Clinical feasibility of deep learning-based synthetic CT images from T2-weighted MR images for cervical cancer patients compared to MRCAT

This work aims to investigate the clinical feasibility of deep learning-based synthetic CT images for cervix cancer, comparing them to MR for calculating attenuation (MRCAT). Patient cohort with 50 pairs of T2-weighted MR and CT images from cervical cancer patients was split into 40 for training and 10 for testing phases. We conducted deformable image registration and Nyul intensity normalization for MR images to maximize the similarity between MR and CT images as a preprocessing step. The processed images were plugged into a deep learning model, generative adversarial network. To prove clinical feasibility, we assessed the accuracy of synthetic CT images in image similarity using structural similarity (SSIM) and mean-absolute-error (MAE) and dosimetry similarity using gamma passing rate (GPR). Dose calculation was performed on the true and synthetic CT images with a commercial Monte Carlo algorithm. Synthetic CT images generated by deep learning outperformed MRCAT images in image similarity by 1.5% in SSIM, and 18.5 HU in MAE. In dosimetry, the DL-based synthetic CT images achieved 98.71% and 96.39% in the GPR at 1% and 1 mm criterion with 10% and 60% cut-off values of the prescription dose, which were 0.9% and 5.1% greater GPRs over MRCAT images.

Influence of circle of Willis modeling on hemodynamic parameters in anterior communicating artery aneurysms and recommendations for model selection

Computational fluid dynamics (CFD) has been utilized to calculate hemodynamic parameters in anterior communicating artery aneurysm (AComA), which is located at a junction between left and right A1 and A2 segments. However, complete or half circle of Willis (CoW) models are used indiscriminately. This study aims to suggest recommendations for determining suitable CoW model. Five patient-specific CoW models with AComA were used, and each model was divided into complete, left-half, and right-half models. After validating the CFD using a flow experiment, the hemodynamic parameters and flow patterns in five AComAs were compared. In four out of five cases, inflow from one A1 side had a dominant influence on the AComA, while both left and right A1 sides affected the AComA in the remaining case. Also, the average difference in time-averaged wall shear stress between the complete and half models for four cases was 4.6%, but it was 62% in the other case. The differences in the vascular resistances of left and right A1 and A2 segments greatly influenced the flow patterns in the AComA. These results may help to enhance clinicians' understanding of blood flow in the brain, leading to improvements in diagnosis and treatment of cerebral aneurysms.

Assessment of Eligibility and Utilization of Accelerated Partial Breast Irradiation in Korean Breast Cancer Patients (KROG 22-15)

PURPOSE

We investigated the proportions of patients eligible for accelerated partial breast irradiation (APBI) among those with pT1-2N0 breast cancer, based on the criteria set by the American Society for Radiation Oncology (ASTRO), the Groupe Européen de Curiethérapie and the European Society for Radiotherapy and Oncology (GEC-ESTRO), the American Brachytherapy Society (ABS), and the American Society of Breast Surgeons (ASBS). Additionally, we analyzed the rate of APBI utilization among eligible patients.

MATERIALS AND METHODS

Patients diagnosed with pT1-2N0 breast cancer in 2019 were accrued in four tertiary medical centers in Korea. All patients had undergone breast conserving surgery followed by radiotherapy, either whole breast irradiation or APBI. To determine which guideline best predicts the use of APBI in Korea, the F1 score and Matthews Correlation Coefficient (MCC) were determined for each guideline.

RESULTS

A total of 1,251 patients were analyzed, of whom 196 (15.7%) underwent APBI. The percentages of eligible patients identified by the ASTRO, GEC-ESTRO, ABS, and ASBS criteria were 13.7%, 21.0%, 50.5%, and 63.5%, respectively. APBI was used to treat 54.4%, 37.2%, 27.1%, and 23.7% of patients eligible by the ASTRO, GEC-ESTRO, ABS, and ASBS criteria, respectively. The ASTRO guideline exhibited the highest F1 score (0.76) and MCC (0.67), thus showing the best prediction of APBI utilization in Korea.

CONCLUSION

The proportion of Korean breast cancer patients who are candidates for APBI is substantial. The actual rate of APBI utilization among eligible patients may suggest there is a room for risk-stratified optimization in offering radiation therapy.

Concurrent Lapatinib With Brain Radiation Therapy in Patients With HER2+ Breast Cancer With Brain Metastases: NRG Oncology-KROG/RTOG 1119 Phase 2 Randomized Trial

PURPOSE

Lapatinib plus whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) was hypothesized to improve the 12-week intracranial complete response (CR) rate compared with either option of radiation therapy (RT) alone for patients with brain metastases (BM) from human epidermal growth factor receptor 2-positive (HER2+) breast cancer.

METHODS AND MATERIALS

This study included patients with HER2+ breast cancer with ≥1 measurable, unirradiated BM. Patients were randomized to WBRT (37.5 Gy/3 wk)/SRS (size-based dosing) ± concurrent lapatinib (1000 mg daily for 6 weeks). Secondary endpoints included objective response rate (ORR), lesion-specific response, central nervous system progression-free survival, and overall survival.

RESULTS

From July 2012 to September 2019, 143 patients were randomized, with 116 analyzable for the primary endpoint. RT + lapatinib did not improve 12-week CR (0% vs 6% for RT alone, 1-sided P = .97), or ORR at 12 weeks. At 4 weeks, RT + lapatinib showed higher ORR (55% vs 42%). Higher graded prognostic assessment and ≤10 lesions were associated with higher 12-week ORR. Grade 3 and 4 adverse event rates were 8% and 0% for RT and 28% and 6% for RT + lapatinib.

CONCLUSIONS

The addition of 6 weeks of concomitant lapatinib to WBRT/SRS did not improve the primary endpoint of 12-week CR rate or 12-week ORR. Adding lapatinib to WBRT/SRS showed improvement of 4-week ORR, suggesting a short-term benefit from concomitant therapy.

Perioperative Low-Dose Aspirin Management for Planned Clipping Surgery: When, How Long, and With What Precautions?

BACKGROUND AND OBJECTIVE

Perioperative low-dose aspirin (ASA) management for open craniotomy surgery lacked information. We analyze to establish the perioperative ASA strategy to minimize both hemorrhagic and thromboembolic complications.

METHODS

The investigators designed a multicenter retrospective study, which included patients scheduled to have clipping surgery for unruptured intracranial aneurysm. The incidence and risk factors were analyzed for postoperative hemorrhagic complications and major cardio- and cerebrovascular events (MACCEs) within 1 month postoperation.

RESULTS

This study included 503 long-term ASA users of 3654 patients at three tertiary centers. The incidence of hemorrhagic complications and MACCEs was 7.4% (37/503) and 8.8% (44/503), respectively. Older age (>70 years, odds ratio [OR]: 2.928, 95% CI [1.337-6.416]), multiple aneurysms operation (OR: 2.201, 95% CI [1.017-4.765]), large aneurysm (>10 mm, OR: 4.483, 95% CI [1.485-13.533]), and ASA continuation (OR: 2.604, 95% CI [1.222-5.545]) were independent risk factors for postoperative hemorrhagic complications. Intracranial hemorrhage was the only type of hemorrhagic complication that increased in the ASA continuation group (10.6% vs 2.9%, P = .001). Between the ASA continuation and discontinuation groups, the overall incidence of MACCEs was not significantly different (log-rank P = .8). In the subgroup analysis, ASA discontinuation significantly increased the risk of MACCEs in the secondary prevention group (adjusted hazard ratio: 2.580, 95% CI [1.015-6.580]).

CONCLUSION

ASA continuation increased the risk of postoperative intracranial hemorrhage. Simultaneously, ASA discontinuation was the major risk factor for postoperative MACCEs in the high-risk group. Without evidence of intracranial hemorrhage, early ASA resumption was indicated (a total cessation duration <7-10 days) in the secondary prevention group.

Choosing the right adjuvant therapy for stage III-IVA endometrial cancer: A comparative analysis of chemoradiotherapy and chemotherapy

OBJECTIVE

The optimal adjuvant treatment for patients with locally advanced endometrial cancer (EC) remains debatable. We comparatively analyzed recurrence patterns and survival outcomes in patients with stage III-IVA EC treated with adjuvant chemotherapy (CT) exclusively or combined with radiotherapy (CRT).

METHODS

We retrospectively analyzed 184 patients treated for stage III-IVA EC at 2 tertiary institutions between 2010 and 2021. All patients underwent standard primary surgery and received either CT alone (n = 89) or CRT (n = 95) as an adjuvant treatment. We compared the failure patterns, recurrence-free survival (RFS), and overall survival (OS) between the CT and CRT groups.

RESULTS

The median follow-up period was 54.8 months. Most patients underwent pelvic (94.6%) or para-aortic (75.5%) lymphadenectomies. The 5-year RFS was 69.2% with CRT versus 56.3% with CT (P = 0.038), and 5-year OS was 86.1% versus 78.9% (P = 0.357). Pelvic and para-aortic recurrence rates were significantly higher in the CT group (pelvic: 29.2%; para-aortic: 20.2%) than in the CRT group (pelvic: 10.5%; para-aortic: 6.3%). The CRT group showed a higher rate of distant recurrence (CRT, 23.2% vs. CT, 14.6%) however, the 5-year cumulative incidence of distant recurrence was not significantly different between the two groups (CRT, 28% vs. CT, 35%).

CONCLUSIONS

This study highlights the potential benefits of adjuvant CRT in patients with stage III-IVA EC. The incorporation of molecular classification is necessary to derive optimal personalized adjuvant treatment strategies for this patient population.

Normal tissue complication probability models of hypothyroidism after radiotherapy for breast cancer

Purpose

We aimed to develop Lyman-Kutcher-Burman (LKB) and multivariable normal tissue complication probability (NTCP) models to predict the risk of radiation-induced hypothyroidism (RIHT) in breast cancer patients.

Materials and methods

A total of 1,063 breast cancer patients who underwent whole breast irradiation between 2009 and 2016 were analyzed. Individual dose-volume histograms were used to generate LKB and multivariable logistic regression models. LKB model was fit using the thyroid radiation dose-volume parameters. A multivariable model was constructed to identify potential dosimetric and clinical parameters associated with RIHT. Internal validation was conducted using bootstrapping techniques, and model performance was evaluated using the area under the curve (AUC) and Hosmer-Lemeshow (HL) goodness-of-fit test.

