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Grimm PD. In Adults Aged <65 Years with Unstable Ankle Fractures, Fibular Nailing Did Not Differ from Open Reduction and Internal Fixation for Functional Outcome at 1 Year. J Bone Joint Surg Am 2022; 104:1504. [PMID: 35700091 DOI: 10.2106/jbjs.22.00486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Grimm PD, Wheatley BM, Tomasino A, Leonhardt C, Hunter DA, Wood MD, Moore AM, Davis TA, Tintle SM. Controlling axonal regeneration with acellular nerve allograft limits neuroma formation in peripheral nerve transection: An experimental study in a swine model. Microsurgery 2022; 42:603-610. [PMID: 35925036 DOI: 10.1002/micr.30943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/06/2022] [Accepted: 07/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Symptomatic neuromata are a common indication for revision surgery following amputation. Previously described treatments, including traction neurectomy, nerve transposition, targeted muscle re-innervation, and nerve capping, have provided inconsistent results or are technically challenging. Prior research using acellular nerve allografts (ANA) has shown controlled termination of axonal regrowth in long grafts. The purpose of this study was to determine the ability of a long ANA to prevent neuroma formation following transection of a peripheral nerve in a swine model. MATERIALS AND METHODS Twenty-two adult female Yucatan miniature swine (Sus scrofa; 4-6 months, 15-25 kg) were assigned to control (ulnar nerve transection only, n = 10), treatment (ulnar transection and coaptation of 50 mm ANA, n = 10), or donor (n = 2) groups. Nerves harvested from donor group animals were treated to create the ANA. After 20 weeks, the transected nerves including any neuroma or graft were harvested. Both qualitative (nerve architecture, axonal sprouting) and quantitative histologic analyses (myelinated axon number, cross sectional area of nerve tissue) were performed. RESULTS Qualitative histologic analysis of control specimens revealed robust axon growth into dense scar tissue. In contrast, the treatment group revealed dwindling axons in the terminal tissue, consistent with attenuated neuroma formation. Quantitative analysis revealed a significantly decreased number of myelinated axons in the treatment group (1232 ± 540) compared to the control group (44,380 ± 7204) (p < .0001). Cross sectional area of nerve tissue was significantly smaller in treatment group (2.83 ± 1.53 mm2 ) compared to the control group (9.14 ± 1.19 mm2 ) (p = .0012). CONCLUSIONS Aberrant axonal growth is controlled to termination with coaptation of a 50 mm ANA in a swine model of nerve injury. These early results suggest further investigation of this technique to prevent and/or treat neuroma formation.
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Affiliation(s)
- Patrick D Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| | - Benjamin M Wheatley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| | - Allison Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Crystal Leonhardt
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Daniel A Hunter
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Thomas A Davis
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Scott M Tintle
- Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
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Ghahramani Z E, Grimm PD, Eary KJ, Swearengen MP, Dayavansha EGSK, Mast TD. Three-dimensional echo decorrelation monitoring of radiofrequency ablation in ex vivo bovine liver. J Acoust Soc Am 2022; 151:3907. [PMID: 35778168 PMCID: PMC9187351 DOI: 10.1121/10.0011641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/14/2022] [Accepted: 05/23/2022] [Indexed: 06/03/2023]
Abstract
Three-dimensional (3D) echo decorrelation imaging was investigated for monitoring radiofrequency ablation (RFA) in ex vivo bovine liver. RFA experiments (N = 14) were imaged by 3D ultrasound using a matrix array, with in-phase and quadrature complex echo volumes acquired about every 11 s. Tissue specimens were then frozen at -80 °C, sectioned, and semi-automatically segmented. Receiver operating characteristic (ROC) curves were constructed for assessing ablation prediction performance of 3D echo decorrelation with three potential normalization approaches, as well as 3D integrated backscatter (IBS). ROC analysis indicated that 3D echo decorrelation imaging is potentially a good predictor of local RFA, with the best prediction performance observed for globally normalized decorrelation. Tissue temperatures, recorded by four thermocouples integrated into the RFA probe, showed good correspondence with spatially averaged decorrelation and statistically significant but weak correlation with measured echo decorrelation at the same spatial locations. In tests predicting ablation zones using a weighted K-means clustering approach, echo decorrelation performed better than IBS, with smaller root mean square volume errors and higher Dice coefficients relative to measured ablation zones. These results suggest that 3D echo decorrelation and IBS imaging are capable of real-time monitoring of thermal ablation, with potential application to clinical treatment of liver tumors.
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Affiliation(s)
- E Ghahramani Z
- Department of Biomedical Engineering, University of Cincinnati, Ohio 45267-0586, USA
| | - P D Grimm
- Department of Biomedical Engineering, University of Cincinnati, Ohio 45267-0586, USA
| | - K J Eary
- Department of Biomedical Engineering, University of Cincinnati, Ohio 45267-0586, USA
| | - M P Swearengen
- Department of Biomedical Engineering, University of Cincinnati, Ohio 45267-0586, USA
| | | | - T D Mast
- Department of Biomedical Engineering, University of Cincinnati, Ohio 45267-0586, USA
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Strong AL, Spreadborough PJ, Dey D, Yang P, Li S, Lee A, Haskins RM, Grimm PD, Kumar R, Bradley MJ, Yu PB, Levi B, Davis TA. BMP Ligand Trap ALK3-Fc Attenuates Osteogenesis and Heterotopic Ossification in Blast-Related Lower Extremity Trauma. Stem Cells Dev 2021; 30:91-105. [PMID: 33256557 PMCID: PMC7826435 DOI: 10.1089/scd.2020.0162] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/25/2020] [Indexed: 01/05/2023] Open
Abstract
Traumatic heterotopic ossification (tHO) commonly develops in wounded service members who sustain high-energy and blast-related traumatic amputations. Currently, no safe and effective preventive measures have been identified for this patient population. Bone morphogenetic protein (BMP) signaling blockade has previously been shown to reduce ectopic bone formation in genetic models of HO. In this study, we demonstrate the efficacy of small-molecule inhibition with LDN193189 (ALK2/ALK3 inhibition), LDN212854 (ALK2-biased inhibition), and BMP ligand trap ALK3-Fc at inhibiting early and late osteogenic differentiation of tissue-resident mesenchymal progenitor cells (MPCs) harvested from mice subjected to burn/tenotomy, a well-characterized trauma-induced model of HO. Using an established rat tHO model of blast-related extremity trauma and methicillin-resistant Staphylococcus aureus infection, a significant decrease in ectopic bone volume was observed by micro-computed tomography imaging following treatment with LDN193189, LDN212854, and ALK3-Fc. The efficacy of LDN193189 and LDN212854 in this model was associated with weight loss (17%-19%) within the first two postoperative weeks, and in the case of LDN193189, delayed wound healing and metastatic infection was observed, while ALK3-Fc was well tolerated. At day 14 following injury, RNA-Seq and quantitative reverse transcriptase-polymerase chain reaction analysis revealed that ALK3-Fc enhanced the expression of skeletal muscle structural genes and myogenic transcriptional factors while inhibiting the expression of inflammatory genes. Tissue-resident MPCs harvested from rats treated with ALK3-Fc exhibited reduced osteogenic differentiation, proliferation, and self-renewal capacity and diminished expression of genes associated with endochondral ossification and SMAD-dependent signaling pathways. Together, these results confirm the contribution of BMP signaling in osteogenic differentiation and ectopic bone formation and that a selective ligand-trap approach such as ALK3-Fc may be an effective and tolerable prophylactic strategy for tHO.
