Recommendations of the Spanish brachytherapy group (GEB) of Spanish Society of Radiation Oncology (SEOR) and the Spanish Society of Medical Physics (SEFM) for high-dose rate (HDR) non melanoma skin cancer brachytherapy.

Clinical indications of brachytherapy in non-melanoma skin cancers, description of applicators and dosimetry recommendations are described based on the literature review, clinical practice and experience of Spanish Group of Brachytherapy and Spanish Society of Medical Physics reported in the XIV Annual Consensus Meeting on Non Melanoma Skin Cancer Brachytherapy held in Benidorm, Alicante (Spain) on October 21st, 2016. All the recommendations for which consensus was achieved are highlighted in blue. Regular and small surfaces may be treated with Leipzig, Valencia, flap applicators or electronic brachytherapy (EBT). For irregular surfaces, customized molds or interstitial implants should be employed. The dose is prescribed at a maximum depth of 3-4 mm of the clinical target volume/planning target volume (CTV/PTV) in all cases except in flaps or molds in which 5 mm is appropriate. Interstitial brachytherapy should be used for CTV/PTV >5 mm. Different total doses and fraction sizes are used with very similar clinical and toxicity results. Hypofractionation is very useful twice or 3 times a week, being comfortable for patients and practical for Radiotherapy Departments. In interstitial brachytherapy 2 fractions twice a day are applied.

Metabolic syndrome and cardiovascular disease following hematopoietic cell transplantation: screening and preventive practice recommendations from CIBMTR and EBMT.

Metabolic syndrome (MetS) is a constellation of cardiovascular risk factors that increases the risk of cardiovascular disease, diabetes mellitus and all cause mortality. Long-term survivors of hematopoietic cell transplantation (HCT) have a substantial risk of developing MetS and cardiovascular disease, with the estimated prevalence of MetS being 31-49% among HCT recipients. Although MetS has not yet been proven to impact cardiovascular risk after HCT, an understanding of the incidence and risk factors for MetS in HCT recipients can provide the foundation to evaluate screening guidelines and develop interventions that may mitigate cardiovascular-related mortality. A working group was established through the Center for International Blood and Marrow Transplant Research and the European Group for Blood and Marrow Transplantation with the goal of reviewing literature and recommend practices appropriate to HCT recipients. Here we deliver consensus recommendations to help clinicians provide screening and preventive care for MetS and cardiovascular disease among HCT recipients. All HCT survivors should be advised of the risks of MetS and encouraged to undergo recommended screening based on their predisposition and ongoing risk factors.

Superparamagnetic iron oxide as a tracer for sentinel node biopsy in breast cancer: A comparative non-inferiority study.

AIMS: The gold standard for detection of Sentinel Lymph Nodes (SLN) is a combined radioisotope and blue dye breast injection, using a gamma probe (GP). A new, non-radioactive method was developed, using a tracer (Sienna+(®)) of superparamagnetic iron oxide (SPIO) nanoparticles and a manual magnetometer (SentiMag(®)) (SM). The IMAGINE study was designed to show the non-inferiority of SM compared to GP, for the detection of SLN in breast cancer patients with SLN biopsy indication. METHODS: From November 2013 to June 2014, 181 patients were recruited, and 321 nodes were excised and assessed ex-vivo. Readings from both SM and GP devices were recorded during transcutaneous, intraoperative, and ex-vivo detection attempts. RESULTS: At the patient level, ex-vivo detection rates (primary variable) with SM and GP were 97.8% and 98.3% (concordance rate 99.4%). Transcutaneous and intraoperative detection rates were 95.5% vs 97.2%, and 97.2% vs 97.8% for SM and GP respectively (concordance rates > 97%). At the node level, intraoperative and ex-vivo detection rates were 92.5% vs 89.3% and 91.0% vs 86.3% for SM and GP respectively. In all cases the non-inferiority of SM compared to SM was shown by ruling out a predefined non-inferiority margin of 5%. CONCLUSIONS: Our study showed the non-inferiority of SM as compared to GP. Moreover, the ex-vivo and intraoperative detection rates at the node level were slightly higher with SM.

Commissioning and initial experience with a commercial software for in vivo volumetric dosimetry.

