Evaluation of the trend of set-up errors during the treatment period using set-up margin in prostate radiotherapy.

Accurate information on set-up error during radiotherapy is essential for determining the optimal number of treatments in hypofractionated radiotherapy for prostate cancer. This necessitates careful control by the radiotherapy staff to assess the patient's condition. This study aimed to develop an evaluation method of the temporal trends in a patient's specific prostate movement during treatment using image matching and margin values. This study included 65 patients who underwent prostate volumetric modulated arc therapy (mean treatment time, 87.2 s). Set-up errors were assessed using bone, inter-, and intra-fraction marker matching across 39 fractions. The set-up margin was determined by dividing the four periods into 39 fractions using Stroom's formula and correlation coefficient. The intra-fraction set-up error was biased in the anterior-superior (AS) direction during treatment. The temporal trend of set-up errors during radiotherapy slightly increased based on bone matching and inter-fraction marker matching, with a 1.6-mm difference in the set-up margin fractions 11 to 20. The correlation coefficient of the mean prostate movement during treatment significantly decreased in the superior-inferior direction, while remaining high in the left-right and anterior-posterior directions. Image matching contributed significantly to the improvement of set-up errors; however, careful attention is needed for prostate movement in the AS direction, particularly during short treatment times. Understanding the trend of set-up errors during the treatment period is essential in numerical information sharing on patient condition and evaluating the margins for tailored hypo-fractionated radiotherapy, considering the facility's image-guided radiation therapy technology.

Transoral removal of a hilo-parenchymal submandibular sialolith.

In sialolithiasis, the lithiasis is often large and located at the junction of the middle and posterior third of the duct, in the hilum region. In such cases, transoral approach for submandibular lithiases (TASL) is a useful treatment of choice in patients with large submandibular stones that can be palpated bimanually.

Platelet adhesion on commercially pure titanium plates in vitro I: effects of plasma components and involvement of the von Willebrand factor and fibronectin.

BACKGROUND: Platelet-rich plasma (PRP) is widely used in regenerative dentistry. Furthermore, it is often applied in the pretreatment of titanium implants to improve their surface bioaffinity and initial stability. However, effects of PRP application on implant surface at cellular and molecular levels remain poorly understood. Therefore, we examined platelet adhesion on commercially pure titanium (cp-Ti) plates, with a particular focus on fibrinogen (FGN), von Willebrand factor (vWF), and fibronectin (FN), in the presence or absence of plasma components. METHODS: Citrated blood samples were obtained from six healthy male volunteers, and pure-PRP (P-PRP) and pure platelet suspensions in phosphate-buffered saline (PBS) were prepared. Platelet adhesion on cp-Ti plate surface was evaluated by phalloidin staining and tetrazolium dye assay. Distribution of FGN, vWF, FN, albumin, CD62P, and CD63 was examined by immunocytochemical analysis. RESULTS: Platelets in PBS suspensions rapidly and time-dependently adhered to cp-Ti plate surface, but this adhesion was substantially disturbed by the presence of plasma components. FGN was most preferably adsorbed regardless of the presence or absence of plasma components, while vWF and FN showed greater accumulation on platelet adhesion area. CONCLUSIONS: Although FGN is rapidly and abundantly adsorbed on cp-Ti plate surface, vWF and FN function as major platelet adhesion molecules in citrated blood samples. After pretreatment with P-PRP, however, platelets adhered to cp-Ti much less efficiently. Therefore, P-PRP pretreatment might not directly contribute to surface functionalization, initial stabilization, and osseointegration of machined or similar types of implants.

The Elental® elemental diet for chemoradiotherapy-induced oral mucositis: A prospective study in patients with oral squamous cell carcinoma.

