Annouschka Laenen

Breathing adapted radiation therapy in comparison with prone position to reduce the doses to the heart, left anterior descending coronary artery, and contralateral breast in whole breast radiation therapy.

PURPOSE To compare 3 different treatment positions in whole breast radiation therapy in terms of target volume coverage and doses to the organs at risk (OAR). METHODS AND MATERIALS Thirty-four breast cancer (BC) patients (17 right-sided and 17 left-sided) were included in this dosimetric planning study. They all underwent a computed tomography (CT) scan in standard supine position in free-breathing (FB), supine position with gating in deep inspiratory breath hold (DIBH)(G), and prone position (P). Three-dimensional treatment plans were made for all 3 CTs. Target coverage and OAR sparing were evaluated. RESULTS Breast volumes varied between 209 and 2814 cm(3). The target coverage, expressed as the mean volume of the breast receiving at least 95% of the prescription dose, was similar for the 3 treatment positions. The mean lung dose and the volume of the lungs receiving >20 Gy were significantly lower in P (1.7 Gy; 2.3%) compared with G (3.4 Gy; 5.6%; P < .0001) and FB (4 Gy; 7.3%; P < .0001). The volume of the contralateral breast receiving >5 Gy was significantly lower in G (P = .001) or FB (P = .004) versus prone. The supine position with gating in DIBH significantly reduced the volume of the heart receiving >30 Gy (V30(heart)), the mean heart (D(heart)), and mean left anterior descending coronary artery (LAD) dose (D(LAD)) for left-sided BC patients (V30(heart) 0.9%, D(heart) 1.6 Gy, DLAD 22.4 Gy) with respect to FB (V30(heart) 4.3%, D(heart) 3.5 Gy, DLAD 30.9 Gy)(V30(heart) and mean D(heart): P ≤ .0001; mean D(LAD): P = .008) and P (V30(heart) 7.9%, D(heart) 5.4 Gy, D(LAD) 36.4 Gy)(V30(heart) and mean D(heart): P = .0004; mean D(LAD): P = .01). CONCLUSIONS The coverage of the planning target volume breast was equal for the 3 treatment positions. The lowest doses to the lungs were achieved in prone. The heart, LAD, and contralateral breast were best spared in the supine position with gating in DIBH.

A comparison of three different radiotherapy boost techniques after breast conserving therapy for breast cancer

PURPOSE Compare different boost techniques after breast conserving therapy (BCT) in terms of local and loco-regional recurrences. MATERIALS AND METHODS From 2000 to 2005, patients treated with BCT for invasive breast cancer (BC) were included. An electron boost (EB) was performed for a superficial boost-volume (less than 29 mm under the epidermis), in all other cases a brachytherapy boost (BTB) was proposed. When patients refused a BTB or it was not possible for technical reasons, a photon boost (PB) was given. The primary endpoints were local and loco-regional recurrences. Secondary endpoints were metastasis-free and overall survival. RESULTS 1379 patients were eligible for analysis. Most patients (1052) received an EB, 225 a BTB and 76 a PB. At a median follow-up of 8.8 years, 35 (2.5%) patients developed a local or loco-regional recurrence. Ten years local relapse-free rate was 97.9%. No differences between boost techniques were observed in relapse risk, metastasis-free and overall survival after multivariate analyses. CONCLUSION In women treated with BCT followed by a boost irradiation to the tumor bed, no difference in local and loco-regional recurrence, metastasis-free and overall survival was observed comparing three different boost techniques. Outcome was excellent regardless of the boost technique.

Yttrium-90 radioembolization for the treatment of chemorefractory colorectal liver metastases: Technical results, clinical outcome and factors potentially influencing survival.

