Coronary stenosis risk analysis following Hodgkin lymphoma radiotherapy: A study based on patient specific artery segments dose calculation.

BACKGROUND AND PURPOSE: The dose effect-effect relationship for cardiac diseases following radiotherapy suffers from uncertainties. Three dimensional coronary artery (CA) dose calculation after mediastinal Hodgkin lymphoma radiotherapy was performed, using the patient's coronary CT angiography (CCTA), and the relationship between the coronary arteries' radiation doses and the risk of stenosis was estimated. MATERIALS AND METHODS: Radiotherapy simulation CT scans and CCTAs of patients treated for a mediastinal Hodgkin lymphoma were used to merge thoracic and detailed cardiovascular anatomies. Radiation treatment parameters were used to estimate CA radiation doses. Twenty-one patients without coronary stenosis (controls) were matched with twelve patients with stenosis (cases). CA segments were considered as sub-volumes of interest. Radiation doses to stenotic segments were compared with those received by normal segments (from cases and controls) using a logistic regression. RESULTS: In eleven cases out of twelve, the highest of the coronary dose distribution was on a damaged segment. Logistic regression with CA segments yielded an odds ratio associated with the risk of coronary stenosis of 1.049 per additional gray with the CA segment median dose (95% confidence interval, 1.004-1.095; p-value <0.05). CONCLUSION: The CA segment dose significantly increased the risk of stenosis on the segment. Such personalized CA dose calculations on larger cohorts are expected to improve the understanding of the cardiovascular radiation dose-effect relationship.

Exposure of the French paediatric population to ionising radiation from diagnostic medical procedures in 2010.

BACKGROUND: Medical examination is the main source of artificial radiation exposure. Because children present an increased sensitivity to ionising radiation, radiology practices at a national level in paediatrics should be monitored. OBJECTIVE: This study describes the ionising radiation exposure from diagnostic medical examinations of the French paediatric population in 2010. MATERIALS AND METHODS: Data on frequency of examinations were provided by the French National Health Insurance through a representative sample including 107,627 children ages 0-15 years. Effective doses for each type of procedure were obtained from the published French literature. Median and mean effective doses were calculated for the studied population. RESULTS: About a third of the children were exposed to at least one examination using ionising radiation in 2010. Conventional radiology, dental exams, CT scans and nuclear medicine and interventional radiology represent respectively 55.3%, 42.3%, 2.1% and 0.3% of the procedures. Children 10-15 years old and babies from birth to 1 year are the most exposed populations, with respectively 1,098 and 734 examinations per 1,000 children per year. Before 1 year of age, chest and pelvis radiographs are the most common imaging tests, 54% and 32%, respectively. Only 1% of the studied population is exposed to CT scan, with 62% of these children exposed to a head-and-neck procedure. The annual median and mean effective doses were respectively 0.03 mSv and 0.7 mSv for the exposed children. CONCLUSION: This study gives updated reference data on French paediatric exposure to medical ionising radiation that can be used for public health or epidemiological purposes. Paediatric diagnostic use appears much lower than that of the whole French population as estimated in a previous study.

Dependence of coronary 3-dimensional dose maps on coronary topologies and beam set in breast radiation therapy: a study based on CT angiographies.