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Affiliation(s)
- Amy L. Strong
- Division of Plastic Surgery, Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - Philip J. Spreadborough
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Peiran Yang
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shuli Li
- Division of Plastic Surgery, Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - Arthur Lee
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland, USA
| | - Ryan M. Haskins
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Patrick D. Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Ravi Kumar
- Acceleron Pharma, Inc., Cambridge, Massachusetts, USA
| | - Matthew J. Bradley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Paul B. Yu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Levi
- Division of Plastic Surgery, Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Thomas A. Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Strong AL, Spreadborough PJ, Pagani CA, Haskins RM, Dey D, Grimm PD, Kaneko K, Marini S, Huber AK, Hwang C, Westover K, Mishina Y, Bradley MJ, Levi B, Davis TA. Small molecule inhibition of non-canonical (TAK1-mediated) BMP signaling results in reduced chondrogenic ossification and heterotopic ossification in a rat model of blast-associated combat-related lower limb trauma. Bone 2020; 139:115517. [PMID: 32622875 PMCID: PMC7945876 DOI: 10.1016/j.bone.2020.115517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
Heterotopic ossification (HO) is defined as ectopic bone formation around joints and in soft tissues following trauma, particularly blast-related extremity injuries, thermal injuries, central nerve injuries, or orthopaedic surgeries, leading to increased pain and diminished quality of life. Current treatment options include pharmacotherapy with non-steroidal anti-inflammatory drugs, radiotherapy, and surgical excision, but these treatments have limited efficacy and have associated complication profiles. In contrast, small molecule inhibitors have been shown to have higher specificity and less systemic cytotoxicity. Previous studies have shown that bone morphogenetic protein (BMP) signaling and downstream non-canonical (SMAD-independent) BMP signaling mediated induction of TGF-β activated kinase-1 (TAK1) contributes to HO. In the current study, small molecule inhibition of TAK1, NG-25, was evaluated for its efficacy in limiting ectopic bone formation following a rat blast-associated lower limb trauma and a murine burn tenotomy injury model. A significant decrease in total HO volume in the rat blast injury model was observed by microCT imaging with no systemic complications following NG-25 therapy. Furthermore, tissue-resident mesenchymal progenitor cells (MPCs) harvested from rats treated with NG-25 demonstrated decreased proliferation, limited osteogenic differentiation capacity, and reduced gene expression of Tac1, Col10a1, Ibsp, Smad3, and Sox2 (P < 0.05). Single cell RNA-sequencing of murine cells harvested from the injury site in a burn tenotomy injury model showed increased expression of these genes in MPCs during stages of chondrogenic differentiation. Additional in vitro cell cultures of murine tissue-resident MPCs and osteochondrogenic progenitors (OCPs) treated with NG-25 demonstrated reduced chondrogenic differentiation by 10.2-fold (P < 0.001) and 133.3-fold (P < 0.001), respectively, as well as associated reduction in chondrogenic gene expression. Induction of HO in Tak1 knockout mice demonstrated a 7.1-fold (P < 0.001) and 2.7-fold reduction (P < 0.001) in chondrogenic differentiation of murine MPCs and OCPs, respectively, with reduced chondrogenic gene expression. Together, our in vivo models and in vitro cell culture studies demonstrate the importance of TAK1 signaling in chondrogenic differentiation and HO formation and suggest that small molecule inhibition of TAK1 is a promising therapy to limit the formation and progression of HO.
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Affiliation(s)
- Amy L Strong
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Philip J Spreadborough
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Academic Department of Military Surgery and Trauma, Royal Centre for Defense Medicine, Birmingham, United Kingdom
| | - Chase A Pagani
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Ryan M Haskins
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Patrick D Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Keiko Kaneko
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Simone Marini
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Amanda K Huber
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Charles Hwang
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Kenneth Westover
- Departments of Biochemistry and Radiation Oncology, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States of America
| | - Yuji Mishina
- Department of Biologic and Materials Science and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States of America
| | - Matthew J Bradley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Benjamin Levi
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America.
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
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Dworak TC, Wagner SC, Nappo KE, Balazs GC, Grimm PD, Colantonio DF, Tintle SM. The Use of Distal Ulnar Hounsfield Units to Predict Future Fragility Fracture Risk. J Hand Surg Am 2018; 43:1010-1015. [PMID: 29891269 DOI: 10.1016/j.jhsa.2018.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 02/28/2018] [Accepted: 04/11/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Distal ulnar Hounsfield unit (HU) measurements obtained from computed tomography (CT) scans of the wrist can be used to accurately screen for low bone mineral density. It is unknown whether HU measurements can also predict the risk of future fragility fractures. Therefore, the purpose of this study was to determine if the HU values of the distal ulna correlate to fragility fracture risk. METHODS An electronic database of radiographs at a single institution was searched for all wrist CT scans, obtained for any reason, between January 1, 2002, and December 31, 2008, to allow a minimum of 5-year follow-up. Manual measurement of HU on sequential coronal CT slices of the distal ulnar head was taken, and mean values were recorded. Previously determined cutoff values for the diagnosis of low bone mineral density were implemented to stratify patients as at risk or not at risk for future fragility fracture. Medical records were then manually reviewed for the occurrence of any future fragility fracture (hip, spine, proximal humerus, or rib). RESULTS There were 161 CTs in 157 patients and 34 fragility fractures in 21 patients, with a prevalence of 13.4%. The mean HU in the fragility fracture group was significantly lower (134.2 vs 197.1 HU). The percentage of low HU patients with fragility fractures was significantly higher (22.7% vs 3.8%). The odds ratio for fragility fracture in the low HU group was 7.4 (95% confidence interval, 2.1-26.2). Using previously determined cutoff values, the sensitivity and specificity of distal ulna HU values for identifying patients who would sustain at least 1 future fragility fracture were 85.7% and 55.2%, respectively. CONCLUSIONS Patients with low distal ulnar HU were significantly more likely to sustain a subsequent fragility fracture. A determination of distal ulnar HUs represents a quick, simple tool to identify patients potentially at risk for fragility fractures. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Theodora C Dworak
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Orthopaedics, Rothman Institute at Thomas Jefferson University, Philadelphia, PA.
