Acute genitourinary toxicity of pencil beam scanning proton therapy for localized prostate cancer: utility of the transition zone index and average urinary flow rate in predicting acute urinary retention.

BACKGROUND: The purpose of this study was to evaluate the incidence of acute genitourinary toxicities in patients undergoing pencil beam scanning proton therapy for prostate cancer and investigate predictive factors associated with acute urinary retention. METHODS: A total of 227 patients treated between 2018 and 2021 were divided into the normo-fractionated proton therapy group (n = 107) and the moderately hypo-fractionated proton therapy group (n = 120), with prescribed doses of 76-78 Gy relative biological effectiveness in 38-39 fractions and 60-63 Gy relative biological effectiveness in 20-21 fractions, respectively. Uroflowmetry parameters and the transition zone index were prospectively evaluated. RESULTS: Forty-five patients (42%) in the normo-fractionated proton therapy and 33 (28%) in the moderately hypo-fractionated proton therapy developed acute grade 2 genitourinary toxicities (P = 0.02). The most common acute genitourinary toxicity was acute urinary retention. Thirty-nine patients (36%) treated with normo-fractionated proton therapy and 27 (23%) treated with moderately hypo-fractionated proton therapy developed grade 2 acute urinary retention (P = 0.02). No patients developed grade ≥ 3 toxicity. Univariate analysis showed the transition zone index, prostate volume, international prostate symptom score, voided volume, maximum flow rate and average flow rate were associated with grade 2 acute urinary retention. Multivariate analysis in both groups revealed the transition zone index (P = 0.025 and 0.029) and average flow rate (P = 0.039 and 0.044) were predictors of grade 2 acute urinary retention. CONCLUSIONS: The incidence of acute genitourinary toxicities was lower in the moderately hypo-fractionated proton therapy compared with the normo-fractionated proton therapy. Lower pretreatment average flow rate and a higher transition zone index were useful predictors of grade 2 acute urinary retention.

Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage.

The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.

Carbon Dioxide Angiography for the Detection of Lower Gastrointestinal Arterial Bleeding Initially Occult to Angiography with Iodinated Contrast Media.

This study evaluated the utility of carbon dioxide (CO2) in angiography for the detection of lower gastrointestinal arterial bleeding initially occult to angiography with iodinated contrast media. Fourteen patients underwent CO2-enhanced angiography. In all patients, extravasation was identified by contrast-enhanced computed tomography but not by initial iodinated contrast-enhanced angiography. After iodinated contrast-enhanced angiography, CO2-enhanced angiography was performed from the same catheter position. The detection capability for extravasation on CO2-enhanced angiography was evaluated. CO2-enhanced angiography allowed for the visualization of extravasation and subsequent transcatheter arterial embolization in 11 of 14 (79%) cases, with extravasation seen during either CO2-enhanced angiography (n = 8) or subsequent repeat iodinated contrast-enhanced angiography immediately after negative CO2-enhanced angiography (n = 3). Conservative treatment was performed in the remaining 3 cases. In conclusion, CO2-enhanced angiography appears useful for identifying occult lower gastrointestinal bleeding.

Delineation of prostatic calcification using quantitative susceptibility mapping: Spatial accuracy for magnetic resonance-only radiotherapy planning.

To investigate the spatial accuracy of delineating prostatic calcifications by quantitative susceptibility mapping (QSM) in comparison with computed tomography (CT), we conducted phantom and human studies. Five differently-sized spherical hydroxyapatites mimicking prostatic calcification (pseudo-calcification) were arranged in the order of their sizes at the center of a plastic container filled with gelatin. This calcification phantom underwent magnetic resonance (MR) imaging, including the multiple spoiled gradient-echo sequences (SPGR) for the QSM and CT as a reference. The volume of each pseudo-calcification and center-to-center distance between the pseudo-calcifications delineated by QSM and CT were measured. In the human study, eight patients with prostate cancer who underwent radiation therapy and had some prostatic calcifications were included. The patients underwent CT and SPGR and modified DIXON sequence for MR-only simulation. The hybrid QSM processing combined with the complex signals in the SPGR and water and fat fraction maps estimated from the modified DIXON sequence were used to reconstruct the pelvic susceptibility map in humans. The threshold of CT numbers was set at 130 HU, while the QSM images were manually segmented in the calcification phantom and human studies. In the phantom study, there was an excellent agreement in the pseudo-calcification volumes between QSM and CT (y = 1.02x - 7.38, R2  = 0.99). The signal profiles had similar trends in CT and QSM. The center-to-center distances between the pseudo-calcifications in the phantom were also identical in QSM and CT. The calcification volumes were almost identical between the QSM and CT in the human study (y = 0.95x - 9.32, R2  = 1.00). QSM can offer geometric and volumetric accuracies to delineate prostatic calcifications, similar to CT. The prostatic calcification delineated by QSM may facilitate image-guided radiotherapy in the MR-only simulation workflow.