Results

RIHT developed in 4 % of patients with a median follow-up of 77.7 months. LKB and multivariable NTCP models exhibited significant agreement between the predicted and observed results (HL P values > 0.05). The multivariable NTCP model outperformed the LKB model in predicting RIHT (AUC 0.62 vs. 0.54). In the multivariable model, systemic therapy, age, and percentage of thyroid volume receiving ≥ 10 Gy (V10) were significant prognostic factors for RIHT. The cumulative incidence of RIHT was significantly higher in patients who exceeded the cut-off values for all three risk predictors (systemic therapy, age ≥ 40 years, and thyroid V10 ≥ 26 %, P < 0.005).

Conclusions

Systemic therapy, age, and V10 of the thyroid were identified as strong risk factors for the development of RIHT. Our NTCP models provide valuable insights to clinicians for predicting and preventing hypothyroidism by identifying high-risk patients.

Diagnostic assessments and treatment results of well-differentiated gastric-type adenocarcinoma of the uterine cervix (Adenoma malignum): A multicenter retrospective analysis of KROG 22-03 study

OBJECTIVE

Among cervical adenocarcinomas, well-differentiated gastric adenocarcinoma of the uterine cervix (WD-GAS), previously termed adenoma malignum (minimal deviation adenocarcinoma) is not well understood. Because of its rarity and difficulty in diagnosis, there is no standard care for WD-GAS. Thus, we conducted the first multicenter retrospective study on WD-GAS to clarify prognostic factors for long-term survival and recurrence.

METHODS

Patients diagnosed with WD-GAS at eight hospitals participated in this multi-center study. Overall survival (OS) and recurrence-free survival (RFS) were calculated with the Kaplan-Meier method. Additionally, OS between the early and advanced FIGO stage groups were compared with the log-rank test. Cox regression analysis was conducted to identify significant factors associated with recurrence-free survival (RFS).

RESULTS

A total of 73 patients from eight hospitals in South Korea were included in the analysis. The median follow-up period was 44.8 months, and all patients underwent curative surgical intervention as the primary treatment. Recurrence was observed in 17 patients (23.3%). Ten patients had locoregional recurrence, four patients had distant metastasis, and three patients presented with both locoregional recurrence and distant metastasis. The Cox regression analysis identified several statistically significant factors associated with RFS, including vaginal invasion (VI), parametrial invasion (PMI), resection margin (RM), and nodal and lymphovascular invasion (LVI). When considering these five factors together, patients without any of the factors exhibited recurrence-free survival (RFS) of 97.0% at three years and those with more than one of these factors had a 3-year RFS of 65.4% (P < 0.001).

CONCLUSION

WD-GAS showed relatively high locoregional recurrence rate. Positive PMI, VI, RM, nodal involvement, and LVI were associated with a significant increase in recurrence or distant metastasis rates.

Experience of Implementing Deep Learning-Based Automatic Contouring in Breast Radiation Therapy Planning: Insights From Over 2000 Cases

PURPOSE

This study evaluated the impact and clinical utility of an auto-contouring system for radiation therapy treatments.

METHODS AND MATERIALS

The auto-contouring system was implemented in 2019. We evaluated data from 2428 patients who underwent adjuvant breast radiation therapy before and after the system's introduction. We collected the treatment's finalized contours, which were reviewed and revised by a multidisciplinary team. After implementation, the treatment contours underwent a finalization process that involved manual review and adjustment of the initial auto-contours. For the preimplementation group (n = 369), auto-contours were generated retrospectively. We compared the auto-contours and final contours using the Dice similarity coefficient (DSC) and the 95% Hausdorff distance (HD95).

RESULTS

We analyzed 22,215 structures from final and corresponding auto-contours. The final contours were generally larger, encompassing more slices in the superior or inferior directions. Among organs at risk (OAR), the heart, esophagus, spinal cord, and contralateral breast demonstrated significantly increased DSC and decreased HD95 postimplementation (all P < .05), except for the lungs, which presented inaccurate segmentation. Among target volumes, CTVn_L2, L3, L4, and the internal mammary node showed increased DSC and decreased HD95 postimplementation (all P < .05), although the increase was less pronounced than the OAR outcomes. The analysis also covered factors contributing to significant differences, pattern identification, and outlier detection.

CONCLUSIONS

In our study, the adoption of an auto-contouring system was associated with an increased reliance on automated settings, underscoring its utility and the potential risk of automation bias. Given these findings, we underscore the importance of considering the integration of stringent risk assessments and quality management strategies as a precautionary measure for the optimal use of such systems.

Assessment of deep learning-based auto-contouring on interobserver consistency in target volume and organs-at-risk delineation for breast cancer: Implications for RTQA program in a multi-institutional study

PURPOSE

To quantify interobserver variation (IOV) in target volume and organs-at-risk (OAR) contouring across 31 institutions in breast cancer cases and to explore the clinical utility of deep learning (DL)-based auto-contouring in reducing potential IOV.

METHODS AND MATERIALS

In phase 1, two breast cancer cases were randomly selected and distributed to multiple institutions for contouring six clinical target volumes (CTVs) and eight OAR. In Phase 2, auto-contour sets were generated using a previously published DL Breast segmentation model and were made available for all participants. The difference in IOV of submitted contours in phases 1 and 2 was investigated quantitatively using the Dice similarity coefficient (DSC) and Hausdorff distance (HD). The qualitative analysis involved using contour heat maps to visualize the extent and location of these variations and the required modification.

RESULTS

Over 800 pairwise comparisons were analysed for each structure in each case. Quantitative phase 2 metrics showed significant improvement in the mean DSC (from 0.69 to 0.77) and HD (from 34.9 to 17.9 mm). Quantitative analysis showed increased interobserver agreement in phase 2, specifically for CTV structures (5-19 %), leading to fewer manual adjustments. Underlying IOV differences causes were reported using a questionnaire and hierarchical clustering analysis based on the volume of CTVs.

CONCLUSION

DL-based auto-contours improved the contour agreement for OARs and CTVs significantly, both qualitatively and quantitatively, suggesting its potential role in minimizing radiation therapy protocol deviation.

Large institutional experience of early outcomes and dosimetric findings with postoperative stereotactic partial breast irradiation in breast cancer

PURPOSE

To analyze the dosimetric and toxicity outcomes of patients treated with postoperative stereotactic partial breast irradiation (S-PBI).

METHODS

We identified 799 women who underwent S-PBI at our institution between January 2016 and December 2022. The most commonly used dose-fraction and technique were 30 Gy in 5 fractions (91.7 %) and a robotic stereotactic radiation system with real-time tracking (83.7 %). The primary endpoints were dosimetric parameters and radiation-related toxicities. For comparison, a control group undergoing ultra-hypofractionated whole breast irradiation (UF-WBI, n = 468) at the same institution was selected.

RESULTS

A total of 815 breasts from 799 patients, with a median planning target volume (PTV) volume of 89.6 cm3, were treated with S-PBI. Treatment plans showed that the mean and maximum doses received by the PTV were 96.2 % and 104.8 % of the prescription dose, respectively. The volume of the ipsilateral breast that received 50 % of the prescription dose was 32.3 ± 8.9 %. The mean doses for the ipsilateral lung and heart were 2.5 ± 0.9 Gy and 0.65 ± 0.39 Gy, respectively. Acute toxicity occurred in 175 patients (21.5 %), predominantly of grade 1. Overall rate of late toxicity was 4 % with a median follow-up of 31.6 months. Compared to the UF-WBI group, the S-PBI group had comparably low acute toxicity (21.5 % vs. 25.2 %, p = 0.12) but significantly lower dosimetric parameters for all organs-at-risks (all p < 0.05).

CONCLUSION

In this large cohort, S-PBI demonstrated favorable dosimetric and toxicity profiles. Considering the reduced radiation exposure to surrounding tissues, external beam PBI with advanced techniques should at least be considered over traditional WBI-based approaches for PBI candidates.

Therapeutic effects of surgical debulking of metastatic lymph nodes in cervical cancer IIICr: a trial protocol for a phase III, multicenter, randomized controlled study (KGOG1047/DEBULK trial)

BACKGROUND

Bulky or multiple lymph node (LN) metastases are associated with poor prognosis in cervical cancer, and the size or number of LN metastases is not yet reflected in the staging system and therapeutic strategy. Although the therapeutic effects of surgical resection of bulky LNs before standard treatment have been reported in several retrospective studies, well-planned randomized clinical studies are lacking. Therefore, the aim of the Korean Gynecologic Oncology Group (KGOG) 1047/DEBULK trial is to investigate whether the debulking surgery of bulky or multiple LNs prior to concurrent chemoradiation therapy (CCRT) improves the survival rate of patients with cervical cancer IIICr diagnosed by imaging tests.

METHODS

The KGOG 1047/DEBULK trial is a phase III, multicenter, randomized clinical trial involving patients with bulky or multiple LN metastases in cervical cancer IIICr. This study will include patients with a short-axis diameter of a pelvic or para-aortic LN ≥2 cm or ≥3 LNs with a short-axis diameter ≥1 cm and for whom CCRT is planned. The treatment arms will be randomly allocated in a 1:1 ratio to either receive CCRT (control arm) or undergo surgical debulking of bulky or multiple LNs before CCRT (experimental arm). CCRT consists of extended-field external beam radiotherapy/pelvic radiotherapy, brachytherapy and LN boost, and weekly chemotherapy with cisplatin (40 mg/m²), 4-6 times administered intravenously. The primary endpoint will be 3-year progression-free survival rate. The secondary endpoints will be 3-year overall survival rate, treatment-related complications, and accuracy of radiological diagnosis of bulky or multiple LNs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05421650; Clinical Research Information Service Identifier: KCT0007137.

A Survey of Practice Patterns for Clinical Nodal Staging Prior to Neoadjuvant Chemotherapy in Breast Cancer

BACKGROUND

The importance of clinical staging in breast cancer has increased owing to the wide use of neoadjuvant systemic therapy (NST). This study aimed to investigate the current practice patterns regarding clinical nodal staging in breast cancer in real-world settings.

MATERIALS AND METHODS

A web-based survey was administered to board-certified oncologists in Korea, including breast surgical, medical, and radiation oncologists, from January to April 2022. The survey included 19 general questions and 4 case-based questions.

