Percutaneous CT–Guided Sympathicolysis with Radiofrequency for the Treatment of Palmar Hyperhidrosis

Purpose

To evaluate the benefits of computed tomography (CT)–guided percutaneous sympathicolysis with radiofrequency in patients with primary palmar hyperhidrosis (PPHH) in terms of safety, patient satisfaction, and short- and long-term efficacy.

Ethanolchlorobenzene dosimetry for absorbed doses below 1 kGy

The consistency of the ethanolchlorobenzene dosimetry system is demonstrated with respect to the useful dose range of the radiation-chemical response (constant value of G(HCl)) and to the analytical methods of evaluation. The radiation chemical yield in terms of G(HCl) values is constant throughout the applicable absorbed dose range 0.1–100 kGy. The investigation of analytical methods (alkalimetric titration, coulometry and oscillometry) relative to mercurimetric titration shows that consistent results can be obtained routinely within ±2.5% over this wide dose range. The importance of the calibration of oscillometric method is illustrated. A linear relationship between the radiolytical generation of HCl and the oscillometric reading makes possible the use of a simple expression for calculating the dose without relying on a calibration graph.     

Primary Care Physicians: First Stop for Exercise Advice?

Patients are urged to consult a physician before starting an exercise program, but how many do and what advice do they receive?     

Ethanol Embolotherapy for the Management of Refractory Chronic Skin Ulcers Caused by Arteriovenous Malformations

Purpose

To describe the clinical features and treatment outcomes of ethanol embolotherapy in refractory chronic skin ulcers caused by arteriovenous malformations (AVMs).

Percutaneous Ethanol Injection for Benign Cystic Thyroid Nodules: Is Aspiration of Ethanol-Mixed Fluid Advantageous?

BACKGROUND AND PURPOSE: We evaluated the differences between percutaneous ethanol injection with and without aspiration of ethanol-mixed fluid for treatment of benign cystic thyroid nodules. METHODS: We examined 60 patients with benign cystic thyroid nodules confirmed by fine-needle aspiration biopsy and divided them into 2 groups according to nonaspiration (group A, n = 30) or aspiration (group B, n = 30) of ethanol-mixed fluid after intracystic ethanol injection. We evaluated in both groups the complete disappearance of the cystic portion of the thyroid nodule on follow-up ultrasonography (first follow-up ultrasonography; mean, 4.6 months in group A; mean, 4.4 months in group B) (chi-square test), side effects or complications during and after the procedure (chi-square test), and the total procedure time (Student t test). RESULTS: Most patients showed complete disappearance of the cystic portion of the thyroid nodule (group A, n = 29; group B, n = 28), and they revealed no recurrence on follow-up ultrasonography. There was no statistical difference in the success rates between group A and group B (P > .05). Pain, the most common side effect, and other mild side effects or complications occurred in small numbers of patients in each group, but there was no significant difference in side effects or complications between the 2 groups (P > .05), except for intracystic hemorrhage (P < .05) and the complaint of all group B patients due to a double puncture (P < .001). The total procedure time was nearly double in group B than in group A because of the additional procedures, such as complete evacuation of the ethanol-mixed fluid and the 10-minute compression. CONCLUSION: Percutaneous ethanol injection without aspiration of ethanol-mixed fluid seems to be the preferable method of treatment of benign cystic thyroid nodules from the perspective of both the physician and the patient.     

CT-Guided Fine-Needle Aspiration Biopsy of Pulmonary Nodules 8 mm or Less Has a Higher Diagnostic Accuracy than Positron Emission Tomography–CT

Purpose

To compare diagnostic accuracy of CT-guided fine-needle aspiration biopsy (FNA-B) with positron emission tomography (PET)–CT for pulmonary nodules ≤ 8 mm.

Axillary irradiation omitting axillary dissection in breast cancer: is there a role for shoulder-sparing proton therapy?

