same patients. All ECFs were recorded on a per patient basis and graded according to the colonography reporting and data system classification.

Results:

There was no significant change in E grade for the cohort (p = 0.171) between the NECT and CECT scans. On the CECT scans, additional findings were detected in 49.1% of patients. Overall, there were 27/179 (15.1%) patients graded E3 and 18/179 (10.1%) patients graded E4 on the CECT study. Compared with the NECT study, there was a decrease of 12.9% of patients graded E3 and no change in the number of patients graded E4.

Conclusion:

With IVC administration, additional ECFs are detected in nearly half of all patients. However, there was no increase in the number of patients with clinically significant lesions. The risk–benefit ratio of routine IVC administration for CTC in symptomatic patients thus requires further evaluation.

Advances in knowledge:

This study reviews the utility of IVC in CTC and is thus relevant to current clinical practice at many institutions.CT colonography (CTC) has emerged as an acceptable diagnostic tool for detection of colonic polyps and cancers. Numerous studies have corroborated the high sensitivity and specificity rates (>90%) in screening for large polyps.¹ Fewer studies have specifically examined the role of CTC for detection of extracolonic findings (ECFs) and the effect of these findings on subsequent patient treatment and cost.^2–8A distinct advantage of CTC over other diagnostic tests for colorectal abnormalities is the additional information provided by concomitant imaging of the extracolonic organs in the abdomen and pelvis, and, to a certain extent, the lower thorax. For example, early detection of extracolonic malignancies or metastases may make a difference to patient management and outcomes. The study by Veerappan et al³ showed that screening CTC without intravenous contrast (IVC) administration itself increased the odds of detection of high-risk lesions by 78%, half of which were ECFs. ECFs of at least moderate importance are seen in between 7% and 11% of patients.^2,4–8 Detection of these abnormalities, such as extracolonic cancers (e.g. renal cell carcinoma) and aortic aneurysms, can sometimes be beneficial.⁹The administration of IVC increases soft-tissue contrast and theoretically increases detection of ECFs. However, it has not been shown in a single patient cohort whether IVC increases detection of clinically significant ECFs in the setting of CTC. This is an important question because routine administration of IVC is not without adverse effects. These include increased cost and potential adverse events resulting from unnecessary subsequent work-up of incidentally detected ECFs. Hence, the purpose of our study was to determine whether IVC is necessary for the detection of clinically significant ECFs in patients undergoing CTC. The hypothesis of this study is that routine IVC in symptomatic patients undergoing CTC is not necessary for the detection of clinically significant ECFs.     

Do hardware artefacts influence the performance of head and neck PET scans in patients with oral cavity squamous cell cancer?

OBJECTIVE: The purpose of this study was to evaluate the influence of (68)Ge-based and CT-based attenuation correction as well as two standard image reconstruction algorithms on the appearance of artefacts due to dental hardware. Additionally, the intensity of such artefacts was compared with (18)F-fluorodeoxyglucose (FDG) uptake in patients with known oral cavity squamous cell cancer. METHODS: Thirty-two metallic and non-metallic objects used for dentistry/dental surgery were scanned in a water-bath filled with FDG on a combined PET/CT scanner. Images were reconstructed with either CT-based or (68)Ge-based transmission data and by using iterative reconstruction or filtered backprojection. The intensity of artefacts was assessed visually using a subjective scale from 0 (no artefact visible) to 4 (very strong artefact), and by quantitative measurements. In a second study, images of 30 patients with known squamous cell cancer and dental hardware were retrospectively analysed by two observers, again using a visual assessment grading system. Wilcoxon signed rank test was used for statistical comparisons. RESULTS: Eighteen of 32 objects caused artefacts, which were visible with both attenuation correction methods. CT-based attenuation correction was visually more intense than (68)Ge-based attenuation correction (P<0.0001), and the measured (18)F concentration was also higher (P=0.0002). No difference was found between the reconstruction algorithms. In 28 of 30 patients the primary tumour was visible. FDG uptake in the primary tumour was significantly higher than measured (18)F concentration in artefacts (P<0.0001). CONCLUSION: Attenuation correction of PET images generates artefacts adjacent to dental hardware that mimic FDG uptake. In this series, the primary lesion was discriminated from artefacts.     