Oral mucositis is a common adverse effect of cancer treatment that can increase the risk for local and systemic infection. This prospective study was designed to evaluate the preventive effects of an amino-acid-rich elemental diet (ED), Elental®, on radiotherapy- or chemoradiotherapy-induced mucositis in oral squamous cell carcinoma (OSCC) patients. Fifty patients were enrolled in this prospective study, who had received radiation (60-70 Gy) with/without chemotherapy [S-1, UFT, cisplatin (CDDP), docetaxel (DOC) plus CDDP, or Cetuximab]. The Elental® group (25 patients) had received Elental® during treatment, and the control group (25 patients) had not. Multivariate logistic regression analysis was used to identify the factors related to abatement of oral mucositis. A comparison of the rates of completion of chemoradiation treatments as well as the nutritional or inflammatory status between Elental® and control groups was performed. Multivariate analysis indicated that most of the patients who received Elental® suffered from a lower degree of mucositis and showed significantly improved rate of completion of chemoradiation (no interruption) compared to the control group. There was a significant difference between the Elental® group and the control group in terms of the mean change of C-reactive protein (CRP) levels in blood serum; however, there was no significant difference in terms of a mean change of body weight and total protein level in blood serum before and after chemoradiation. Our study shows that the Elental® elemental diet could be useful for the treatment of oral mucositis induced by chemoradiation. Elental® might also promote improved completion rates of chemoradiotherapy in OSCC patients.

Intrathecal Isoniazid for Refractory Tuberculous Meningitis with Cerebral Infarction.

A 30-year-old Vietnamese woman, about 19 weeks pregnant, was admitted for acute cerebral infarction with stenosis of the left middle cerebral artery (LMCA), tuberculous meningitis, and miliary tuberculosis. Treatment with heparin, quadruple anti-tuberculosis therapy, and dexamethasone afforded prompt symptomatic improvement. However, she delivered a stillbirth, after which there was recurrence of acute cerebral infarction with LMCA occlusion, sinus thrombosis, and cranial base inflammation. A thrice-weekly 100 mg dose of intrathecal isoniazid (INH) improved the signs of meningeal inflammation. The patient was discharged ambulatory after 7 months. In refractory tuberculous meningitis, multimodal therapy with intrathecal INH and steroids should be considered.

Clinical assessment of coiled fiducial markers as internal surrogates for hepatocellular carcinomas during gated stereotactic body radiotherapy with a real-time tumor-tracking system.

BACKGROUND AND PURPOSE: To report the clinical usefulness of coiled fiducial markers as an internal surrogate in gated stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC) using a real-time tumor-tracking radiotherapy (RTRT) system. MATERIALS AND METHODS: Seventeen HCC patients with Child-Pugh (CP) scores of A or B received gated SBRT (45-50Gy in 5-10 fractions) using an RTRT system and Visicoil markers. Local control (LC), progression-free (PFS), and overall survival (OS) rates were assessed using the Kaplan-Meier method. Toxicities were assessed using the Common Terminology Criteria for Adverse Events, Version 4.0. RESULTS: Of the 17 patients, 14 had a CP score A. The mean planning target volume was 54.6cc. Only 1 patient developed pneumothorax after marker implantation. Visicoil tracking during SBRT was possible in all cases. With a median follow-up of 16months, 1-year LC, PFS, and OS rates were 100%, 53%, and 82%, respectively. Grade≥2 late toxicity was observed in 2 patients (grade 2 duodenal ulcer and grade 3 temporary transaminase elevation). CONCLUSIONS: Using an RTRT system and Visicoil markers, gated SBRT was well tolerated in patients with HCC. This can be considered a safe treatment strategy with potential for delivering favorable outcomes.

Clinical outcomes of stage I and IIA non-small cell lung cancer patients treated with stereotactic body radiotherapy using a real-time tumor-tracking radiotherapy system.