Embolization for acute arterial bleeding: use of the triaxial system and N-butyl-2-cyanoacrylate.

PURPOSE: The aim of this study was to evaluate the usefulness of transcatheter arterial embolization (TAE) using the triaxial system with N-butyl-2-cyanoacrylate (NBCA) for acute arterial bleeding in comparison to TAE using the triaxial system with gelatin sponges (GS)　and/or coils. MATERIAL AND METHODS: Between October 2013 and November 2018, 95 patients with acute arterial bleeding underwent emergency TAE using the triaxial system. Six patients underwent multiple TAEs and thus, 104 TAEs using the triaxial system were performed. In 26 of the 104 cases, TAE were performed with NBCA (NBCA group), and in the remaining 78 cases, TAE were performed with GS and/or coils (control group). RESULTS: Hemorrhagic shock and coagulopathy more often occurred in the NBCA group. Procedure time was shorter in the NBCA group. The technical success rate was 100% in both groups (p > 0.99). The clinical success rate in the NBCA and control groups was 92% and 96%, respectively (p = 0.6). There was one minor complication (4%, 1/26) of liver dysfunction in a patient of the NBCA group, but no complication in the control group (p = 0.26). CONCLUSION: TAE using the triaxial system with NBCA may be useful for acute arterial bleeding, especially in patients with hemorrhagic shock and coagulopathy.

Helical tomotherapy for asymptomatic chemotherapy-refractory or -unfit multiple (3 or more) metastases.

Background: Despite chemotherapy innovations, prognosis of patients with chemotherapy-refractory or -unfit multiple metastases (CRMM/CUMM) remains poor. In this prospective study, the efficacy and toxicity of helical tomotherapy for CRMM/CUMM were evaluated. Materials and methods: Between 2014 and 2020, asymptomatic patients with CRMM/CUMM with ≥ 3 lesions and no prior radiotherapy of the targets were enrolled. Patients who had intolerable toxicities to chemotherapy and those who refused chemotherapy were included in the CRMM and CUMM groups, respectively. Prostate cancer patients and patients with metastases mainly localized in the liver, lung, or brain were excluded. By helical tomotherapy, up to 10 lesions per patient were irradiated in order of volume. The standard dose was 50-60 Gy in 25-30 fractions. Results: Forty-five patients (median age, 63 years; 35 CRMM/10 CUMM) were enrolled. Primary tumors included lung, gynecological, and gastrointestinal cancers. The most frequently treated targets were lymph node metastases, followed by peritoneal/pleural disseminations and bone tumors. The 1-year survival rate was 51% (median, 12.5 months). In the 35 patients with CRMM, the median survival time was 12.5 months, and the median pre-radiation chemotherapy period was 8.8 months (p > 0.05). The 6-month target control rate was 78%. Acute adverse events (grade ≥ 2) occurred in 33 patients: hematologic toxicities in 23, dermatitis in 6, and others in 8. Late grade ≥ 2 toxicities occurred in 6 patients: pneumonitis in 4 and gastric hemorrhage in 2. Conclusion: Tomotherapy for CRMM/CUMM resulted in median survival times > 1 year. This treatment should be investigated further in larger prospective studies.

The importance of choosing the right strategy to treat small cell carcinoma of the cervix: a comparative analysis of treatments.