RESULTS

In total, 122 oncologists (45 radiation, 44 surgical, and 33 medical oncologists) completed the survey. Among them, 108 (88%) responded that clinical staging before NST was primarily performed by breast surgeons. All the respondents referred to imaging studies during nodal staging. Overall, 64 (52.5%) responders determined the stage strictly based on the radiology reports, whereas 58 (47.5%) made their own decision while noting radiology reports. Of those who made their own decisions, 88% referred to the number or size of the suspicious node. Of the 75 respondents involved in prescribing regimens for neoadjuvant chemotherapy, 58 (77.3%) responded that the reimbursement regulations in the selection of NST regimens affected nodal staging in clinical practice. In the case-based questions, high variability was observed among the clinicians in the same cases.

CONCLUSIONS

Diverse assessments by specialists owing to the lack of a clear, harmonized staging system for the clinical nodal staging of breast cancer can lead to diverse practice patterns. Thus, practical, harmonized, and objective methods for clinical nodal staging and for the outcomes of post-NST response are warranted for appropriate treatment decisions and accurate outcome evaluation.

Investigation of paraclinoid aneurysm formation by comparing the combined influence of hemodynamic parameters between aneurysmal and non-aneurysmal arteries

Numerous studies have evaluated the effects of hemodynamic parameters on aneurysm formation. However, the reasons why aneurysms do not initiate in intracranial arteries are still unclear. This study aimed to investigate the influence of hemodynamic parameters, wall shear stress (WSS) and strain, on aneurysm formation by comparing between aneurysmal and non-aneurysmal arteries. Fifty-eight patients with paraclinoid aneurysms on one side were enrolled. Based on magnetic resonance angiography, each patient's left and right internal carotid arteries (ICAs) were reconstructed. For a patient having an aneurysm on one side, the ICA with the paraclinoid aneurysm was defined as the aneurysmal artery after eliminating the aneurysm, whereas the opposite ICA without aneurysm was defined as the non-aneurysmal artery. Computational fluid dynamics and fluid-structure interaction analyses were then performed for both aneurysmal and non-aneurysmal arteries. Finally, the relationship between high hemodynamic parameters and aneurysm location was investigated. For aneurysmal arteries, high WSS and strain locations were well-matched with the aneurysm formation site. Also, considerable correlations between high WSS and strain locations were observed. However, there was no significant relationship between high hemodynamic parameters and aneurysm formation for non-aneurysmal arteries. The findings are helpful for understanding aneurysm formation mechanism and encouraging further relevant research.

An Investigation of the Effect of Virtual Reality on Alleviating Anxiety in Patients With Breast Cancer Undergoing Radiation Therapy: A Randomized Controlled Trial

PURPOSE

The aim of this study was to evaluate the anxiety-reducing effects of virtual reality (VR) on patients with breast cancer undergoing adjuvant radiation therapy (RT).

METHODS AND MATERIALS

This randomized controlled trial was conducted among patients with breast cancer receiving RT at a single institution. Of 196 enrolled and randomized patients, 97 were assigned to a VR explanation group (intervention) and 99 were assigned to the standard-of-care group (control). Anxiety levels were measured using the Amsterdam Preoperative Anxiety and Information Scale (APAIS) as the primary endpoint and the State-Trait Anxiety Inventory (STAI) and Linear Analogue Scale Assessment (LASA) as secondary endpoints. Knowledge of the RT procedure, patient satisfaction, and time spent for counseling were also assessed.

RESULTS

Intervention significantly reduced patient anxiety immediately, not only on the primary endpoint, APAIS, but also on the STAI and LASA anxiety scales. Specifically, in the intervention group, there were immediate reductions of 26.0%, 16.1%, and 55.8% for APAIS, STAI, and LASA, respectively, whereas in the control group, the respective reductions were 8.1%, 8.5%, and 13.7%. Among the 3 anxiety scales, long-term anxiety reduction was observed only when anxiety was measured by LASA. Subgroup analyses showed that the effect on anxiety did not differ based on the physician, baseline anxiety level, use of hormone therapy, or health literacy. The intervention also significantly improved knowledge of the RT procedure (81.9/100 vs 76.8/100; P = .006) and patient satisfaction with the explanation manner (6.56 vs 5.72; P < .001) compared with the control group.

CONCLUSIONS

Immersive VR applied to the current procedure reduces anxiety during RT planning for patients with breast cancer. Further research is necessary to investigate the long-term effects of VR on anxiety.

Stereotactic radiosurgery for noncavernous sinus dural arteriovenous fistulas: treatment outcomes and their predictors

OBJECTIVE

Stereotactic radiosurgery (SRS) has emerged as a safe and effective treatment modality for dural arteriovenous fistulas (dAVFs), particularly cavernous sinus (CS) dAVFs. However, the long-term outcomes of non-CS dAVFs are not well known. This study aimed to evaluate the efficacy and safety of SRS for non-CS dAVFs and to investigate the risk factors for incomplete obliteration.

METHODS

Between 2007 and 2020, 65 non-CS dAVFs in 63 patients were treated using SRS at a single institution. Demographic characteristics, initial clinical presentations, clinical outcomes, and radiological findings were retrospectively reviewed. The procedure-related complications were assessed. Radiological outcomes were evaluated as complete obliteration, incomplete obliteration, and angiographic worsening, whereas clinical outcomes were evaluated for symptom recovery.

RESULTS

At a median follow-up of 17 months, the overall complete obliteration rate was 63.1%, and the cumulative obliteration rates were 24.6%, 60.0%, 70.0%, and 74.3% at 12, 24, 36, and 48 months, respectively. Six patients underwent retreatment due to angiographic worsening; in 5 of these patients, recruitment of arterial feeders was newly observed in the adjacent sinus, which was not treated in the initial SRS. In the multivariate analysis, high-flow shunt and venous ectasia were associated with incomplete obliteration. No adverse events occurred after SRS.

CONCLUSIONS

SRS for non-CS dAVFs is safe, and its efficacy is highly variable according to location. High-flow shunts may indicate greater radioresistance. In the retreated cases, new fistulas tended to be accompanied by sinus steno-occlusion and formed in the adjacent sinus segments.

New morphological parameter for intracranial aneurysms and rupture risk prediction based on artificial neural networks

BACKGROUND

Numerous studies have evaluated the rupture risk of intracranial aneurysms using morphological parameters because of their good predictive capacity. However, the limitation of current morphological parameters is that they do not always allow evaluation of irregularities of intracranial aneurysms. The purpose of this study is to propose a new morphological parameter that can quantitatively describe irregularities of intracranial aneurysms and to evaluate its performance regarding rupture risk prediction.

METHODS

In a retrospective study, conventional morphological parameters (aspect ratio, bottleneck ratio, height-to-width ratio, volume to ostium ratio, and size ratio) and a newly proposed morphological parameter (mass moment of inertia) were calculated for 125 intracranial aneurysms (80 unruptured and 45 ruptured aneurysms). Additionally, hemodynamic parameters (wall shear stress and strain) were calculated using computational fluid dynamics and fluid-structure interaction. Artificial neural networks trained with each parameter were used for rupture risk prediction.

RESULTS

All components of the mass moment of inertia (Ixx, Iyy, and Izz) were significantly higher in ruptured cases than in unruptured cases (p values for Ixx, Iyy, and Izz were 0.032, 0.047, and 0.039, respectively). When the conventional morphological and hemodynamic parameters as well as the mass moment of inertia were considered together, the highest performance for rupture risk prediction was obtained (sensitivity 96.3%; specificity 85.7%; area under the receiver operating characteristic curve 0.921).

CONCLUSIONS

The mass moment of inertia would be a useful parameter for evaluating aneurysm irregularity and hence its risk of rupture. The new approach described here may help clinicians to predict the risk of aneurysm rupture more effectively.

Cosmetic Outcome and Toxicity After Stereotactic Accelerated Partial Breast Irradiation in Early Breast Cancer: A Prospective Observational Cohort Study

PURPOSE

The aim of this work was to prospectively evaluate the toxicity and cosmetic outcomes of 5-fraction, stereotactic, accelerated partial breast irradiation (APBI).

METHODS AND MATERIALS

This prospective observational cohort study enrolled women who underwent APBI for invasive carcinoma or carcinoma in situ of the breast. APBI was delivered using a CyberKnife M6 robotic radiosurgery system at 30 Gy in 5 nonconsecutive, once-daily fractions. Women undergoing whole breast irradiation (WBI) were also enrolled for comparison. Patient-reported and physician-assessed adverse events were recorded. Breast fibrosis was measured using a tissue compliance meter, and breast cosmesis was assessed using BCCT.core (an automatic, computer-based software). Outcomes were collected until 24 months posttreatment according to the study protocol.

RESULTS

In total, 204 patients (APBI, n = 103; WBI, n = 101) were enrolled. Regarding patient-reported outcomes, the APBI group reported significantly less skin dryness (6.9% vs 18.3%; P = .015), radiation skin reaction (9.9% vs 23.5%; P = .010), and breast hardness (8.0% vs 20.4%; P = .011) at 6 months than the WBI group. On physician assessment, the APBI group had significantly less dermatitis at 12 months (1.0% vs 7.2%; P = .027) than the WBI group. Any severe toxicities after APBI were rare in patient-reported outcomes (score ≥3, 3.0%) and physician assessments (grade ≥3, 2.0%). In the uninvolved quadrants, measured fibrosis in the APBI group was significantly lower than that in the WBI group at 6 (P = .001) and 12 (P = .029) months but not at 24 months. In the involved quadrant, measured fibrosis in the APBI group was not significantly different from that in the WBI group at any time. Cosmetic outcomes in the APBI group were mostly excellent or good (77.6%) at 24 months, and there was no significant cosmetic detriment from the baseline.

CONCLUSIONS

Stereotactic APBI was associated with less fibrosis in the uninvolved breast quadrants than WBI. Patients showed minimal toxicity and no detrimental effects on cosmesis after APBI.

Study protocol for prospective multi-institutional phase III trial of standard of care therapy with or without stereotactic ablative radiation therapy for recurrent ovarian cancer (SABR-ROC)

BACKGROUND

Efforts have been made to investigate the role of salvage radiotherapy (RT) in treating recurrent ovarian cancer (ROC). Stereotactic ablative radiation therapy (SABR) is a state-of-the-art therapy that uses intensity modulation to increase the fractional dose, decrease the number of fractions, and target tumors with high precision.

