Genitourinary toxicity after permanent iodine-125 seed implantation: The nationwide Japanese prostate cancer outcome study of permanent iodine-125 seed implantation (J-POPS)

PurposeThe purpose of this study was to evaluate acute and late genitourinary (GU) toxicity and to elucidate factors associated with GU toxicity in patients with prostate cancer treated with permanent seed implantation (PI) enrolled in a nationwide prospective cohort study in Japan.Methods and MaterialsOf 2,354 patients enrolled in this study, GU toxicity was evaluated in 2,339 patients at 3, 12, 24, and 36 months after PI. To elucidate independent factors predictive of acute and late Common Terminology Criteria for Adverse Events Grade 2 or higher (Grade ≥2) GU toxicity, multivariate logistic regression analyses were carried out. Regarding acute urinary retention (AUR), the incidence rate and the recovery rate for AUR were estimated using the Kaplan–Meier curve.ResultsApproximately 53% of the patients treated with PI alone and 42% of those treated with combination therapy with PI therapy and external beam radiation therapy showed urinary frequency/urgency at 3 months. The multivariate analysis revealed that age, prostate volume, pretreatment international prostate symptom score, drinking status, and PI were independent predictors of acute GU toxicity Grade ≥2. Of all patients, 53 (2.3%) suffered from AUR, and 49 (92.5%) recovered from AUR with a median time of 4.3 months during the followup period.ConclusionsThe results of GU toxicity in Japanese patients who underwent low-dose-rate brachytherapy were acceptable and comparable to those previously reported in U.S. patients. The patients treated with PI alone showed a significantly higher incidence rate of GU toxicity than did those undergoing combination therapy with PI and external beam radiation therapy in the acute phase.     

Early outcomes of high-dose-rate brachytherapy combined with ultra-hypofractionated radiation in higher-risk prostate cancer

PURPOSEThis study evaluated outcomes associated with a high-dose-rate (HDR) brachytherapy boost combined with stereotactic body radiation therapy (SBRT) for patients with higher-risk localized prostate cancer.MATERIALS AND METHODSWe identified 101 patients with National Comprehensive Cancer Network high-risk, unfavorable intermediate-risk, or favorable intermediate-risk with probable extra-prostatic extension treated with HDR brachytherapy (15 Gy x 1 fraction) followed by SBRT (5 Gy x 5 daily fractions to the prostate and/or seminal vesicles and/or pelvic lymph nodes). Androgen deprivation therapy was used in 55.4% of all patients (90% of high-risk, 33% of intermediate-risk). Toxicities according to Common Terminology Criteria for Adverse Events (CTCAE) v4.0 and International Prostate Symptom Scores were prospectively documented at each followup visit. Biochemical relapse was defined as PSA nadir +2ng/mL.RESULTSThe median follow-up time after SBRT was 24.1 months. No grade ≥3 toxicities were observed. The incidence of acute and late grade 2 gastrointestinal toxicities was both 0.99%. Acute and late grade 2 genitourinary (GU) toxicities were observed in 5.9% and 9.9%, respectively. Median time to a grade 2 GU toxicity was 6 months with a 14% 2-year actuarial rate of grade 2 GU toxicity. Median International Prostate Symptom Scores at 24 months was not significantly different than baseline (6 vs. 5; p = 0.24). Inclusion of pelvic lymph nodes and absence of a rectal spacer were significantly associated with more frequent grade ≥1 GU toxicity, but not grade ≥2 GU or gastrointestinal toxicity. The 2-year biochemical relapse free survival was 97%.CONCLUSIONSHDR brachytherapy combined with SBRT was associated with a favorable early toxicity profile and encouraging cancer control outcomes.     

Moderate hypofractionation and simultaneous integrated boost with volumetric modulated arc therapy (RapidArc) for prostate cancer

Purpose

In the present study, the acute toxicity profiles for prostate patients treated with simultaneous integrated boost (SIB) with volumetric modulated arcs in a hypofractionated regime are reported.