BACKGROUND: Standard treatments for small cell carcinoma of the cervix (SCCC) have not been established. In this study, we aimed to estimate the optimal treatment strategy for SCCC. METHODS: This was a multicenter retrospective study. Medical records of patients with pathologically proven SCCC treated between 2003 and 2016 were retrospectively analyzed. Overall survival (OS) was plotted using the Kaplan-Meier method. Log-rank tests and Cox regression analysis were used to assess the differences in survival according to stage, treatment strategy, and chemotherapy regimen. RESULTS: Data of 78 patients were collected, and after excluding patients without immunohistopathological staining, 65 patients were evaluated. The median age of the included patients was 47 (range: 24-83) years. The numbers of patients with International Federation of Gynecology and Obstetrics (FIGO) 2018 stages I-IIA, IIB-IVA, IVB were 23 (35%), 34 (52%), and 8 (12%), respectively. Of 53 patients who had undergone chemotherapy, 35 and 18 received SCCC and non-SCCC regimens as their first-line chemotherapy regimen, respectively. The 5-year OS for all patients was 49%, while for patients with FIGO stages I-IIA, IIB-IVA, IVB, it was 60, 50, and 0%, respectively. The 5-year OS rates for patients who underwent treatment with SCCC versus non-SCCC regimens were 59 and 13% (p < 0.01), respectively. This trend was pronounced in locally advanced stages. Multivariate analysis showed that FIGO IVB at initial diagnosis was a significant prognostic factor in all patients. Among the 53 patients who received chemotherapy, the SCCC regimen was associated with significantly better 5-year OS in both the uni- and multivariate analyses. CONCLUSION: Our results suggest that the application of an SCCC regimen such as EP or IP as first-line chemotherapy for patients with locally advanced SCCC may play a key role in OS. These findings need to be validated in future nationwide, prospective clinical studies.

Changes in Apparent Diffusion Coefficient (ADC) during Cardiac Cycle of the Brain in Idiopathic Normal Pressure Hydrocephalus Before and After Cerebrospinal Fluid Drainage.

BACKGROUND: The causative mechanisms of idiopathic normal-pressure hydrocephalus (iNPH) symptoms are currently unknown. PURPOSE: To assess the dynamic changes in the apparent diffusion coefficient (ADC) during the cardiac cycle (ΔADC) of the brain before and after the lumbar tap and shunt surgery for the purpose of determining changes in hydrodynamic and biomechanical properties in the brain after cerebrospinal fluid (CSF) drainage for iNPH. STUDY TYPE: Retrospective. SUBJECTS: Overall, 22 patients suspected to have iNPH were examined before and after the lumbar tap and were divided into patients who showed symptomatic improvements (positive group, n = 17) and those without improvement (negative group, n = 5) after the lumbar tap. Seven patients in the positive group were examined after the shunt surgery. FIELD STRENGTH/SEQUENCE: 1.5T, electrocardiographically synchronized single-shot diffusion echo-planar imaging. ASSESSMENT: The frontal white matter ΔADC and mean ADC (ADCmean ) were compared between before and 24 hours after lumbar tap and from 1 week to 1 month after the shunt surgery. STATISTICAL TESTS: Wilcoxon signed-rank test was used. P < 0.05 was considered statistically significant. RESULTS: The ΔADC after the lumbar tap in the positive group was significantly lower than that before (P < 0.05), whereas no significant difference was found in the negative group (P = 0.23). After the lumbar tap, ΔADC decreased in 16 of 17 patients in the positive group, whereas ADCmean did not significantly change (P = 0.96). After the shunt surgery, ΔADC decreased in all seven patients (P < 0.05), whereas ADCmean did not significantly change (P = 0.87). DATA CONCLUSION: The frontal white matter ΔADC in iNPH decreased after the lumbar tap and shunt surgery. ΔADC analysis may provide detailed information regarding changes in the hydrodynamic and biomechanical properties through CSF drainage. LEVEL OF EVIDENCE: 4. TECHNICAL EFFICACY STAGE: 4.

Preoperative CT Findings for Predicting Acute Exacerbation of Interstitial Pneumonia After Lung Cancer Surgery: A Multicenter Case-Control Study.