METHODS

The SABR-ROC trial is a phase 3, multicenter, randomized, prospective study to evaluate whether the addition of SABR to the standard of care significantly improves the 3-year overall survival (OS) of patients with ROC. Patients who have completed the standard treatment for primary epithelial ovarian cancer are eligible. In addition, patients with number of metastases ≤ 10 and maximum diameter of each metastatic site of gross tumor ≤ 5 cm are allowed. Randomization will be stratified by (1) No. of the following clinical factors met, platinum sensitivity, absence of ascites, normal level of CA125, and ECOG performance status of 0-1; 0-3 vs. 4; (2) site of recurrence; with vs. without lymph nodes; and (3) PARP inhibitor; use vs. non-use. The target number of patients to be enrolled in this study is 270. Participants will be randomized in a 1:2 ratio. Participants in Arm 2 will receive SABR for recurrent lesions clearly identified in imaging tests as well as the standard of care (Arm 1) based on treatment guidelines and decisions made in multidisciplinary discussions. The RT fraction number can range from 1 to 10, and the accepted dose range is 16-45 Gy. The RT Quality Assurance (QA) program consists of a three-tiered system: general credentialing, trial-specific credentialing, and individual case reviews.

DISCUSSION

SABR appears to be preferable as it does not interfere with the schedule of systemic treatment by minimizing the elapsed days of RT. The synergistic effect between systemic treatment and SABR is expected to reduce the tumor burden by eradicating gross tumors identified through imaging with SABR and controlling microscopic cancer with systemic treatment. It might also be beneficial for quality-of-life preservation in older adults or heavily treated patients.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT05444270) on June 29th, 2022.

Retinal artery/arteriole occlusion risks after endovascular treatment for unruptured intracranial aneurysm

BACKGROUND

To evaluate the association between retinal artery/arteriole occlusion (RAO) and unruptured intracranial aneurysm (UIA).

METHODS

Incident UIA patients from a nationwide cohort (n=253 240) were categorised into three groups based on subsequent treatment: observation (n=208 993), microsurgical clipping (n=14 168) and endovascular treatment (EVT) groups (n=30 079). The incidence and the incident time of RAO were analysed. HRs of RAO and associated risk factors were evaluated. Additionally, a hospital cohort comprising 2569 consecutive UIA patients treated at a tertiary hospital was analysed with detailed clinical information of UIAs.

RESULTS

In the nationwide cohort analysis, the incidence of RAO was significantly higher in EVT group than in observation and clipping groups, especially within 60 days (early RAO (within 60 days): HR=4.00, 95% CI: 2.44 to 6.56); delayed RAO (after 60 days): HR=1.74, 95% CI: 1.13 to 2.68). Multivariable analysis showed that the presence of chronic kidney disease (p=0.009) and use of a balloon microcatheter during the procedure (p=0.013) were associated with a higher risk of RAO. In hospital cohort analysis, 11 (0.8%) cases of RAO occurred after EVT, whereas none occurred after microsurgical clipping (p<0.001). Patients with RAO were younger and received balloon microcatheters more frequently than their counterparts. Ten cases of RAO (90.9%) occurred in paraclinoid aneurysms, where EVT was preferred over microsurgical clipping.

CONCLUSIONS

Performing EVT for UIA may increase the risk of subsequent RAO. Care should be taken when treating paraclinoid aneurysms with balloon microcatheters.

Comparison of Early Outcomes of Stereotactic Accelerated Partial Breast Irradiation vs. Volumetric Modulated Arc Therapy-Based FAST-FORWARD Whole Breast Irradiation for Breast Cancer

PURPOSE/OBJECTIVE(S)

Despite evidence supporting APBI from 8 published prospective randomized trials enrolling over 10,000 women, the uptake of APBI in clinical practice is surprisingly low. This is being exacerbated by a new, convenient, and safe shortened WBI schedule. Here, we report the dosimetric and early outcome analyses of the first >1000 patients treated at our institution since the first adoption of stereotactic APBI and the ultra-hypofractionated WBI regimen.

MATERIALS/METHODS

From 2016 to 2022, 801 women with breast cancers in the suitable or cautionary categories according to the ASTRO APBI consensus panel guidelines, received 30 Gy in 5 fractions (92%) either using a robotic stereotactic radiation system (83%) or stereotactic volumetric-based arc therapy (VMAT, 17%). Between 2020 and 2022, 468 women, who were not candidates for APBI and not undergoing any regional irradiation received 26 Gy in 5 fractions using VMAT to the whole breast with the addition of cardiac sparing technique in left-sided breast cancer patients. Tumor bed boosts were delivered in 99% of FF-WBI patients. We evaluated dose-volume histogram parameters for target volumes and organs-at-risk and radiation-related toxicities during RT or within 6 months after the end of RT.

RESULTS

Target volume coverage was acceptable in both groups, with mean 96% of the target volumes receiving 95% of the prescribed doses and 0 cm3 within target volumes exceeding 105% of the prescribed doses. S-APBI resulted in small, but statistically significant, reductions in the radiation dose delivered to the ipsilateral breast, contralateral breast, lungs, heart, and coronary artery compared with FF-WBI. Comparing WBI to APBI, the mean contralateral breast dose, ipsilateral lung V20 Gy, mean contralateral lung dose, and mean heart dose, were reduced by 89%, 78%, 73%, and 29%, respectively. With median follow-up periods of 32 months for s-APBI and 19 months for FF-WBI, acute toxicity was assessable in all patients. The risks of any grade acute toxicity were 21% for s-APBI and 25% for FF-WBI (p = .117). Among them, grade 2 rates were 1.3% in both groups and no severe toxicity has been reported.

CONCLUSION

We found s-APBI and VMAT-based FF WBI were associated with favorable dosimetric and acute toxicity profiles. However, considering significantly less irradiated volume in the breast, lungs, and heart, APBI with advanced available technique options should be considered over any WBI-based approach for patients at low risk for local recurrence.

Machine learning‑based radiomics models for prediction of locoregional recurrence in patients with breast cancer

Locoregional recurrence (LRR) is the predominant pattern of relapse after definitive breast cancer treatment. The present study aimed to develop machine learning (ML)-based radiomics models to predict LRR in patients with breast cancer by using preoperative magnetic resonance imaging (MRI) data. Data from patients with localized breast cancer that underwent preoperative MRI between January 2013 and December 2017 were collected. Propensity score matching (PSM) was performed to adjust for clinical factors between patients with and without LRR. Radiomics features were obtained from T2-weighted with and without fat-suppressed MRI and contrast-enhanced T1-weighted with fat-suppressed MRI. In the present study five ML models were designed, three base models (support vector machine, random forest, and logistic regression) and two ensemble models (voting model and stacking model) composed of the three base models, and the performance of each base model was compared with the stacking model. After PSM, 28 patients with LRR and 86 patients without LRR were included. Of these 114 patients, 80 patients were randomly selected to train the models, and the remaining 34 patients were used to evaluate the performance of the trained models. In total, 5,064 features were obtained from each patient, and 47-51 features were selected by applying variance threshold and least absolute shrinkage and selection operator. The stacking model demonstrated superior performance in area under the receiver operating characteristic curve (AUC), with an AUC of 0.78 compared to a range of 0.61 to 0.70 for the other models. An external validation study to investigate the efficacy of the stacking model of the present study was initiated and is still ongoing (Korean Radiation Oncology Group 2206).

Patterns and Longitudinal Changes in The Practice of Breast Cancer Radiotherapy in Korea: Korean Radiation Oncology Group 22-01

PURPOSE/OBJECTIVE(S)

To analyze contemporary practice patterns in breast cancer radiotherapy (RT) and to assess longitudinal changes therein over 5 years in Korea.

MATERIALS/METHODS

A nationwide survey was conducted among board-certified radiation oncologists in Korea by the Division for Breast Cancer of the Korean Radiation Oncology Group in March 2022. The survey consisted of 44 questions related to six domains: hypofractionated (HypoFx) whole breast RT, accelerated partial breast RT (APBI), regional nodal irradiation (RNI), RT for ductal carcinoma in situ (DCIS), postmastectomy RT (PMRT), and tumor bed boost.

RESULTS

In total, 70 radiation oncologists from 61 of 101 (60%) institutions participated in the survey. HypoFx RT was used by 62 respondents (89%), which has significantly increased from 36% in 2017. The HypoFx RT was commonly administered at 40-42.5 Gy in 15-16 fractions. APBI was used by 12 respondents (17%), which has increased from 5% in 2017. The use of RNI did not change significantly: ≥ pN2 (6%), ≥ pN1 (33%), and ≥ pN1 with pathological risk factors (61%). However, the indications for use of internal mammary lymph node (IMN) irradiation have expanded. In particular, the rates of routine treatment of IMN (11% from 6% in 2017) and treatment in cases of ≥ pN2 (27% from 14% in 2017) have doubled; however, the rate of treatment for only IMN involvement, identified on imaging, has decreased to 31% from 47% in 2017. With regard to DCIS, the use of hypoFx RT increased to 75% from 25%, and the rate of omission on of RT after breast-conserving surgery decreased to 38% from 48% in 2017. The use of hypoFx RT for PMRT also increased to 36% from 8% in 2017.

CONCLUSION

The adoption of HypoFx RT after breast-conserving surgery in invasive breast cancer and DCIS has increased significantly, whereas that for PMRT has increased moderately, compared to 2017. Further studies are required to determine the optimal use of RNI.

The Updated World Health Organization Classification Better Predicts Survival in Patients With Endocervical Adenocarcinoma (KROG 20-07)

PURPOSE

The 2020 World Health Organization classification divided endocervical adenocarcinoma (ADC) into human papillomavirus-associated (HPVA) and human papillomavirus-independent (HPVI) ADCs. This multi-institutional study aimed to investigate the clinical features and prognosis of patients with endocervical ADC based on the updated World Health Organization classification.

METHODS AND MATERIALS

We retrospectively reviewed the 365 patients with endocervical ADC who underwent radical hysterectomy from 7 institutions. Tumor characteristics, patterns of failure, and survival outcomes were compared between HPVA and HPVI ADCs.

RESULTS

Two hundred seventy-five (75.3%) and 90 (24.7%) patients had HPVA and HPVI ADC diagnoses, respectively. In all cases, the 5-year disease-free survival (DFS) and overall survival (OS) rates were 58.2% and 71.3%, respectively. HPVI ADC showed higher rates of local recurrence (25.6% vs 10.9%) and distant metastasis (33.3% vs 17.5%) than HPVA ADC. Multivariate survival analysis revealed that HPVI ADC showed significantly worse DFS (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.324-2.781; P < .001), distant metastasis-free survival (HR, 2.100; 95% CI, 1.397-3.156; P < .001), and OS (HR, 2.481; 95% CI, 1.586-3.881; P < .001) than HPVA ADC. Patients with gastric- and serous-type HPVI ADC had significantly worse OS than those with other HPVI ADCs (P = .020). Similarly, invasive stratified mucin-producing-type HPVA ADC showed significantly worse OS than other HPVA ADCs (P < .001).

