Pure abscopal effect of radiotherapy in a salivary gland carcinoma: Case report, literature review, and a search for new approaches.

We report the case of an 84-year-old woman with poorly differentiated non-small cell carcinoma of the right parotid who presented with headache, was found to have a primary right parotid gland cancer as well as metastatic disease, and underwent palliative radiotherapy to the primary site. The patient received no chemotherapy or immunotherapy, but both the primary site and several non-irradiated foci in the lungs regressed or completely resolved. The patient remained free of disease for about one year before progression. The case is a rare instance of abscopal regression of metastatic disease in the absence of pharmacologic immunomodulation. A literature review surveys the history of the abscopal effect of radiation therapy, attempts to understand the mechanisms of its successes and failures, and points to new approaches that can inform and improve the outcomes of radioimmunotherapy.

The effect of ionizing radiation on intraocular lenses.

BACKGROUND: The native crystalline lens is the principal shield against ultraviolet radiation (UV), damage to the human retina. Every year in the United States, more than one million patients undergo removal of the natural lens in the course of cataract surgery (phakectomy), at which time an intraocular lens (IOL) is placed in the lens capsule. The IOL thenceforth serves as the principal barrier to ultraviolet radiation over the life of the implant, potentially for decades. The synthetic organic molecules of which IOLs are composed offer little UV protection unless ultraviolet-absorbing chromophores are incorporated into the lens material during manufacture. However, chromophores are alkenes potentially subject to radiolytic degradation. It is unknown whether ionizing radiation at clinical doses (e.g., to the brain or in the head-and-neck region) affects the UV-absorbing capacity of chromophore-bearing IOLs and consequently exposes the retina to potentially chronic UV damage. In addition, the polymers of which IOLs are composed are themselves subject to radiation damage, which theoretically might result in optical distortion in the visible light range. OBJECTIVE: To determine whether megavoltage photon ionizing radiation alters the absorption spectra of ultraviolet-shielding polymethylmethacrylate (PMMA) and organopolysiloxane (silicone) intraocular lenses (IOLs) in the UV (280 nm < or = lambda < 400 nm), visible (400 nm < or = lambda < or = 700 nm), and low-end near-infrared (700 nm < lambda < or = 830 nm) ranges. DESIGN: Prospective, nonrandomized trial of dose-paired IOL cohorts. METHODS: Fourteen IOLs, seven of PMMA (Chiron 6842B) and seven of silicone (IOLAB L141U), were paired and examined for absorption spectra in 1-nm intervals over the range lambda = 280-830 nm on a Cary 400 deuterium and quartz halogen source-lamp UV/visible spectrophotometer before and after undergoing megavoltage ionizing irradiation to doses of 2, 5, 10, 20, 40, 60, and 100 Gray, respectively. Because of artifactual aberrations inherent in analyzing convex lenses on a conventional flat-plate spectrophotometer, post-irradiation absorption spectra were subsequently reanalyzed on a Cary 300 spectrophotometer outfitted with a Labsphere Diffused Reflectance Accessory (DRA-CA-30-I) incorporating a Spectralon-coated integrating sphere. MAIN OUTCOME MEASURES: Primary: Changes in UV absorbance after irradiation. Secondary: Changes in visible and low-end near-infrared absorbance after irradiation. RESULTS: Photon ionizing radiation in the 2-Gy to 100-Gy range produced no detectable alterations in the UV (280 nm < or = lambda < 400 nm), visible (400 nm < or = lambda < or = 700 nm), or low-end near-infrared (700 nm < lambda < or = 830 nm) absorption spectra of any of the lenses irradiated. However, silicone IOLs as a group revealed peak post-irradiation UV absorption at a shorter wavelength than did PMMA IOLs, with marginally greater UV transmission at the uppermost extreme of the UV spectrum (lambda = 384.5-400 nm). CONCLUSIONS: At clinically relevant doses used in radiation therapy, megavoltage photon ionizing radiation produces no significant alterations in the absorption spectra of PMMA and silicone IOLs over the range lambda = 280- 830 nm. These findings indicate that, even at supraclinical doses, the UV-absorbing capacity of chromophore-bearing PMMA and silicone IOLs remains unimpaired. It is not clear whether the lower UV peak of silicone lenses represents a radiation effect or a peculiarity of the chromophore used in the lenses tested.

Current therapy in the management of heterotopic ossification of the elbow: a review with case studies.

Heterotopic ossification, or the appearance of ectopic bone in para-articular soft tissues after surgery, immobilization, or trauma, complicates the surgical and physiatric management of injured joints. The chief symptoms of heterotopic ossification are joint and muscle pain and a compromised range of motion. Current therapies for prevention or treatment of heterotopic ossification include surgery, physical therapy, radiation therapy, and medical management. Unlike heterotopic ossification of the hip, heterotopic ossification of the elbow has not been extensively investigated, leaving its optimal management ill-defined. To remedy this deficiency, we review risk factors, clinical anatomy, physical findings, proposed mechanisms, and current practice for treatment and prevention of heterotopic ossification. We then consider and draw conclusions from four cases of elbow injury treated at our institutions (three complicated by heterotopic ossification) in which treatment included surgery, radiation therapy, physical therapy, and medical therapy. We summarize our institutional practices and conclude with a call for a randomized clinical trial to better define optimal management of heterotopic ossification of the elbow.