BACKGROUND. Acute exacerbation (AE) is a life-threatening complication of inter-stitial pneumonia (IP). Thoracic surgery may trigger AE. OBJECTIVE. The purpose of this study is to explore the role of preoperative CT findings in predicting postoperative AE in patients with IP and lung cancer. METHODS. This retrospective case-control study included patients from 22 institutions who had IP and underwent thoracic surgery for lung cancer. AE was diagnosed on the basis of symptoms and imaging findings noted within 30 days after surgery and the absence of alternate causes. For each patient with AE, two control patients without AE were identified. After exclusions, the study included 92 patients (78 men and 14 women; 31 with AE [the AE group] and 61 without AE [the no-AE group]; mean age, 72 years). Two radiologists independently reviewed preoperative thin-slice CT examinations for pulmonary findings and resolved differences by consensus. The AE and no-AE groups were compared using the Fisher exact and Mann-Whitney U tests. Multivariable logistic regression was performed. Interreader agreement was assessed by kappa coefficients. RESULTS. A total of 94% of patients in the AE group underwent segmentectomy or other surgery that was more extensive than wedge resection versus 75% in the no-AE group (p = .046). The usual IP pattern was present in 58% of the AE group versus 74% of the no-AE group (p = .16). According to subjective visual scoring, the mean (± SD) ground-glass opacity (GGO) extent was 6.3 ± 5.4 in the AE group versus 3.9 ± 3.8 in the no-AE group (p = .03), and the mean consolidation extent was 0.5 ± 1.2 in the AE group versus 0.1 ± 0.3 in the no-AE group (p = .009). Mean pulmonary trunk diameter was 28 ± 4 mm in the AE group versus 26 ± 3 mm in the no-AE group (p = .02). In a model of CT features only, independent predictors of AE (p < .05) were GGO extent (odds ratio [OR], 2.8), consolidation extent (OR, 9.4), and pulmonary trunk diameter (OR, 4.2); this model achieved an AUC of 0.75, a PPV of 71%, and an NPV of 77% for AE. When CT and clinical variables were combined, undergoing segmentectomy or more extensive surgery also independently predicted AE (OR, 8.2; p = .02). CONCLUSION. The presence of GGO, consolidation, and pulmonary trunk enlargement on preoperative CT predicts AE in patients with IP who are undergoing lung cancer surgery. CLINICAL IMPACT. Patients with IP and lung cancer should be carefully managed when predictive CT features are present. Wedge resection, if possible, may help reduce the risk of AE in these patients. TRIAL REGISTRATION. University Hospital Medical Information Clinical Trial Registry UMIN000029661.

Feasibility of transrectal and transperineal fiducial marker placement for prostate cancer before proton therapy.

BACKGROUND: To compare the feasibility of transrectal and transperineal fiducial marker placement for prostate cancer before proton therapy. MATERIALS AND METHODS: From 2013 to 2015, the first 40 prostate cancer patients that were scheduled for proton therapy underwent transrectal fiducial marker placement, and the next 40 patients underwent transperineal fiducial marker placement (the first series). Technical and clinical success and pain scores were evaluated. In the second series (n = 280), the transrectal or transperineal approach was selected depending on the presence/absence of comorbidities, such as blood coagulation abnormalities. Seven patients refused to undergo the procedure. Thus, the total number of patients across both series was 353 (262 and 91 underwent the transrectal and transperineal approach, respectively). Technical and clinical success, complications, marker migration and the distance between the two markers were evaluated. RESULTS: In the first series, the technical and clinical success rates were 100% in both groups. The transrectal group exhibited lower pain scores than the transperineal group. The overall technical success rates of the transrectal and transperineal groups were 100% (262/262) and 99% (90/91), respectively (P > 0.05). The overall clinical success rate was 100% in both groups, and there were no major complications in either group. The migration rates of the two groups did not differ significantly. The mean distance between the two markers was 25.6 ± 7.1 mm (mean ± standard deviation) in the transrectal group and 31.9 ± 5.2 mm in the transperineal group (P < 0.05). CONCLUSION: Both the transrectal and transperineal fiducial marker placement methods are feasible and safe.