Abstract Background: The purpose of this study was to retrospectively assess the technical and clinical outcomes, overall survival and prognostic factors for prolonged survival after yttrium-90 (90Y) radioembolization as a salvage therapy for patients with chemorefractory liver-only or liver-dominant colorectal metastases. Material and methods: From January 2005 to January 2014, all the patients selected for 90Y radioembolization to treat chemorefractory colorectal liver metastases were identified. Demographic, laboratory, imaging and dosimetry data were collected. Post-treatment technical and clinical outcomes were analyzed as well as overall survival; finally several factors potentially influencing survival were analyzed. Results: In total 88 patients were selected for angiographic workup; 71 patients (81%) finally underwent catheter-directed 90Y microsphere infusion into the hepatic artery 25 days (standard deviation 13 days) after angiographic workup. Median infused activity was 1809 MBq; 30-day toxicity included: fatigue (n = 39; 55%), abdominal discomfort (n = 33; 47%), nausea (n = 5; 7%), fever (n = 14; 20%), diarrhea (n = 6; 9%), liver function abnormalities and elevated bilirubin (transient) (n = 3; 4%). Gastric ulcer was found in five patients (7%). A late complication was radioembolization-induced portal hypertension (REIPH) in three patients (4%). Median time to progression in the liver was 4.4 months. Estimated survival at six and 12 months was 65% and 30%, respectively, with a 50% estimated survival after 8.0 months in this group of chemorefractory patients. Prognostic factors for worse survival were high preprocedural bilirubin, alkaline phosphatase and tumor volume levels. Conclusion: 90Y microsphere radioembolization for chemorefractory colorectal liver metastases has an acceptable safety profile with a 50% estimated survival after 8.0 months. Pretreatment high bilirubin, alkaline phosphatase and tumor volume levels were associated with early death.

Soft Tissue Bleeding Associated with Antithrombotic Treatment: Technical and Clinical Outcomes after Transcatheter Embolization

PURPOSE To assess retrospectively technical and clinical outcomes after transcatheter embolization in patients presenting with soft tissue bleeding associated with antithrombotic therapy and to determine factors potentially affecting the clinical outcomes after embolization. MATERIALS AND METHODS There were 42 patients who underwent embolization for soft tissue bleeding associated with antithrombotic therapy. Principal clinical symptoms were hemodynamic shock (n = 21), abdominal pain (n = 9), back pain (n = 7), and buttock or thigh pain (n = 5). Ultrasound or computed tomography (CT) or both were performed in 40 patients (95%); 2 patients (5%) were immediately referred for angiography. Several laboratory and radiographic factors were analyzed to determine if any influenced the clinical outcome. RESULTS A hematoma was identified in the anterior abdominal wall (n = 18 [43%]), in the retroperitoneum (n = 18 [43%]), or in the thigh or gluteal region (n = 6 [14%]). Embolization was successful in all patients; early recurrent bleeding with a fatal outcome was recorded in one patient (2%). In nine patients (22%), secondary surgical drainage of the hematoma was performed to manage a compartment syndrome. During follow-up (mean, 37.9 months; range, 0.03-85.28 months), 11 patients (26%) died; death was related to the bleeding in 6 patients (14%). Both activated partial thromboplastin time (aPTT) and prothrombin time (PT) were correlated with hematoma size. Prolonged aPTT before embolization was associated with a higher risk of bleeding-related mortality (P = .04). CONCLUSIONS Transcatheter embolization was very effective in stopping soft tissue bleeding associated with antithrombotic therapy. However, there was still considerable morbidity and mortality after successful embolization. aPTT prolongation emerged as a risk factor for bleeding-related deaths.

Safety and efficacy of doxorubicin-eluting superabsorbent polymer microspheres for the treatment of liver metastases from neuroendocrine tumours: preliminary results

Abstract Background The aim of the study was to retrospectively evaluate the symptom control, tumour response, and complication rate in patients with liver-predominant metastatic neuroendocrine tumours treated with transarterial chemoembolization using doxorubicin-eluting superabsorbent polymer (SAP) microspheres. Patients and methods Patients with neuroendocrine liver metastases who underwent hepatic transarterial chemoembolization using doxorubicin-eluting SAP-microspheres (50–100 μm Hepasphere/Quadrasphere Microsphere® particles, Merit Medical, South Jordan, Utah, USA) were included in this study. Pre-and post-procedure imaging studies were evaluated to assess short and intermediate-term tumour response using modified RECIST criteria. Symptom relief and procedure-related complications were evaluated. Results A total of 27 embolization procedures were performed on 17 patients. Twelve of 17 patients (70%) were symptomatic, including carcinoid syndrome (n = 8) and severe, uncontrollable hypoglycemia (n = 4). Eight of 12 patients (67%) had complete symptom relief, and the remaining 4 (33%) had partial relief. One patient developed ischemic cholecystitis (6%). No other hepatobiliary complications occurred. Short-term and intermediate-term imaging follow-up was available for 15/17 patients (88%) and 12/14 patients (86%) respectively. At short-term follow-up (< 3 months), 14 patients (93%) showed partial response and the remaining patient had progressive disease (7%). At intermediate-term imaging follow-up (> 3 months), partial response, stable disease and progressive disease were found respectively in 7 (58%), 3 (25%) and 2 (17%) patients. Conclusions Chemoembolization with doxorubicin-eluting SAP-microspheres is a safe and effective treatment option for neuroendocrine liver metastases and is associated with a low complication rate. In particular, no clinically evident liver necrosis or bile duct complications were encountered.