INTRODUCTION AND PURPOSE: Dosimetry Check (DC) (Math Resolutions) is a commercial EPID-based dosimetry software, which allows performing pre-treatment and transit dosimetry. DC provides an independent verification of the treatment, being potentially of great interest due to the high benefits of the in vivo volumetric dosimetry, which guarantee the treatment delivery and anatomy constancy. The aim of this work is to study the differences in dose between DC and the Treatment Planning System (TPS) to establish an accuracy level of the system. MATERIAL AND METHODS: DC v.3.8 was used along with Varian Clinac iX accelerator equipped with EPID aS1000 and Eclipse v.10.0 with AAA and Acuros XB calculation algorithms. The DC evaluated version is based on a pencil beam calculation algorithm. Various plans were generated over several homogeneous and heterogeneous phantoms. Isocentre point doses and gamma analysis were evaluated. RESULTS: Total dose differences at the isocentre between DC and TPS for the studied plans are less than 2%, but single field contributions achieve greater values. In the presence of heterogeneities, the discrepancies can reach up to 15%. In transit mode, DC does not consider properly the couch attenuation, especially when there is an air gap between phantom and couch. CONCLUSIONS: The possibility of this in vivo evaluation and the potentiality of this new system have a very positive impact on improving patient QA. But improvements are required in both calculation algorithm and integration with the record and verify system.

SU-E-T-316: New Design of the Valencia Applicators to Reduce Radiation Leakage.

PURPOSE: The Valencia applicators are designed to treat skin lesions with the microSelectron-HDR afterloader. Although the radiation is highly directed to the treatment area, radiation might leak through the backside of the applicator. Recently, the manufacturer has introduced a new applicator design to reduce such radiation leakage. This new design consists mainly in the addition of about 4 mm of tungsten in the backside of the applicator making it thicker. The purpose of this study is to evaluate by means of the Monte Carlo method the radiation leakage of this new design and to evaluate whether this modification affects the dose rate distributions in the treatment area. METHODS: The complete geometry of the new applicators has been introduced in the Monte Carlo code GEANT4. The applicators have been located on the surface of a cylindrical water phantom following a methodology similar to the used in the original study of the Valencia applicators by Granero et al [Med.Phys 2008;35:495-503]. Kerma in the water phantom and kerma in air outside the phantom have been evaluated to estimate the radiation leakage of the new designed Valencia applicators. RESULTS: The Monte Carlo simulations of the new applicators show that the radiation leakage has been reduced significantly from the previous design. The largest radiation leakage of this design is now about 30% of the dose at the prescription point and about 10% at 1 cm from the backside of the applicators. The dose rate distributions in the area of treatment have not changed. CONCLUSIONS: In this study the radiation leakage of the new design of the Valencia applicators has been obtained. The radiation leakages have been largely reduced from the previous design without compromising dose rate distributions in the treatment area.

QA of dynamic MLC based on EPID portal dosimetry.

PURPOSE: Dynamic delivery of intensity modulated beams (dIMRT) requires not only accurate verification of leaf positioning but also a control on the speed of motion. The latter is a parameter that has a major impact on the dose delivered to the patient. Time consumed in quality assurance (QA) procedures is an issue of relevance in any radiotherapy department. Electronic portal imaging dosimetry (EPID) can be very efficient for routine tests. The purpose of this work is to investigate the ability of our EPID for detecting small errors in leaf positioning, and to present our daily QA procedures for dIMRT based on EPID. METHODS AND MATERIALS: A Varian 2100 CD Clinac equipped with an 80 leaf Millennium MLC and with amorphous silicon based EPID (aS500, Varian) is used. The daily QA program consists in performing: Stability check of the EPID signal, Garden fence test, Sweeping slit test, and Leaf speed test. RESULTS AND DISCUSSION: The EPID system exhibits good long term reproducibility. The mean portal dose at the centre of a 10 × 10 cm(2) static field was 1.002 ± 0.004 (range 1.013-0.995) for the period evaluated of 47 weeks. Garden fence test shows that leaf position errors of up to 0.2 mm can be detected. With the Sweeping slit test we are able to detect small deviations on the gap width and errors of individual leaves of 0.5 and 0.2 mm. With the Leaf speed test problems due to motor fatigue or friction between leaves can be detected. CONCLUSIONS: This set of tests takes no longer than 5 min in the linac treatment room. With EPID dosimetry, a consistent daily QA program can be applied, giving complete information about positioning/speed MLC.

[Ocurrence of scorpionism in sanitary districts of Mérida State, Venezuela]. / Ocurrencia de escorpionismo en los distritos sanitarios del estado Mérida, Venezuela.