CONCLUSIONS

We demonstrated that HPVI ADC exhibited inferior DFS and OS and higher rates of local and distant recurrence compared with HPVA ADC. Gastric- and serous-type HPVI ADCs and invasive stratified mucin-producing-type HPVA ADC showed worse OS than other types of HPVI and HPVA ADCs, respectively. Our observation of significant differences in prognoses according to the histologic types needs to be validated in larger cohorts of patients with endocervical ADC.

Quality-adjusted survival in women with gynecologic malignancies receiving IMRT after surgery: A Ppatient Rreported Ooutcome study of NRG oncology's RTOG 1203

INTRODUCTION

NRG/RTOG 1203 compared 3-D conformal radiotherapy (3D CRT) to intensity-modulated radiotherapy (IMRT) in patients with endometrial or cervical cancer requiring post-operative radiotherapy after hysterectomy. The purpose of this study was to report the first quality-adjusted survival analysis comparing the two treatments.

METHODS

NRG/RTOG 1203 randomized patients having undergone hysterectomy to either 3DCRT or IMRT. Stratification factors included RT dose, chemotherapy, and disease site. The EQ-5D, both index and visual analog scale (VAS), were obtained at baseline, 5 weeks after the start of RT, 4-6 weeks post RT and 1 and 3-years post RT. EQ-5D index and VAS scores along with quality-adjusted survival (QAS) were compared between treatment arms using the t-test at a two-sided significance level of 0.05.

RESULTS

NRG/RTOG 1203 enrolled 289 patients of which 236 consented to participate in the patient reported outcome (PRO) assessments. QAS was higher in women treated with IMRT, 1374 vs 1333 days (p = 0.5) compared to patients treated with 3DCRT, but this difference was not statistically different. Patients treated with IMRT had less of a decline in VAS score 5 weeks post RT, -5.04, compared to patients treated with 3DCRT, -7.48, although not statistically significant (p = 0.38).

CONCLUSION

This is the first report of the use of the EQ-5D comparing two radiotherapy techniques in the treatment of gynecologic malignancies after surgery. While there were no significant differences in QAS and VAS scores between patients who received IMRT vs. 3DCRT, RTOG 1203 was not powered to show statistical differences in these secondary endpoints.

Incorporating axillary-lateral thoracic vessel juncture dosimetric variables improves model for predicting lymphedema in patients with breast cancer: A validation analysis

Background

A relationship between the axillary-lateral thoracic vessel juncture (ALTJ) dose and lymphedema rate has been reported in patients with breast cancer. The purpose of this study was to validate this relationship and explore whether incorporation of the ALTJ dose-distribution parameters improves the prediction model's accuracy.

Methods

A total of 1,449 women with breast cancer who were treated with multimodal therapies from two institutions were analyzed. We categorized regional nodal irradiation (RNI) as limited RNI, which excluded level I/II, vs extensive RNI, which included level I/II. The ALTJ was delineated retrospectively, and dosimetric and clinical parameters were analyzed to determine the accuracy of predicting the development of lymphedema. Decision tree and random forest algorithms were used to construct the prediction models of the obtained dataset. We used Harrell's C-index to assess discrimination.

Results

The median follow-up time was 77.3 months, and the 5-year lymphedema rate was 6.8 %. According to the decision tree analysis, the lowest lymphedema rate (5-year, 1.2 %) was observed in patients with ≤ six removed lymph nodes and ≤ 66 % ALTJ V_35Gy. The highest lymphedema rate was observed in patients with > 15 removed lymph nodes and an ALTJ maximum dose (D_max) of > 53 Gy (5-year, 71.4 %). Patients with > 15 removed lymph nodes and an ALTJ D_max ≤ 53 Gy had the second highest rate (5-year, 21.5 %). All other patients had relatively minor differences, with a rate of 9.5 % at 5 years. Random forest analysis revealed that the model's C-index increased from 0.84 to 0.90 if dosimetric parameters were included instead of RNI (P <.001).

Conclusion

The prognostic value of ALTJ for lymphedema was externally validated. The estimation of lymphedema risk based on individual dose-distribution parameters of the ALTJ seemed more reliable than that based on the conventional RNI field design.

Radiotherapy in recurrent ovarian cancer: updated results of involved-field radiation therapy

OBJECTIVE

This study aimed to update the possible clinical benefits of radiation therapy in recurrent ovarian cancer.

METHODS

The medical records of 495 patients with recurrent ovarian cancer after initially undergoing maximal cytoreductive surgery and adjuvant platinum-based chemotherapy based on the pathologic stage between January 2010 and December 2020 were analyzed: 309 and 186 patients were treated without and with involved-field radiation therapy, respectively. Involved-field radiation therapy is defined as radiation therapy only to the areas of the body involved by tumor. The prescribed doses were ≥45 Gy (equivalent dose in 2 Gy/fraction). Overall survival was compared between patients treated with and without involved-field radiation therapy. The favorable group was defined as patients who satisfied at least four of the following factors: good performance, no ascites, normal CA-125, platinum-sensitive tumor, and nodal recurrence.

RESULTS

The median age of the patients was 56 years (range 49-63) and median time to recurrence was 11.1 months (range 6.1-15.5). 217 patients (43.8%) were treated at a single site. Radiation therapy, performance status, CA-125, platinum sensitivity, residual disease, and ascites were all significant prognostic factors. The 3-year overall survival of all patients, patients treated without radiation therapy, and patients treated with radiation therapy was 54.0%, 44.8%, and 69.3%, respectively. Radiation therapy was associated with higher overall survival rates in the unfavorable and favorable patient groups. Patient characteristics showed higher rates of normal CA-125, lymph node metastasis only, lower platinum sensitivity, and higher rates of ascites in the radiation therapy group. After propensity score matching, the radiation therapy group showed superior overall survival to the non-radiation therapy group. Normal CA-125, good performance status, and platinum sensitivity were associated with a good prognosis in patients treated with radiation therapy.

CONCLUSION

Our study showed that higher overall survival was observed in patients treated with radiation therapy in recurrent ovarian cancer.

Endoscope-assisted microsurgical clipping and reduction of post-clipping cerebral infarction: historical comparison using diffusion-weighted images

Endoscopic assistance for aneurysm clipping and its possible benefits have been suggested in previous studies, but its clinical significance has not been fully elucidated. This study aimed to present the efficacy of endoscopy-assisted clipping in reducing post-clipping cerebral infarction (PCI) and clinical outcomes via a historical comparison of patients in our institution from January 2020 to March 2022. A total of 348 patients were included, 189 of whom underwent endoscope-assisted clipping. The overall incidence of PCI was 10.9% (n = 38); it was 15.7% (n = 25) before applying endoscopic assistance and decreased to 6.9% (n = 13) after endoscope application (p = 0.010). The application of a temporary clip (odds ratio [OR]: 2.673, 95% confidence interval [CI]: 1.291-5.536), history of hypertension (OR: 2.176, 95% CI: 0.897-5.279), history of diabetes mellitus (OR: 2.530, 95% CI: 1.079-5.932), and current smoker (OR: 3.553, 95% CI: 1.288-9.802) were independent risk factors of PCI, whereas endoscopic assistance was an independent inverse risk factor (OR: 0.387, 95% CI: 0.182-0.823). Compared to the location of the unruptured intracranial aneurysms, internal carotid artery aneurysms showed a significant decrease in the incidence of PCI (5.8% vs. 22.9%, p = 0.019). In terms of clinical outcomes, PCI was a significant risk factor for longer admission duration, intensive care unit stay, and poor clinical outcomes. However, endoscopic assistance itself was not a significant risk factor for clinical outcomes on the 45-day modified Rankin Scale. In this study, we noted the clinical significance of endoscope-assisted clipping in preventing PCI. These findings could reduce the incidence of PCI and improve the understanding of its mechanisms of action. However, a larger and longer-term study is required to evaluate the benefits of endoscopy on clinical outcomes.

Comparison of initial and sequential salvage brain-directed treatment in patients with 1-4 vs. 5-10 brain metastases from breast cancer (KROG 16-12)

PURPOSE

We aimed to compare the initial and salvage brain-directed treatment and overall survival (OS) between patients with 1-4 brain metastases (BMs) and those with 5-10 from breast cancer (BC). We also organized a decision tree to select the initial whole-brain radiotherapy (WBRT) for these patients.

METHODS

Between 2008 and 2014, 471 patients were diagnosed with 1-10 BMs. They were divided into two groups based on the number of BM: 1-4 BMs (n = 337) and 5-10 BMs (n = 134). Median follow-up duration was 14.0 months.

RESULTS

Stereotactic radiosurgery (SRS)/fractionated stereotactic radiotherapy (FSRT) was the most common treatment modality (n = 120, 36%) in the 1-4 BMs group. In contrast, 80% (n = 107) of patients with 5-10 BMs were treated with WBRT. The median OS of the entire cohort, 1-4 BMs, and 5-10 BMs was 18.0, 20.9, and 13.9 months, respectively. In the multivariate analysis, the number of BM and WBRT were not associated with OS, whereas triple-negative BC and extracranial metastasis decreased OS. Physicians determined the initial WBRT based on four variables in the following order: number and location of BM, primary tumor control, and performance status. Salvage brain-directed treatment (n = 184), mainly SRS/FSRT (n = 109, 59%), prolonged OS by a median of 14.3 months.

CONCLUSION

The initial brain-directed treatment differed notably according to the number of BM, which was chosen based on four clinical factors. In patients with ≤ 10 BMs, the number of BM and WBRT did not affect OS. The major salvage brain-directed treatment modality was SRS/FSRT and increased OS.

Subdural hygroma and hemorrhagic conversion after microsurgical clipping for unruptured intracranial aneurysm

BACKGROUND

Chronic subdural hematoma (cSDH) is a unique hemorrhagic complication associated with microsurgical clipping. We aimed to investigate the risk factors of subdural hygroma (SDG) formation and its hemorrhagic conversion to cSDH.

METHODS

We reviewed the medical records of 229 patients who underwent microsurgical clipping for unruptured intracranial aneurysms (UIA) from 2016 to 2019. Risk factors for SDG and cSDH formation were analyzed.