A new imaging technology to reduce the radiation dose during uterine fibroid embolization

Background Uterine fibroid embolization (UFE) is a minimally invasive imaging-guided treatment using radiation exposure. Purpose To compare the patients’ radiation exposure during UFE before and after introduction of a new X-ray imaging platform. Material and Methods Forty-one patients were enrolled in a prospective, comparative two-arm project before and after introduction of a new X-ray imaging platform with reduced dose settings, i.e. novel real-time image processing techniques (AlluraClarity). Demographic, pre-interventional imaging, and procedural data, including dose area product (DAP) and estimated organ dose on the ovaries and uterus, were recorded and angiographic quality of overall procedure was assessed. Results There were no significant differences in demographic characteristics and preoperative fibroid and uterine volumes in the two groups. The new imaging platform led to a significant reduction in mean total DAP (102 vs. 438 Gy.cm2; P < 0.001), mean fluoroscopy DAP (32 vs. 138 Gy.cm2; P < 0.001), mean acquisition DAP (70 vs. 300 Gy.cm2; P < 0.001), and acquisition DAP estimated organ dose in ovaries (42 vs. 118 mGy; P < 0.001) and uterus (40 vs. 118 mGy, P < 0.001), without impairment of the procedure and angiographic image quality. Conclusion A substantial 77% reduction of DAP values and 64% and 66% reduction in organ dose on ovaries and uterus, respectively, was demonstrated with the new imaging platform, while maintaining optimal imaging quality and efficacy.

Ophthalmological examination in neurofibromatosis type 1: a long-term retrospective analysis

tive vitreoretinopathy (Mulder et al. 2017). Here, we measured aqueous flare in patients with wAMD, diabetic macular oedema (DME), cystoid macular oedema (CME) due to retinal vein occlusion (RVO) and CME related to other retinal disease, including eyes with, for example pseudophakic, myopic and postvitrectomy CME and chronic serous chorioretinopathy. The patients were receiving treatment with antivascular endothelial growth factor injections (anti-VEGF) and analysed according to whether the injections were continued or whether no injections were needed. Aqueous flare values were measured using a laser flaremeter (FM-600,Kowa Company, Ltd., Nagoya, Japan) and a mean of five reliable measurements was used in the analysis. Aqueous flare was measured in the beginning of each visit before the injection or the decision to follow without injection. No dilating drops were installed before themeasurements. All the measurements were performed by an experienced research technician blinded from the treating physician. The study was conducted by monitoring the clinical practice. To patients with wAMD, anti-VEGF treatment (aflibercept or bevacizumab) was given using the treat-and-extend (TER) protocol (n = 189). The need for retreatment was evaluated before each injection, and the treatment interval was gradually extended up to a maximum of 12 weeks. After successfully reaching the 12-week interval, patients with inactive disease (n = 13)were observedwithout treatment. In patients with DME (n = 50),RVO(n = 28)andother retinal disease (n = 14), a fixed-PRN protocol was used. Patients were given three monthly anti-VEGF injections and then evaluated 6 weeks after the last injection regardless of the anti-VEGF agent. In the absence of macular oedema, followupwasorganizedat theoutpatient clinic. Aqueous flare was higher among patient groups during anti-VEGF treatment compared to visits when no treatment was necessary (Table 1). In wAMD patients, flare values were 22.7 35.5 photon units (pu)/ms (mean SD) during treatment versus 10.9 5.2 pu/mswhenno injectionwas given (p < 0.001). In DME patients, the values were 19.7 16.6 pu/ms versus 7.1 2.9 pu/ms (p = 0.009), and in patients with other retinal disease 28.7 31.8 pu/ms versus 6.2 2.2 pu/ ms (p = 0.021) respectively. Our data suggest that aqueous flare reflects retinal disease activity by decreasing during treatment-free periods. Further studies are still warranted to investigate whether aqueousflare canbeused tohelpestimate optimal follow-up interval and risk of reactivation in patients with anti-VEGF injections for retinal diseases.