Early results and volumetric analysis after spot-scanning proton therapy with concomitant hyperthermia in large inoperable sacral chordomas

OBJECTIVE

Large inoperable sacral chordomas show unsatisfactory local control rates even when treated with high dose proton therapy (PT). The aim of this study is assessing feasibility and reporting early results of patients treated with PT and concomitant hyperthermia (HT).

METHODS:

Patients had histologically proven unresectable sacral chordomas and received 70 Gy (relative biological effectiveness) in 2.5 Gy fractions with concomitant weekly HT. Toxicity was assessed according to CTCAE_v4. A volumetric tumor response analysis was performed.

RESULTS:

Five patients were treated with the combined approach. Median baseline tumor volume was 735 cc (range, 369-1142). All patients completed PT and received a median of 5 HT sessions (range, 2-6). Median follow-up was 18 months (range, 9-26). The volumetric analysis showed an objective response of all tumors (median shrinkage 46%; range, 9-72). All patients experienced acute Grade 2-3 local pain. One patient presented with a late Grade 3 iliac fracture.

CONCLUSION

Combining PT and HT in large inoperable sacral chordomas is feasible and causes acceptable toxicity. Volumetric analysis shows promising early results, warranting confirmation in the framework of a prospective trial.

ADVANCES IN KNOWLEDGE:

This is an encouraging first report of the feasibility and early results of concomitant HT and PT in treating inoperable sacral chordoma.

Image analysis in posttreatment non-small cell lung cancer surveillance: specialists’ interpretations reviewed by the thoracic multidisciplinary tumor board

Background: Data show that the initial specialist’s image interpretation and final multidisciplinary tumor board (MTB) assessment can vary substantially in the pretherapeutic cancer setting. The aim of this post hoc analysis was to investigate the concordance of the specialist’s and MTB’s image interpretations in patients undergoing systematic posttreatment lung cancer image surveillance. Methods: In the initial prospective study, lung cancer patients who had received curative-intent treatment were randomly assigned to undergo either contrast-enhanced computed tomography (CE-CT) or integrated 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT). Imaging was performed every 6months for 2 years, and all imaging studies were finally assessed by our MTB. This post hoc analysis assessed differences between the initial specialist’s image interpretation and the final MTB’s image interpretation. Results: In 89 patients, 266 imaging studies (129 PET-CT, 137 CE-CT) were analyzed. In 87.2% (88.4, 86.1%) of the studies, complete concordance was found. Out of the 12.8% (11.6, 13.9%) with discordant results, 7.5% (6.9, 8.0%) had implications for alterations in patient management (major disagreements). Twenty major disagreements were detected in 17 study patients. Retrospectively, in eight out of these 17 (47%) patients, in contrast to the MTB’s view, the specialist’s interpretation was more appropriate, whereas in nine out of 17 patients (53%), the MTB’s interpretation was more accurate. Conclusions: In an experienced MTB, the agreement between imaging specialists and the rest of the MTB with regard to the interpretation of images is high in a setting of posttreatment lung cancer image surveillance. It seems that in cases of disagreements, the rates of more accurate interpretation are well balanced between imaging specialists and the MTB. Trial registration: ISRCTN16281786, Date 23. February 2017.

Image analysis in posttreatment non-small cell lung cancer surveillance: specialists' interpretations reviewed by the thoracic multidisciplinary tumor board

Background

Data show that the initial specialist’s image interpretation and final multidisciplinary tumor board (MTB) assessment can vary substantially in the pretherapeutic cancer setting. The aim of this post hoc analysis was to investigate the concordance of the specialist’s and MTB’s image interpretations in patients undergoing systematic posttreatment lung cancer image surveillance.

Methods

In the initial prospective study, lung cancer patients who had received curative-intent treatment were randomly assigned to undergo either contrast-enhanced computed tomography (CE-CT) or integrated 18^F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT). Imaging was performed every 6 months for 2 years, and all imaging studies were finally assessed by our MTB. This post hoc analysis assessed differences between the initial specialist’s image interpretation and the final MTB’s image interpretation.

Results

In 89 patients, 266 imaging studies (129 PET-CT, 137 CE-CT) were analyzed. In 87.2% (88.4, 86.1%) of the studies, complete concordance was found. Out of the 12.8% (11.6, 13.9%) with discordant results, 7.5% (6.9, 8.0%) had implications for alterations in patient management (major disagreements).

Twenty major disagreements were detected in 17 study patients. Retrospectively, in eight out of these 17 (47%) patients, in contrast to the MTB’s view, the specialist’s interpretation was more appropriate, whereas in nine out of 17 patients (53%), the MTB’s interpretation was more accurate.