RESULTS

Male sex, age ≥ 60 years, higher degree of arachnoid dissection, severe brain atrophy, and a large volume of subdural fluid collection (SFC) before discharge were independent risk factors for SDG formation. The risk factors for hemorrhagic conversion from SDG were continuous use or early resumption of antiplatelet drugs (odds ratio (OR): 15.367, 95% CI: 1.172-201.402) and a larger volume of SFC before discharge (OR: 0.932, 95% CI: 0.886-0.980). In the early resumption group, antiplatelet drug was resumed at a mean duration of 7.48 days postoperatively, and hemorrhagic conversion was detected earlier than that in the late resumption or no-use groups (4.09 vs. 7.18 weeks, P = 0.046). Following the receiver operating characteristic analysis, the SFC cutoff volume for hemorrhagic conversion was determined to be 23.55 mL.

CONCLUSION

These findings can assist clinicians in identifying patients at a high risk of SDG and cSDH formation. Antiplatelet resumption and its timing should be determined with consideration of the risk of cSDH formation as well as individual medical conditions.

Omission of axillary lymph node dissection in patients with ypN+ breast cancer after neoadjuvant chemotherapy: A retrospective multicenter study (KROG 21-06)

BACKGROUND

We evaluated the impact of omitting axillary lymph node dissection (ALND) on oncological outcomes in breast cancer patients with residual nodal disease after neoadjuvant chemotherapy (NAC).

METHODS

The medical records of patients who underwent NAC followed by surgical resection and had residual nodal disease were retrospectively reviewed. In total, 1273 patients from 12 institutions were included; all underwent postoperative radiotherapy. Axillary surgery consisted of ALND in 1103 patients (86.6%) and sentinel lymph node biopsy (SLNBx) alone in 170 (13.4%). Univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed before and after propensity score matching (PSM).

RESULTS

The median follow-up was 75.3 months (range, 2.5-182.7). Axillary recurrence rates were 4.8% in the ALND group (n = 53) and 4.7% in the SLNBx group (n = 8). Before PSM, univariate analysis indicated that the 5-year OS rate was inferior in the ALND group compared to the SLNBx group (86.6% vs. 93.3%, respectively; P = 0.002); multivariate analysis did not show a difference between groups (P = 0.325). After PSM, 258 and 136 patients were included in the ALND and SLNBx groups, respectively. There were no significant differences between the ALND and SLNBx groups in DFS (5-year rate, 75.8% vs. 76.9%, respectively; P = 0.406) or OS (5-year rate, 88.7% vs. 93.1%, respectively; P = 0.083).

CONCLUSIONS

SLNBx alone did not compromise oncological outcomes in patients with residual nodal disease after NAC. The omission of ALND might be a possible option for axillary management in patients treated with NAC and postoperative radiotherapy.

Risk factors for recanalization of basilar tip aneurysm after endovascular treatment: a retrospective cohort study

OBJECTIVES

Endovascular treatment (EVT) of basilar tip aneurysms (BTAs) is arduous because of the lesions' angioarchitecture and the relatively high recanalization rate after EVT. In this study, we aimed to report the clinical characteristics of BTAs and evaluate the incidence of and risk factors for recanalization.

METHODS

One hundred twenty-five patients with BTAs (11 ruptured, 114 unruptured) treated with EVT between 2009 and 2019 at one institution were retrospectively reviewed. Among them, 113 patients were included in statistical analyses. The anatomical parameters of the aneurysms and clinical data were analyzed. Univariate (chi-square test and t-test) and multivariate (multiple logistic regression) analyses were performed to identify risk factors for recanalization.

RESULTS

        Recanalization of the BTA occurred in 15 patients (13.3%). One patient (0.9%) was retreated endovascularly. The mean follow-up duration was 49.8 months. Neck size, posterior cerebral artery (PCA) angle, maximum diameter, and the rupture rate differed significantly between the recanalization and non-recanalization groups (P=.007, P<.001, P=.006, and P=.048, respectively). The maximum diameter (odds ratio, 1.483 per mm; 95% confidence interval, 1.145-1.919; P=.003) and PCA angle (odds ratio, 1.020 per degree; 95% confidence interval, 1.001-1.039; P=.036) were independently associated with recanalization.

CONCLUSIONS

Of all investigated BTAs, 96.8% were wide-neck aneurysms. The recanalization rate of BTAs after EVT was 13.3%. The PCA angle and maximal aneurysmal diameter were independently associated with recanalization; no associations were observed regarding vertebral artery dominance or modality of treatment. As such, BTA patients with wide PCA angles should be carefully monitored over time.

Development and Validation of a Normal Tissue Complication Probability Model for Lymphedema After Radiation Therapy in Breast Cancer

PURPOSE

To develop and test a multivariable normal tissue complication probability (NTCP) model predicting lymphedema in patients with breast cancer receiving radiation therapy.

METHODS AND MATERIALS

We retrospectively reviewed 1345 patients with breast cancer who received radiation therapy from 2 independent institutions. The patients were divided into a training cohort (institution A, n = 368, all treated with 3-dimensional conformal external beam radiation therapy [RT] with 2 Gy/fraction) and an external validation cohort (institution B, n = 977, treated either with 3-dimensional conformal external beam RT or with volumetric modulated RT and either with 1.8-2.0 Gy/fraction or with 2.67 Gy/fraction). Axillary-lateral thoracic vessel juncture (ALTJ) was delineated. The multivariable model was generated using dosimetric and clinical parameters. The performance of the model was comprehensively validated internally and externally.

RESULTS

During a median follow-up of 78.7 months for the entire cohort, 97 patients (7.2%) developed lymphedema. The multivariable model that took into account the number of lymph nodes dissected, as well as the volume of the ALTJ receiving a dose ≥35 Gy equivalent doses in 2-Gy fractions (ALTJ V35), showed good agreement between predicted and observed results for both internal and external validation (Hosmer-Lemeshow P value > .05). The area under the receiver operating characteristic curve (AUC) and negative log-likelihood values for the multivariable NTCP model were 0.89 and 0.19 in internal validation and 0.83 and 0.19 in external validation. In addition, the multivariable model performance was acceptable for hypofractionated regimens (AUC 0.70) and volumetric modulated arc therapy (AUC 0.69). The number of lymph nodes dissected and ALTJ V35 were found to be the most important factors influencing lymphedema after radiation therapy.

CONCLUSIONS

We first developed and validated the multivariable NTCP model for the lymphedema incidence in patients with breast cancer after radiation therapy. The multivariable NTCP model showed excellent performance and robustness in predicting lymphedema in both internal and completely independent external validations. The multivariable model for lymphedema prediction was robust and reliable for different treatment modalities and fractionation regimens.

Rupture risk prediction of cerebral aneurysms using a novel convolutional neural network-based deep learning model

BACKGROUND

Cerebral aneurysms should be treated before rupture because ruptured aneurysms result in serious disability. Therefore, accurate prediction of rupture risk is important and has been estimated using various hemodynamic factors.

OBJECTIVE

To suggest a new way to predict rupture risk in cerebral aneurysms using a novel deep learning model based on hemodynamic parameters for better decision-making about treatment.

METHODS

A novel convolutional neural network (CNN) model was used for rupture risk prediction retrospectively of 123 aneurysm cases. To include the effect of hemodynamic parameters into the CNN, the hemodynamic parameters were first calculated using computational fluid dynamics and fluid-structure interaction. Then, they were converted into images for training the CNN using a novel approach. In addition, new data augmentation methods were devised to obtain sufficient training data. A total of 53,136 images generated by data augmentation were used to train and test the CNN.

RESULTS

The CNNs trained with wall shear stress (WSS), strain, and combination images had area under the receiver operating characteristics curve values of 0.716, 0.741, and 0.883, respectively. Based on the cut-off values, the CNN trained with WSS (sensitivity: 0.5, specificity: 0.79) or strain (sensitivity: 0.74, specificity: 0.71) images alone was not highly predictive. However, the CNN trained with combination images of WSS and strain showed a sensitivity and specificity of 0.81 and 0.82, respectively.

CONCLUSION

CNN-based deep learning algorithm using hemodynamic factors, including WSS and strain, could be an effective tool for predicting rupture risk in cerebral aneurysms with good predictive accuracy.

Added Predictive Values of Proton Density Magnetic Resonance Imaging on Posterior Communicating Artery Aneurysms and Surrounding Soft Tissues with Simple Classification

Objective

Deciphering the anatomy of posterior communicating artery (PCoA) aneurysms in relation to surrounding structures is essential to determine adjuvant surgical procedures. However, it is difficult to predict surgical structures through preoperative imaging studies. We aimed to present anatomical structures using preoperative high-resolution three-dimensional proton density-weighted turbo spin-echo magnetic resonance (PDMR) imaging with simple classification.

Methods

From January 2020 to April 2022, 30 patients underwent PDMR before microsurgical clipping for unruptured PCoA aneurysms in a single tertiary institute. We retrospectively reviewed the radiographic images and operative data of these patients. The structural relationship described by PDMR and intraoperative findings were compared. Subsequently, we classified aneurysms into two groups and analyzed the rate of adjuvant surgical procedures and contact with the surrounding structures.

Results

Correlations between preoperative PDMR predictions and actual intraoperative findings for PCoA aneurysm contact to the oculomotor nerve, temporal uncus, and anterior petroclinoid fold (APCF) reported a diagnostic accuracy of 0.90, 0.87, and 0.90, respectively. In 12 patients (40.0%), an aneurysm dome was located on the plane of the oculomotor triangle and was classified as the infratentorial type. Compared to the supratentorial type PCoA aneurysm, adjuvant procedures were required more frequently (66.7% vs. 22.2%, p=0.024) for infratentorial type PCoA aneurysm clipping.

Conclusion

Preoperative PCoA aneurysm categorization using PDMR can be helpful for predicting surgical complexity and planning of microsurgical clipping.

Comprehensive clinical evaluation of deep learning-based auto-segmentation for radiotherapy in patients with cervical cancer

Background and purpose

Deep learning-based models have been actively investigated for various aspects of radiotherapy. However, for cervical cancer, only a few studies dealing with the auto-segmentation of organs-at-risk (OARs) and clinical target volumes (CTVs) exist. This study aimed to train a deep learning-based auto-segmentation model for OAR/CTVs for patients with cervical cancer undergoing radiotherapy and to evaluate the model's feasibility and efficacy with not only geometric indices but also comprehensive clinical evaluation.

Materials and methods

A total of 180 abdominopelvic computed tomography images were included (training set, 165; validation set, 15). Geometric indices such as the Dice similarity coefficient (DSC) and the 95% Hausdorff distance (HD) were analyzed. A Turing test was performed and physicians from other institutions were asked to delineate contours with and without using auto-segmented contours to assess inter-physician heterogeneity and contouring time.