The highest number of accidents caused by scorpion stings in Mérida State, Venezuela, are caused by the genus Tityus. This study intended to find epidemic data on the occurrence of scorpionism in the Sanitary Districts of the State from 1994 to 2003. The data were gathered from the records of the Epidemiologic Coordination of the region. The monthly mortality EPI15 and mortality EPI13, respectively, were reviewed and evaluated. The data demonstrated that the highest incidence was registered in the Tovar, Vigía and Mérida districts. Eleven fatal accidents were recorded only in the Tovar and Vigía districts. All fatalities (100%) involved children younger than ten years of age. The authors suspect that all of the cases could be caused by the Tityus zulianus scorpion, which is the most abundant species in the region.

[S100 protein in tumours of the central nervous system]. / Proteína S100 en tumores del sistema nervioso central.

OBJECTIVE: S100 protein has been detected in glials cells. The subject of this study is to evaluate the usefulness of serum levels of S100 as tumor marker for the screening diagnosis and follow up in patients with CNS tumors. PATIENTS AND METHODS: 57 patients were studied with tumors of the CNS: 24 multiform glioblastomas (GM), 11 anaplastic astrocytomas (AA), 3 oligodedrogliomas, 1 pinealoblastoma, 3 neurinomas, 1 low grade glioma and 13 brain metastasis of other extraneural primary tumors. 25 healthy people have been taken as control group. The S100 was analyzed by an immunoradiometric assay (IRMA) with 125 Iode. The cut off value was 0.2 g/L. RESULTS: The presurgical mean serum values of S100 didn t differ of the mean values of the control group (0.08 and 0.07 g/L, respectively). In the surgical treated patients with residual tumoral or recurrent tumors, the values of S100 increases to 38.9% in GM, 57.11% in AA and 76.9% in brain metastasis. In GM the serum values are significantly higher in patients with active tumor before receiving treatment with chemotherapy, radiotherapy or radiosurgery (p < 0.05). The values decreses to normal levels after response to oncological therapies. During the follow up (mean 551 days), the global sensitivity of S100 for progression of the disease was 47.5% and specificity was 90% with a correspondence between S100 and disease s evolution of 56%. CONCLUSIONS: S100 protein is not useful in the initial diagnosis of tumoral disease but it could be of help in the follow up of the disease because it decreases with successful treatments and increases at the time when the tumor progress.

Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound.

BACKGROUND: Gallstone ileus is an uncommon cause of mechanical obstruction. Its high mortality rate can be reduced with earlier diagnosis and treatment. We wanted to determine whether ultrasound (US) performed after plain film increases the sensitivity for the preoperative diagnosis. METHODS: We performed a 5-year retrospective analysis of radiologic and sonographic results of 23 patients who had surgery because of gallstone ileus. RESULTS: Rigler's triad was identified by plain abdominal film in two patients (9%) and by US in 16 patients (69%). Plain abdominal film contributed to a definitive diagnosis in four cases and to a probable diagnosis in six cases (sensitivities of 17% for definitive diagnoses and 43% for definitive and probable diagnoses). US confirmed the diagnosis in six cases of probable gallstone ileus and provided the diagnosis in seven of 13 patients without suspected gallstone ileus based on plain abdominal film. The best results were obtained by combining plain film and US findings, with sensitivities of 74% for definitive diagnoses and 96% for definitive plus probable diagnoses. CONCLUSION: The preoperative diagnosis of gallstone ileus significantly increases by combining plain film and US findings.

Phase I dose escalation study of topotecan combined with alternating schedules of paclitaxel and carboplatin in advanced solid tumors.

BACKGROUND: Combining topotecan with other cytotoxics has been problematic due to marrow suppression. A phase I trial was initiated to identify the optimal sequence and maximum-tolerated dose of topotecan in combination with paclitaxel and carboplatin. PATIENTS AND METHODS: Patients with advanced cancer and performance status ECOG < or = 2. The starting dose was paclitaxel 175 mg/m2 day 1, carboplatin AUC 6.0 day 1, and topotecan 0.5 mg/m2 daily day 1-5 (early sequence). The next course of paclitaxel and carboplatin administration was delayed to day 5 (late sequence). Treatment was repeated every three weeks. After determining maximum-tolerated dose without cytokines, granulocyte colony-stimulating factor (G-CSF) was added and further dose escalation was pursued. RESULTS: Fifty-one patients were entered; men: women ratio 30:21. Dose-limiting toxicity (DLT) for the early sequence was neutropenia at doses paclitaxel mg/m2/carboplatin AUC 5/topotecan mg/m2 (PCT) 175/5/0.75 for four to five days. DLT for the late sequence was neutropenia at PCT doses of 175/5/ 1.0 for four days. G-CSF 5 microg/kg subcutaneously starting day 6 permitted further topotecan dose escalation. After adding G-CSF, late sequence DLT was neutropenia at doses 175/5/1.25 for four days. Forty-six patients were evaluable for response and of those, there were thirteen partial responses. CONCLUSIONS: The late sequence resulted in less toxicity and was better tolerated. The early sequence maximum-tolerated dose (MTD) was 175/6/0.5 for five days. The late sequence MTD was PCT 175/5/0.75 for five days. The late sequence MTD with G-CSF was 175/5/1.0 for four days. The recommended phase II PCT dose is the late sequence 175/5/1.0 for four days with G-CSF.