Patients and methods

A total of 70?patients treated with RapidArc between May 2010 and September 2011 were retrospectively evaluated. Patients were stratified into low (36%), intermediate (49%), and high-risk (16%) groups. Target volumes (expanded to define the planning volumes (PTV)) were clinical target volume (CTV) 1: prostate; CTV2: CTV1 + seminal vesicles; CTV3: CTV2 + pelvic nodes. Low-risk patients received 71.4?Gy to PTV1; intermediate-risk 74.2?Gy to PTV1 and 61.6 or 65.5?Gy to PTV2; high-risk 74.2?Gy to PTV1, 61.6 or 65.5?Gy to PTV2, and 51.8?Gy to PTV3. All treatments were in 28?fractions. The median follow-up was 11?months (range 3.5–23?months). The acute rectal, gastrointestinal (GI) and genitourinary (GU) toxicities were scored according to EORTC/RTOG scales.

Results

Acute toxicities were recorded for the GU [G0?=?31/70 (44%), G1?=?22/70 (31%); G2?=?16/70 (23%); G3?=?1/70 (1%)], the rectum [G0?=?46/70 (66%); G1?=?12/70 (17%); G2?=?12/70 (17%); no G3], and the GI [G0?=?54/69 (77%); G1?=?11/69 (16%); G2?=?4/69 (6%); no G3]. Median time to rectal, GU, and GI toxicities were 27, 30, and 33 days, respectively. Only the GI toxicity correlated with stage and pelvic irradiation. Univariate analysis presented significant correlations between GI toxicity and intestinal irradiation (V_50?Gy and V_60?Gy). In the multivariate analysis, the only significant dosimetric variable was V_50?Gy for the intestinal cavity.

Conclusion

Moderate hypofractionation with SIB and RapidArc was shown to be safe, with acceptable acute toxicity. Longer follow-up is needed to assess late toxicity and clinical outcome.     

Reduced rectal toxicity with ultrasound-based image guided radiotherapy using BAT™ (B-mode acquisition and targeting system) for prostate cancer

Purpose

To evaluate the effect of image guided radiotherapy with stereotactic ultrasound BAT (B-mode acquisition and targeting system) on rectal toxicity in conformal radiotherapy of prostate cancer.

Patients and Methods

42 sequential patients with prostate cancer undergoing radiotherapy before and after the introduction of BAT were included. Planning computed tomography (CT) was performed with empty rectum and moderately filled bladder. The planning target volume (PTV) included the prostate and seminal vesicles with a safety margin of 1.5 cm in anterior and lateral direction. In posterior direction the anterior 1/3 of the rectum circumference were included. Total dose was 66 Gy and a boost of 4 Gy excluding the seminal vesicles. 22 patients (BAT group) were treated with daily stereotactic ultrasound positioning, for the other 20 patients (NoBAT group) an EPID (electronic portal imaging device) was performed once a week. Acute and late genito-urinary (GU) and rectal toxicity and PSA values were evaluated after 1.5, 3, 6, 9 and 12 months. The total median follow up of toxicity was 3 years in the BAT group and 4 years in the NoBAT group.

Results

In the NoBAT group significant more rectal toxicity occurred, while in GU toxicity no difference was seen. Two patients in the NoBAT group showed late rectal toxicity grade 3, no toxicity > grade 2 occurred in the BAT group. There was no significant difference in PSA reduction between the groups.

Conclusion

Without BAT significant more acute and a trend to more late rectal toxicity was found. With regard to dose escalation this aspect is currently evaluated with a larger number of patients using intensity-modulated radiotherapy (IMRT).     

Toxicity and early treatment outcomes in low- and intermediate-risk prostate cancer managed by high-dose-rate brachytherapy as a monotherapy

PurposeTo determine the acute and late genitourinary (GU) and gastrointestinal (GI) toxicity and present short-term biochemical no evidence of disease (bNED) rates after high-dose-rate brachytherapy (HDR-B) monotherapy.Methods and MaterialsBetween October 2003 and June 2006, 36 patients with low (28) and intermediate (8) risk prostate cancer (PCA) were treated by HDR-B monotherapy. All patients received one implant and four fractions of 9.5 Gy within 48 h for a total prescribed dose (PD) of 38 Gy. Five patients received hormonal therapy (HT). Median age was 63.5 years and median followup was 3 years (range, 0.4–4 years). Toxicity was scored according to the CTCAE version 3.0. Biochemical failure was defined according to the Phoenix criteria.ResultsAcute and late Grade 3 GU toxicity was observed in 1 (3%) and 4 (11%) patients, respectively. Grade 3 GI toxicity was absent. The three- year bNED survival rate was 100%. The sexual preservation rate in patients without HT was 75%. Late Grade 3 GU toxicity was associated with the planning target volume (PTV) V₁₀₀ (% PTV receiving ≥100% of the PD; p = 0.036), D₉₀ (dose delivered to 90% of the PTV; p = 0.02), and the urethral V₁₂₀ (urethral volume receiving ≥120% of the PD; p = 0.043). The urethral V₁₂₀ was associated with increased PTV V₁₀₀ (p < 0.001) and D₉₀ (p = 0.003).ConclusionsAfter HDR-B monotherapy, late Grade 3 GU toxicity is associated with the urethral V₁₂₀ and the V₁₀₀ and D₉₀ of the PTV. Decrease of the irradiated urethral volume may reduce the GU toxicity and potentially improve the therapeutic ratio of this treatment.     

