What does "Advanced" mean in 2023? reflecting on 10 years of the ESTRO advanced Skills in modern radiotherapy course.

The roles and responsibilities of radiation therapists (RTTs) are many and varied. Professional expectations are influenced by the technology available, as well as the level of autonomy RTTs have in their daily practice. This professional range requires RTTs to possess a unique set of ever evolving skills, posing challenges from an educational perspective. Teaching these "advanced skills" has been the ambition the ESTRO Advanced Skills in Modern Radiotherapy course. In the 10th year of this course, the Faculty look back and reflect on how our programme has evolved and what it has achieved.

Evaluation of mediastinal lymphadenopathy with endoscopic US-guided fine-needle aspiration biopsy.

PURPOSE: To evaluate the safety and accuracy of endoscopic ultrasonography (US)-guided fine-needle aspiration biopsy (FNAB) of lymph nodes in the paratracheal, aortopulmonic, subcarinal, and posterior mediastinal regions. MATERIALS AND METHODS: Eighty-six consecutive patients with mediastinal lymphadenopathy who did not have a primary gastrointestinal neoplasm were examined. In 29 patients, endoscopic US-guided FNAB of mediastinal lymphadenopathy was performed as a component of staging non-small cell lung cancer (NSCLC); in the remaining 57 patients, it was performed to obtain a primary diagnosis. Final diagnosis was based on clinical follow-up, cytologic, and/or surgical results. RESULTS: In 82 patients in whom a final diagnosis was available, the sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of endoscopic US-guided FNAB in distinguishing benign from malignant mediastinal lymph nodes were 96%, 100%, 98%, 94%, and 100%, respectively. In those patients who underwent staging of NSCLC, endoscopic US-guided FNAB had superior mediastinal lymph node staging accuracy compared with endoscopic US alone (79%) and CT alone (79%) (P =.01). The results of endoscopic US-guided FNAB prompted a change to nonsurgical management in 66 (80%) of 82 patients who underwent the procedure. One minor complication, postprocedural fever that resolved with oral antibiotics, occurred (1%; 95% CI: 0%, 6%). CONCLUSION: Endoscopic US-guided FNAB is accurate and safe for biopsy of mediastinal lymph nodes to stage NSCLC, establish a primary diagnosis, or examine patients with prior inconclusive biopsy results.

EUS-guided fine-needle aspiration combined with flow cytometry and immunocytochemistry in the diagnosis of lymphoma.

BACKGROUND: Limited information is available regarding the use of EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of lymphoproliferative disorders. The aim of this study was to evaluate the yield of this technique in the primary diagnosis of lymphoma. METHODS: The records were reviewed of 38 consecutive patients with GI lesions and/or enlarged lymph nodes identified on imaging studies that raised a suspicion of lymphoma who underwent EUS-FNA of lymph nodes or the gut wall. Final diagnosis was based on clinical follow-up, imaging studies, or surgical findings. RESULTS: Twenty-three patients with lymphoma and 15 patients with benign disease or reactive lymphadenopathy were identified. The overall sensitivity, specificity, and accuracy of EUS-FNA cytology with flow cytometry/immunocytochemistry (FC/IC) for the diagnosis of lymphoma were, respectively, 74%, 93%, and 81%. When comparing patients who had EUS-FNA with FC/IC versus those who had EUS-FNA without FC/IC, sensitivity was 86% versus 44% (p = 0.04), specificity was 100% versus 90% (not significant), and accuracy was 89% versus 68% (not significant). CONCLUSION: EUS-FNA can provide cytology specimens diagnostic for lymphoma. Selective use of FC/IC in patients with suspected lymphoma improves the yield of EUS-FNA and may guide diagnostic evaluation and treatment decisions.

What prognostic factors are important in duodenal adenocarcinoma?

