Craniospinal Axis Irradiation in Children Treatment in Supine Position Including Field Verification as a Prerequisite for Anesthesia without Intubation

Purpose: For craniospinal axis irradiation in young children sometimes anesthesia is required. In order to minimize risks from the anesthesist's point of view supine position would be preferable to standard prone position. In case of irradiation in supine position verification of the 3-field junction in the cervical region causes problems, because there is no direct visual control. For such situations the clinical application of a new technique is presented. Patients and Methods: For treatment planning a modern 3D planning system was necessary. Patient's positioning was done by using a vacuum-form body immobilizer and an integrated head mask. Radiation fields were placed only by table movements being calculated by the planning system in relation to a reference point at the patient's surface. In addition to common verification films specially prepared small films were used for the 3-field junction in the cervical region. These films were placed close to the patient for the whole time of each radiation session being exposed by every radiation field. Results: Two children (age 3 and 5 years, respectively) were irradiated as described. Twenty-eight of those specially prepared films were exposed. Two films (7%) had to be excluded because of inadequate exposure. An overlap of radation fields was seen on 1 of the 26 remaining films (4%), whereas an unacceptable gap was not found. Acute skin reactions were comparable to those observed in patients beeing irradiated in standard prone position. Conclusion: The presented technique for craniospinal axis irradiation in supine position including field verification was not only precise and reproducable, but also comfortable and safe for the patient. We suggest it as a new option for craniospinal axis irradiation in children. Hintergrund: Für die Durchführung einer Neuroachsenbestrahlung bei Kleinkindern ist mitunter eine Narkose erforderlich. Aus anästhesiologischer Sicht wäre zur Minimierung entsprechender Risiken eine Bestrahlung in Rückenlage statt der üblicherweise durchgeführten Bestrahlung in Bauchlage wünschenswert. Bei der Bestrahlung in Rückenlage stellt die Verifikation der drei Felder im Halsbereich ein besonderes Problem dar, da eine direkte visuelle Kontrolle fehlt. Die klinische Anwendung einer neuen Technik für derartige Situationen wird präsentiert. Patienten und Methode: Zur Bestrahlungsplanung war ein modernes 3D-Planungssystem erforderlich. Bei der Lagerung des Patienten wurden zur Immobilisation ein Vakuumkissen und eine Kopfmaske verwendet. Die Positionierung der Bestrahlungsfelder erfolgte ausschließlich anhand des vom Planungssystem in Relation zu einem Referenzpunkt an der Hautoberfläche des Patienten berechneten Tischversatzes. Zusätzlich zu den üblichen Verifikationsfilmen wurden speziell präparierte, kleine Filme im Ansatzbereich der drei Felder in der Halsregion verwendet. Diese Filme wurden während der gesamten Dauer einer jeden Bestrahlung direkt am Patienten belassen und von allen drei Bestrahlungsfeldern b elichtet. Ergebnisse: Zwei Kinder (drei und fünf Jahre alt) wurden in der genannten Weise bestrahlt. 28 der speziell präparierten Filme wurden belichtet. Zwei dieser Filme (7%) waren aufgrund inadäquater Belichtung nicht verwertbar. Auf einem der verbleibenden 26 Filme (2%) war eine Feldüberlappung erkennbar, ein zu großer Abstand zwischen den Bestrahlungsfeldern zeigte sich hingegen nicht. Die beobachtete aktuten Toxizitäten im Bereich der Haut waren vergleichbar mit den akuten Hautreaktionen bei in Bauchlage bestrahlten Patienten. Schlußfolgerung: Die dargestellte Methode der Neuroachsenbestrahlung in Rückenlage inklusive der Feldverifikation erwies sich nicht nur als präzise und reproduzierbar, sondern darüber hinaus als bequem und sicher für den Patienten. Sie kann als eine neue Möglichkeit für die Neuroachsenbestrahlung bei Kindern angesehen werden.     