Stereotactic body radiotherapy using a hydrogel spacer for localized prostate cancer: A dosimetric comparison between tomotherapy with the newly-developed tumor-tracking system and cyberknife.

PURPOSE: With a new tumor-tracking system (Synchrony®) for tomotherapy (Radixact®), the internal and set-up margins can be tightened, like cyberknife (CyberKnife®), in the planning of stereotactic body radiotherapy (SBRT) for prostate cancer. Recently, the usefulness of placing a hydrogel spacer between the prostate and rectum has been established in prostate radiotherapy. We evaluated the characteristics of tomotherapy plans with the tumor-tracking system and compared them with cyberknife SBRT plans for localized prostate cancer using a hydrogel spacer. METHODS: In 20 patients, two plans were created and compared using tomotherapy and cyberknife. All patients underwent hydrogel spacer injection behind the prostate before simulation CT and MRI for fusion. For all plans, 36.25 Gy in 7.25-Gy fractions for a minimum coverage dose of 95% of planning target volume (PTV) (D95%) was prescribed. The D99% of PTV and D0.1 ml of the PTV, urethra, bladder, and rectum were intended to be > 90%, 110-130%, 100-110%, <110%, and <100%, respectively, of the prescribed doses. RESULTS: All plans using tomotherapy and cyberknife achieved the intended dose constraints. The cyberknife plans yielded better median PTV-V110% (volume of PTV covered by 110% isodose line, 54.8%), maintaining lower median D0.1 ml of the urethra (37.5 Gy) and V80% of the bladder (11.0 ml) compared to the tomotherapy plans (39.0%; p < 0.0001, 38.2 Gy; p < 0.0001, and 18.3 ml; p < 0.0001, respectively). The tomotherapy plans were superior to the cyberknife plans for the rectum (V80% = 0.4 vs. 1.0 ml, p < 0.001; D1ml = 26.4 vs. 29.0 Gy, p = 0.013). CONCLUSIONS: Our results suggested that tomotherapy with the tumor-tracking system has reasonable potential for SBRT for localized prostate cancer using a hydrogel spacer.

2D-shear wave elastography in the prediction of type II endoleaks after endovascular aneurysm repair.

PURPOSE: To evaluate the usefulness of 2D-shear wave elastography (2D-SWE) in the prediction of type II endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA). MATERIAL AND METHODS: Twenty-nine patients underwent EVAR for AAA, and 2D-SWE was performed after EVAR. Follow-up contrast-enhanced CT and ultrasonography were performed to evaluate endoleaks in all patients. The median follow-up period was 12 months (range, 3-12 months). Patients were divided into two groups: one with an endoleak (endoleak group) and another without it (control group). We compared the elasticity index (EI) of intraluminal thrombus (ITL) and fresh thrombus (FT) between the two groups. RESULTS: Type II endoleaks were confirmed in five of the 29 patients (endoleak group), and there were no endoleaks in the other 24 (control group). ILT was observed in 21 patients of the control group and in all patients of the endoleak group. There was a difference only in EI of ILT; the mean EI (± standard deviation) of ILT was 89 ± 16 kPA in the control group and 113 ± 25 kPA in the endoleak group (p=.037). CONCLUSIONS: High EI of ILT may predict the occurrence of type II endoleaks after EVAR of AAA.

Utility of 70-kV single-energy CT in depicting the extent of breast cancer for preoperative planning.