| | - Kyle E Nappo
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Patrick D Grimm
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Donald F Colantonio
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, PA
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Wagner SC, Dworak TC, Grimm PD, Balazs GC, Tintle SM. Measurement of Distal Ulnar Hounsfield Units Accurately Predicts Bone Mineral Density of the Forearm. J Bone Joint Surg Am 2017; 99:e38. [PMID: 28419040 DOI: 10.2106/jbjs.15.01244] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hounsfield unit (HU) measurement obtained from computed tomography (CT) scans of the wrist is a potential new screening method for low bone mineral density (BMD). We hypothesized that HU measurements of the ulnar head obtained from CT scans would correlate with BMD assessed with dual x-ray absorptiometry (DXA) scans of the forearm. METHODS Patients with both upper-extremity CT and DXA scans performed at a single institution were included in the study. Hounsfield units were manually measured in the distal part of the ulna by 1 author blinded to the DXA results. Average values were then compared with forearm BMD values as determined with a DXA scan. RESULTS Seventy-seven CT scans of 74 patients were included. Average HU values were significantly lower in the osteoporotic and osteopenic groups in comparison with the normal BMD group. The upper limit of the 95% confidence interval for osteopenic patients was 145.9 HU. The average forearm T-score for patients with an HU value at or below the cutoff of 146 was significantly lower than the average T-score for those with an HU value of >146 HU (p < 0.0001). Sensitivity and negative predictive value for low BMD using this cutoff value were calculated to be 91% and 89%, respectively. CONCLUSIONS Distal ulnar HU measurements accurately reflect the BMD of the forearm as diagnosed with a DXA scan. Our results suggest that distal ulnar HU measurements of ≤146 HU are strongly associated with low BMD and that values above this cutoff accurately rule out low forearm BMD with a high degree of sensitivity and negative predictive value. Utilizing this technique may improve the capture of at-risk patients and streamline the screening process for osteoporosis. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Scott C Wagner
- 1Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland 2Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland 3Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Balazs GC, Brelin AM, Grimm PD, Dickens JF, Keblish DJ, Rue JPH. Hybrid Tibia Fixation of Soft Tissue Grafts in Anterior Cruciate Ligament Reconstruction: A Systematic Review. Am J Sports Med 2016; 44:2724-2732. [PMID: 26801921 DOI: 10.1177/0363546515621541] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimal fixation of soft tissue grafts in anterior cruciate ligament (ACL) reconstruction remains a controversial topic, and tibial-sided fixation is frequently cited as the "weak point" of the femur-graft-tibia construct. Some studies have recommended the use of hybrid fixation (combining intratunnel aperture fixation and extracortical suspensory fixation) on the tibial side to increase the strength of the reconstructed ACL and decrease the risk of graft slippage and subsequent failure. However, no consensus has emerged on the necessity or suitability of this technique, relative to single modes of fixation. PURPOSE This study sought answers to the following questions: (1) Does hybrid fixation result in stronger, stiffer initial fixation of soft tissue grafts? (2) Does hybrid fixation reduce side-to-side laxity differences in clinical practice? (3) Does hybrid fixation increase complication rates when compared with a single mode of tibial fixation? STUDY DESIGN Systematic review. METHODS A systematic keyword search of PubMed, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews was performed. Candidate articles were included if they compared biomechanical or clinical characteristics of tibial-sided hybrid fixation (defined as a combination of aperture and suspensory fixation methods) with single-mode fixation of soft tissue grafts in ACL reconstruction. RESULTS A total of 21 studies (15 biomechanical, 6 clinical) met criteria for inclusion. Most biomechanical studies reported significantly increased strength and stiffness with hybrid fixation versus single modes of fixation. Among clinical studies, 66% reported significantly decreased anterior-posterior laxity when hybrid fixation methods were employed, with the remainder showing no difference. CONCLUSION Hybrid methods of tibial-sided graft fixation in ACL reconstruction result in stronger initial fixation and less side-to-side laxity after healing but do not change patient-reported outcomes at 1- to 3-year follow-up. REGISTRATION PROSPERO International Prospective Register of Systematic Reviews No. 42014015464.
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Affiliation(s)
- George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Alaina M Brelin
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Patrick D Grimm
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jonathan F Dickens
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David J Keblish
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, Maryland, USA
| | - John-Paul H Rue
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, Maryland, USA
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Abstract
This study aims to report the clinical and functional outcomes of revision anterior cruciate ligament (ACL) reconstruction in a young, active duty military population. Patients undergoing revision ACL reconstruction were enrolled in an institutional clinical database and followed prospectively. The primary outcomes were patients' scores on a timed run, as compared with recorded scores before reinjury. Secondary outcomes included scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the International Knee Documentation Committee subjective (IKDC subjective), the Short Form - 36 health survey (SF-36) version 2, the Single Assessment Numeric Evaluation (SANE), and the Tegner activity scale. A total of 13 patients were identified who met the inclusion criteria and had complete follow-up. The mean age at revision ACL reconstruction was 20.5 years (range, 19-22 years), and mean follow-up was 40.2 months (range, 13-66 months). All patients underwent a single stage revision ACL reconstruction with ipsilateral bone-patellar tendon-bone autograft, ipsilateral hamstring autograft, or bone-tendon-bone allograft. Mean physical readiness test (PRT) score at final follow-up was not statistically different than documented preinjury PRT score (77.9 vs. 85.5, p > 0.05), nor was the mean run time (7:12 vs. 6:43/mile, p > 0.05). Significant improvements exceeding published minimal clinically important differences were seen in SANE score, SF-36 physical component summary score, KOOS sports and recreation, KOOS quality of life, WOMAC pain score, and WOMAC function score. Patients undergoing revision ACL reconstruction at our facility show good recovery of baseline physical performance as measured by the semiannual PRT and timed run test, and significant improvements in patient-reported outcome scores. Level of Evidence Level IV, case series.
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Affiliation(s)
- George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Patrick D Grimm
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Michael A Donohue
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David J Keblish
- Department of Orthopaedic Surgery and Sports Medicine, Naval Health Clinic Annapolis, US Naval Academy, Annapolis, Maryland
| | - John-Paul Rue
- Department of Orthopaedic Surgery and Sports Medicine, Naval Health Clinic Annapolis, US Naval Academy, Annapolis, Maryland
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Grimm PD, Blasko JC, Sylvester JE, Meier RM, Cavanagh W. 10-year biochemical (prostate-specific antigen) control of prostate cancer with (125)I brachytherapy. Int J Radiat Oncol Biol Phys 2001; 51:31-40. [PMID: 11516848 DOI: 10.1016/s0360-3016(01)01601-7] [Citation(s) in RCA: 378] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To report 10-year biochemical (prostate-specific antigen [PSA]) outcomes for patients treated with 125I brachytherapy as monotherapy for early-stage prostate cancer. METHODS AND MATERIALS One hundred and twenty-five consecutively treated patients, with clinical Stage T1-T2b prostate cancer were treated with 125I brachytherapy as monotherapy, and followed with PSA determinations. Kaplan-Meier estimates of PSA progression-free survival (PFS), on the basis of a two consecutive elevations of PSA, were calculated. Aggregate PSA response by time interval was assessed. Comparisons were made to an earlier-treated cohort. RESULTS The overall PSA PFS rate achieved at 10 years was 87% for low-risk patients (PSA < 10, Gleason Sum 2-6, T1-T2b). Of 59 patients (47%) followed beyond 7 years, 51 (86%) had serum PSAs less than 0.5 ng/mL; 48 (81%) had serum PSAs less than 0.2 ng/mL. Failures were local, 3.0%; distant, 3.0%. No patients have died of prostate carcinoma. The proportion of patients with a PSA < or =0.2 ng/mL continued to increase until at least 7-8 years posttherapy. A plot of PSA PFS against the proportion of patients achieving serum PSA of less than 0.2 ng/mL suggests a convergence of these two endpoints at 10 years. Patients treated in the era of this study (1988-1990) experienced a statistically improved PFS compared with an earlier era (1986-1987). This difference appears independent of patient selection, suggesting that the maturation of the technique resulted in improved biochemical control. CONCLUSION With modern technique, monotherapy with 125I achieves a high rate (87%) of biochemical and clinical control in patients with low-risk disease at 10 years. The decline of PSA following brachytherapy with low-dose-rate isotopes can be protracted. Absolute PSA and PFS curves merge, and are comparable at 10 years.