HYPOTHESIS: Survival of patients with adenocarcinoma of the duodenum depends on the ability to perform a complete resection and the tumor stage DESIGN: Retrospective case series. SETTING: Tertiary care referral center. PATIENTS: A cohort of 101 consecutive patients (mean age, 62 years), undergoing surgery for duodenal adenocarcinoma from January 1, 1976, through December 31, 1996. Patients with ampullary carcinoma were specifically excluded. Mean duration of follow-up was 4 years. INTERVENTIONS: Surgery was curative in 68 patients (67%) and palliative in 33 patients (33%). Of the curative group, 50 patients (74%) underwent radical surgery, ie, 30 (60%), pancreaticoduodenectomy; 15 (30%), pylorus-preserving pancreaticoduodenectomy; and 5 (10%), total pancreatectomy. A more limited resection procedure was used in 18 patients (26%) involving a segmental duodenal resection in 15 (83%) and a transduodenal excision in 3 (17%). patient survival, and correlation with patient and tumor variables using univariate and multivariate analysis. RESULTS: Actuarial 5-year survival for the curative group was 54%. Only 1 patient in the unresected group survived beyond 3 years. Nodal metastasis (P = .002), advanced tumor stage (P<.001), positive resection margin (P = .02), and weight loss (P<.001) had a significant negative impact on survival in multivariate analysis. Tumor grade, size, and location within the duodenum had no impact on survival. Patient age and tumor depth of invasion influenced survival in univariate analysis, but lost their prognostic significance in multivariate analysis. CONCLUSIONS: Metastasis to lymph nodes, advanced tumor stage, and positive resection margins are associated with decreased survival in patients with duodenal adenocarcinoma. An aggressive surgical approach that achieves complete tumor resection with negative margins should be pursued. Pancreaticoduodenectomy is usually required for cancers of the first and second portion of the duodenum. Segmental resection may be appropriate for selected patients, especially for tumors of the distal duodenum.

Impact of weight loss on health-related quality of life.

To examine the effect of treatment-induced weight loss on Health-Related Quality of Life (HRQL), 38 mildly-to-moderately overweight persons recruited to participate in a study to examine the efficacy of a lifestyle modification treatment program completed a sociodemographic questionnaire, the Beck Depression Inventory (BDI), the Medical Outcomes Study Short-Form Health Survey (SF-36, as an assessment of HRQL), and underwent a series of clinical evaluations prior to treatment. After baseline evaluations, participants were randomly assigned to either a program of lifestyle physical activity or a program of traditional aerobic activity. Participants again completed the SF-36 and BDI after the 13-week treatment program had ended. Weight loss averaged 8.6 +/- 2.8 kg over the 13-week study. We found that weight loss was associated with significantly higher scores (enhanced HRQL), relative to baseline, on the physical functioning, role-physical, general health, vitality and mental health domains of the SF-36. The largest improvements were with respect to the vitality, general health perception and role-physical domains. There were no significant differences between the lifestyle and aerobic activity groups on any of the study measures. These data indicate that, at least in the short-term, weight loss appears to profoundly enhance HRQL.

Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment.

BACKGROUND & AIMS: Endosonography-guided fine-needle aspiration biopsy (EUS-FNA) permits cytological confirmation of EUS findings. A multicenter prospective evaluation of EUS-FNA for primary diagnosis, staging, and/or follow-up purposes was undertaken. METHODS: EUS-FNA was performed in 457 patients with 554 lesions. Clinical (n = 218) or histopathologic (n = 256) confirmation was available in 192 lymph nodes, 145 extraluminal masses, 115 gastrointestinal wall lesions, and 22 cystic lesions. RESULTS: EUS-FNA sensitivity, specificity, and accuracy was 92%, 93%, and 92% for lymph nodes, 88%, 95%, and 90% for extraluminal masses, and 61%, 79%, and 67% for gastrointestinal wall lesions, respectively. The sensitivity and accuracy for lymph nodes and extraluminal masses was superior to that for gastrointestinal wall lesions. When EUS-FNA was compared with EUS size criteria in lymph node evaluation, specificity (93% vs. 24%) and accuracy (92% vs. 69%) were superior, whereas sensitivity (92% vs. 86%) was similar. The accuracy of EUS-FNA in patients with previously failed biopsy procedures was 81% (73 of 90). Five nonfatal complications occurred for a rate of 0.5% (95% confidence interval, 0.1%-0.8%) in solid lesions vs. 14% (95% confidence interval, 6%-21%) in cystic lesions. CONCLUSIONS: EUS-FNA accurately and safely evaluates solid peri-intestinal lesions and improves lymph node staging accuracy.

Endosonography-guided celiac plexus neurolysis.