Conclusions

In an experienced MTB, the agreement between imaging specialists and the rest of the MTB with regard to the interpretation of images is high in a setting of posttreatment lung cancer image surveillance. It seems that in cases of disagreements, the rates of more accurate interpretation are well balanced between imaging specialists and the MTB.

Trial registration

ISRCTN16281786, Date 23. February 2017.

[Post-traumatic orbital reconstruction comparing preformed versus non preformed titanium mesh plates]

AIM

We compared, clinically and radiologically, the accuracy and reliability of two types of titanium mesh plates used for orbital reconstruction. The first were non-preshaped mesh plates (NPMP) and the second were three-dimensionally preformed mesh plates (PMP).

METHODS

Two groups were created, each including 15 patients treated with NPMP and the second formed by 15 patients treated with PMP. The volume of each orbit was computed from coronal CT-scans using the OsiriX medical imaging software (version 3.3.2, www.osirix-viewer.com). Measurements were done for both, healthy and reconstructed sides. The other studied parameters were: sex, age, fracture distribution, and complications (diplopia and enophthalmia).

RESULTS

The orbital volume difference between the reconstructed and the healthy contralateral side was not statistically significant in either group (NPMP: p=0.991 PMP: p=0.200). The mean orbital volume of reconstructed orbits was not statistically significant in either group (NPMP: 21.76 cm(3) and PMP: 20.28 cm(3), p=0.441).

DISCUSSION

There is no difference in orbital volume reconstructions measured by the OsiriX software between non-preshaped and three-dimensionally preformed titanium mesh plates.

Iatrogenic FDG foci in the lungs: a pitfall of PET image interpretation

2-[F-18]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) has become an important staging modality for many tumors, including bronchial carcinoma; however it is important to know that there are several pitfalls in PET image interpretation. In this report we demonstrate three cases in which focal intrapulmonary FDG uptake could possibly represent iatrogenic microembolism. These FDG accumulations would have been interpreted as malignant tumor mass in the lung if no anatomic correlation would have been performed. For this reason, we further present an integrated PET/CT scanner, which recently has been introduced. This correlation of molecular and morphological information enables the specification of the FDG-PET findings.

[Role of radiotherapy in non-small cell lung cancer]

Lung cancer has the highest cancer mortality in Switzerland. 80% of all lung cancer patients are patients with non-small cell lung cancer. Despite advances in the pre-treatment evaluation and treatment strategies, cure for non-small cell lung cancer ist still rare. Multimodality approaches specifically for locally advanced non-small cell lung cancer are among the most promising strategies to improve long term tumour control. In this paper we discuss the role of radical primary and adjuvant radiotherapy for a stage one to four non-small cell lung cancer.

[The indications for and results of video thoracoscopic sympathectomy]

BACKGROUND AND OBJECTIVES

Thoracoscopic sympathectomy, for years an effective way to treat mainly palmar and axilla hyperhidrosis, experienced a revival since the application of the principles of minimally invasive surgery. We report the personal experiences of three surgeons with this technique, as well as patients' view of the outcome.

PATIENTS AND METHODS

Between January 1990 and November 1997, 73 procedures were performed in 43 patients (23 males, 20 females, mean age 38.1 years, range 15-82 years), and the outcome was prospectively studied. Palmar hyperhidrosis without axilla symptoms was the indication for the operation in 27 patients (54 sympathectomies), Raynaud's syndrome in 15 (18 sympathectomies), and causalgia in one. Thoracic ganglia 2-4 were always completely resected. Perioperative morbidity as well as patient satisfaction in the long-term course (standardized interview) 25.8 (1-77) months postoperatively were assessed.

RESULTS

The complication rate in all 73 sympathectomies was 8.2%. Only two severe incidents were observed: in one patient intermittent Horner's syndrome (1.4%) occurred, and in another severe bleeding required conversion to open surgery (1.4%). Both complications occurred in the early study phase. The initial success rate in all 27 patients with hyperhidrosis was 100%. In 30% of these cases a mild partial relapse was observed, which did not interfere with their daily activities. 53% of the patients reported compensatory and 23% gustatory sweating. 9% would have refused the operation, had they known these side effects. In all patients with Raynaud's disease the ulcerations healed completely. At the time of the interview, two patients (13%) complained of painless relapses. They too stated that they had refused the operation, if they had known about the relapses.

CONCLUSIONS

Even in the longer-term course, thoracoscopic sympathectomy is rated subjectively successful by 93% of patients after treatment of hyperhidrosis of the upper extremities, and by 87% of patients after treatment of Raynaud's disease, despite some untoward effects and partial relapses.