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Affiliation(s)
- P D Grimm
- Seattle Prostate Institute, Swedish Medical Center, Seattle, WA 98104, USA.
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Sylvester J, Blasko JC, Grimm PD, Meier R, Cavanagh W. Short-course androgen ablation combined with external-beam radiation therapy and low-dose-rate permanent brachytherapy in early-stage prostate cancer: a matched subset analysis. Mol Urol 2001; 4:155-9;discussion 161. [PMID: 11062369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND AND PURPOSE In order to evaluate the effect of short-term androgen blockade on biochemical control rates for high-risk patients receiving a combination regimen of external-beam radiation therapy and low-dose-rate permanent seed implant brachytherapy, a retrospective matched subset analysis was performed. PATIENTS AND METHODS Inclusion in the high-risk cohort required at least two of the following poor prognostic factors: serum prostate specific antigen (PSA) concentration > or = 10.0 ng/mL, Gleason score > or = 7, or clinical stage T(2c) or T(3a) disease. Twenty-one patients who underwent androgen ablation between June 1991 and December 1995 in addition to combined-modality radiation therapy qualified as high risk, as did 77 patients who underwent combined-radiation therapy only. There was no statistically significant difference between the two groups in terms of follow-up (mean 44.6 v 47.8 months, respectively), pretreatment PSA, clinical stage, biopsy Gleason score, or the presence of all three poor prognostic factors. RESULTS The overall rates of freedom from biochemical failure at 5 years were 77% in the hormonally treated group and 58% in the nonhormonally treated group. The difference was not statistically significant by log rank test (P = 0.08). CONCLUSION Longer follow-up with larger patient numbers is needed to define the role of adjuvant androgen ablation combined with radiation therapy.
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Affiliation(s)
- J Sylvester
- Seattle Prostate Institute, Seattle, Washington, USA
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12
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Abstract
BACKGROUND AND PURPOSE To compare the biochemical outcomes of patients treated with Pd-103/I-125 brachytherapy alone vs. brachytherapy combined with external beam radiotherapy for early stage prostate carcinoma. METHODS Brachytherapy monotherapy was used in 403 patients. Brachytherapy was combined with 45 Gy of external beam radiotherapy in 231 patients. Median follow-up was 58 months. To compare the biochemical outcomes of these two treatment approaches, patients were stratified into three relative risk groups: low risk, T(1)-T(2), Gleason 2-6/10, PSA< or =10.0; intermediate risk, T(3), Gleason 7-10/10, PSA>10.0 (one factor); high risk, T(3), Gleason 7-10/10, PSA>10.0 (two factors). RESULTS The actuarial biochemical progression-free rate (bNED) for the entire 634 patients was 85% at 10 years. The bNED outcomes by risk group for monotherapy vs. combined therapy respectively were: low risk, 94 vs. 87%; intermediate risk, 84 vs. 85%; high risk, 54 vs. 62%. These differences did not reach statistical significance for any risk group. Rectal morbidity was slightly greater in the combined treatment patients. CONCLUSION Although the addition of external beam irradiation to brachytherapy is conceptually appealing for patients with higher risk prostate carcinoma, we were unable to demonstrate a benefit. Whether this is because of patient selection biases within the risk groupings, an artefact of retrospective review, or because external radiotherapy does not offer additional benefit is uncertain.
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Affiliation(s)
- J C Blasko
- Seattle Prostate Institute, 1101 Madison Street, Suite 1101, WA 98104, Seattle, USA
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Cavanagh W, Blasko JC, Grimm PD, Sylvester JE. Transient elevation of serum prostate-specific antigen following (125)I/(103)Pd brachytherapy for localized prostate cancer. Semin Urol Oncol 2000; 18:160-5. [PMID: 10875459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Based on suggestions by anecdotal evidence to date, an attempt is made to estimate the occurrence of non-disease-related prostate-specific antigen (PSA) spiking in the serum PSA profiles of a series of men treated by (125)I/(103)Pd brachytherapy with or without external beam irradiation. Five hundred ninety-one patients treated between January 1988 and December 1993 were eligible for study. Patients whose clinical status was described as equivocal (declining PSA > 1.0 ng/mL or rising PSA without documented disease [9.6% of the cohort]) were not considered. Evidence of PSA increases that were followed by decline were identified. Treatment and disease-specific parameters were examined for influence of the occurrence of spiking. In patients judged biochemical successes at last follow-up (serum PSA < or = 1.0 ng/mL), 35.8% exhibited a temporary increase of 0.2 ng/mL or more. Seventy-five percent of these patients exhibited a temporary increase between 0.3 and 3.4 ng/mL. The average time of the temporary increases was 24.8 months after implant. Spiking was not associated with a higher risk of clinical failure in this data set. Conventional risk factors for recurrent disease were not associated with benign PSA spiking. Low-magnitude serum PSA spiking may occur in up to one third of patients following permanent, low-dose rate brachytherapy of the prostate. Most of these observations occur up to 3 years after implant and do not appear to be related to disease recurrence. Caution should be taken before initiating further therapy pursuant to the observation of PSA spiking of less than 2 to 3 ng/mL shortly following brachytherapy. Frequent serum PSA sampling following prostate brachytherapy with early follow-up may overestimate biochemical failure rates.
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Affiliation(s)
- W Cavanagh
- Seattle Prostate Institute, WA 98104, USA
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Abstract
PURPOSE A report of biochemical outcomes for patients treated with palladium-103 (Pd-103) brachytherapy over a fixed time interval. METHODS AND MATERIALS Two hundred thirty patients with clinical stage T1-T2 prostate cancer were treated with Pd-103 brachytherapy and followed with prostate-specific antigen (PSA) determinations. Kaplan-Meier estimates of biochemical failure on the basis of two consecutive elevations of PSA were utilized. Multivariate risk groups were constructed. Aggregate PSA response by time interval was assessed. RESULTS The overall biochemical control rate achieved at 9 years was 83.5%. Failures were local 3.0%; distant 6.1%; PSA progression only 4.3%. Significant risk factors contributing to failure were serum PSA greater than 10 ng/ml and Gleason sum of 7 or greater. Five-year biochemical control for those exhibiting neither risk factor was 94%; one risk factor, 82%; both risk factors, 65%. When all 1354 PSA determinations obtained for this cohort were considered, the patients with a proportion of PSAs < or = 0.5 ng/ml continued to increase until at least 48 months post-therapy. These data conformed to a median PSA half-life of 96.2 days. CONCLUSIONS Prostate brachytherapy with Pd-103 achieves a high rate of biochemical and clinical control in patients with clinically organ-confined disease. PSA response following brachytherapy with low-dose-rate isotopes is protracted.
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Affiliation(s)
- J C Blasko
- Seattle Prostate Institute, Seattle, WA 98104, USA.