Magnetic resonance image-guided adaptive stereotactic body radiotherapy for prostate cancer: preliminary results of outcome and toxicity

Objective:Using moderate or ultra-hypofractionation, which is also known as stereotactic body radiotherapy (SBRT) for treatment of localized prostate cancer patients has been increased. We present our preliminary results on the clinical utilization of MRI-guided adaptive radiotherapy (MRgRT) for prostate cancer patients with the workflow, dosimetric parameters, toxicities and prostate-specific antigen (PSA) response.Methods:50 prostate cancer patients treated with ultra-hypofractionation were included in the study. Treatment was performed with intensity-modulated radiation therapy (step and shoot) technique and daily plan adaptation using MRgRT. The SBRT consisted of 36.25 Gy in 5 fractions with a 7.25 Gy fraction size. The time for workflow steps was documented. Patients were followed for the acute and late toxicities and PSA response.Results:The median follow-up for our cohort was 10 months (range between 3 and 29 months). The median age was 73.5 years (range between 50 and 84 years). MRgRT was well tolerated by all patients. Acute genitourinary (GU) toxicity rate of Grade 1 and Grade 2 was 28 and 36%, respectively. Only 6% of patients had acute Grade 1 gastrointestinal (GI) toxicity and there was no Grade ≥ 2 GI toxicity. To date, late Grade 1 GU toxicity was experienced by 24% of patients, 2% of patients experienced Grade 2 GU toxicity and 6% of patients reported Grade 2 GI toxicity. Due to the short follow-up, PSA nadir has not been reached yet in our cohort.Conclusion:In conclusion, MRgRT represents a new method for delivering SBRT with markerless soft tissue visualization, online adaptive planning and real-time tracking. Our study suggests that ultra-hypofractionation has an acceptable acute and very low late toxicity profile.Advances in knowledge:MRgRT represents a new markerless method for delivering SBRT for localized prostate cancer providing online adaptive planning and real-time tracking and acute and late toxicity profile is acceptable.     

Intracranial carotid artery calcification on head CT and its association with ischemic changes on brain MRI in patients presenting with stroke-like symptoms: retrospective analysis

Introduction Our purpose was to study the association between the intracranial arterial calcifications observed on head CT and brain infarcts demonstrated by MRI in patients presenting with acute stroke symptoms. Methods Institutional review board approval was obtained for this retrospective study which included 65 consecutive patients presenting acutely who had both head CT and MRI. Arterial calcifications of the vertebrobasilar system and the intracranial cavernous carotid arteries (intracranial carotid artery calcification, ICAC) were assigned a number (1 to 4) in the bone window images from CT scans. These four groups were then combined into high calcium (grades 3 and 4) and low calcium (grades 1 and 2) subgroups. Brain MRI was independently evaluated to identify acute and chronic large-vessel infarcts (LVI) and small-vessel infarcts (SVI). The relationship between ICAC and infarcts was evaluated before and after adjusting for demographics and cardiovascular risk factors. Results Statistical analysis could not be performed for the vertebrobasilar system due to an insufficient number of patients in the high calcium group. Of the 65 patients, 46 (71%) had a high ICAC grade on head CT. They were older and had a higher prevalence of cardiovascular risk factors. Acute SVI (P = 0.006), chronic SVI (P = 0.006) and acute LVI (P = 0.04) were associated with a high ICAC grade. After adjustment for age and other risk factors, only acute SVI was associated with a high ICAC grade (P = 0.002). Conclusion Although age emerged as the most important determinant of ischemic cerebral changes, there were rather complex interactions among multiple risk factors with different infarct types. A high ICAC grade demonstrated a correlation with acute SVI in our patients independent of these risk factors.     