Endosonography-guided celiac plexus neurolysis is a new technique that permits chemical splanchnicectomy in patients with abdominal pain due to malignancy. The procedure can be performed on an outpatient basis in individuals undergoing endosonographic examinations for staging and biopsy purposes.

Endosonography-guided celiac plexus neurolysis.

BACKGROUND: We have evaluated the safety and efficacy of performing endosonography-guided celiac plexus neurolysis (EUS CPN) in patients with pain due to intra-abdominal malignancies. METHODS: Thirty patients with upper abdominal pain requiring narcotic analgesia and suspected or known intra-abdominal malignancy were selected for EUS CPN. This group included 25 patients with pancreas carcinoma and 5 patients with intra-abdominal metastases. Using the linear array ultrasound endoscope and a prototype needle catheter, transgastric injection of the celiac plexus with bupivacaine and 98% dehydrated absolute alcohol was accomplished. RESULTS: Pain scores were significantly lower compared with baseline at 2, 4, 8, and 12 weeks after EUS CPN (median follow-up: 10 weeks). At these follow-up intervals, 82% to 91% of patients required the same or less pain medication and 79% to 88% of patients had persistent improvement in their pain score. Comparison of patients with TXNXM1 versus TXNXMO pancreatic carcinoma revealed higher initial pain scores (7.9 +/- 1.92 versus 5.8 +/- 2.0, p = .02) and a greater decline in pain scores (decrease of 6.1 +/- 3.1 versus 4.8 +/- 2.0, p = .004). Complications were minor and consisted of transient diarrhea in four patients. CONCLUSION: EUS CPN is a safe and effective means for improving pain control in patients with intra-abdominal malignancy. The technique may be performed as an outpatient at the same setting as the EUS staging examination.

Endosonography-guided cholangiopancreatography.

BACKGROUND: Detailed imaging of the common bile duct and main pancreatic duct is possible with endosonography. Utilizing a custom manufactured flexible needle, we have developed a technique of performing endosonography-guided cholangiopancreatography (EGCP). METHODS: Of 205 patients undergoing ERCP, complete ductography was not possible in 11 patients. Employing a linear scanning echoendoscope in conjunction with a 4 cm, 22 to 23 gauge aspiration needle, transduodenal cholangiography (n = 10) or transgastric pancreatography (n = 1) was attempted. RESULTS: Successful ductography was possible in 8 of 11 patients (EGCP success 73% vs ERCP 0%, p < .001, Fisher's exact test). In 5 patients, abnormalities identified on EGCP subsequently led to repeat ERCP with precut sphincterotomy. In all of these cases 100% agreement was found between EGCP and ERCP findings. One postprocedure case of pancreatitis occurred in a patient who underwent EGCP at the same setting as the failed ERCP. No early or late complications occurred in the patient group with EGCP performed at a separate setting. CONCLUSION: EGCP allows an alternative method for obtaining cholangiopancreatography in those patients in whom ERCP is unsuccessful. Further studies are necessary to define the safety and success rate of this new procedure.

Endosonography of the pancreas: normal variation versus changes of early chronic pancreatitis.

The normal pancreas may have a hypoechoic ventral segment that does not correlate with the presence of pancreas divisum. Elderly individuals and heavy alcohol users may have abnormalities of their pancreas detected by EUS that are entirely asymptomatic. In patients with early stages of chronic pancreatitis, EUS can reveal abnormalities when other imaging tests including ERCP are normal. Determining the accuracy of EUS in diagnosing chronic pancreatitis is made difficult by the absence of a readily available gold standard. Whether EUS-guided fine needle aspiration biopsy will assist in this determination requires further investigation.

Duplex Doppler endosonography in the diagnosis of splenic vein, portal vein, and portosystemic shunt thrombosis.