PURPOSE: In left-side breast radiation therapy (RT), doses to the left main (LM) and left anterior descending (LAD) coronary arteries are usually assessed after delineation by prior anatomic knowledge on the treatment planning computed tomography (CT) scan. In this study, dose sensitivity due to interindividual coronary topology variation was assessed, and hot spots were located. METHODS AND MATERIALS: Twenty-two detailed heart models, created from heart computed tomography angiographies, were fitted into a single representative female thorax. Two breast RT protocols were then simulated into a treatment planning system: the first protocol comprised tangential and tumoral bed beams (TGs_TB) at 50 + 16 Gy, the second protocol added internal mammary chain beams at 50 Gy to TGs_TB (TGs_TB_IMC). For the heart, the LAD, and the LM, several dose indicators were calculated: dose-volume histograms, mean dose (Dmean), minimal dose received by the most irradiated 2% of the volume (D2%), and 3-dimensional (3D) dose maps. Variations of these indicators with anatomies were studied. RESULTS: For the LM, the intermodel dispersion of Dmean and D2% was 10% and 11%, respectively, with TGs_TB and 40% and 80%, respectively, with TGs_TB_IMC. For the LAD, these dispersions were 19% (Dmean) and 49% (D2%) with TGs_TB and 35% (Dmean) and 76% (D2%) with TGs_TB_IMC. The 3D dose maps revealed that the internal mammary chain beams induced hot spots between 20 and 30 Gy on the LM and the proximal LAD for some coronary topologies. Without IMC beams, hot spots between 5 and 26 Gy are located on the middle and distal LAD. CONCLUSIONS: Coronary dose distributions with hot spot location and dose level can change significantly depending on coronary topology, as highlighted by 3D coronary dose maps. In clinical practice, coronary imaging may be required for a relevant coronary dose assessment, especially in cases of internal mammary chain irradiation.

Predicted cancer risks induced by computed tomography examinations during childhood, by a quantitative risk assessment approach.

The potential adverse effects associated with exposure to ionizing radiation from computed tomography (CT) in pediatrics must be characterized in relation to their expected clinical benefits. Additional epidemiological data are, however, still awaited for providing a lifelong overview of potential cancer risks. This paper gives predictions of potential lifetime risks of cancer incidence that would be induced by CT examinations during childhood in French routine practices in pediatrics. Organ doses were estimated from standard radiological protocols in 15 hospitals. Excess risks of leukemia, brain/central nervous system, breast and thyroid cancers were predicted from dose-response models estimated in the Japanese atomic bomb survivors' dataset and studies of medical exposures. Uncertainty in predictions was quantified using Monte Carlo simulations. This approach predicts that 100,000 skull/brain scans in 5-year-old children would result in eight (90 % uncertainty interval (UI) 1-55) brain/CNS cancers and four (90 % UI 1-14) cases of leukemia and that 100,000 chest scans would lead to 31 (90 % UI 9-101) thyroid cancers, 55 (90 % UI 20-158) breast cancers, and one (90 % UI <0.1-4) leukemia case (all in excess of risks without exposure). Compared to background risks, radiation-induced risks would be low for individuals throughout life, but relative risks would be highest in the first decades of life. Heterogeneity in the radiological protocols across the hospitals implies that 5-10 % of CT examinations would be related to risks 1.4-3.6 times higher than those for the median doses. Overall excess relative risks in exposed populations would be 1-10 % depending on the site of cancer and the duration of follow-up. The results emphasize the potential risks of cancer specifically from standard CT examinations in pediatrics and underline the necessity of optimization of radiological protocols.

Risk of cancer associated with cardiac catheterization procedures during childhood: a cohort study in France.

BACKGROUND: Radiation can be used effectively for diagnosis and medical treatment, but it can also cause cancers later on. Children with congenital heart disease frequently undergo cardiac catheterization procedures for diagnostic or treatment purposes. Despite the clear clinical benefit to the patient, the complexity of these procedures may result in high cumulative radiation exposure. Given children's greater sensitivity to radiation and the longer life span during which radiation health effects can develop, an epidemiological cohort study is being launched in France to evaluate the risks of leukaemia and solid cancers in this specific population. METHODS/DESIGN: The study population will include all children who have undergone at least one cardiac catheterization procedure since 2000 and were under 10 years old and permanent residents of France at the time of the procedure. Electronically stored patient records from the departments of paediatric cardiology of the French national network for complex congenital heart diseases (M3C) are being searched to identify the children to be included. The minimum dataset will comprise: identification of the subject (file number in the centre or department, full name, sex, date and place of birth), and characteristics of the intervention (date, underlying disease, type of procedure, technical details, such as fluoroscopy time and dose area product, (DAP), which are needed to reconstruct the doses received by each child). The cohort will be followed up through linkage with the two French paediatric cancer registries, which have recorded all cases of childhood leukaemia and solid cancers in France since 1990 and 2000, respectively. Radiation exposure will be estimated retrospectively for each child. 4500 children with catherizations between 2000 and 2011 have been already included in the cohort, and recruitment is ongoing at the national level. The study is expected to finally include a total of 8000 children. DISCUSSION: This French cohort study is specifically designed to provide further knowledge about the potential cancer risks associated with paediatric cardiac catheterization procedures. It will also provide new information on typical dose levels associated with these procedures in France. Finally, it should help improve awareness of the importance of radiation protection in these procedures.

Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis.

BACKGROUND: In rectal surgery, some situations can be critical, such as anterior topography of locally advanced low tumors with a positive predictive radial margin, especially in a narrow pelvis of men who are obese. Transanal proctectomy is a new laparoscopic technique that uses the transanal endoscopic microsurgery device. OBJECTIVE: The aim of this study is to evaluate the technical feasibility of laparoscopic transanal proctectomy in patients with unfavorable features. DESIGN AND PATIENTS: This is a single-center, prospective analysis of selected patients with rectal cancer operated on from January 2009 to June 2011. MAIN OUTCOME MEASURES: Intraoperative details and short-term postoperative outcome were described. RESULTS: Thirty men with advanced or recurrent low rectal tumors associated with unfavorable anatomical and/or tumor characteristics underwent a sphincter-sparing transanal endoscopic proctectomy. Twenty-nine patients had received preoperative treatment. We report a 6% conversion rate, no postoperative mortality, and a 30% morbidity rate. At the beginning of our experience, a urethral injury was diagnosed in 2 patients and easily sutured intraoperatively, without postoperative after-effect. The mesorectal resection was graded as "good" in all patients. R0 resection was achieved in 26 patients (87%). The short-term stoma closure rate was 85%. After a median follow-up of 21 months, 4 patients experienced locoregional recurrence alone. Overall survival rates at 12 and 24 months were 96.6% (95% CI, 78.0-99.5) and 80.5% (95% CI, 53.0-92.9). Relapse-free survival rates at 12 and 24 months were 93.3% (95% CI, 75.9-98.3) and 88.9% (95% CI, 69.0-96.3). LIMITATIONS: Although the transanal endoscopic proctectomy was performed by trained surgeons, we report a slight increase in early postoperative morbidity and relatively poor early outcome. There was a clear selection bias related to the study cohort exclusively composed of high-risk patients, but we need to be cautious before generalizing this technique. CONCLUSION: The transanal endoscopic proctectomy is a feasible alternative surgical option to conventional laparoscopy for radical rectal resection in selected cases with unfavorable characteristics. Further investigations with larger cohorts are required to validate its safety and to clarify its best indication.

Characterization of MOSFET detectors for in vivo dosimetry in interventional radiology and for dose reconstruction in case of overexposure.

As MOSFET (Metal Oxide Semiconductor Field Effect Transistor) detectors allow dose measurements in real time, the interest in these dosimeters is growing. The aim of this study was to investigate the dosimetric properties of commercially available TN-502RD-H MOSFET silicon detectors (Best Medical Canada, Ottawa, Canada) in order to use them for in vivo dosimetry in interventional radiology and for dose reconstruction in case of overexposure. Reproducibility of the measurements, dose rate dependence, and dose response of the MOSFET detectors have been studied with a Co source. Influence of the dose rate, frequency, and pulse duration on MOSFET responses has also been studied in pulsed x-ray fields. Finally, in order to validate the integrated dose given by MOSFET detectors, MOSFETs and TLDs (LiF:Mg,Cu,P) were fixed on an Alderson-Rando phantom in the conditions of an interventional neuroradiology procedure, and their responses have been compared. The results of this study show the suitability of MOSFET detectors for in vivo dosimetry in interventional radiology and for dose reconstruction in case of accident, provided a well-corrected energy dependence, a pulse duration equal to or higher than 10 ms, and an optimized contact between the detector and the skin of the patient are achieved.