Intraparenchymal Doppler ultrasound after proximal embolization of the splenic artery in trauma patients

We studied the changes in proximal embolization of the splenic artery to the intraparenchymal blood flow with Doppler ultrasound. Seventeen trauma patients with spleen injury OIS grade 2–5 underwent embolization of the splenic artery. Peak-systolic velocity (PSV) and end-diastolic velocity (EDV) were measured in intrasplenic arteries initially 1 day after embolization, at early follow-up after 7 days, at intermediate follow-up after 10 weeks, and at late follow-up after 10 months. Resistance index (RI), systolic/diastolic ratio (S/D ratio), acceleration (AC), and acceleration time (AT) were calculated. The results were compared to values from 17 volunteers. RI increased from 0.39 initially to 0.49 (P = 0.002) at intermediate and to 0.52 (P < 0.001) at late follow-up. S/D ratio increased from 1.68 initially to 1.99 (P = 0.002) and to 2.10 (P < 0.001) at intermediate and late follow-up, respectively. Follow-up results of RI and S/D ratio differed significantly from the reference group. AC increased from 1.06 m/s² initially to 1.89 m/s² at late follow-up (P = 0.01). AC at late follow-up was not different from reference group (2.33 m/s²). In conclusion, Doppler ultrasound is a useful tool in the evaluation of improvable intraparenchymal blood flow over time after central splenic artery embolization.     

FDG PET as a predictor of response to resynchronisation therapy in patients with ischaemic cardiomyopathy

Purpose Although resynchronisation therapy (CRT) is a promising addition to heart failure therapy, a substantial number of patients do not respond to CRT. As FDG PET has routinely been used for prediction of improvement after revascularisation in ischaemic cardiomyopathy, it was hypothesised that there is also a relationship between the extent of viable tissue and improvement as a result of CRT. Methods Thirty-nine patients with ischaemic cardiomyopathy (ejection fraction 27 ± 9%) and a wide QRS complex underwent temporary pacing to determine the optimal pacing combination, i.e. that with the highest increase in cardiac index (CI) compared with baseline (measured by Doppler echocardiography). All patients also underwent FDG PET imaging. In 19 patients, CI measurements were repeated 10–12 weeks after permanent biventricular pacemaker implantation. Results Echocardiography (13-segment model) showed a mean of 9.8 ± 1.6 dyssynergic segments, with preserved FDG uptake in 4.1 ± 2.4 segments. CI improvement at the optimal pacing site was 20 ± 9%. There was a linear relationship between the extent of viable tissue and CI improvement during pacing (p < 0.001). Using a cut-off value of more than three viable segments (ROC analysis), FDG PET had a sensitivity of 72% and a specificity of 71% for detection of the presence of haemodynamic improvement (i.e. a CI improvement >15%). The relation between CI improvement and viable tissue was similar at follow-up. Conclusion A correlation was found between the extent of viable tissue and the haemodynamic response to CRT in patients with ischaemic cardiomyopathy, suggesting that FDG PET imaging may be useful to discriminate between responders and non-responders to CRT.     

MRI evaluation of anterior knee pain: predicting response to nonoperative treatment

Objective  Tibial tubercle lateral deviation and patellofemoral chondromalacia are associated with anterior knee pain (AKP). We hypothesized that increased tibial tubercle lateral deviation and patellofemoral chondromalacia on magnetic resonance imaging correlates with the presence of AKP and with failure of nonoperative management. Materials and methods  In this retrospective comparative study, a blinded musculoskeletal radiologist measured tibial tubercle lateral deviation relative to the trochlear groove in 15 controls, 15 physical therapy responders with AKP, and 15 physical therapy nonresponders with AKP. Patellar and trochlear cartilage was assessed for signal abnormality, irregularity, and defects. Results  The mean tibial tubercle lateral deviation in controls, physical therapy responders, and physical therapy nonresponders were 9.32 ± 0.68, 13.01 ± 0.82, and 16.07 ± 1.16 mm, respectively (data are mean ± standard deviation). The correlation coefficients for tubercle deviation, chondromalacia patellae, and trochlear chondromalacia were 0.51 (P < 0.01), 0.44 (P < 0.01), and 0.28 (P < 0.05), respectively. On analysis of variance, tubercle deviation and chondromalacia patellae contributed significantly to prediction of AKP and response to physical therapy. The presence of chondromalacia patellae and a tubercle deviation greater than 14.6 mm is 100% specific and 67% sensitive with a positive predictive value of 100% and negative predictive value of 75% for failure of nonoperative management. Conclusion  Subjects with AKP have more laterally positioned tibial tubercles and are more likely to have patellar chondromalacia. Patients with AKP, chondromalacia patellae, and a tubercle deviation greater than 14.6 mm are unlikely to respond to nonoperative treatment. Knowledge of tibial tubercle lateralization and presence of chondromalacia patellae may assist clinicians in determining patient prognosis and selecting treatment options.     

