Proficiency-based training of medical students using virtual simulators for laparoscopy and robot-assisted surgery: results of a pilot study

Proficiency-based training has become essential in the training of surgeons such that on completion they can execute complex operations with novel surgical approaches including direct manual laparoscopic surgery (DMLS) and robotically assisted laparoscopic surgery (RALS). To this effect, several virtual reality (VR) simulators have been developed. The objective of the present study was to assess and establish proficiency gain curves for medical students on VR simulators for DMLS and RALS. Five medical students participated in training course consisting of didactic teaching and practical hands-on training with VR simulators for DMLS and RALS. Evaluation of didactic component was by questionnaire completed by participating students, who also were required to undertake selected exercises to reach proficiency at each VR simulator: (1) 12 tasks on LapSim VR (Surgical Science, Gothenburg, Sweden) for DMLS, and (2) six selected exercises on the dV-Trainer Mimic (Seattle, WA, United States). The five medical students reached the 60% threshold on the questionnaire-based didactic component. During selected hands-on simulation on VR simulators, students with previous experience with simulators (n?=?3) outperformed those without (n?=?2) in ten out of twelve LapSim tasks and all six at dV-Trainer, by requiring fewer attempts to reach proficiency although the difference was not significant (p?<?0.05). In this work, we developed a proficiency-based training program for medical undergraduates based on surgical simulation for DMLS and RALS.z. Larger studies are needed to evaluate the benefit of this program in stimulating interest for surgical career amongst medical students after the qualify.     

Radiation‐induced nausea and vomiting in head and neck cancer: Is it something worth considering in the intensity modulated radiotherapy era? “A narrative review”

Radiation therapy is one of the cornerstones in the treatment of head and neck squamous cell carcinomas (HNSCC), alone or in combination with chemotherapy or surgery. Technological advances which occurred over the last few decades have increased the efficacy of radiotherapy (RT), particularly, intensity‐modulated RT (IMRT). IMRT can deliver treatments on complex tumoral targets with dose escalation while sparing organs at risk; anyway IMRT deposits dose in unpredictable patterns outside of the target volume with the purpose of improving conformality. Radiation‐induced nausea and vomiting (RINV) is a frequent albeit neglected side effect of RT that can lead to delays in treatment with serious consequences on cure rates. According to several guidelines (MASCC 2016, NCCN 2018), RT for HNSCC has traditionally been regarded as a low emetic risk treatment. Nevertheless, several works suggest that IMRT could increase RINV. Further studies are needed to define the exact incidence and the detailed pathophysiology of RINV in patients with HNSCC treated with state of art IMRT techniques, with and without concurrent chemotherapy.     

Adoption of Expansion Margins to Reduce the Dose Received by the Coronary Arteries and the Risk of Cardiovascular Events in Lymphoma Patients

PurposeMediastinal radiation therapy (RT) in patients with lymphoma implies involuntary coronary artery (CA) exposure, resulting in an increased risk of coronary artery disease (CAD). Accurate delineation of CAs may spare them from higher RT doses. However, heart motion affects the estimation of the dose received by CAs. An expansion margin (planning organ at risk volume [PRV]), encompassing the nearby area where CAs displace, may compensate for these uncertainties, reducing CA dose and CAD risk. Our study aimed to evaluate if a planning process optimized on CA-specific PRVs, rather than just on CAs, could provide any dosimetric or clinical benefit.Methods and MaterialsForty patients receiving RT for mediastinal lymphomas were included. We contoured left main trunk, left anterior descending, left circumflex, and right coronary arteries. An isotropic PRV was then applied to all CAs, in accordance with literature data. A comparison was then performed by optimizing treatment plans either on CAs or on PRVs, to detect any difference in CA sparing in terms of maximum (D_max), median (D_med), and mean (D_mean) dose. We then investigated, through risk modeling, if any dosimetric benefit obtained with the PRV-related optimization process could translate to a lower risk of ischemic complications.ResultsPlan optimization on PRVs demonstrated a significant dose reduction (range, 7%-9%) in D_max, D_med, and D_mean for the whole coronary tree, and even higher dose reductions when vessels were located 5- to 20-mm from PTV (range, 13%-15%), especially for left main trunk and left circumflex (range, 16%-21%). This translated to a mean risk reduction of developing CAD of 12% (P < .01), which increased to 17% when CAs were located 5- to 20-mm from PTV.ConclusionsIntegration of CA-related PRVs in the optimization process reduces the dose received by CAs and translates to a meaningful prevention of CAD risk in patients with lymphoma treated with mediastinal RT.     

Radiotherapy role in non-seminomatous germ cell tumors,radiobiological and technical issues of an unexplored scenario

International Journal of Clinical Oncology - Historically, non-seminomatous germ cell tumor (NSGCT) has been considered a radio-resistant disease, excluding radiotherapy (RT) from curative...