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Merrick GS, Butler WM, Grimm PD. Prostate-specific antigen levels after radical prostatectomy versus brachytherapy. Urology 1999; 53:865-6. [PMID: 10197879 DOI: 10.1016/s0090-4295(98)00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Tapen EM, Blasko JC, Grimm PD, Ragde H, Luse R, Clifford S, Sylvester J, Griffin TW. Reduction of radioactive seed embolization to the lung following prostate brachytherapy. Int J Radiat Oncol Biol Phys 1998; 42:1063-7. [PMID: 9869230 DOI: 10.1016/s0360-3016(98)00353-8] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Ultrasound-guided interstitial implantation of radioactive seeds is a common treatment for early stage prostate cancer. One of the risks associated with this therapy is seed embolization to the lung. This paper reports on the incidence and possible adverse effects of seed migration. METHODS AND MATERIALS Two hundred ninety consecutive patients were treated with permanent radioactive seed brachytherapy for prostate cancer between January 1 and December 31, 1995. One hundred fifty-four patients were treated with iodine-125 (I-125), and 136 patients were treated with palladium-103 (Pd-103). All but one patient had a routine post implant chest radiograph (CXR), leaving 289 evaluable patients. RESULTS Twenty radioactive seed pulmonary emboli were identified in 17 patients; 3 patients had two emboli each. The radioactive seed pulmonary embolism rate for the entire group of patients was 5.9%. Acute pulmonary symptoms were not reported by any patient in this series. One hundred forty-six study patients were implanted with free seeds alone (136 Pd-103 and 11 I-125), and 143 were implanted with linked seed embedded in a vicryl suture for the peripheral portions of their implants. The radioactive seed embolization rate by patient was 11% (16/146) versus 0.7% (1/143) for free seed implants and implants utilizing linked seeds, respectively. The difference was statistically significant, p = 0.0002. No patient had detectable morbidity as a consequence of seed emboli. CONCLUSION The use of linked seeds embedded in vicryl sutures for the peripheral portion of permanent radioactive seed prostate implants significantly reduced the incidence of pulmonary seed embolization in patients treated with the Seattle technique.
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Affiliation(s)
- E M Tapen
- Department of Radiation Oncology, Comprehensive Cancer Center, Alta Bates Hospital, Berkeley, CA 94704, USA
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Pathak SD, Grimm PD, Chalana V, Kim Y. Pubic arch detection in transrectal ultrasound guided prostate cancer therapy. IEEE Trans Med Imaging 1998; 17:762-771. [PMID: 9874300 DOI: 10.1109/42.736032] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
New biopsy techniques, increased life expectancy, and prostate-specific antigen (PSA) screening have contributed to an increase in the reported incidence of prostate cancer. Among several treatment options available to the patients, transperineal prostate brachytherapy has emerged as a medically successful, cost-effective outpatient procedure for treating localized prostate cancer. Transperineal prostate brachytherapy employs transrectal ultrasound (TRUS) as the primary imaging modality to accurately preplan and subsequently execute the placement of radioactive seeds into the prostate. Under TRUS guidance, a needle (preloaded with radioactive seeds) is inserted through a template guide, through the perineum and into a predetermined prostate target. The pubic arch, formed by the central union of pelvic bones, is a potential barrier to the passage of these needles in the prostate. A critical aspect, therefore, in the planning and execution of the brachytherapy procedure is the accurate assessment of pubic arch interference (PAI) in relation to the prostate. Traditionally, the evaluation of PAI has involved computed tomography correlate scanning or crude subjective evaluations. In this paper, we describe a new method of assessing PAI by detecting the pubic arch via image processing on the TRUS images. The PAI detection (PAID) algorithm first uses a technique known as sticks to selectively enhance the contrast of linear features in ultrasound images. Next, the enhanced image is thresholded via percentile thresholding. Finally, we fit a parabola (a model for the pubic arch) recursively to the thresholded image. Our evaluation result from 15 cases indicates that the algorithm can successfully detect the pubic arch with 90% accuracy. Based on this study, we believe that detecting the pubic arch and assessing PAI can be done practically and more accurately in the clinical setting using TRUS rather than the current available methods.
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Affiliation(s)
- S D Pathak
- Department of Bioengineering, University of Washington, Seattle 98195, USA
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18
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Bice WS, Prestidge BR, Grimm PD, Friedland JL, Feygelman V, Roach M, Prete JJ, Dubois DF, Blasko JC. Centralized multiinstitutional postimplant analysis for interstitial prostate brachytherapy. Int J Radiat Oncol Biol Phys 1998; 41:921-7. [PMID: 9652858 DOI: 10.1016/s0360-3016(98)90123-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the feasibility and utility of performing centralized postimplant analysis for transperineal interstitial permanent prostate brachytherapy (TIPPB) by conducting a pilot study that compares the results obtained from 125I implants conducted at five different institutions. METHODS AND MATERIALS Dose-volume histogram (DVH) analysis was performed on 10 postimplant CT scans from each of five institutions. This analysis included the total implanted activity of 125I, ultrasound, and CT volumes of the prostate, target-volume ratios, dose homogeneity quantifiers, prostate dose coverage indices, and rectal doses. As a result of the uncertainty associated with the delineation of the prostatic boundaries on a CT scan, the contours were redrawn by a single, study center physician, and a repeat DVH analysis was performed. This provided the basis for comparison between institutions in terms of implant technique and quality. RESULTS By comparing total activity to preimplant ultrasound volume we clearly demonstrated that differences exist in implant technique among these five institutions. The difficulty associated with determining glandular boundaries on CT scans was apparent, based upon the variability in prostate volumes drawn by the various investigators compared to those drawn by the study center physician. This made no difference, of course, in the TVR or homogeneity quantifiers that are independent of target location. Furthermore, this variability made surprisingly little difference in terms of dose coverage of the prostate gland. Rectal doses varied between institutions according to the various implant techniques. CONCLUSIONS Centralized, outcome-based evaluation of transperineal interstitial permanent prostate brachytherapy is viable and appropriate. Such an approach could be reasonably used in the conduct of multiinstitutional trials used to study the efficacy of the procedure.