Feasibility of IMRT to Cover Pelvic Nodes While Escalating the Dose to the Prostate Gland: Dosimetric Data on 35 Consecutive Patients

Utilizing available dosimetric and acute toxicity data, we confirm the feasibility of intensity modulated radiotherapy (IMRT) to include treatment of the pelvic nodes (PN) while escalating the dose to the prostate. Data were obtained from 35 consecutive patients with prostate cancer with ≥15% risk of PN involvement. Patients received an initial boost to the prostate, delivering 16 Gy over 8 fractions using a 6-field conformal technique, followed by an 8-field coplanar inverse planning IMRT technique delivering an additional 60 Gy over 30 fractions to the prostate (76 Gy total) and 54 Gy over 30 fractions to the seminal vesicles (SV) and PN. Dose-volume histogram analysis was performed for planning target volumes and organs at risk. Acute toxicity (RTOG/EORTC scale) was prospectively and independently scored weekly for each patient. The maximum, mean, minimum dose, and D95 to each planning target volume is provided: prostate (82.2, 78.2, 72.6, 75.2 Gy), SV (79.0, 72.5, 56.9, 61.1 Gy), and PN (80.4, 59.7, 46.5, 53.3 Gy), respectively. The percent volume receiving a dose at or above “x” Gy (Vx) was recorded for V75, V70, V65, V60, and V50 as: bladder (14%, 24%, 32%, 39%, and 54%) and rectum (3%, 18%, 26%, 34%, and 51%), respectively. Acute toxicity was as follows: 54% grade 2+ GI (n = 19), 25% grade 2+ GU (n = 9). IMRT enables treatment of pelvic nodes while escalating dose to the prostate and is clinically feasible with acute toxicity within expected ranges.     

Determinants and impact of microvascular obstruction in successfully reperfused ST-segment elevation myocardial infarction. Assessment by magnetic resonance imaging

Microvascular obstruction (MVO) is an important and independent determinant of post-infarct remodeling. Fifty-two patients with a successfully reperfused ST-segment elevation acute myocardial infarction (MI) were studied with MRI in the first week and at 4 months post-infarction. On early (i.e., 2–5 min) post-contrast MRI, MVO was detected in 32 patients with an MVO to infarct ratio of 36.3 ± 24.9%. On late (i.e., 10–25 min) post-contrast MRI, MVO was detected in only 27 patients, with an MVO to infarct ratio of 15.9 ± 13.9%. MVO infarcts (n = 32) were associated with higher cardiac enzymes (troponin I, P = 0.016), and lower pre-revascularization thrombolysis in myocardial infarction (TIMI) flow (P = 0.018) than non-MVO infarcts (n = 20). Infarct size was larger in MVO infarcts (25.0 ± 14.3 g) than non-MVO infarcts (12.5 ± 7.9 g), P = 0.0007. Systolic wall thickening in the infarct and peri-infarct area, and left ventricular (LV) ejection fraction (EF) were worse in MVO (46.1 ± 7.2%) than non-MVO infarcts (50.5 ± 6.6%, P = 0.038). At 4 months, MVO infarcts showed more adverse remodeling and lack of functional improvement, whereas non-MVO infarcts improved significantly (LV EF at 4 months, MVO, 47.5 ± 7.8%, P = 0.31; non-MVO, 55.2 ± 10.3%, P = 0.0028). In the majority of patients with successfully reperfused ST-segment elevation MI, MVO is observed, whose present and maximal extent can be best evaluated on early post-contrast MRI. Presence of MVO is associated with more extensive infarctions, and characterized by greater adverse LV remodeling and lack of functional recovery.     