BACKGROUND/AIMS: Endoscopic ultrasonography is a promising procedure for imaging mesenteric vascular structures. METHODS: Duplex and color Doppler endosonography were used to prospectively evaluate 20 asymptomatic paid volunteers. Subsequently, 11 patients with nondiagnostic transabdominal ultrasound and suspected thrombosis of the splenic and/or portal veins or a portosystemic shunt were evaluated with duplex endosonography. The final diagnosis was based on CT, angiography, and/or surgery or autopsy findings in 9 of 11 patients. RESULTS: In normal volunteers, mesenteric vessel flow velocities and diameters were similar to previously described values. In 10 of the 11 patients with failed transabdominal ultrasound, duplex endosonography was able to provide the correct diagnosis (accuracy of ultrasound 0% versus EUS 91%, p < .001). Mean portal vein diameter was greater in the patient group than in the normal volunteers (18.5 mm versus 10.7 mm, p < .001) and all of the normal volunteers had a portal vein diameter less than 13 mm. No complications were experienced. CONCLUSION: Duplex endosonography allows visualization of the intra-abdominal vasculature and can be considered when transabdominal ultrasound is nondiagnostic in patients with suspected thrombosis of their splenic vein, portal vein, or portosystemic shunt. EUS is able to identify indirect findings of portal hypertension including portal vein enlargement and venous collaterals.

Endosonography-guided real-time fine-needle aspiration biopsy.

Twenty-six patients were prospectively evaluated with endosonography-guided real-time fine-needle-aspiration biopsy. This cohort comprised 14 patients with a pancreatic mass revealed by CT or a stricture of the main pancreatic duct seen at ERCP, 7 patients with mediastinal lymphadenopathy, 3 patients with extrapancreatic abdominal masses, and 2 patients with subepithelial or infiltrative lesions. Endosonography-guided real-time fine-needle-aspiration biopsy was diagnostic in 18 of 20 patients in whom surgical confirmation was available or in whom malignancy was found and confirmed by clinical follow-up (accuracy of 90%). In the subgroup of patients with pancreatic lesions, 3 had previously undergone nondiagnostic CT-guided fine-needle-aspiration biopsy and 2 did not have evidence of a mass by CT. Real-time fine-needle-aspiration biopsy was diagnostic for malignancy in 4 of these individuals. In the 7 patients with mediastinal lymph nodes, 2 had nondiagnostic transbronchial biopsy and 2 had no evidence of mediastinal lymphadenopathy by CT scan. Endosonography-guided real-time fine-needle-aspiration biopsy diagnosed malignancy in both individuals with nondiagnostic transbronchial studies and was able to identify mediastinal lymphadenopathy in the 2 patients with negative CT scans (malignancy confirmed with real-time fine-needle-aspiration biopsy in 1). Overall, in 9 of 10 lesions in which visualization by CT was not possible (5), CT-guided fine-needle aspiration was unsuccessful (3), or prior nonsurgical biopsy techniques were unsuccessful (2), real-time fine-needle-aspiration biopsy was diagnostic.(ABSTRACT TRUNCATED AT 250 WORDS)

pH testing of feeding-tube aspirates to determine placement.

Although radiologic confirmation of tube placement remains the "gold standard," there is growing evidence that pH testing of feeding-tube aspirates can reduce (although not totally eliminate) reliance on x-rays used for this purpose. This article describes that evidence and tells how it was obtained. Reducing the number of x-rays needed to confirm tube position can have far-reaching financial benefits.

Combined endosonography and fine-needle aspiration cytology in the evaluation of gastrointestinal lesions.

Fifty consecutive patients with extrinsic or submucosal masses, gastric ulcers, or surgical anastomoses suspected of malignancy but with previously negative findings on conventional forceps biopsy or brush cytology underwent endoscopic ultrasonography followed by fine-needle aspiration cytology. Diagnostic cytology results were obtained in 37 of 50 (74%) patients. In 11 of the 13 patients with negative fine-needle aspirates, the endosonographic findings supported the final diagnosis as assessed by clinical follow-up or surgical pathology findings. In all patients, endosonography was useful for identifying the extent of the lesion and detailing regional anatomy to permit an assessment of the safest and most appropriate site for needle biopsy. The highest yield was found in evaluating tumors extrinsic to the gastrointestinal tract that were impinging on the lumen (14 of 15 or 93%). In 14 patients who underwent subsequent surgical therapy, the accuracy of fine-needle aspiration cytology was 86% (12 of 14). No complications occurred in any of the patients. EUS combined with fine-needle aspiration cytology appears to be useful in the evaluation of extrinsic or submucosal masses and suspicious appearing ulcerative lesions and surgical anastomoses of the gastrointestinal tract when conventional biopsy and brush cytology techniques have been unsuccessful.