The recent EORTC 10981-22023 AMAROS trial showed that axillary radiotherapy and axillary lymph node dissection provide comparable local control and reduced lymphoedema in the irradiated group. However, no significant differences between the two groups in range of motion and quality of life were reported. It has been acknowledged that axillary irradiation could have induced some toxicity, particularly shoulder function impairment. In fact, conventional breast irradiation by tangential beams has to be modified to achieve full-dose coverage of the axillary nodes, including in the treatment field a larger portion of the shoulder structures. In this scenario, alternative irradiation techniques were discussed. Compared with modern photon techniques, axillary irradiation by proton therapy has the potential for sparing the shoulder without detrimental increase of the medium-to-low doses to the other normal tissues.After the advent of conservative breast cancer therapy, morbidity of combined surgery and radiotherapy (RT) still remains a matter of debate. Since a substantial proportion of patients report moderate or marked arm and shoulder symptoms, axillary lymph node dissection (ALND) may be omitted in specific groups of patients. At least some of these patients would likely profit from regional RT.¹In the recent EORTC 10981-22023 AMAROS trial, ALND was compared with axillary radiotherapy (AxRT) in node-positive patients.² The results of the trial confirmed that both AxRT and ALND provide comparable local control and showed reduced lymphoedema in the AxRT group. However, no significant differences were observed between the two groups regarding range of motion (ROM) and quality of life. These findings raised some discussion on the potential effect of the additional irradiation produced to the shoulder''s structures by AxRT, as it was hypothesized that the dose delivered in the AxRT group counteracted the benefits expected by omitting ALND.³The magnitude of the late effects of treatment for breast cancer on shoulder function 1 year or more after diagnosis, with a focus on RT, was reviewed by Levangie and Drouin.⁴ They reviewed 10 studies (total number of patients: 1520) comparing RT with no RT or RT in a different area.Two of five studies that compared RT with no RT reported no evidence of between-group differences; the other three reported statistically significantly increased odds for various outcomes that included flexion and abduction ROM, pain and loss of mobility. All five studies that compared chest/axillary RT with chest only or no RT reported statistically significant limitations for chest/axillary treatment for outcomes that included abduction or flexion ROM, internal and external rotation and impaired mobility. Regarding RT to the axilla and chest vs RT to the chest, a relative risk of 1.7 was observed in one included study and reduced ROM in 20–49% vs 4–14% of the study population in the other included studies.In a successive review,⁵ comparing AxRT vs no AxRT, risk factors for reduced ROM in abduction, flexion and external rotation was reported at Level 1 evidence (using the Oxford Centre for Evidence-Based Medicine, 2011).The shoulder morbidity induced by AxRT is likely related to the adopted irradiation technique, as shown in Figure 1. Conventional whole-breast irradiation is performed by standard tangential fields (Figure 1a), which typically include only part of the axilla⁶ and the shoulder.⁷ Irradiation of the Level I and II axillary lymph node volumes requires significant modification of standard tangential fields to achieve adequate dose coverage in the axillary region.⁶ As a consequence of full nodal AxRT, in some patients, a large portion of shoulder structures is included in the treatment fields (Figure 1b).Open in a separate windowFigure 1.Dose distributions in axillary radiotherapy (AxRT) techniques. (a) Conventional whole-breast irradiation by tangential irradiation without full axillary coverage. (b) AxRT by modified tangential beams. (c) Shoulder-sparing AxRT by non-tangential intensity-modulated irradiation. (d) Shoulder-sparing AxRT by proton therapy. Planning target volumes of the breast (PTVb) and of the Level I–II lymph nodes (PTVn) are shown. The involved shoulder structures are indicated by black arrowheads (a–d). The reported isodoses are 95%, 60% and 40% of the prescribed dose (50 Gy).In the literature, the organ that needs to be spared to limit potential shoulder morbidity has not yet been fully clarified. In a cohort of 183 patients, significant correlations were found between shoulder joint volume receiving a dose of approximately 15 Gy and clinical end points such as arm pain, arm stiffness, swollen arm, use of arm, numbness and impaired shoulder abduction.⁸ Stubblefield, in his review,⁹ reported that any structure with tendons or neurovascular innervation traversing the field can be affected by radiation fibrosis syndrome. Neuromuscular and musculoskeletal complications can be observed even in patients typically treated by 30–36 Gy, as reported in long-term Hodgkin''s lymphoma survivors.⁹ Higher doses might increase the risk of myositis and muscle fibrosis. In the newly published ESTRO consensus for target delineation in breast cancer,¹⁰ it has been recommended to avoid inclusion in the clinical target of the scapulahumeral joint and the connective tissues around this joint.Because the AMAROS protocol was written and initiated in the late 1990s, it has been acknowledged that AxRT could have induced some toxicity in the AMAROS trial, particularly shoulder function impairment and that irradiation of the shoulder muscles can be diminished with modern irradiation techniques of the axilla.¹¹In this scenario, alternative irradiation techniques have to be discussed. Non-tangential and rotational techniques can decrease the dose to the shoulder, but at the expense of an increase of the lower doses to the other normal tissues, which might be detrimental when extensively adopted in long-term surviving patients.¹² In fact, even after conventional radiation treatment, long-term outcomes have raised concerns about increased risk of cardiac and pulmonary toxicity and increased incidence of contralateral breast cancer and other secondary malignancies. In Figure 1c, the dose distribution is obtained by non-tangential intensity-modulated radiation therapy as a compromise between shoulder sparing and normal tissues sparing. Further decreasing the medium-to-low dose to the shoulder might reduce morbidity but would increase the volume of the other normal tissues receiving the same dose.Proton therapy (PT) has the potential for sparing the shoulder in axillary irradiation (Figure 1d) without increasing the dose to other normal tissues, as proton dose deposition occurs in a defined range. The dosimetric advantage of proton radiation for the treatment of breast cancer has been demonstrated when attempting to cover regional lymph nodes,¹³ and initial clinical studies reported that PT was feasible and well tolerated.¹⁴ Furthermore, the treatment by pencil beam scanning¹⁵ markedly limits undesired neutron production, which might be highly effective in inducing second cancers.Despite substantial capital and operational costs, several proton facilities have recently opened or are in planning or construction phases. Moreover, breast PT could be delivered with limited gantry angles and limited energies/ranges, so that dedicated cheaper systems (or treatment rooms) could be developed in the future. Since breast PT will become more and more available, it could be an effective therapeutic option in axillary irradiation.In conclusion, we expect that PT can diminish the incidence of shoulder toxicity in the emerging therapeutic approach that replaces ALND with AxRT, and therefore, its evaluation should be the goal of a prospective study.     