Emergency MRI of acute pelvic pain: MR protocol with no oral contrast

The aim of this study was to evaluate the efficacy of magnetic resonance (MR) without oral contrast in the assessment of suspected acute pathologies of the pelvis in pregnant and non-pregnant patients. Sixty-seven patients who had MR of the lower abdomen and pelvis for acute abdomen were included in the study. The MR examinations were evaluated for indication of the study, type of MR sequences, and sensitivity of MR in diagnosing the disease. T2 single shot fast spin echo (SS-FSE), T2 FSE, short tau inversion recovery, pre-gadolinium T1, and post-gadolinium T1 sequences were utilized. There were 30 pregnant and two postpartum women in the study group. Positive pelvic MR findings were seen in 73% (49/67). Final diagnoses were acute appendicitis (n = 12), ovarian torsion (n = 6), abscess (n = 3), tubo-ovarian abscess (n = 2), ovarian tumor (n = 2), degenerating fibroid (n = 3), and perianal fistula (n = 2). For acute appendicitis, sensitivity was 100% (12/12), and positive predictive value was 92% (12/13). Post-gadolinium T1-weighted sequences and T2 SS-FSE with FS were the sequences, which were most likely to best demonstrate the acute appendicitis. For ovarian torsion, the sensitivity was 86% (6/7), and positive predictive value was 100% (6/6). MR imaging is an efficacious means of diagnosing acute appendicitis, ovarian torsions, and other adnexal diseases in the acute setting. The four sequence protocol without oral contrast offers an excellent means of investigating the cause of acute lower abdominal and pelvic pain.     

Radioguided sentinel lymph node dissection in patients with localised prostate carcinoma: influence of the dose of radiolabelled colloid to avoid failure of the procedure

Introduction The purpose of this study was to determine the role of the injected dose of tracer in the non-detection of pelvic sentinel lymph nodes (SLN) in patients with prostate carcinoma. Methods Data were evaluated from 100 patients (age range 43–77, mean 63 years). The first 72 patients (group 1) received 2 × 0.3 ml of 30 MBq-nanocolloid-99 mTc and the remaining 28 patients (group 2) received 2 × 0.3 ml of 100 MBq. Surgery consisted of the detection and dissection of lymph nodes identified as sentinel nodes, followed by an extended lymphadenectomy. Results SLNs were located in the interiliac group in 54.2% of patients, in the obturator fossa in 30.7%, in the external iliac group in 10.9% and in the common iliac group in 4.2% of cases. Lymph node involvement was observed in 12% of patients. But there was a 30.6% (22/72) failure rate of the SLN procedure in group 1 and 7.1% (2/28) in group 2. An increased risk of unsuccessful SLN procedure was statistically associated with the low dose of MBq-nanocolloids (p < 0.017). Statistical correlation is also found after the exclusion of the first 30 patients from the study (learning phase of the team) (p < 0.034). None of the other parameters showed a statistical association (age, p < 0.9; Gleason score, p < 0.3; grade pT, p < 0.7). A higher grade or a greater extension of cancer inside the prostate are not responsible for the failure of the SLN procedure. Conclusion It seems necessary to inject at least 200 MBq inside the prostate to avoid a failed SLN procedure.     

Concurrent chemoradiotherapy with gemcitabine plus regional hyperthermia for locally advanced pancreatic carcinoma: initial experience

Purpose  The aim of this study was to evaluate the efficacy and toxicity of concurrent chemoradiotherapy (CRT) with gemcitabine plus regional hyperthermia (HT) for locally advanced pancreatic carcinoma (LAPC). Materials and methods  A total of 29 patients with LAPC treated with concurrent CRT using gemcitabine were retrospectively analyzed. Radiotherapy was administered with a median total dose of 61.2 Gy. Of the 29 patients, 20 (69%) also underwent regional HT during CRT (CRHT group). The remaining 9 patients did not receive regional HT (CRT group) because of a common bile duct stent placement, patient refusal, older age, or obesity. The efficacy and toxicity of the treatments and the predictors of good outcome were evaluated. Results  The median disease progression-free and overall survival times were significantly better for the CRHT group than for the CRT group (8.8 vs. 4.9 months, P = 0.02, and 18.6 vs. 9.6 months, P = 0.01), respectively. Grade 3–4 hematological toxicities for the CRHT group were detected in eight patients (40%) and grade 3 nonhematologic toxicity in one (diarrhea). Conclusion  Concurrent CRT using gemcitabine with regional HT may be a feasible and promising regimen for LAPC, and the results justified further evaluation in a large number of patients to confirm its definite benefit.     