Simultaneous presence of t(2;8)(p12;q24) and t(14;18)(q32;q21) in a B-cell lymphoproliferative disorder with features suggestive of an aggressive variant of splenic marginal-zone lymphoma.

We report a case of an aggressive variant of splenic marginal-zone lymphona (SMZL) with circulating villous lymphocytes. The karyotype of all examined cells had multiple structural and numerical abnormalities, including two lymphoma characteristic translocations, t(2;8)(p12;q24) and t(14;18)(q32;q21). Based on a literature review of cytogenetic aberrations of splenic lymphoma with villous lymphocytes (SLVL) and SMZL, this is apparently the first documentation of these two translocations in a case of SMZL, and could reflect the heterogeneity of the disorder.

[The home treatment of deep venous thromboses with low-molecular-weight heparin]. / Tratamiento domiciliario de las trombosis venosas profundas con heparina de bajo peso molecular.

Low-molecular-weight heparins (LMWH) have shown to be at least as safe and efficient as non-fractionated heparin in the treatment of deep-vein thrombosis (DVT). Moreover, no serial laboratory controls are required. Therefore, LMWH allow the patients to be treated at home. From July 1995 to July 1996, 30 consecutive patients with DVT were enrolled in a prospective study and treated with nadroparin. Ambulatory treatment was feasible in 24 patients (9 patients did not require admission and 15 patients were discharged in less than 6 days). The main causes for admission were the inability to obtain a diagnosis, the severity of symptoms in the involved limb, and the presence of associated disease. None of the 24 patients to whom the possibility of home therapy was offered desired to remain at hospital. The ambulatory care of these patients increased the burden on primary care teams. There was no case of clinical recurrent thromboembolism nor a major hemorrhagic complication. Ambulatory treatment of DVT with nadroparin seems to be feasible, efficient and safe. Nevertheless, before using this therapeutic alternative a series of factors should be considered, which include the severity of clinical presentation, the embolic and hemorrhagic risks, and the presence of associated diseases.

[Peroperative myocardial infarction and myocardial ischemia in non cardiac surgery: prevalence and predictive factors]. / Infarto e isquemia miocárdica peroperatoria en cirugía no cardíaca: prevalencia y factores predictivos.

BACKGROUND: The decrease in the prevalence of infarction in the population has not been accompanied by a reduction in postinfarct mortality, particularly in the population segment which does not present major symptoms of coronary disease. The aim of the present study was to determine the incidence and predictive factors of cardiac complications in patients undergoing non cardiac surgery. METHODS: Eight hundred seventy-five patients undergoing elective surgery from May 1990-1991 had some of the following criteria: history of heart disease, major surgery, and medical risk other than cardiac. A sample of 328 patients was selected to whom an ECG an CK-MB isoenzyme test were performed on admission, every 8 h, and at the second and third days. Infarction or ischemia were diagnosed by electrocardiographic and enzymatic criteria. Minimum follow up was 72 hours. RESULTS: IAM was diagnosed in 10 cases (3%, confidence interval 95%, 2 to 4%) and ischemia in 47 cases (14%, CI 95%, 11 to 18%). Operative mortality of cardiac origin was 4% (CI 95%, 2 to 6%). Arrhythmia not preoperatively present was detected in 11%, hemodynamic instability in 25%, and sinusal tachycardia in 21%. Other complications were: abdominal 12%, respiratory 14%, neurologic 6% and renal 4%. The appearance of cardiac complications was related with: ASA classification (p < 0.05), previous history of heart disease (p < 0.01), cardiovascular drug administration (p < 0.01) and changes in preoperative electrocardiogram (p < 0.001). CONCLUSIONS: The present study suggests that patients with changes of the ST-T segment in the preoperative ECG should undergo examination to determine the degree of cardiac involvement. A strict peroperative hemodynamic control may reduce the prevalence of cardiac complications in those patients at high risk.