Potential of hybrid computational phantoms for retrospective heart dosimetry after breast radiation therapy: a feasibility study.

PURPOSE: Current retrospective cardiovascular dosimetry studies are based on a representative patient or simple mathematic phantoms. Here, a process of patient modeling was developed to personalize the anatomy of the thorax and to include a heart model with coronary arteries. METHODS AND MATERIALS: The patient models were hybrid computational phantoms (HCPs) with an inserted detailed heart model. A computed tomography (CT) acquisition (pseudo-CT) was derived from HCP and imported into a treatment planning system where treatment conditions were reproduced. Six current patients were selected: 3 were modeled from their CT images (A patients) and the others were modelled from 2 orthogonal radiographs (B patients). The method performance and limitation were investigated by quantitative comparison between the initial CT and the pseudo-CT, namely, the morphology and the dose calculation were compared. For the B patients, a comparison with 2 kinds of representative patients was also conducted. Finally, dose assessment was focused on the whole coronary artery tree and the left anterior descending coronary. RESULTS: When 3-dimensional anatomic information was available, the dose calculations performed on the initial CT and the pseudo-CT were in good agreement. For the B patients, comparison of doses derived from HCP and representative patients showed that the HCP doses were either better or equivalent. In the left breast radiation therapy context and for the studied cases, coronary mean doses were at least 5-fold higher than heart mean doses. CONCLUSIONS: For retrospective dose studies, it is suggested that HCP offers a better surrogate, in terms of dose accuracy, than representative patients. The use of a detailed heart model eliminates the problem of identifying the coronaries on the patient's CT.

Results of two bi-institutional prospective studies using intraperitoneal oxaliplatin with or without irinotecan during HIPEC after cytoreductive surgery for colorectal carcinomatosis.

OBJECTIVE: To assess the perioperative and long-term results of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) using oxaliplatin+irinotecan (ox-irino) versus oxaliplatin alone (ox-alone). BACKGROUND: Treatment of peritoneal carcinomatosis (PC) of colorectal origin with CRS+HIPEC using mitomycin-C or oxaliplatin monotherapy has shown encouraging survival results. This bi-centric study evaluates an intensified intraperitoneal combination of ox-irino and compares it with ox-alone. PATIENTS AND METHODS: All consecutive patients with PC undergoing CRS+HIPEC using either ox-alone or ox-irino between 1998 and 2007 were evaluated. RESULTS: One hundred forty-six patients underwent CRS+HIPEC for PC, 103 received ox-irino and 43 received ox-alone. The median peritoneal carcinomatosis index (PCI) was 11 in both groups. 90.4% had complete cytoreduction. Overall mortality rate was 4.1%. The overall morbidity rate was 47.2% and was significantly lower with ox-alone (34.9% vs. 52.4%, P = 0.05). After a median follow-up of 48.5 months, the median overall survival (OS) was 41 months (95% CI, 32-60) and median relapse-free survival (RFS) was 15.7 months (95% CI, 12-18). The median RFS of ox-alone (16.8 months; 95% CI, 11-25) was not significantly different from ox-irino (15.7 months; 95% CI, 11-18; P = 0.93). There was no significant difference between median OS of ox-alone (40.83 months; 95% CI, 29-61) and ox-irino (47 months; 95% CI, 32-61; P = 0.94). At 5 years, OS and RFS rates were 41.8% and 13.8% in ox-alone and 42.4% and 14.2% in ox-irino, respectively. Prognostic factors confirmed on multivariate analysis were lymph node metastasis and PCI. CONCLUSION: Our study showed no advantage of intensification of HIPEC by adding irinotecan, contrary to the results obtained with IV combination. Ox-alone HIPEC should continue as one of the standard HIPEC regimens for PC.

Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial.