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Affiliation(s)
- W S Bice
- Radiation Oncology Service, Wilford Hall Medical Center, Lackland AFB, TX, USA
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Prete JJ, Prestidge BR, Bice WS, Friedland JL, Stock RG, Grimm PD. A survey of physics and dosimetry practice of permanent prostate brachytherapy in the United States. Int J Radiat Oncol Biol Phys 1998; 40:1001-5. [PMID: 9531387 DOI: 10.1016/s0360-3016(97)00901-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To obtain data with regard to current physics and dosimetry practice in transperineal interstitial permanent prostate brachytherapy (TIPPB) in the U.S. by conducting a survey of institutions performing this procedure with the greatest frequency. METHODS AND MATERIALS Seventy brachytherapists with the greatest volume of TIPPB cases in 1995 in the U.S. were surveyed. The four-page comprehensive questionnaire included questions on both clinical and physics and dosimetry practice. Individuals not responding initially were sent additional mailings and telephoned. Physics and dosimetry practice summary statistics are reported. Clinical practice data is reported separately. RESULTS Thirty-five (50%) surveys were returned. Participants included 29 (83%) from the private sector and 6 (17%) from academic programs. Among responding clinicians, 125I (89%) is used with greater frequency than 103Pd (83%). Many use both (71%). Most brachytherapists perform preplans (86%), predominately employing ultrasound imaging (85%). Commercial treatment planning systems are used more frequently (75%) than in-house systems (25%). Preplans take 2.5 h (avg.) to perform and are most commonly performed by a physicist (69%). A wide range of apparent activities (mCi) is used for both 125I (0.16-1.00, avg. 0.41) and 103Pd (0.50-1.90, avg. 1.32). Of those assaying sources (71%), the range in number assayed (1 to all) and maximum accepted difference from vendor stated activity (2-20%) varies greatly. Most respondents feel that the manufacturers criteria for source activity are sufficiently stringent (88%); however, some report that vendors do not always meet their criteria (44%). Most postimplant dosimetry imaging occurs on day 1 (41%) and consists of conventional x-rays (83%), CT (63%), or both (46%). Postimplant dosimetry is usually performed by a physicist (72%), taking 2 h (avg.) to complete. Calculational formalisms and parameters vary substantially. At the time of the survey, few institutions have adopted AAPM TG-43 recommendations (21%). Only half (50%) of those not using TG-43 indicated an intent to do so in the future. Calculated doses at 1 cm from a single 1 mCi apparent activity source permanently implanted varied significantly. For 125I, doses calculated ranged from 13.08-40.00 Gy and for 103Pd, from 3.10 to 8.70 Gy. CONCLUSION While several areas of current physics and dosimetry practice are consistent among institutions, treatment planning and dose calculation techniques vary considerably. These data demonstrate a relative lack of consensus with regard to these practices. Furthermore, the wide variety of calculational techniques and benchmark data lead to calculated doses which vary by clinically significant amounts. It is apparent that the lack of standardization with regard to treatment planning and dose calculation practice in TIPPB must be addressed prior to performing any meaningful comparison of clinical results between institutions.
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Affiliation(s)
- J J Prete
- Department of Radiation Oncology, Wilford Hall Medical Center, San Antonio, TX 78236-5300, USA
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20
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Prestidge BR, Prete JJ, Buchholz TA, Friedland JL, Stock RG, Grimm PD, Bice WS. A survey of current clinical practice of permanent prostate brachytherapy in the United States. Int J Radiat Oncol Biol Phys 1998; 40:461-5. [PMID: 9457836 DOI: 10.1016/s0360-3016(97)00715-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To help establish standards of care for transperineal interstitial permanent prostate brachytherapy (TIPPB) by obtaining data regarding current clinical practice among the most experienced TIPPB brachytherapists in the United States. METHODS AND MATERIALS The 70 brachytherapists who performed the greatest number of TIPPB cases in 1995 in the U.S. were surveyed. Each received a comprehensive four page questionnaire that included sections on training and experience, patient and isotope selection criteria, manpower, technique, and follow-up. Thirty-five (50%) surveys were ultimately returned after three mailings and follow-up phone calls. The cumulative experience of the 35 respondents represented approximately 45% of the total TIPPB volume in the U.S. for 1995. Respondents included 29 from the private sector and six from academic programs. RESULTS The median physician experience with TIPPB was reported as 4.9 years. Each performed an average of 73 TIPPB procedures in 1995 (range 40-300). This represented an increase in volume for most (74%) of the respondents. Sixty-three percent of the respondents attended a formal training course, 54% had TIPPB-specific residency training, and 31% had been proctored (16 had received two or more types of training experience). The most commonly reported selection criteria for implant alone was on Gleason score < or = 7, PSA < 15, < or = Stage T2a, and gland size < or = 60 cc, although no clear consensus was found. Fifty-four percent considered a history of TURP to be a relative contraindication, while 34% considered TURP to have no impact on patient selection. Eighty-six percent of respondents combine brachytherapy with external beam radiation in an average of 32% of their patients. Boosts were given with both 125I prescribed to 120 Gy (75%) or 103Pd to 90 Gy (50%). Sixty percent reported using a Mick applicator, 46% prefer using preloaded needles, and (11%) use both techniques. Real-time imaging was usually performed with ultrasound (94%); most included fluoroscopy (60%). Definitions of PSA control varied widely. CONCLUSIONS TIPPB clinical practice in the U.S. demonstrates similarities in technique, but differences in patient selection and definitions of biochemical control. It is, therefore, incumbent on those beginning TIPPB programs to carefully review the specific practice details of those institutions with a broad experience.
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Affiliation(s)
- B R Prestidge
- Department of Radiation Oncology, Wilford Hall Medical Center, San Antonio, TX 78236-5300, USA
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Ragde H, Blasko JC, Grimm PD, Kenny GM, Sylvester J, Hoak DC, Cavanagh W, Landin K. Brachytherapy for clinically localized prostate cancer: results at 7- and 8-year follow-up. Semin Surg Oncol 1997; 13:438-43. [PMID: 9358591 DOI: 10.1002/(sici)1098-2388(199711/12)13:6<438::aid-ssu8>3.0.co;2-b] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In recent years, there has been a resurgence of interest in interstitial radiation as a cost-effective and efficient method of treating organ-confined prostate cancer. We describe our 7- and 8-year results with transperineal Iodine-125 and Palladium-103 implantation. A total of 551 consecutive patients were treated. Of these, 320/551 (58%) received implant alone (Group I), and 231/551 (42%)--considered higher risk patients--were also treated with a modest dose (45 Gy) of external beam irradiation (Group II). The median follow-up for Group I was 55 months, and for Group II, 60 months. At 7 years, the actuarial freedom from biochemical failure (prostate-specific antigen (PSA) < or = 1.0 ng/mL) was 80% in Group I patients, and, at 8 years, 65% in Group II patients. Morbidity was minimal if patients had not undergone prior transurethral prostate resections. The results indicate that interstitial radiation is a valid treatment for clinically localized prostate cancer.
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Affiliation(s)
- H Ragde
- Northwest Hospital, Seattle, Washington, USA
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Ragde H, Blasko JC, Grimm PD, Kenny GM, Sylvester JE, Hoak DC, Landin K, Cavanagh W. Interstitial iodine-125 radiation without adjuvant therapy in the treatment of clinically localized prostate carcinoma. Cancer 1997; 80:442-53. [PMID: 9241078 DOI: 10.1002/(sici)1097-0142(19970801)80:3<442::aid-cncr12>3.0.co;2-x] [Citation(s) in RCA: 218] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study was designed to evaluate the efficacy of iodine-125 interstitial radiation in the treatment of prostate carcinoma classified as T1 or T2. METHODS One hundred twenty-six consecutive patients with adenocarcinoma of the prostate (T1, 23%; T2, 77%) were treated with iodine-125 radionuclides between January 1, 1988, and December 31, 1990. Four patients died of intercurrent illness within 1 year postimplant, leaving 122 men in the study. The prescribed minimum radiation dose was 160 gray. Median follow-up was 69.3 months. Prebiopsy prostate specific antigen (PSA) values (median, 5.0 ng/mL) were available for all patients. Posttherapy evaluation included clinical, biochemical (PSA), and pathologic (repeat needle biopsy) studies. No patient was surgically staged, and none received androgen deprivation therapy. Morbidity was graded according to the Radiation Therapy Oncology Group grading scale. Statistical appraisal was performed by the Kaplan-Meier method. PSA failure was defined in two ways: (1) PSA progression, i.e., 2 consecutive increases from a nadir value; and (2) failure to attain an arbitrary serum PSA value of 1.0 or 0.5 ng/mL at last follow-up. RESULTS The overall 7-year survival was 77%; there were no deaths from prostate carcinoma in this cohort. The 7-year actuarial PSA progression free outcome was 89%, and the PSA < or = 1.0 ng/mL outcome was 87%. When PSA < or = 0.5 ng/mL was selected as an outcome end point, and PSA values in this series of radiation-treated patients were compared with PSA values proposed to indicate disease free survival after radical prostatectomy (PSA < or = 0.3-< or = 0.6 ng/mL), the 7-year actuarial disease free survival was 79%. Morbidity was minimal except in patients who had preimplant or postimplant transurethral prostate resection. CONCLUSIONS Outpatient-based iodine-125 prostate brachytherapy for prostate carcinoma classified as T1 or T2 resulted in biochemical outcomes comparable to end points resulting from radical prostatectomy and external beam radiation.