Effectiveness of Hypofractionated Radiotherapy in Painful Bone Metastases Two Prospective Studies with 1 × 4 Gy and 4 × 4 Gy

Background: Although effectiveness of fractionated radiotherapy for painful bone metastases is well documented, there are unanswered questions regarding the adequacy of low-dose short radiation schedules for long-term pain control which give maximum benefit in patients with a short life expectancy. Patients and Methods: Two consecutive non-randomized prospective follow-up studies were performed at a single institution to analyze pain response and duration of response in patients with a variety of primary tumors. Included were only patients with symptomatic nonvertebral bone metastases and without impending pathologic fracture. Forty-five patients received 1 2 4 Gy to 50 different sites (group I) while 86 patients received 4 2 4 Gy to 96 sites (group II). Pain relief to irradiation was evaluated according to patient interviews using a 4-point categorical scale. Follow-up was performed 7 and 90 days after radiotherapy. Results: Pain relief after 4 2 4 Gy was significantly superior to 1 2 4 Gy with pain control rates being 86.5% vs 48% at day 7 (after end of treatment) and 80% vs 55% at day 90, respectively. A subgroup analysis of patients treated with 4 2 4 Gy demonstrated a more favorable outcome for breast cancer patients in comparison to patients with other primaries concerning pain relief (96% vs 81%), pain control after 90 days (93% vs 72%), median time to pain progression (9 vs 3 months), and median overall survival (14 vs 5.5 months). Conclusions: In this study 4 2 4 Gy proved to be clearly superior to 1 2 4 Gy in relieving pain from symptomatic nonvertebral bone metastases without impending pathologic fracture. Even if radiotherapy with 1 single fraction seems to be applicable in specific cases doses higher than 4 Gy should be chosen. In breast cancer patients pain control seems to be better compared to other primaries. Hintergrund: Obwohl die Strahlentherapie schmerzhafter Knochenmetastasen als etabliertes Verfahren anzusehen ist, gibt es weiterhin offene Fragen zur Angemessenheit der Kurzzeitbestrahlung hinsichtlich lokaler Schmerzkontrolle bei Patienten mit begrenzter Lebenserwartung. Patienten und Methode: In zwei monoinstitutionellen, nichtrandomisierten, prospektiven Follow-up-Studien wurden die Ansprechrate und Remissionsdauer der Bestrahlung von Patienten mit schmerzhaften Knochenmetastasen verschiedenen Ursprungs untersucht, welche ausschließlich außerhalb der Wirbelsäule lagen und nicht frakturgefährdet waren. 45 Patienten erhielten eine Einmalbestrahlung (single shot) in Höhe von 1 2 4 Gy auf 50 Lokalisationen (Gruppe I), während 86 Patienten vier Fraktionen in Höhe von 4 Gy auf 96 Lokalisationen erhielten (Gruppe II). Das Schmerzansprechen wurde sieben und 90 Tage nach Bestrahlung mittels einer Vier-Punkte-Schmerzskala analysiert. Ergebnisse: Die lokale Schmerzkontrolle nach 4 2 4 Gy war derjenigen nach 1 2 4 Gy signifikant überlegen mit Schmerzkontrollraten an Tag 7 (nach Therapieende) von 86,5% vs. 48% und an Tag 90 von 80% vs. 55%. Die Subgruppenanalyse der Behandlungsgruppe mit 4 2 4 Gy zeigte günstigere Therapieresultate bei Brustkrebspatienten (n =28) gegenüber Patienten mit anderer Tumordiagnose bezüglich primärem Schmerzansprechen (96% vs. 81%), lokaler Schmerzkontrollrate nach 9 Tagen (93% vs. 72%), medianem Intervall bis zur Schmerzprogression (neun vs. drei Monate) und medianem Gesamtüberleben (14 vs. 5,5 Monate). Schlußfolgerungen: In dieser Studie konnte die Überlegenheit von 4 2 4 Gy gegenüber 1 2 4 Gy in der analgetischen Bestrahlung von Knochenmetastasen, welche außerhalb der Wirbelsäule lagen und nicht frakturgefährdet waren, gezeigt werden. Soweit in bestimmten Situtionen eine Einmalbestrahlung angestrebt wird, sollte die gewählte Dosis mehr als 4 Gy betragen. Bei Brustkrebspatienten scheint eine bessere Schmerzkontrolle erreichbar zu sein als bei anderen Primärtumoren.     

A left nonrecurrent inferior laryngeal nerve in a patient with right-sided aorta, truncus arteriosus communis, and an aberrant left innominate artery

The identification and prevention of injury to the inferior laryngeal nerve is one of the main issues in thyroid surgery. Sound knowledge of anatomic variants of the nerve is of major importance. In rare cases the nerve does not run the recurrent way and it is therefore difficult to identify the nerve. Abnormal developments of the aortic arch during embryogenesis include malformation of the great vessels and can be the reason for anatomic abnormalities. A cause for a nonrecurrent nerve on the right side is the so-called lusorian artery, a right retroesophageal subclavian artery. Left-sided nonrecurrent nerves are seldom if ever documented. Only two cases have been published so far of patients with situs inversus viscerum, where left nonrecurrent nerves were associated with inverse, left-sided lusorian arteries.     