PURPOSE: After curative resection, the prognosis of gastroesophageal adenocarcinoma is poor. This phase III trial was designed to evaluate the benefit in overall survival (OS) of perioperative fluorouracil plus cisplatin in resectable gastroesophageal adenocarcinoma. PATIENTS AND METHODS: Overall, 224 patients with resectable adenocarcinoma of the lower esophagus, gastroesophageal junction (GEJ), or stomach were randomly assigned to either perioperative chemotherapy and surgery (CS group; n = 113) or surgery alone (S group; n = 111). Chemotherapy consisted of two or three preoperative cycles of intravenous cisplatin (100 mg/m(2)) on day 1, and a continuous intravenous infusion of fluorouracil (800 mg/m(2)/d) for 5 consecutive days (days 1 to 5) every 28 days and three or four postoperative cycles of the same regimen. The primary end point was OS. RESULTS: Compared with the S group, the CS group had a better OS (5-year rate 38% v 24%; hazard ratio [HR] for death: 0.69; 95% CI, 0.50 to 0.95; P = .02); and a better disease-free survival (5-year rate: 34% v 19%; HR, 0.65; 95% CI, 0.48 to 0.89; P = .003). In the multivariable analysis, the favorable prognostic factors for survival were perioperative chemotherapy (P = .01) and stomach tumor localization (P < .01). Perioperative chemotherapy significantly improved the curative resection rate (84% v 73%; P = .04). Grade 3 to 4 toxicity occurred in 38% of CS patients (mainly neutropenia) but postoperative morbidity was similar in the two groups. CONCLUSION: In patients with resectable adenocarcinoma of the lower esophagus, GEJ, or stomach, perioperative chemotherapy using fluorouracil plus cisplatin significantly increased the curative resection rate, disease-free survival, and OS.

Intra-operative radiotherapy of rectal cancer: results of the French multi-institutional randomized study.

PURPOSE: To assess efficacy and tolerance of intra-operative radiation therapy (IORT) in patients suffering from locally advanced rectal cancer, treated with preoperative radiotherapy followed by surgical resection. METHODS AND MATERIALS: In this French, multicenter, comparative, phase III study, 142 patients with locally advanced rectal cancer (T3 or T4 or N+, and M0), treated with a 4-week preoperative radiotherapy (40 grays) were randomly assigned to either surgical resection alone ( CONTROL GROUP: n=69) or combined to 18-gray intra-operative radiation therapy (IORT group: n=73) between 1993 and 2001. RESULTS: The 5-year cumulative incidence of local control was 91.8% with IORT and 92.8% with surgery alone (p=0.6018); the mean duration without local relapse (Kaplan-Meier method) was 107 versus 126 months, respectively. No statistically significant difference was demonstrated for overall survival (p=0.2578) disease-free survival (p=0.7808) and probability of metastatic relapse (p=0.6037) with 5-year cumulative incidences of 69.8% versus 74.8%, 63.7% versus 63.1%, and 26.1% versus 30.2%, respectively. 48 patients of the IORT group and 53 patients of the control group were alive with a median follow-up of 60.1 and 61.2 months, respectively. Post-operative complications were observed in the IORT group in 21 patients (29.6%) and in the control group in 13 patients (19.1%) (p=0.15), with an acceptable tolerance profile. CONCLUSIONS: Although this randomized study did not demonstrate any significant improvement in local control and disease-free survival in rectal cancer patients treated with preoperative radiation therapy receiving IORT or not, it confirmed the technical feasibility and the necessity for evaluating IORT for rectal carcinoma in further clinical studies.

Uterine artery embolization for leiomyomata: optimization of the radiation dose to the patient using a flat-panel detector angiographic suite.