Results

The correlation between the manual and auto-segmented contours was acceptable for the anorectum, bladder, spinal cord, cauda equina, right and left femoral heads, bowel bag, uterocervix, liver, and left and right kidneys (DSC greater than 0.80). The stomach and duodenum showed DSCs of 0.67 and 0.73, respectively. CTVs showed DSCs between 0.75 and 0.80. Turing test results were favorable for most OARs and CTVs. No auto-segmented contours had large, obvious errors. The median overall satisfaction score of the participating physicians was 7 out of 10. Auto-segmentation reduced heterogeneity and shortened contouring time by 30 min among radiation oncologists from different institutions. Most participants favored the auto-contouring system.

Conclusion

The proposed deep learning-based auto-segmentation model may be an efficient tool for patients with cervical cancer undergoing radiotherapy. Although the current model may not completely replace humans, it can serve as a useful and efficient tool in real-world clinics.

Comparison of Single-Session, Neoadjuvant, and Adjuvant Embolization Gamma Knife Radiosurgery for Arteriovenous Malformation

BACKGROUND

The purpose of intracranial arteriovenous malformations (AVMs) treatment is to prevent bleeding or subsequent hemorrhage with complete obliteration. For large, difficult-to-treat AVMs, multimodal approaches including surgery, endovascular embolization, and gamma knife radiosurgery (GKRS) are frequently used.

OBJECTIVE

To analyze the outcomes of AVMs treated with single-session, neoadjuvant, and adjuvant embolization GKRS.

METHODS

We retrospectively reviewed a database of 453 patients with AVMs who underwent GKRS between January 2007 and December 2017 at our facility. The obliteration rate, incidence of latent period bleeding, cyst formation, and radiation-induced changes were compared among the 3 groups, neoadjuvant-embolized, adjuvant-embolized, nonembolized group. In addition, the variables predicting AVM obliteration and complications were investigated.

RESULTS

A total of 228 patients were enrolled in this study. The neoadjuvant-embolized, adjuvant-embolized, and nonembolized groups comprised 29 (12.7%), 19 (8.3%), and 180 (78.9%) patients, respectively. Significant differences were detected among the 3 groups in the history of previous hemorrhage and the presence of aneurysms ( P < .0001). Multivariate Cox regression analyses revealed a significant inverse correlation between neoadjuvant embolization and obliteration occurring 36 months after GKRS (hazard ratio, 0.326; P = .006).

CONCLUSION

GKRS with either neoadjuvant or adjuvant embolization is a beneficial approach for the treatment of AVMs with highly complex angioarchitectures that are at risk for hemorrhage during the latency period. Embolization before GKRS may be a negative predictive factor for late-stage obliteration (>36 months). To confirm our conclusions, further studies involving a larger number of patients and continuous follow-up are necessary.

Risk factors for lower extremity lymphedema after surgery in cervical and endometrial cancer

OBJECTIVE

Lower extremity lymphedema (LEL) is a well-known adverse effect related to cervical and endometrial cancer (CEC); however, very few studies have elucidated the clinicopathologic risk factors related to LEL. We investigated the incidence and risk factors in patients who received primary surgery and/or adjuvant radiotherapy (RT) or chemotherapy for CEC.

METHODS

We retrospectively reviewed 2,565 patients who underwent primary surgery following CEC diagnosis between January 2007 and December 2020. LEL diagnosis was based on objective and subjective assessments by experts. We identified important predictors of LEL to construct a nomogram predicting individual risks of LEL. For internal validation of the nomogram, the original data were separated using the split-sample method in a 7:3 ratio of training data and test data.

RESULTS

Overall, 858 patients (33.5%) received RT, 586 received external beam RT (EBRT), and 630 received intracavitary RT. During follow-up period, LEL developed in 331 patients, with an overall cumulative 5-year incidence of 13.3%. In multivariate analysis, age at primary treatment, use of docetaxel-based chemotherapy, type of hysterectomy, type of surgical pelvic lymph node (LN) assessment, number of dissected pelvic and para-aortic LNs, and EBRT field were the independent predictors of LEL. We subsequently developed the nomogram showing excellent predictive power for LEL.

CONCLUSION

LEL is associated with various treatment modalities, and their interactions may increase the possibility of occurrences. De-escalation strategies for treatment modalities should be considered to reduce LEL in patients with CEC.

Journey to hypofractionation in radiotherapy for breast cancer: critical reviews for recent updates

Historical conventional fractionated radiation therapy (RT) for breast cancer consisted of 1.8-2.0 Gy per fraction with a total dose of 45-60 Gy over 5-7 weeks. Based on radiobiological characteristics, a low α/β is suspected of breast cancer resulting in sensitivity to higher dose per fraction (2.5-3.0 Gy). Over the past 10 years, multiple clinical trials support the application of shorter treatment regimen with hypofractionated RT (HypoRT). Recently, ultra-HypoRT with 5 fractions showed favorable outcomes. Although the safety and efficacy of HypoRT has been supported by high-quality randomized trials, there are still some worries and doubts around HypoRT from radiation oncologists. However, the radiation oncology community have now reached an important timepoint for adopting HypoRT during the COVID-19 pandemic. The aim of this review is to provide an overview of HypoRT in breast cancer based on prospective randomized trials and discuss the special consideration regarding HypoRT.

Efficacy and safety of stereotactic radiosurgery versus endovascular treatment for symptomatic cavernous sinus dural arteriovenous fistula without ophthalmological emergency: a single-center 10-year experience

OBJECTIVE

Stereotactic radiosurgery (SRS) is emerging as a treatment option for cavernous sinus dural arteriovenous fistula (CS dAVF); it is less invasive and has a lower complication rate than conventional surgeries. However, little is known regarding the advantages and limitations of SRS compared to those of endovascular treatment (EVT). The aim of this study was to compare the efficacy and safety between EVT and SRS for treatment of CS dAVF.

METHODS

Between January 2011 and April 2021, a total of 86 consecutive patients diagnosed with CS dAVF were treated with EVT or SRS. Among them, 8 patients with ophthalmological emergency and 8 without follow-up data at ≥ 12 months were excluded. During the same period, no neurological deficit due to intracranial hemorrhage or seizure was noted in any of the patients. Ultimately, 70 patients (EVT 33, SRS 37) were included in this study. Demographic characteristics, initial clinical presentations, clinical outcomes, and radiological findings were retrospectively reviewed and compared. Procedure-related complications were also assessed after the treatments.

RESULTS

The patients’ baseline characteristics (except conjunctival symptoms) and angiographic features of CS dAVF were not significantly different between the EVT and SRS groups. Conjunctival symptoms were more frequently noted in the EVT than in the SRS group (69.7% vs 40.5%, p = 0.015). After EVT, initial complete obliteration was achieved in 20 cases (60.6%). Complete obliteration was achieved at 6 months in 86.4% of cases with EVT and in 77.8% of those treated with SRS (p = 0.507), and at 12 months in 86.4% cases with EVT and in 94.4% of those treated with SRS (p = 0.357). Worsening of symptoms developed at 1 month in 24.2% of cases with EVT and in 5.4% of those treated with SRS (p = 0.038); at 6 months in 22.6% of cases with EVT and in 10.8% of those treated with SRS; and at 12 months in 30.0% of cases with EVT and in 13.5% of those treated with SRS (p = 0.099). The angioarchitecture of CS dAVF did not affect angiographic obliteration after SRS. Procedure-related morbidity and mortality occurred more frequently in the EVT than in the SRS group (27.3% vs 8.1%, p = 0.034).

CONCLUSIONS

Both EVT and SRS were effective for the treatment of CS dAVF without ophthalmological emergency. However, procedure-related morbidity and mortality was less frequent in SRS than in EVT, and consequently SRS may be more advantageous in terms of safety.

Protocol for the postoperative radiotherapy in N1 breast cancer patients (PORT-N1) trial, a prospective multicenter, randomized, controlled, non-inferiority trial of patients receiving breast-conserving surgery or mastectomy

Background

Postoperative radiotherapy (PORT) could be useful for pN1 breast cancer patients who have undergone breast-conserving surgery (BCS) or mastectomy. However, the value of regional nodal irradiation (RNI) for BCS patients, and the indications for post-mastectomy radiotherapy (PMRT) for pN1 breast cancer mastectomy patients, have recently been challenged due to the absence of relevant trials in the era of modern systemic therapy. “PORT de-escalation” should be assessed in patients with pN1 breast cancer.

Methods

The PORT-N1 trial is a multicenter, randomized, phase 3 clinical trial for patients with pN1 breast cancer that compares the outcomes of control [whole-breast irradiation (WBI) and RNI/PMRT] and experimental (WBI alone/no PMRT) groups. PORT-N1 aims to demonstrate non-inferiority of the experimental group by comparing 7-year disease-free survival rates with the control group. Female breast cancer patients with pT1-3 N1 status after BCS or mastectomy are eligible. Participants will be randomly assigned to the two groups in a 1:1 ratio. Randomization will be stratified by surgery type (BCS vs. mastectomy) and histologic subtype (triple-negative vs. non-triple-negative). In patients who receive mastectomy, dissection of ≥5 nodes is required when there is one positive node, and axillary lymph node dissection when there are two or three positive nodes. Patients receiving neoadjuvant chemotherapy are not eligible. RNI includes a “high-tangent” or wider irradiation field. This study will aim to recruit 1106 patients.

Discussion

The PORT-N1 trial aims to verify that PORT de-escalation after BCS or mastectomy is safe for pN1 breast cancer patients in terms of oncologic outcomes and capable of reducing toxicity rates. This trial will provide information crucial for designing PORT de-escalation strategies for patients with pN1 breast cancer.

Trial registration

This trial was registered at ClinicalTrials.gov (NCT05440149) on June 30, 2022.