PURPOSE: To investigate the clinical outcomes of stage I and IIA non-small cell lung cancer (NSCLC) patients treated with stereotactic body radiotherapy (SBRT) using a real-time tumor-tracking radiotherapy (RTRT) system. MATERIALS AND METHODS: Patterns-of-care in SBRT using RTRT for histologically proven, peripherally located, stage I and IIA NSCLC was retrospectively investigated in four institutions by an identical clinical report format. Patterns-of-outcomes was also investigated in the same manner. RESULTS: From September 2000 to April 2012, 283 patients with 286 tumors were identified. The median age was 78 years (52-90) and the maximum tumor diameters were 9 to 65 mm with a median of 24 mm. The calculated biologically effective dose (10) at the isocenter using the linear-quadratic model was from 66 Gy to 126 Gy with a median of 106 Gy. With a median follow-up period of 28 months (range 0-127), the overall survival rate for the entire group, for stage IA, and for stage IB + IIA was 75%, 79%, and 65% at 2 years, and 64%, 70%, and 50% at 3 years, respectively. In the multivariate analysis, the favorable predictive factor was female for overall survival. There were no differences between the clinical outcomes at the four institutions. Grade 2, 3, 4, and 5 radiation pneumonitis was experienced by 29 (10.2%), 9 (3.2%), 0, and 0 patients. The subgroup analyses revealed that compared to margins from gross tumor volume (GTV) to planning target volume (PTV) ≥ 10 mm, margins < 10 mm did not worsen the overall survival and local control rates, while reducing the risk of radiation pneumonitis. CONCLUSIONS: This multi-institutional retrospective study showed that the results were consistent with the recent patterns-of-care and patterns-of-outcome analysis of SBRT. A prospective study will be required to evaluate SBRT using a RTRT system with margins from GTV to PTV < 10mm.

Acute Motor-dominant Polyneuropathy as Guillain-Barré Syndrome and Multiple Mononeuropathies in a Patient with Sjögren's Syndrome.

A patient with xerostomia and xerophthalmia due to Sjögren's syndrome presented with acute motor-dominant polyneuropathy and multiple mononeuropathy with antiganglioside antibodies. Nerve conduction studies and a sural nerve biopsy revealed the neuropathy as a mixture of segmental demyelination and axonal degeneration. Positive results were obtained for several antiganglioside antibodies. Corticosteroid treatment proved effective. The neuropathy was considered to represent a mixture of polyneuropathy as Guillain-Barré syndrome and multiple mononeuropathy via Sjögren's syndrome. We speculate that Guillain-Barré syndrome occurred in the patient and Guillain-Barré syndrome itself activated multiple mononeuropathy via Sjögren's syndrome.

Three cases of neuromyelitis optica spectrum disorder.

Neuromyelitis optica (NMO) is characterized by attacks of optic neuritis and longitudinally extensive transverse myelitis. Cases positive for aquaporin 4 antibodies are classified to NMO spectrum disorder (NMOSD) which includes cases with optic neuritis, transverse myelitis, or with brain lesions typical of NMO. Our three cases with NMO/NMOSD revealed five imaging features: (i) extensive transverse cord lesions, extending more than three vertebral segments, partially persisting as cavitation; (ii) periependymal lesions; (iii) lesions of the corticospinal tracts; (iv) extensive and confluent hemispheric white matter lesions reflecting vasogenic edema and partially involving the cerebral cortices and basal ganglia; and (v) two patterns of serial hemispheric white matter lesions: one is cavitation and another is partial regression or disappearance. Cavitations, in the upper spinal cord and hemispheric white matter, are considered to be caused by severe vasogenic edema and are likely to be one of the characteristic findings in NMOSD.

Evaluation of the incident directional dependence of radiochromic film by use of Monte Carlo simulation and measurement.

In high-precision radiotherapy, absolute and relative doses are evaluated for patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA). In our institution, we use GAFCHROMIC EBT3 (EBT3) for relative dose evaluation in IMRT QA. We usually use two directional film configurations, which are in the axial and sagittal planes. The QA in our institution shows some differences between the gamma pass rates in the axial and sagittal directions. The purpose of this study was to evaluate the incident directional dependence of EBT3 by using the percent depth dose (PDD) and the off-center ratio (OCR) between EBT3 films positioned perpendicular to the beam axis and along the beam axis. Furthermore, we compared the PDD in EBT3 films positioned perpendicular to the beam axis and the PDD by using an ionization chamber. In addition, PDDs in water phantoms with and without EBT3 films were calculated by Monte Carlo simulation. The results showed that the PDD in EBT3 films positioned perpendicular to the beam axis increased with the depth from the phantom surface. Monte Carlo simulation showed the same trend as did the film measurements. The OCR results were slightly different at dose levels below 20 %. The OCR in EBT3 films positioned along the beam axis was higher than that perpendicular to the beam axis. Thus, we conclude that EBT3 film has incident directional dependence. In IMRT QA, the gamma analysis results may be affected by the incident directional dependence of EBT3 film.