The purpose of this study was to assess the ability of low-dose/low-frame fluoroscopy/angiography with a flat-panel detector angiographic suite to reduce the dose delivered to patients during uterine fibroid embolization (UFE). A two-step prospective dosimetric study was conducted, with a flat-panel detector angiography suite (Siemens Axiom Artis) integrating automatic exposure control (AEC), during 20 consecutive UFEs. Patient dosimetry was performed using calibrated thermoluminescent dosimeters placed on the lower posterior pelvis skin. The first step (10 patients; group A) consisted in UFE (bilateral embolization, calibrated microspheres) performed using the following parameters: standard fluoroscopy (15 pulses/s) and angiography (3 frames/s). The second step (next consecutive 10 patients; group B) used low-dose/low-frame fluoroscopy (7.5 pulses/s for catheterization and 3 pulses/s for embolization) and angiography (1 frame/s). We also recorded the total dose-area product (DAP) delivered to the patient and the fluoroscopy time as reported by the manufacturer's dosimetry report. The mean peak skin dose decreased from 2.4 +/- 1.3 to 0.4 +/- 0.3 Gy (P = 0.001) for groups A and B, respectively. The DAP values decreased from 43,113 +/- 27,207 microGy m(2) for group A to 9,515 +/- 4,520 microGy m(2) for group B (P = 0.003). The dose to ovaries and uterus decreased from 378 +/- 238 mGy (group A) to 83 +/- 41 mGy (group B) and from 388 +/- 246 mGy (group A) to 85 +/- 39 mGy (group B), respectively. Effective doses decreased from 112 +/- 71 mSv (group A) to 24 +/- 12 mSv (group B) (P = 0.003). In conclusion, the use of low-dose/low-frame fluoroscopy/angiography, based on a good understanding of the AEC system and also on the technique during uterine fibroid embolization, allows a significant decrease in the dose exposure to the patient.

Intraoperative radiotherapy in early-stage breast cancer: results of the montpellier phase II trial.

PURPOSE: We recently presented the intraoperative radiotherapy (IORT) technique given as a reliable alternative to conventional boost radiation after breast-conserving surgery. The low crude numbers of recurrence in elderly patients led us to investigate the feasibility and the efficacy of this procedure as a sole treatment. METHODS AND MATERIALS: We included 94 patients older than 65 years in this phase II trial. Among them, 42 patients presented with all the inclusion criteria, i.e., stages pT0 to pT1 and pN0, ductal invasive unifocal carcinoma, and tumor-free margin of >2 mm. IORT was delivered using a dedicated linear accelerator. One 21-Gy fraction was prescribed and specified at the 90% isodose, using electrons. In vivo dosimetry was performed for all patients. The primary endpoint was the quality index. Secondary endpoints were quality of life, local recurrences, cosmetic results, and specific and overall rates of survival. RESULTS: The median follow-up was 30 months (range, 12-49 months), and median age was 72 years (range, 66-80 years). The median tumor diameter was 10 mm. All patients received the total prescribed dose. No acute grade 3 toxicities were observed. Endpoints for all but one patient corresponded to acceptable quality index criteria. Pretreatment quality-of-life scores were maximal, and no significant decrease was observed during follow-up. Cosmesis was good to excellent at 6 months. Two patients experienced recurrence but underwent salvage mastectomy. CONCLUSION: Our results confirm that exclusive partial-breast IORT is feasible for treating early-stage breast cancer in the elderly. IORT may be considered an alternative treatment for a selected population and offers a safe one-step treatment.

Volumetria hepática computadorizada como método de avaliação e acompanhamento da regeneração hepática após hepatectomia parcial em suínos / Computerized liver volume for evaluation and following liver regeneration after partial hepatectomy in swines