High-dose-rate interstitial brachytherapy as monotherapy in one fraction and transperineal hyaluronic acid injection into the perirectal fat for the treatment of favorable stage prostate cancer: treatment description and preliminary results

PurposeTo evaluate the technical feasibility, acute and late genitourinary (GU) toxicity, and gastrointestinal toxicity after high-dose-rate (HDR) brachytherapy as monotherapy in one fraction with transperineal hyaluronic acid injection into the perirectal fat to displace the rectal wall away from the radiation sources to decrease rectal toxicity.Methods and MaterialsBetween April 2008 and January 2010, 40 consecutive patients were treated with favorable clinically localized prostate cancer; the median followup was 19 months (range, 8–32). No patients received external beam radiation, and 35% received hormone therapy before brachytherapy. All patients received one implant and one fraction of HDR. Fraction dose was 19 Gy. Toxicity was reported according to the Common Toxicity Criteria for Adverse Event, Version 4.0.ResultsAll patients tolerated the implantation procedure very well with minimal discomfort. No intraoperative or perioperative complications occurred. Acute toxicity Grade 2 or more was not observed in any patients. No chronic toxicity has been observed after treatment. Logistic regression showed that the late Grade 1 GU toxicity was associated with D₉₀ (p = 0.050). The 32-month actuarial biochemical control was 100% and 88%, respectively (p = 0.06) for low- and intermediate-risk groups.ConclusionsThis is the first published report of the use of HDR brachytherapy as monotherapy in one fraction for patients with favorable-risk prostate cancer. This protocol is feasible and very well tolerated with low GU morbidity, no gastrointestinal toxicity, and the same level of low-dose-rate biochemical control at 32 months.     

Predictive CT findings of malignancy in ground-glass nodules on thin-section chest CT: the effects on radiologist performance

Our purpose was to identify thin-section chest computed tomography (CT) findings of malignancy other than the presence of a solid portion within ground-glass nodules (GGNs) and to evaluate whether the radiologists’ performance in determining malignancy can be enhanced with this information. The predictive CT findings of malignancy extracted from the CT findings of 80 GGNs (47 malignant, 33 benign) were a size of >8 mm [odds ratio (OR), 10.930; P = 0.045] and a lobulated border (OR, 13.769; P = 0.016) for pure GGNs and a lobulated border (OR, 10.200; P = 0.024) for mixed GGNs. Four chest radiologists and five radiology residents participated in the observer performance study with CT of 130 GGNs (67 malignant, 63 benign). Receiver-operating characteristic (ROC) analysis was used to compare radiologists’ performances before and after providing these predictive findings. For pure GGNs, mean areas under the curve (A_z) of all readers without and with CT predictive information were significantly different (0.621 ± 0.052 and 0.766 ± 0.055, P < 0.05). For mixed GGNs, the A_z values achieved without and with predictive information were not significantly different (0.727 ± 0.064 and 0.764 ± 0.056, P > 0.05). Information about lesion size and morphological characteristics can enhance radiologists’ performance in determining malignancy of pure GGNs.     

Detection and characteristics of microvascular obstruction in reperfused acute myocardial infarction using an optimized protocol for contrast-enhanced cardiovascular magnetic resonance imaging