Efficacy of elemental diet on prevention for chemoradiotherapy-induced oral mucositis in patients with oral squamous cell carcinoma.

PURPOSE: Oral mucositis induced by radiation or chemoradiation can compromise the quality of life of oral squamous cell carcinoma (OSCC) patients. The present study was designed to evaluate the preventive effects of elemental diet (ED), Elental®, on radiotherapy- or chemoradiotherapy-induced mucositis in OSCC patients. PATIENTS AND METHODS: Seventy-four patients who underwent radiation (60-70 Gy) with/without chemotherapy [S-1, cisplatin (CDDP), CDDP plus S-1] were enrolled in this retrospective study; 37 had received Elental® during treatment (Elental® group) and 37 had not (control group). Factors related to alleviation of oral mucositis were identified by multivariate logistic regression analysis. Rates of completion of chemoradiation treatments were compared between Elental® and control groups according to the treatment regimen. The comparison of the nutritional status between groups was also performed. RESULTS: Multivariate analysis indicated that the administration of Elental® and no combined chemotherapy (radiation alone) were significant factors associated with the degree of oral mucositis, i.e., most of the patients who consumed Elental® suffered from a lower degree of mucositis compared to the control group. Elental® was associated with a significantly improved rate of completion of chemoradiation (no interruption). There was no significant difference between Elental® group and control group in terms of mean change of body weight or total protein and albumin levels in blood serum before and after (chemo)radiation. CONCLUSIONS: The present study indicates that Elental® is effective for ameliorating oral mucositis induced by (chemo)radiation in OSCC patients. Elental® was also associated with improved completion rates of (chemo)radiotherapy.

[Electroencephalogram with Pharyngeal Electrodes to Identify the Origin of Diffuse Spike-Wave-Like Discharges in a Case of Palatal Tremor].

Electromyographic artifacts are sometimes misinterpreted as epileptic discharges in scalp electroencephalograms (EEGs). In addition, the distribution of the epileptic discharges near the earlobe is often distorted by earlobe activation; therefore, these epileptic discharges may not be correctly diagnosed. Here, we report a case of palatal tremor in which diffuse spike-wave-like discharges were apparent on EEG. A 51-year-old woman was referred to our hospital because of transient loss of consciousness while driving. She had a past history of cerebral infarction, cerebellar hemorrhages, and symptomatic epilepsy. Magnetic resonance imaging findings showed T2 hyperintensity in the right inferior olivary nucleus. Single-photon emission computerized tomographic images demonstrated hypoperfusion of the left basal ganglion, bilateral thalamus, and bilateral anteroparietal lobes. Monopolar EEG recording showed diffuse spike-wave-like discharges with a frequency of 3-4 Hz cycle. To clarify the origin of these discharges, pharyngeal EEG recording simultaneously with conventional scalp electrodes was performed, which revealed that the discharges originated from the left pharynx. Rhythmic muscle contraction could be identified at the posterior pharynx and soft palate on close pharyngeal inspection. The electromyographic activities of the palatal tremor spread to the earlobe, and the activated earlobe electrodes apparently induced diffuse spike-wave-like discharges observed on monopolar EEG recording.

[A case of corticosteroid-responsive Lemierre syndrome with clivus osteomyelitis and a mass in the cavernous sinus-suprasellar region].