ACR–ABS–ACNM–ASTRO–SIR–SNMMI practice parameter for selective internal radiation therapy or radioembolization for treatment of liver malignancies

PurposeThe American College of Radiology (ACR), American Brachytherapy Society (ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology (ASTRO), Society of Interventional Radiology (SIR), and Society of Nuclear Medicine and Molecular Imaging (SNMMI) have jointly developed a practice parameter on selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. Radioembolization is the embolization of the hepatic arterial supply of hepatic primary tumors or metastases with a microsphere yttrium-90 brachytherapy device.Materials and MethodsThe ACR -ABS -ACNM -ASTRO -SIR -SNMMI practice parameter for SIRT or radioembolization for treatment of liver malignancies was revised in accordance with the process described on the ACR website (https://www.acr.org/ClinicalResources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters—Interventional and Cardiovascular Radiology of the ACR Commission on Interventional and Cardiovascular, Committee on Practice Parameters and Technical Standards—Nuclear Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the Committee on Practice Parameters—Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with ABS, ACNM, ASTRO, SIR, and SNMMI.ResultsThis practice parameter is developed to serve as a tool in the appropriate application of radioembolization in the care of patients with conditions where indicated. It addresses clinical implementation of radioembolization including personnel qualifications, quality assurance standards, indications, and suggested documentation.ConclusionsThis practice parameter is a tool to guide clinical use of radioembolization. It focuses on the best practices and principles to consider when using radioemboliozation effectively. The clinical benefit and medical necessity of the treatment should be tailored to each individual patient.     