Incidence rate and predictors of recurrent aneurysms after clipping: long-term follow-up study of survivors of subarachnoid hemorrhage

Recurrent aneurysms are a major cause of re-aneurysmal subarachnoid hemorrhage (aSAH), but information on long-term clip durability and predictors is insufficient. This study aimed to present the incidence rate of > 10 years and investigate predictors of a recurrent aneurysm in aSAH survivors. We included 1601 patients admitted with aSAH and treated by microsurgical clipping between January 1993 and May 2010. Of these patients, 435 aSAH survivors were included in this study (27.2%). The total follow-up time was 5680.9 patient-years, and the overall incidence rate was 0.77% per patient-year. The cumulative probability of recurrence without residua and regrowth of the neck remnant was 0.7% and 13.9% at 10 years, respectively. Neck remnant (hazard ratio [HR], 10.311; 95% confidence interval [CI], 5.233-20.313) and alcohol consumption over the moderate amount (HR, 3.166; 95% CI, 1.313-7.637) were independent risk factors of recurrent aneurysm. Current smoking and multiplicity at initial aSAH presentation were significant factors in a univariate analysis. Furthermore, de novo intracranial aneurysms (DNIAs) were more common in the recurrent group than in the non-recurrent group (40.9% vs. 11.5%, P < 0.001). In the present study, we noted the long-term clip durability and predictor of recurrence after microsurgical clipping. These findings can assist clinicians in identifying patients at a high risk of recurrent aneurysm and recommending selective long-term surveillance after microsurgical clipping.

Intensity-Modulated Radiation Therapy Reduces Patient-Reported Chronic Toxicity Compared With Conventional Pelvic Radiation Therapy: Updated Results of a Phase III Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The purpose of this update was to determine differences in patient-reported chronic toxicity and disease outcomes with intensity-modulated radiation therapy (IMRT) compared with conventional pelvic radiation. Patients with cervical and endometrial cancers who received postoperative pelvic radiation were randomly assigned to conventional radiation therapy (CRT) or IMRT. Toxicity and quality of life were assessed using Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, Expanded Prostate Cancer Index Composite (EPIC) bowel and urinary domains, and Functional Assessment of Cancer Therapy-General. Between 2012 and 2015, 279 eligible patients were enrolled to the study with a median follow-up of 37.8 months. There were no differences in overall survival (P = .53), disease-free survival (P = .21), or locoregional failure (P = .81). One year after RT, patients in the CRT arm experienced more high-level diarrhea frequency (5.8% IMRT v 15.1% CRT, P = .042) and a greater number had to take antidiarrheal medication two or more times a day (1.2% IMRT v 8.6% CRT, P = .036). At 3 years, women in the CRT arm reported a decline in urinary function, whereas the IMRT arm continued to improve (mean change in EPIC urinary score = 0.5, standard deviation = 13.0, IMRT v -6.0, standard deviation = 14.3, CRT, P = .005). In conclusion, IMRT reduces patient-reported chronic GI and urinary toxicity with no difference in treatment efficacy at 3 years.

Angioarchitectural Analysis of Arteriovenous Shunts in Dural Arteriovenous Fistulas and Its Clinical Implications

BACKGROUND

Detailed understanding of the angioarchitecture of arteriovenous shunts in dural arteriovenous fistulas (DAVFs) is essential when planning endovascular treatment.

OBJECTIVE

To analyze shunt patterns and their clinical implications in transverse-sigmoid sinus and superior sagittal sinus DAVFs.

METHODS

A total of 48 DAVFs treated with endovascular embolization between January 2010 and June 2021 were investigated. The preprocedural and intraprocedural digital subtraction angiograms were examined to characterize the shunt patterns of DAVFs in terms of anatomic relations to the sinuses and cortical veins. Treatment characteristics and outcomes were evaluated.

RESULTS

The shunt patterns were categorized into 4 types: the direct sinus fistula (n = 8/48, 16.7%), compartmental sinus channel (n = 14/48, 29.1%), mural channel (n = 13/48, 27.1%), and bridging vein shunt (n = 13/48, 27.1%). Mural channel lesions revealed direct (n = 4/13, 30.8%) and indirect (n = 6/13, 46.2%) cortical venous connections. Multiple shunt types were seen in 7 patients. Overall, complete or near-complete occlusion was achieved in 43 patients (89.6%) after the final embolization. Patients with mural channels received the most embolization sessions (1.4 sessions per patient). Procedural venous drainage-related complications occurred in patients with multiple shunt types including mural channel shunts (n = 3). All bridging vein shunts were completely occluded during a single transarterial embolization session.

CONCLUSION

The 4 shunt patterns of DAVFs demonstrate distinct characteristics for the fistula, sinus and cortical vein connection. Meticulous analysis of the angioarchitectural characteristics and clinical implications is warranted for safe and effective treatment.

Prognostic factors of dose-response relationship for nodal control in metastatic lymph nodes of cervical cancer patients undergoing definitive radiotherapy with concurrent chemotherapy

Objective

Regional control is occasionally unsatisfactory in cervical cancer, with the optimal radiation dose for nodal metastases in definitive radiotherapy (RT) with concurrent chemotherapy (CRT) remaining controversial. We investigated dose-response relationship for nodal local control in cervical cancer.

Methods

We identified 115 patients with 417 metastatic nodes who received definitive CRT for cervical cancer with nodal metastases. External beam radiation therapy and brachytherapy plans were summated to determine total dose received by each node. Prognostic factors of nodal control and dose-response relationship were investigated using Cox-regression and restricted cubic spline function.

Results

The 2-year progression-free survival rate was 69.4%. Among 43 patients with failures, 17 patients (37.5%) had regional failure included in first failure sites of which all except one were in-field only regional failures. Total 30 nodes showed recurrence at initial metastatic site after treatment. Neutrophil-to-lymphocyte ratio (NLR) ≥3.1, total radiation dose (minimum dose received by 98% of the target volume in equivalent dose in 2 Gy per fractions), and initial nodal volume ≥5.29 mL were poor prognostic factors (all p<0.050) of nodal local control. Restricted cubic spline functions revealed strongest dose-response relationship in high NLR (NLR ≥3.1) and initial nodal volume ≥5.29 mL subgroup.

Conclusion

Initial nodal volume, radiation dose_, and NLR were significant factors of nodal local control in cervical cancer; a stronger dose-response relationship was seen in bulky nodes with high NLR. Clinicians may consider these factors when determining the RT dose and the need for boost to nodal metastases in cervical cancer.

One-third of cervical cancer with nodal metastases had regional failure as first failure, mostly in-field failures. Neutrophil-to-lymphocyte ratio (NLR) ≥3.1, radiation dose, and initial nodal volume ≥5.29 mL were significant factors of nodal control. The strongest radiation dose-response was found in bulky nodes with a high NLR.

Flow diverter for the treatment of large (> 10 mm) vertebral artery dissecting aneurysms

OBJECTIVE

To evaluate the outcomes of flow-diverting device (FDD) treatment for large vertebral artery dissecting aneurysms (VADAs).

METHODS

This retrospective study evaluated 12 patients with 12 VADAs who were treated using FDD between 2013 and 2020. Clinical and radiographic data, including procedure-related complications and clinical outcomes assessed using the modified Rankin Scale (mRS) at the time of the last follow-up, were collected and reviewed.

RESULTS

All 12 patients had unruptured aneurysms. There were 3 (25%) female and 9 (75%) male patients, and the mean patient age was 54.6 years. The mean size of the aneurysm was 15.9 ± 4.8 mm. The mean follow-up duration was 15.8 months. Single FDD without additional coils was used in all patients. One patient underwent second-line treatment with FDD for recurrence of large VADA after stent-assisted coiling. Immediate follow-up angiography after placement of the FDD demonstrated intra-aneurysmal contrast stasis. There were 2 (17%) patients who had peri-procedural stroke. Angiography at the 6-month follow-up in 10 patients showed favorable occlusion (OKM grade C3 + D). A total of 11 (92%) patients had good clinical outcome (modified Rankin Scale ≤ 2) at the last follow-up. No re-treatment or delayed aneurysm rupture occurred during the follow-up period.

CONCLUSIONS

Reconstructive technique with FDD is a feasible and effective modality for the treatment of large VADAs, showing favorable occlusion rate and clinical outcome.

Endovascular treatment for large (> 10 mm) basilar tip aneurysms: a retrospective case series

PURPOSE

To report the long-term clinical and angiographic outcomes of the endovascular treatment of large/giant basilar tip aneurysms (BTAs) in our institutions.

METHODS

We retrospectively reviewed cases of BTA larger than 10 mm that received endovascular treatment between January 2009 and December 2019. Data on the demographic and clinical characteristics and radiologic severity were obtained from the patients' medical records. The collected clinical follow-up data included neurological evaluation. Magnetic resonance angiography (MRA) was performed 6 to 12 months after the procedure, followed by once every 1 to 2 years as needed.

RESULTS

A total of 12 patients with BTA were included in this study. The median age was 60.08 years (27-80 years), and the mean clinical follow-up was 66.78 months (19.00-142.87 months). Almost half of the patients presented with unruptured BTAs (58.33%, n = 7). The median maximum aneurysm diameter was 13.00 mm (10.46-20.90 mm) and the mean neck size was 8.34 mm (4.82-13.04 mm). A Modified Raymond Roy Classification (MRRC1) of 1 or 2 was observed in 66.67% of the patients (n = 8) immediately after the first procedure. Procedural morbidity and mortality were 33.33% and 8.33%, respectively. Major recanalization occurred in two patients, one of whom underwent additional coiling with the other being merely observed due to older age.

CONCLUSION

It is very difficult to cure a large BTA completely at once and recanalization occurred often after endovascular treatment. Conducting long-term follow-up studies at short intervals is warranted, as well as improving existing treatment methods and developing new approaches.

Speech Outcomes of Treatment for Velopharyngeal Insufficiency: Combined Use of an Overlapping Intravelar Veloplasty and Dynamic Sphincter Pharyngoplasty

BACKGROUND

Velopharyngeal insufficiency involving a large velopharyngeal gap and poor lateral wall movement is referred to as a "black hole" and remains a challenging problem for cleft surgeons. The effect of the pharyngeal flap on this form of velopharyngeal insufficiency is still debatable because a wide pharyngeal flap is associated with a high incidence of airway obstruction. The present study aimed to evaluate the speech outcomes of combined overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency.

METHODS

Between March 2016 and June 2019, 15 patients with velopharyngeal insufficiency were treated with a combination of overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty. Preoperative speech evaluation was performed on the basis of perceptual speech evaluation, nasometry, and nasoendoscopy. Postoperative speech evaluation using the same approach as that used preoperatively was performed after completion of speech therapy.

RESULTS

All 15 patients achieved satisfactory velopharyngeal port closure and speech phonation after completion of speech therapy. No additional procedures were performed to improve velopharyngeal port closure and speech production. The preoperative and postoperative results of perceptual speech evaluation, nasometry, and nasoendoscopy evaluation were significantly different (P < 0.01).

CONCLUSION

Combined treatment with overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty can correct the velopharyngeal insufficiency "black hole" with highly reliable results and minimal risk of airway obstruction.