Substance P-like immunoreactivity and somatostatin-like immunoreactivity in the ventricular fluid of patients with chronic pain syndromes

Summary Substance P-like and somatostatin-like immunoreactivities (SPLI and SLI) were determined in ventricular fluid of patients with chronic pain syndromes and in a comparison group with multiple sclerosis, essential tremor, epilepsy and postanoxic myoclonus. Concentrations of SPLI and SLI were non-significantly decreased by 40% and 33% in chronic pain patients as compared with control patients without pain. There were no differences apparent between subgroups of pain patients (deaferentation pain, neoplasia-induced pain, thalamic pain). High pressure liquid chromatography combined with radioimmunoassay showed marked heterogeneity of SPLI and SLI.     

Role of PET in lymphoma

In Hodgkin's lymphoma (HL), PET imaging should be performed in all patients, particularly in stage I or II disease where change in staging will alter management. For aggressive Non-Hodgkin's lymphoma (NHL), PET imaging is valuable to provide a baseline for response evaluation. For indolent NHL, it is concluded that PET imaging is not generally indicated. For HL, a negative FDG-PET scan is highly indicative of long-term, disease-free survival and is particularly useful in the presence of residual CT mass. For aggressive NHL, a positive FDG-PET scan is predictive of disease persistence or recurrence. There is a significant incidence of false-negative FDG-PET scans, which in most cases means minimal residual disease that cannot be detected by the current instrumentation. For both NHL and aggressive HL, early assessment of response appears to be predictive of long-term outcome. Optimal time of FDG-PET scan during therapy needs to be determined. For indolent NHL, the high rate of false-negative FDG-PET scans raises questions to its clinical role in response evaluation. FDG-PET and PET-CT improve primary staging and restaging of lymphomas. Metabolic imaging will be the standard technology for assessment of therapy with documented prognostic value. Imaging during therapy may be valuable to individualize therapeutic protocols and to define chemosensitivity of tumor tissue. Minimal residual disease cannot be detected with current imaging devices.     

Gene expression profiles highlight adaptive brain mechanisms in corticotropin releasing factor overexpressing mice

Corticotropin-releasing factor (CRF) plays an important role in mediating central and peripheral responses to stress. Alterations in CRF system activity have been linked to a number of psychiatric disorders, including anxiety and depression. Aim of this study was to elucidate homeostatic mechanisms induced by lifelong elevated CRF levels in the brain. We therefore profiled gene expression in several brain areas of transgenic mice overexpressing CRF (CRF-OE), a model for chronic stress. Several genes showed altered expression levels in CRF-OE mice when compared to their wild type littermates and were confirmed by quantitative PCR. Differences in gene expression profiles revealed the presence of previously unrecognized homeostatic mechanisms in CRF-OE animals. These included changes in glucocorticoid signaling, as exemplified by changes in 11beta-hydroxysteroid dehydrogenase type 1, FK506 binding protein 5 and serum/glucocorticoid kinase. Alterations in expression of genes involved in myelination (myelin, myelin-associated glycoprotein), cell proliferation and extracellular matrix formation (Edg2, Fgfr2, decorin, brevican) suggest changes in the dynamics of neurogenesis in CRF-OE. Pronounced changes in neurotensin (NT) receptors 1 and 2 mRNA were identified. Overall downregulation of NT receptors in CRF-OE animal was substantiated by receptor binding studies. Pronounced neurotensin receptor downregulation was observed for NT type 1 receptors in limbic brain areas, suggesting that NT could be implicated in some of the effects attributed to CRF overexpression. These data show that lifelong exposure to excessive CRF leads to adaptive changes in the brain which could play a role in some of the behavioral and physiological alterations seen in these animals.     

Making image guidance work: understanding control of accuracy

Use of image-guided surgery is becoming increasingly common in both sinus surgery and neuro-otologic applications. The purpose of this study was to determine the effect of fiducial distribution and mean fiducial error on point accuracy. Using a plastic model, we determined that optimal navigation accuracy was achieved by surrounding the operative target with a widespread field of fiducials. True accuracy was always highest when we targeted a surface point. Accuracy was decreased at points removed from the center of the registration target zone created by the fiducials. Inaccurate registration resulted in increased mean fiducial error and lower accuracy at the target point. Understanding the registration process will enhance the utility of image-guided surgery in otolaryngology and skull base surgery.