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Affiliation(s)
- H Ragde
- Pacific Northwest Cancer Foundation/Northwest Hospital, Seattle, Washington 98125-7001, USA
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Prestidge BR, Hoak DC, Grimm PD, Ragde H, Cavanagh W, Blasko JC. Posttreatment biopsy results following interstitial brachytherapy in early-stage prostate cancer. Int J Radiat Oncol Biol Phys 1997; 37:31-9. [PMID: 9054874 DOI: 10.1016/s0360-3016(96)00390-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To assess pathologic control rates for prostatic carcinoma as determined by postimplant prostate biopsy in a large series of consecutive patients who have received permanent interstitial brachytherapy using a contemporary transrectal ultrasound-directed, transperineal, computer generated, volume technique. METHODS AND MATERIALS Four hundred and two patients received permanent 125I or 103Pd interstitial brachytherapy as primary treatment for early stage prostatic carcinoma at the Northwest Tumor Institute between January 1988 and January 1994. Of these, 201 have consented to biopsy 12 or more months postimplant with a median follow-up of 40 months (range: 12-83 months). None had received hormonal manipulation. A total of 361 biopsies was performed on 201 patients with a range of one to six annual biopsies per patient (91 received multiple, serial biopsies). Of the 161 patients more than 12 months postimplant who have not been biopsied, most have been unwilling or unable to submit to biopsy. Only six patients with biochemical progression have not been biopsied. There was no difference in the presenting characteristics or implant parameters between those patients biopsied and those that were not. One hundred and forty-three received 125I (71%) prescribed to a MPD of 160 Gy with a median activity of 35.5 mCi, and 58 (29%) received 103Pd prescribed to a MPD of 115 Gy with a median activity of 123 mCi. Multiple biopsies were performed under transrectal ultrasound guidance, and all specimens were classified as either negative, indeterminate, or positive. RESULTS At the time of last biopsy, 161 (80%) have achieved negative pathology, 34 (17%) remain indeterminate, and 6 (3%) have been positive. Only 2 of the 186 patients with a PSA < 4.0 ng/ml at the time of biopsy were positive. Among those 33 indeterminate patients with a subsequent biopsy, 28 have converted to negative, 2 to positive, and 3 remain unchanged to date. CONCLUSIONS These data demonstrate at least an 80% pathologically confirmed local control rate following permanent interstitial brachytherapy for early stage prostate cancer. A higher local control rate is expected with further follow-up as the majority of indeterminate biopsies convert to negative over time. The indeterminate category of postirradiation biopsy described here includes specimens that have probably been interpreted as positive in other series, but correlate clinically and biochemically with negative biopsies. These results support the use of modern interstitial brachytherapy techniques for selected patients with early stage adenocarcinoma of the prostate.
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Affiliation(s)
- B R Prestidge
- Department of Radiation Oncology, Wilford Hall Medical Center, San Antonio, TX 78236-5300, USA
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Blasko JC, Ragde H, Luse RW, Sylvester JE, Cavanagh W, Grimm PD. Should brachytherapy be considered a therapeutic option in localized prostate cancer? Urol Clin North Am 1996; 23:633-50. [PMID: 8948417 DOI: 10.1016/s0094-0143(05)70342-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Contemporary prostate brachytherapy incorporates advances in computer analysis, imaging technology, and delivery apparatus, allowing exacting and reproducible results compared with historical approaches. The advances permit brachytherapy to be performed on a cost-effective, outpatient basis with low morbidity in the appropriately selected patient. Although unsettled questions remain regarding dosimetric issues, long-term outcomes, and morbidity, the weight of evidence to date appears to support the use of brachytherapy in selected patients. Brachytherapy may be considered a therapeutic option: as monotherapy for early-stage disease and also a boost following moderate doses of external beam irradiation for locally advanced disease.
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Affiliation(s)
- J C Blasko
- Northwest Tumor Institute, University of Washington School of Medicine, Seattle, USA
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Abstract
The goal of radiation therapy is to deliver a high dose to the tumor while preserving normal surrounding tissue. For early-stage prostate cancer, the ultimate conformal irradiation is to place radioactive sources directly into the gland either as permanent or temporary seeds. Permanent seed implantation is capable of delivering two times the radiobiologically equivalent dose of external beam irradiation to the prostate and tumor. In the past, the results of prostate brachytherapy were likely poor owing to the technical difficulty in accurately placing the radioactive seeds uniformly throughout the prostate. The use of low-dose-rate I-125 to treat high-grade cancers probably also contributed to the poorer results as compared with external beam irradiation. Over the last 10 years, however, technologic advances in transrectal ultrasonography, computer dosimetry, and template-based transperineal techniques have dramatically improved the accuracy and consistency of the brachytherapist to place radioactive sources directly into the prostate gland. Transperineal ultrasound or CT directed seed implantation has replaced the older retropubic method. Brachytherapists are now able to accurately map out the gland prior to the implant and carefully evaluate preoperatively seed placement. The availability of such radioactive sources as iodine-125, palladium-103, and iridium-192 has also given the brachytherapist isotopes that can be more carefully matched to the biology and stage of the tumor. More sensitive definitions of failure have prompted radiation oncologists and urologists to carefully evaluate the efficacy of external beam irradiation and surgery. Accurate comparison of the efficacy of brachytherapy to surgery and to external beam radiation requires a randomized study. Comparisons of retrospective studies are fraught with the problems of the heterogeneous nature of early-stage prostate cancer. Imbalances in stage, grade, initial PSA extraprostatic disease, and nodal status of patient groups make comparisons difficult. Most of the long-term data for permanent seed implantation are the result of work at a single institution. These results will need to be repeated at other institutions treating patients in a similar manner. Because techniques vary from institution to institution, permanent implant results will need to be carefully evaluated for technique as well as stratified for pretreatment variables. Pretreatment PSA and grade appear to be more sensitive variables than stage in predicting failure after radiation. As more patients are diagnosed with very early and nonpalpable disease, future studies will need to stratify patients based on these pretreatment factors. Patients with early-stage disease but identified as high risk for extraprostatic disease will require more intensive regimens. The treatment outcomes based on biopsy results are inconclusive. A lack of consensus on the definition of a truly positive biopsy remains forthcoming. The value of a positive prostate biopsy as an outcome predictor for clinical failure is still unclear. The use of prostate nuclear cell antigen staining may help clarify the issue. Comparison of treatment outcome based on absolute PSA is also difficult. The Seattle series suggest that brachytherapy by permanent seed implantation is as efficacious as external beam irradiation for early-stage disease in patients with a low PSA (< 10 ng/mL). As the PSA value rises above 10 ng/mL, the probability of failure after external beam rises substantially. Results from the Seattle series suggest an advantage to seed implant alone or the judicious application of seed implant boost to external beam radiation for these patients with more advanced cancer. The most sensitive measurement of therapeutic outcome is progression-free survival. Few studies to date have evaluated progression-free survival.