Lemierre syndrome is a clinical syndrome that presents with internal jugular thrombophlebitis, septicemia and systemic abscess formations. In general, the condition is preceded by oropharyngeal infections. We report a case of a 73-year-old man with Lemierre syndrome, clivus osteomyelitis and a steroid-responsive mass in the cavernous sinus-suprasellar region. He complained of fever, occipital pain, diplopia and right ptosis. Administration of oral steroids ameliorated the ophthalmic symptoms for a period before he was admitted to our hospital. After admission, the severity of his headache advanced, and his ophthalmic symptoms progressed bilaterally. Brain magnetic resonance imaging showed contrast enhancement of the clivus and revealed a mass lesion contrast-enhancement effect in the cavernous sinus-suprasellar region. Fusobacterium nucleatum was detected by blood culture, and computed tomography revealed multiple bacterial emboli in both lung fields and thrombosis of the left internal jugular vein; thus, he was diagnosed with Lemierre syndrome. After venous administration of antibiotics, his fever and headache markedly improved, but the ophthalmic symptoms did not. We prescribed an oral steroid because the cavernous sinus-suprasellar lesion was probably an inflammatory granuloma caused by a para-infectious mechanism rather than by infection. After the series of treatments, his ophthalmic symptoms improved, and the cavernous sinus-suprasellar region mass lesion decreased. He was eventually discharged in a fully ambulatory state and had no ophthalmic difficulties. We thought that the osteomyelitis of clivus was caused by Lemierre syndrome and its inflammatory processes formed the granuloma in the cavernous sinus-suprasellar region. This was a case of Lemierre syndrome with a rare combination of clivus osteomyelitis and a steroid-responsive tumour in the cavernous sinus-suprasellar region that was successfully treated.

Long term follow-up for small pure ground-glass nodules: implications of determining an optimum follow-up period and high-resolution CT findings to predict the growth of nodules.

PURPOSE: To identify the optimum follow-up period for pure ground-glass nodules (GGN) measuring less than 15 mm in diameter, and to evaluate whether the initial HRCT findings can be used as predictors for the progression of pure GGN. MATERIALS AND METHODS: A total of 150 pure GGNs present in 111 patients were evaluated. The series of HRCT images for each GGN at the time of the initial detection, 2 years after detection, and at the final follow-up were evaluated. The HRCT findings of GGN were compared between the "increasing nodule" and "non-increasing nodule" groups. RESULTS: Most (87.3%) pure GGN did not increase whereas some nodules (12.7%) eventually increased after long-term follow-up (mean 66.0 ± 25.0 months). Six (31.6%) out of the 19 increasing nodules were regarded as stable at the 2 year follow-up examination. Some morphological findings on initial HRCT, including a size greater than 10 mm (p = 0.001), lobulated margins (p = 0.015), and a bubble-like appearance (p = 0.002), were significantly associated with the growth of pure GGNs. CONCLUSION: More than 2 years of follow-up are necessary to detect the growth of pure GGNs. Some characteristic findings indicated a high likelihood of future growth of the GGN.

Evaluation of small ischemic lesions after carotid artery stenting: the usefulness of thin-slice diffusion-weighted MR imaging.

INTRODUCTION: There has been concern regarding the usefulness of diffusion-weighted imaging (DWI) to evaluate the ischemic lesions associated with carotid artery stent placement (CAS). Some small lesions may be detected not by standard DWI but by thin-slice DWI alone, since most of the cerebral lesions are very small in size and clinically silent. The purpose of this study is to compare the detectability of the small ischemic lesions after CAS by standard and thin-slice DWI. METHODS: Both standard DWI with slice thickness of 6 mm and thin-slice DWI with slice thickness of 2 mm were obtained at the same MR examination within 2 to 7 days after 20 procedures of CAS in 17 patients. Number and measured diameter size of the detected lesions on both DWI were compared. RESULTS: All CAS procedures in 17 patients were successfully completed. The focal ischemic lesions were detected in 14 of 20 on thin-slice DWI and seven examinations on standard DWI. The total numbers of hyperintense lesions were 31 on thin-slice DWI and ten on standard DWI (p < 0.001). The sizes of these ten lesions on thin-slice DWI were larger than those of standard DWI, and the mean size of the thin-slice DWI and that of standard DWI were significantly different (p < 0.005). CONCLUSION: Thin-slice DWI was able to detect small cortical lesions better than standard DWI. Thin-slice DWI may be useful to evaluate small silent ischemic lesions after CAS.