PURPOSE: To evaluate the detectability of breast cancer and visibility of the tumor extent using 70-kV single-energy contrast-enhanced (CE) breast computed tomography (70-kV CECT) compared with CE breast magnetic resonance imaging (CEMR). METHODS: Between 2013 and 2015, 110 patients with 112 breast cancer lesions who underwent breast surgery after undergoing both 70-kV CECT and CEMR were enrolled. The major axis lengths of the breast lesion were measured and compared with the pathologically determined major axes. Agreement in the measured major axes was evaluated using the intra-class correlation coefficient (ICC). RESULTS: Both 70-kV CECT and CEMR depicted all breast cancer lesions. The mean major axis was 3.0 (95% confidence interval [CI], 2.5-3.4) cm on CECT and 2.9 (2.6-3.3) cm on CEMR. The mean differences between the pathologically and radiologically measured major axes on 70-kV CECT and CEMR were 0.9 (0.7-1.1) and 1.0 (0.8-1.2) cm, respectively. The accuracy of the radiological major axes compared with the pathological major axes was 82.1% and 80.4% on CECT and CEMR, respectively (p = 0.81). The major axes on the two modalities demonstrated moderate agreement (ICC = 0.69, 95% CI 0.58-0.77). Pathologically and radiologically measured major axes on 70-kV CECT and CEMR demonstrated excellent agreement (ICC = 0.91, 95% CI 0.93-0.96). CONCLUSIONS: Low-tube voltage (70-kV) CECT is the preferred modality to identify breast cancer lesions and tumor extent for preoperative planning because it has a similar diagnostic ability to CEMR and can be performed in the supine position.

Simultaneous voxel-based magnetic susceptibility and morphometry analysis using magnetization-prepared spoiled turbo multiple gradient echo.

This study aimed to develop and test a simultaneous acquisition and analysis pipeline for voxel-based magnetic susceptibility and morphometry (VBMSM) on a single dataset using young volunteers, elderly healthy volunteers, and an Alzheimer's disease (AD) group. 3D T1 -weighted and multi-echo phase images for VBM and quantitative susceptibility mapping (QSM) were simultaneously acquired using a magnetization-prepared spoiled turbo multiple gradient echo sequence with inversion pulse for QSM (MP-QSM). The magnitude image was split into gray matter (GM) and white matter (WM) and was spatially normalized. The susceptibility map was reconstructed from the phase images. The segmented image and susceptibility map were compared with those obtained from conventional multiple spoiled gradient echo (mGRE) and MP-spoiled gradient echo (MP-GRE) in healthy volunteers to validate the availability of MP-QSM by numerical measurements. To assess the feasibility of the VBMSM analysis pipeline, voxel-based comparisons of susceptibility and morphometry in MP-QSM were conducted in volunteers with a bimodal age distribution, and in elderly volunteers and the AD group, using spatially normalized GM and WM volume images and a susceptibility map. GM/WM contrasts in MP-QSM, MP-GRE, and mGRE were 0.14 ± 0.011, 0.17 ± 0.015, and 0.045 ± 0.010, respectively. Segmented GM and WM volumes in the MP-QSM closely coincided with those in the MP-GRE. Region of interest analyses indicated that the mean susceptibility values in MP-QSM were completely in agreement with those in mGRE. In an evaluation of the aging effect, a significant increase and decrease in susceptibility and volume were found by VBMSM in deep GM and WM, respectively. Between the elderly volunteers and the AD group, the characteristic susceptibility and volume changes in GM and WM were observed. The proposed MP-QSM sequence makes it possible to acquire acceptable-quality images for simultaneous analysis and determine brain atrophy and susceptibility distribution without image registration by using voxel-based analyses.

Feasibility and Safety of Sac Embolization Using N-Butyl Cyanoacrylate in Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms or Isolated Iliac Artery Aneurysms.

PURPOSE: To evaluate the feasibility and safety of sac embolization with N-butyl cyanoacrylate (NBCA) in emergency endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) and iliac artery aneurysm (IAA) in comparison to EVAR without sac embolization. MATERIALS AND METHODS: Between February 2012 and December 2019, among 44 consecutive patients with ruptured AAA or IAA, 29 underwent EVAR. Of these, 22 patients (median age 77.5 years; 18 men) had concomitant sac embolization using NBCA; the remaining 7 patients (median age 88 years; 6 men) underwent EVAR without sac embolization and form the control group. The technical success, clinical success (hemodynamic stabilization), procedure-related complications, and mortality were compared between the groups. RESULTS: All EVAR procedures and embolizations were successful. The clinical success rates in the NBCA and control groups were 95% (21/22) and 71% (5/7), respectively (p=0.14). There was no complication related to the procedure. Type II endoleak occurred in 4 of 21 patients (19%) in the NBCA group vs none of the control patients. One patient (5%) died in the NBCA group vs 3 (43%) in the controls (p=0.034). CONCLUSION: Sac embolization using NBCA in emergency EVAR appears to be feasible and safe for ruptured AAA and IAA.