Abstracts of the Association for Radiation Research Winter Meeting,Leeds, 6–8 January 1988

Summary

A sensitive experimental design and data analysis were used to test rigorously whether the repair capacity in the skin of the mouse foot changes during a course of repeated 240 k Vp X-ray doses. Any such changes might reflect saturation or induction of repair enzymes resulting from progressive radiation damage, but most importantly this assumption of equal effect per dose fraction is central to all analyses of multiple-fraction radiation treatments, and remained to be demonstrated conclusively in skin. An X-ray dose of 2·5 Gy was given two, eight, 14 or 20 times with an interfraction interval of 8 h. Individual skin reactions for each mouse were analysed separately, giving 139 estimates of the effectiveness of 2·5 Gy (～ 35 in each of the four fractionation schedules). Regression analysis of effect per fraction versus number of fractions showed that there was no significant trend, i.e. the damage per fraction was constant regardless of the number of fractions used. The mean damage per fraction was 3·75 ± 0·15 per cent (95 per cent CL) of the full underlying damage equivalent to transient moist desquamation, and the slope of this plot was 0·0075 per cent ± 0·022 per cent (95 per cent CL) per fraction. It was concluded that the assumption of equal effect per fraction was not invalidated in mouse skin. Shorter interfraction intervals would not allow full repair between fractions, and this could be misinterpreted as a progressive loss of repair capacity in this type of experiment. This was tested in skin by giving 2·5 Gy doses two, eight and 14 times with a 1-h interfraction interval. Effect per fraction increased with number of fractions, by an extra 37 per cent from two to eight fractions and by a further 14 per cent from eight to 14 fractions, giving the illusion of loss of repair as predicted. This confirms the need to check that where loss of repair capacity is suspected, this is not due artifactually to incomplete repair between fractions in slowly repairing systems.     

CEC/AECL Workshop on Methods for Determining Differential Radiosensitivity in Humans, 7–9 September, 1988, Brighton,UK

Summary

The cytotoxic effects of X-irradiation may be delayed for many generations of replication in mammalian cells. In addition to a reduced cloning efficiency, progeny of surviving Chinese hamster ovary (CHO) cells isolated after 12–34 population doublings postirradiation showed a variety of abnormalities including lower attachment ability to culture dishes and slower cell cycle progression. When these progeny were seeded as single cells 12–23 generations after irradiation, they formed a higher fraction of abortive colonies and of non-homogeneous colonies containing giant cells. All of these characteristics were evident whether progeny cells were subcultured by trypsinization or by mitotic selection. These results suggest that residual damage may be carried by surviving progeny of irradiated cells over many mitotic cycles; this damage is eventually expressed in terms of pleomorphic changes leading to delayed reproductive failure.     

A simple quantitation method for benzoylecgonine from oral fluid, blood, and urine samples used for determining 22 illicit and licit drugs by GC–MS with liquid–liquid extraction

The analytical system used for determination of 22 illicit and licit drugs by gas chromatography–mass spectrometry following liquid–liquid extraction has been extended with an additional extraction step with n-butyl acetate:CH₂Cl₂ = 1:8 to determine benzoylecgonine from the same oral fluid, blood, or urine samples. The extraction recovery of benzoylecgonine was 39.7% for oral fluid, 14.9% for blood, and 26.7% for urine; the cutoffs were 25, 8.0, and 8.0 ng/ml, respectively. The method was fully validated and proved suitable in further proficiency tests and for analysis of 2738 oral fluid, 197 blood, and 1298 urine samples.