Same-day <Superscript>90</Superscript>Y radioembolization: implementing a new treatment paradigm

Purpose

To assess the feasibility of conducting pretreatment mesenteric angiography, coil embolization, ^99mTc macroaggregated albumin (^99mTc-MAA) scintigraphy, and ⁹⁰Y radioembolization treatment in a single, same-day, combined outpatient encounter.

Methods

This was a retrospective study of 78 patients treated during the period 2008 – 2015 who were managed in a single outpatient encounter under the guidance of the Interventional Radiology Department and The Nuclear Medicine Department. Pretreatment planning was performed by reviewing baseline imaging and estimated perfused liver volume bearing the tumor. The region of interest was estimated using 3-D software; this value was used for dosimetry planning. Maximum lung shunting fractions of 10 % for hepatocellular carcinoma and 5 % for liver metastases were assumed. Subsequently, hepatic angiography and ^99mTc-MAA scintigraphy were performed followed by ⁹⁰Y treatment in one outpatient encounter. Total in-room procedure time was recorded.

Results

All patients underwent same-day angiography, ^99mTc-MAA scintigraphy and ⁹⁰Y radioembolization. Of the 78 patients, 16 received multiple segmental treatments to both lobes, 44 received treatment to the right lobe, and 18 received treatment to the left lobe. The median dose was 106 Gy. The median number of ⁹⁰Y vials needed was two (range one to six). The median in-room time was 160 min (75 – 250 min). The residential status of the patients was as follows, 18 % (14/78) were local residents, 55 % (43/78) traveled from outside the city limits, 18 % (14/78) were from out-of-state, and 9 % (7/78) were resident abroad. Of the 78 patients, 61 (77 %) had hepatocellular carcinoma, and 17 (22 %) had liver metastases. The median lung dose was 3.5 Gy.

Conclusion

This study demonstrated the feasibility of same-day ⁹⁰Y evaluation and treatment while maintaining the principles of safe and effective ⁹⁰Y infusion including tumoricidal dosimetry (lobar, segmentectomy), minimization of nontarget flow, and minimization of lung dose. This paradigm translates into expeditious cancer care and significant cost savings.

     

Anterior column reconstruction with PMMA: an effective long-term alternative in spinal oncologic surgery

Open image in new window

A number of anterior reconstruction options are available in patients managed for symptomatic metastatic spinal column disease. Polymethylmethacrylate (PMMA) has been traditionally used as a reconstruction option in patients with limited life expectancy as an anterior fusion is not expected. In this article, we present the outcome of a 13-year follow-up of a long anterior reconstruction using PMMA of the upper thoracic spine in a myelopathic female secondary to a compressive breast metastasis affecting the upper 4 thoracic vertebrae. We discuss the use of PMMA in spinal oncological surgery and review the evidence pertinent to its use.

     

Does transcranial stimulation for motor evoked potentials (TcMEP) worsen seizures in epileptic patients following spinal deformity surgery?

Purpose

To investigate the effect of Transcranial Motor Evoked Potentials (TcMEP) in increasing the severity or frequency of post-operative seizures in patients undergoing deformity corrective spine surgery with a known history of seizures pre-operatively.

Methods

The information on all patients with history of epilepsy/seizures who underwent spinal TcMEP cord monitoring for deformity correction surgery was retrospectively collected through a review of the hospital notes. The benefits of TcMEP in the early detection of potential cord ischemia were deemed by the operating surgeon to outweigh the increased risks of seizures, tongue biting, etc. Data on age, gender, pre-operative diagnosis, curve type, intra-operative monitoring alerts, duration of hospital stay, and post-operative in-hospital seizures were collected. Additionally, the patients were contacted following discharge and data on any change in the frequency of the seizures or an alteration in seizure-related medication post-operatively was also collected.

Results

The records of 449 consecutively monitored patients were reviewed and 12 (2.7 %) patients with a history of seizures pre-operatively were identified. The mean age was 23 (9–59) years, 7 females, 11 scoliosis corrections (4 neuromuscular, 1 degenerative, 6 idiopathic adolescent), and one sagittal balance correction surgery. Intra-operatively, all patients had TcMEP monitoring, were catheterised, and had no neuromonitoring alerts or record of tongue biting or laceration. Post-operatively, the mean hospital stay was 12 (4–25) days with no recorded seizures. At a mean of 23 (12–49) months post-discharge, none of the patients reported a worsening of seizures (pattern or frequency) or required an alteration in the seizure-related medications.

Conclusion

TcMEP does not appear to trigger intra-operative or post-operative seizures and is not associated with deterioration in the seizure control of patients suffering seizures pre-operatively.

     

External validation of the Heidenreich criteria for patient selection for unilateral or bilateral retroperitoneal lymph node dissection for post-chemotherapy residual masses of testicular cancer

Objective

To validate the Heidenreich criteria for patient selection for unilateral retroperitoneal lymph node dissection (RPLND) for residual masses after chemotherapy for nonseminomatous germ cell tumor (NSGCT).

Subjects/patients and methods

For validation, the data of 59 patients who underwent RPLND for residual masses of NSGCT were used. Of these patients, 23 (39 %) qualified for a modified RPLND, the others had an indication for a bilateral dissection. Results from histopathology after RPLND and follow-up data for relapse inside or outside the zone of the resection template were considered for validation.

Results

In the study cohort, median age at time of RPLND was 31 years. The 2-year disease-free survival was 90 and 96 % for the bilateral and the unilateral RPLND patients, respectively. Overall, 8 (14 %) relapses were observed after a median follow-up of 54 month. Of these, 6 were outside of the resection field and 2 were in-field. Of the 23 patients with indication for a modified RPLND, 1 patient relapsed in the contralateral testis and 1 inside the modified RPLND template. No relapse was observed outside the modified RPLND field and inside the untouched contralateral RPLND field. The Heidenreich criteria did therefore not misclassify a single patient.

Conclusion

The Heidenreich criteria for the selection of candidates for unilateral RPLND for residual masses after chemotherapy allow a highly reliable selection of patients. The application of the Heidenreich criteria can help to reduce comorbidity and invasiveness of RPLND.     

SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME)

Techniques in Coloproctology - The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot...     

Routine versus selective histologic analysis of gallbladder specimens for the detection of incidental gallbladder cancers. A retrospective review over 9 years of activity with a special focus on patients' age

Background

Incidental gallbladder cancer (IGC) is an infrequent possibility in patients undergoing cholecystectomies. Routine histologic examination of all gallbladder specimens is the current approach to detect this disease. Our study presents the influence of age to perform a selective histologic analysis.

Methods

A retrospective review was conducted of all gallbladder specimens during the last 9 years in our hospital. The medical notes were retrieved for cases of IGC or dysplasia and perioperative data were collected.

Results

A total of 3,330 cholecystectomies were conducted over the study period, 3,041 for gallstone disease. Twelve patients were found with dysplasia and 13 patients with IGC, all of them occurred in gallbladders removed for gallstone diseases. There were 18 men with a median age of 65 years (range 18 to 85). Median age for cancer patients was 70 years (range 51 to 85) and 54 years for dysplasia (range 18 to 75). No patient below the age of 51 years (n = 1,464) experienced IGCs.

Conclusion

Age should be considered as an additional factor for a selective approach to the histologic analysis of all gallbladder specimens following cholecystectomies.     

Neuromodulatory effects of green coffee bean extract against brain damage in male albino rats with experimentally induced diabetes

Metabolic Brain Disease - Diabetes mellitus is an increasing metabolic disease worldwide associated with central nervous system disorders. Coffee is a widely consumed beverage that enriched with...