Several cardiovascular magnetic resonance imaging (CMR) techniques are used to detect microvascular obstruction (MVO) after acute myocardial infarction (AMI). To determine the prevalence of MVO and gain more insight into the dynamic changes in appearance of MVO, we studied 84 consecutive patients with a reperfused AMI on average 5 and 104 days after admission, using an optimised single breath-hold 3D inversion recovery gradient echo pulse sequence (IR-GRE) protocol. Early MVO (2 min post-contrast) was detected in 53 patients (63%) and late MVO (10 min post-contrast) in 45 patients (54%; p = 0.008). The extent of MVO decreased from early to late imaging (4.3 ± 3.2% vs. 1.8 ± 1.8%, p < 0.001) and showed a heterogeneous pattern. At baseline, patients without MVO (early and late) had a higher left ventricular ejection fraction (LVEF) than patients with persistent late MVO (56 ± 7% vs. 48 ± 7%, p < 0.001) and LVEF was intermediate in patients with early MVO but late MVO disappearance (54 ± 6%). During follow-up, LVEF improved in all three subgroups but remained intermediate in patients with late MVO disappearance. This optimised single breath-hold 3D IR-GRE technique for imaging MVO early and late after contrast administration is fast, accurate and allows detection of patients with intermediate remodelling at follow-up.     

Gray-scale and color Doppler ultrasonographic evaluation of reactivated post-traumatic/postoperative chronic osteomyelitis

Objective  We aimed to carry out a systematic assessment of gray-scale and color Doppler ultrasonography (CDUS) findings of reactivated post-traumatic/postoperative chronic osteomyelitis (COM) in adults. Materials and methods  Gray-scale and color Doppler ultrasonography were performed on 40 consecutive patients with a history of long-standing post-traumatic/post-operative chronic osteomyelitis and clinical suggestion of reactivation, in a 32-month-period. All patients had metallic implants: 16 internal fixations, nine external fixations, 11 hip arthroplasties and four knee arthroplasties. The final diagnosis of reactivated COM was based upon biopsy findings, with microbiological and histological examination (n = 27), or a combination of laboratory, clinical and magnetic resonance (MR) findings (n = 13). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of sonographic signs, including fistulous tracts, periosteal thickening, cortical discontinuity, soft tissue abscess and cellulitis, juxtacortical fluid, distension of the pseudocapsule in arthroplasties, and periosteal vascularity, were estimated. Results  Statistically significant differences between patients with and without reactivated COM were found for fistulous tracts (P < 0.0001), juxtacortical fluid collections (P < 0.001) periosteal thickening (P < 0.01), distension of pseudocapsule (P < 0.05), and periosteal vascularity (P < 0.0001). Low-resistance arterial flow of periosteal vessels presented the highest sensitivity (92%), specificity, and PPV (100%), yielding only two false negative results in two obese patients. Among gray-scale findings, the presence of a fistulous tract yielded the highest specificity and PPV (100%), whereas periosteal thickening was the most sensitive (92%), though not specific, finding (specificity 50%). Conclusion  A constellation of gray-scale and CDUS findings can be highly indicative of reactivated bone infection in patients with long-standing chronic post-traumatic/post-operative osteomyelitis.     

Infarct size in primary angioplasty without on-site cardiac surgical backup versus transferal to a tertiary center: a single photon emission computed tomography study

Background  Primary percutaneous coronary intervention (PCI) performed in large community hospitals without cardiac surgery back-up facilities (off-site) reduces door-to-balloon time compared with emergency transferal to tertiary interventional centers (on-site). The present study was performed to explore whether off-site PCI for acute myocardial infarction results in reduced infarct size. Methods and results  One hundred twenty-eight patients with acute ST-segment elevation myocardial infarction were randomly assigned to undergo primary PCI at the off-site center (n = 68) or to transferal to an on-site center (n = 60). Three days after PCI, ^99mTc-sestamibi SPECT was performed to estimate infarct size. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 ± 54 versus 125 ± 59 min, respectively, p < 0.01), although symptoms-to-treatment time was only insignificantly reduced (257 ± 211 versus 286 ± 146 min, respectively, p = 0.39). Infarct size was comparable between treatment centers (16 ± 15 versus 14 ± 12%, respectively p = 0.35). Multivariate analysis revealed that TIMI 0/1 flow grade at initial coronary angiography (OR 3.125, 95% CI 1.17–8.33, p = 0.023), anterior wall localization of the myocardial infarction (OR 3.44, 95% CI 1.38–8.55, p < 0.01), and development of pathological Q-waves (OR 5.07, 95% CI 2.10–12.25, p < 0.01) were independent predictors of an infarct size > 12%. Conclusions  Off-site PCI reduces door-to-balloon time compared with transferal to a remote on-site interventional center but does not reduce infarct size. Instead, pre-PCI TIMI 0/1 flow, anterior wall infarct localization, and development of Q-waves are more important predictors of infarct size.