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Affiliation(s)
- P D Grimm
- Tumor Institute Group of Seattle, Washington, USA
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Blasko JC, Wallner K, Grimm PD, Ragde H. Prostate specific antigen based disease control following ultrasound guided 125iodine implantation for stage T1/T2 prostatic carcinoma. J Urol 1995. [PMID: 7543606 DOI: 10.1016/s0022-5347(01)66985-4] [Citation(s) in RCA: 216] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We report the prostate specific antigen (PSA) based recurrence-free survival rate after 125iodine (125I) implantation for early stage prostatic carcinoma. MATERIALS AND METHODS A total of 197 patients with clinical stage T1 and T2 prostatic carcinoma underwent outpatient 125I seed implantation. Followup was 1 to 7 years (median 3). Pretreatment serum PSA levels were elevated (greater than 4.0 ng./ml.) in 138 patients (70%). There were 105 well differentiated (Gleason score 2 to 4), 87 moderately differentiated (Gleason score 5 to 6) and 5 indeterminate tumors. The prescribed minimum prostatic dose was 160 Gy. The total dosage of 125I implanted ranged from 15 to 62 mCi. (median 37). Staging lymph node dissection and seminal vesicle biopsies were not routinely performed. RESULTS Among 138 patients with an elevated PSA level before implantation and no prior hormonal treatment, the PSA value returned to normal in 98% and decreased to less than 1.0 ng./ml. in 82% within 24 months of treatment. In 97% of those 138 patients the PSA level decreased to less than 1.0 ng./ml. at 48 months after implantation. Of 8 patients with an increasing PSA value 5 also had clinically evident failure. The actuarial rate of chemical (increasing PSA) or clinical failure at 5 years following implantation was 7%, with 15 patients still at risk at 5 years. There was a trend for higher failure rates among patients with higher pretreatment PSA levels (p = 0.57), Gleason scores 5 and 6 versus 2 to 4 (p = 0.51) or higher stage of disease (p = 0.17). CONCLUSIONS There is a high rate of clinical and chemical freedom from progression following 125I implantation for select patients with early stage prostatic carcinoma.
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Affiliation(s)
- J C Blasko
- Tumor Institute Group, Northwest Tumor Institute, Seattle, Washington 98133, USA
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Blasko JC, Wallner K, Grimm PD, Ragde H. Prostate specific antigen based disease control following ultrasound guided 125iodine implantation for stage T1/T2 prostatic carcinoma. J Urol 1995; 154:1096-9. [PMID: 7543606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE We report the prostate specific antigen (PSA) based recurrence-free survival rate after 125iodine (125I) implantation for early stage prostatic carcinoma. MATERIALS AND METHODS A total of 197 patients with clinical stage T1 and T2 prostatic carcinoma underwent outpatient 125I seed implantation. Followup was 1 to 7 years (median 3). Pretreatment serum PSA levels were elevated (greater than 4.0 ng./ml.) in 138 patients (70%). There were 105 well differentiated (Gleason score 2 to 4), 87 moderately differentiated (Gleason score 5 to 6) and 5 indeterminate tumors. The prescribed minimum prostatic dose was 160 Gy. The total dosage of 125I implanted ranged from 15 to 62 mCi. (median 37). Staging lymph node dissection and seminal vesicle biopsies were not routinely performed. RESULTS Among 138 patients with an elevated PSA level before implantation and no prior hormonal treatment, the PSA value returned to normal in 98% and decreased to less than 1.0 ng./ml. in 82% within 24 months of treatment. In 97% of those 138 patients the PSA level decreased to less than 1.0 ng./ml. at 48 months after implantation. Of 8 patients with an increasing PSA value 5 also had clinically evident failure. The actuarial rate of chemical (increasing PSA) or clinical failure at 5 years following implantation was 7%, with 15 patients still at risk at 5 years. There was a trend for higher failure rates among patients with higher pretreatment PSA levels (p = 0.57), Gleason scores 5 and 6 versus 2 to 4 (p = 0.51) or higher stage of disease (p = 0.17). CONCLUSIONS There is a high rate of clinical and chemical freedom from progression following 125I implantation for select patients with early stage prostatic carcinoma.
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Affiliation(s)
- J C Blasko
- Tumor Institute Group, Northwest Tumor Institute, Seattle, Washington 98133, USA
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Abstract
Brachytherapy is one of the oldest techniques of radiation therapy for prostate cancer. However, its use has been controversial due to mixed results with older implant techniques and the availability of different treatment methods. New methods of brachytherapy based on improved technology and increased understanding of radiobiology hold promise for consistently improved results. This article describe the various methods of prostate brachytherapy and reviews the clinical results for these methods.
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Affiliation(s)
- A T Porter
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Hawkins RA, Phelps ME, Huang SC, Wapenski JA, Grimm PD, Parker RG, Juillard G, Greenberg P. A kinetic evaluation of blood-brain barrier permeability in human brain tumors with [68Ga]EDTA and positron computed tomography. J Cereb Blood Flow Metab 1984; 4:507-15. [PMID: 6438122 DOI: 10.1038/jcbfm.1984.75] [Citation(s) in RCA: 70] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Twelve patients with primary and metastatic brain tumors were evaluated with [68Ga]ethylenediaminetetraacetate (EDTA) and positron computed tomography. Using a two-compartment tracer kinetic model, forward (K1) and reverse (k2) rate constants for molecular diffusion across the blood-brain barrier (BBB) were obtained and averaged 0.0029 +/- 0.0016 (mean +/- SD) ml/min/g for K1 and 0.0310 +/- 0.0156 min-1 for k2. Most tracer kinetic models are based on the assumption that tissue radioactivity contains no vascular component or require independent measures of cerebral blood volume (CBV) which are then subtracted from the measure tissue activity. The model in this work differs from that approach by assuming a vascular compartment in the tissue kinetic data. This vascular parameter is estimated from sequential measurements of activity concentrations in regions with an intact BBB or from measurements of 68Ga concentrations in the plasma (the input function). Thus, this approach does not require the assumption of a zero vascular contribution, does not require a separate measurement of CBV, and uses the criteria of constrained estimation to provide estimates of the local CBV and molecular diffusion through the BBB. Estimates of the relative CBV of the lesions in four studies (three subjects) with [68Ga]EDTA correlated well with those obtained with the C15O hemoglobin technique (correlation coefficient of 0.97).
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