Intensity-modulated radiation therapy for multiple targets with tomotherapy using multiple sets of static ports from different angles.

BACKGROUND: To treat multiple targets separated in the craniocaudal direction within a short time, we invented a new technique using multiple static-port tomotherapy with the dynamic-jaw mode and named it the pseudo-DJDC (pDJDC) technique. We compared the pDJDC plans and helical tomotherapy plans using the dynamic-jaw mode (HDJ) for multiple targets. In the pDJDC plans, we used a beam set with 2-7 ports to the targets at the same level in the craniocaudal direction, and employed another beam set for other targets using different port angles (9-12 angles in total). METHODS: In seven patients, two plans using the pDJDC and HDJ techniques were compared. For multiple targets (n = 2-6), 20-60 Gy in 2- to 7.5-Gy fractions were prescribed for the planning target volumes at D50%. The conformity index, uniformity index (D5%/D95%), dose distribution in the lung, and treatment time were evaluated. RESULTS: The median conformity index of all seven patients was 3.0 for the pDJDC plans and 2.4 for the HDJ plans (P = 0.031). The median uniformity indices of the planning target volume (n = 25) for the two plans were 1.048 and 1.057, respectively (P = 0.10). For five patients with thoracic targets, the median mean lung doses were 2.6 Gy and 2.4 Gy, respectively (P = 0.63). The median V5Gy and V20Gy of the lungs in the five patients were 11.8% and 8.5% (P = 0.63), and 1.6% and 2.1% (P = 0.31), respectively. The pDJDC plans reduced the treatment time by 48% compared to the HDJ plans (median: 462 and 884 sec, respectively, P = 0.031). CONCLUSION: The pDJDC technique allows treatment of multiple targets in almost half the time of the HDJ technique. The pDJDC plans were comparable to the HDJ plans in dose distribution, although the conformity index deteriorated.

Use of a steerable triaxial system for challenging catheterization.

Purpose: A steerable triaxial system consisting of a small microcatheter, a high-flow steerable microcatheter, and a 4-Fr. catheter is currently used in clinical settings. The purpose of the present study was to evaluate the efficacy and safety of the steerable triaxial system for challenging catheterization.Material and methods: Sixteen patients underwent an interventional procedure with the steerable triaxial system. Medical records and images of the procedures were reviewed, and the technical success rate, clinical success rate, and complications related to the procedures were evaluated. Technical success was defined as successful catheterization to the target artery using the steerable triaxial system, and clinical success as completion of the aimed procedure.Results: Catheterization to the target artery was successfully performed with the steerable triaxial system in 14 out of 16 patients, but was unsuccessful in two. Therefore, the technical success rate was 88% (14/16). The procedure was successfully accomplished in the 14 technical success patients. Thus, the clinical success rate was 88% (14/16). There were no complications related to the procedures.Conclusions: The steerable triaxial system has potential as a useful and safe technique for challenging catheterization.

Differentiation of Kawasaki Disease From Other Causes of Fever and Cervical Lymphadenopathy: A Diagnostic Scoring System Using Contrast-Enhanced CT.