Is the assessment of the central skeleton sufficient for osseous staging in breast cancer patients? A retrospective approach using bone scans

Objective

By analyzing bone scans we aimed to determine whether the assessment of the central skeleton is sufficient for osseous staging in breast cancer patients. This might be of interest for future staging modalities, especially positron emission tomography/computed tomography, usually sparing the peripheral extremities, as well as the skull.

Materials and methods

In this retrospective study, a total of 837 bone scans for initial staging or restaging of breast cancer were included. A total of 291 bone scans in 172 patients were positive for bone metastases. The localization and distribution of the metastases were re-evaluated by two readers in consensus. The extent of the central skeleton involvement was correlated to the incidence of peripheral metastases.

Results

In all 172 patients bone metastases were seen in the central skeleton (including the proximal third of humerus and femur). In 34 patients (19.8 %) peripheral metastases of the extremities (distally of the proximal third of humerus and femur) could be detected. Sixty-four patients (37.2 %) showed metastases of the skull. Summarizing the metastases of the distal extremities and skull, 79 patients (45.9 %) had peripheral metastases. None of the patients showed peripheral metastases without any affliction of the central skeleton. The incidence of peripheral metastases significantly correlated with the extent of central skeleton involvement (p?<?0.001).

Conclusions

Regarding bone scans, an isolated metastatic spread to the peripheral skeleton without any manifestation in the central skeleton seems to be the exception. Thus, the assessment of the central skeleton should be sufficient in osseous breast cancer staging and restaging. However, in case of central metastases, additional imaging of the periphery should be considered for staging and restaging.     

Longitudinal evaluation of patients with cancer in the oral tongue, tonsils, or base of tongue--does interstitial radiation dose affect quality of life?

PURPOSE: To evaluate health-related quality of life (HRQL) in patients with oral tongue, tonsil, or base of tongue cancer in a prospective longitudinal study and explore correlations between HRQL scores and interstitial radiation dose, dose rate, and volume of implant. METHODS AND MATERIALS: Ninety patients with oral tongue cancer (n=30) and tonsil or base of tongue cancer (n=60) were assessed with the European Organization of Research and Treatment of Cancer Quality of Life Questionnaire Core-30 and the European Organization of Research and Treatment of Cancer Head and Neck module at diagnosis, and after 3, 12, and 36 months of starting treatment. RESULTS: The HRQL of all patients decreased during treatment. Most HRQL scores returned to baseline values after 3 years; however, 60% of patients with oral tongue cancer and 80% with tonsil and base of tongue cancer reported problems with dry mouth and half of the patients with tonsil and base of tongue cancer reported problems with swallowing solid food at the 3-year followup. No correlations between brachytherapy quality indices and HRQL scores were found. CONCLUSIONS: Patients with oral tongue, tonsil, or base of tongue cancer reported significant problems with dry mouth and swallowing solid food throughout this 3-year followup study.     

Is simulation necessary for each high-dose-rate tandem and ovoid insertion in carcinoma of the cervix?

PURPOSE: To evaluate the dose variation in high-dose-rate (HDR) intracavitary brachytherapy for cancer of the cervix when treatment planning is performed prior to each applicator insertion versus when the initial plan is used for each treatment. METHODS AND MATERIALS: Fourteen patients with carcinoma of the cervix were treated with chemoradiotherapy followed by five intracavitary tandem and ovoid insertions of 600 cGy/fraction. We modified the actual plans to calculate the dose each dose point would have received using only the treatment plan created for the initial fraction. RESULTS: An increase in the percent dose to the rectum, bladder, and vaginal surface of 5%, cGy (p = 0.038), 6% (p = 0.006), and 11%, respectively, were observed when the initial treatment plan was used versus using the optimized treatment plan for each insertion. The greatest single change resulted in a percent increase of 35%, 30%, and 45% to the rectum, bladder, and vaginal surface points, respectively. CONCLUSIONS: Increased dose to at-risk structures occurred when individualized treatment planning was not performed. Since a significant increase in dose to the rectum (p = 0.038) and bladder (p = 0.006) was obtained without customized treatment planning, we continue to advocate individualized treatment planning in HDR tandem and ovoid insertions for the treatment of cervix cancer.