OBJECTIVE: The purpose of this study is to determine the characteristic findings of contrast-enhanced CT (CECT) of the neck in patients with Kawasaki disease (KD) and to develop a diagnostic scoring system to facilitate the diagnosis of KD versus other causes of fever and cervical lymphadenopathy. MATERIALS AND METHODS: Two blinded radiologists evaluated CECT images of 37 patients with KD and 92 patients without KD who had febrile cervical lymphadenopathy, first independently and then in consensus. Significant findings in CECT images were evaluated through cervical edema and lymph node scores. CT attenuation of the nodal low-attenuation area and its ratio to the CT attenuation of the trapezius muscle were measured. On the basis of these indexes, a diagnostic scoring system was developed to differentiate between patients with and without KD. Its diagnostic performance was determined using ROC curve analysis. RESULTS: Retropharyngeal edema, lateral cervical edema, nasopharyngeal wall edema, level IIA lymphadenopathy, and retropharyngeal lymphadenopathy were more common in patients with KD than in patients without KD (p < 0.001, < 0.001, < 0.001, 0.003, and 0.028, respectively). Level VB lymphadenopathy was more common in patients without KD (p = 0.013), and the presence of nodal low-attenuation areas with lower attenuation indexes (attenuation of nodal low-attenuation area ≤ 50 HU, or ratio of attenuation of nodal low-attenuation area to trapezius muscle attenuation ≤ 0.7) was specific to patients without KD. In cases of higher attenuation indexes and cervical edema and lymph node scores of 4 or higher, sensitivity, specificity, and accuracy of the diagnostic scoring system were 86% (32/37), 86% (79/92), and 86% (111/129), respectively, for diagnosing KD. CONCLUSION: The proposed diagnostic scoring system was useful in differentiating between patients with and without KD.

Factors associated with a preference for disclosure of life expectancy information from physicians: a cross-sectional survey of cancer patients undergoing radiation therapy.

PURPOSE: This study aimed to investigate experiences and preferences for disclosure of life expectancy, agreement between them, and the factors associated with preferences for disclosure of life expectancy with physicians among cancer patients undergoing radiation therapy. METHODS: Cancer patients aged 20 years or older were consecutively sampled when they started radiation therapy at two university hospitals. Patients completed self-administered questionnaires concerning their experiences of and preferences for disclosure of life expectancy, treatment decision-making, psychological distress, physical symptoms, sociodemographic and medical factors, physician's communication style, and provision of psychological, physical, and practical support. RESULTS: Among the 226 respondents (response rate: 58%) who responded, 54% experienced disclosure of life expectancy, and 45% preferred it. The agreement is 65%. Eighty-five percent recognized their aim of radiation therapy as curative. A univariate analysis indicated that having a full/part-time job and wishing to leave treatment decisions to doctors were significantly associated with preference for disclosure of life expectancy, but psychological distress was not. A multiple regression analysis revealed that having a full-time/part-time job was significantly associated with preference of communication about life expectancy. CONCLUSIONS: Fifty-four percent of the patients experienced and 45% of the patients preferred disclosure of life expectancy. The agreement is moderate. Our results show that there was a significant association between employment status and patient's preference for disclosure of life expectancy with physicians. Communication of prognosis is difficult but whether a patient continues to work or not may be an indicator of preference.

Low-dose Gamma Knife radiosurgery plus whole-brain radiation therapy for patients with 5 or more brain metastases with or without meningeal dissemination.

PURPOSE/OBJECTIVE(S): Radiosurgery plus whole-brain radiotherapy (WBRT) has been reported to be useful for patients with ≤ 4 brain metastases (BM), but we hypothesized that similar treatment may be applicable to patients with ≥ 5 BM with or without meningeal dissemination. The purpose of this study was to evaluate the efficacy and toxicity of low-dose Gamma Knife (GK) followed by WBRT for patients with advanced BM. MATERIALS/METHODS: Major eligibility criteria for this phase II study were: (1) ≥ 5 BM with or without meningeal dissemination and (2) the largest tumor diameter ≤ 4 cm. During 2013-2016, 40 patients (13 men and 27 women) entered the study. Nineteen had meningeal dissemination. The GK dose was 12 Gy at the periphery when the longest diameter was 3-4 cm and 14 Gy when it was < 3 cm. The WBRT dose to the isocenter was 30 Gy in 10 fractions, or 37.5 Gy in 15 fractions for two patients, with an expected survival of > 12 months. The median number of target BM was 17.5. RESULTS: After GK plus WBRT for 40 patients, 31 did not develop further intracranial recurrence until death or last follow-up, whereas 9 developed recurrence. With a follow-up period up to 24 months, the overall survival rate was 36% at 12 months and median survival time was 8 months. The cumulative incidence of intracranial recurrence was 25% at 12 months. Toxicity was considered acceptable. CONCLUSION: Treatment with low-dose GK followed by WBRT for advanced-stage BM appeared to contribute to local control.