OBJETIVO: O estudo analisou a volumetria hepática por tomografia axial computadorizada, através de um programa informatizado semi-automático de aquisição e processamento de imagens digitalizadas, como parâmetro de acompanhamento da regeneração hepática em suínos, após hepatectomia parcial. MÉTODO: Doze suínos fêmeas, da raça Landrace, jovens, foram distribuídos em 3 grupos, conforme tempo de observação após o procedimento cirúrgico: 5(G5), 10(10) ou 15(G15) dias. Todos foram submetidos à hepatectomia parcial e, posteriormente, após acompanhamento, sacrificados, procedendo-se a retirada do fígado regenerado. A peça da hepatectomia e o fígado regenerado foram pesados e submetidos à realização da tomografia e aferição do volume através do software HEPATO®. Para análise estatística foram utilizados os testes não-paramétricos de Kruskal-Wallis e Wilcoxon. Valores de p<0,05 indicaram significância estatística. RESULTADOS: O peso do fígado regenerado foi de: G5=434,5g, G10=449,25g e G15=486,5 g), p=0,592. A regeneração hepática a partir do peso do fígado foi de 83,58 por cento (G5), 94,95 por cento (G10) e 101,63 por cento (G15), p=0,197. O volume do fígado regenerado foi de 403,58 cm² (G5), 450,88 cm² (G10) e 458,93 cm² (G15), p=0,941. A regeneração hepática a partir do volume do fígado foi de 74,25 por cento (G5), 88 por cento (G10) e 100 por cento (G15), p=0,326. Não houve diferença estatística significativa entre os parâmetros. CONCLUSÃO: A avaliação volumétrica por tomografia computadorizada, utilizando um programa informatizado semi-automático de aquisição e processamento de imagens digitalizadas, é método fidedigno para avaliação e acompanhamento da regeneração hepática em suínos, após hepatectomia parcial.

OBJECTIVES: To analyze the hepatic volume by computerized tomography using a semiautomatic computerized program of acquisition and processing digitalized images, to follow the hepatic regeneration in swine after partial hepatectomy. METHODS: Twelve female young Landrace swine were separated in three groups according to the observation time between hepatectomy and sacrifice: G5 (5 days), G10 (10 days) and G15 (15 days). All animals were submitted to partial hepatectomy of the right lobe and followed until sacrifice, when regenerated liver was ressected. The surgical piece and the regenerated liver were weighted and submitted to tomographic volume evaluation by the software HEPATO®, taking place acquisition and analysis of the tomography images in a semiautomatic way. Statistical analysis used the non-parametric Kruskal-Wallis and Wilcoxon tests. RESULTS: Medium weigh of regenerated liver was G5=434,5 g, G10=449,25g and G15=486,5 g (p=0,592). The regeneration index obtained using liver weight was 83,58 percent (G5), 94,95 percent (G10) and 101,63 percent (G15) (p=0,197). Medium volume of regenerated liver was G5=403,58 cm², G10=450,88 cm² and G15=458,93 cm² (p=0,941). Liver regeneration index obtained using liver volume was 74,25 percent (G5), 88 percent (G10) and 100 percent (G15) (p=0,326). Liver regeneration index was not different when assessed using liver weigh or liver volume. CONCLUSION: The liver volumetric evaluation by computerized tomography using a computerized semiautomatic program of digitalized images acquisition and processing is a trustworthy method for evaluation and following the liver regeneration in swine after partial hepatectomy.

Adjuvant radioimmunotherapy trial with iodine-131-labeled anti-carcinoembryonic antigen monoclonal antibody F6 F(ab')2 after resection of liver metastases from colorectal cancer.

PURPOSE: To evaluate the feasibility of radioimmunotherapy (RIT) with radiolabeled anti-carcinoembryonic antigen antibodies after complete resection of liver metastases (LM) from colorectal cancer. PATIENTS AND METHODS: Twenty-two patients planned for surgery of one to four LM received a preoperative diagnostic dose of a 131I-F(ab')2-labeled anti-carcinoembryonic antigen monoclonal antibody F6 (8-10 mCi/5 mg). 131I-F(ab')2 uptake was analyzed using direct radioactivity counting, and tumor-to-normal liver ratios were recorded. Ten patients with tumor-to-normal liver ratios of >5 and three others were treated with a therapeutic injection [180-200 mCi 131I/50 mg F(ab')2] 30 to 64 days after surgery. RESULTS: Median 131I-F(ab')2 immunoreactivity in patient serum remained at 91% of initial values for up to 96 hours after injection. The main and dose-limiting-toxicity was hematologic, with 92% and 85% grades 3 to 4 neutropenia and thrombocytopenia, respectively. Complete spontaneous recovery occurred in all patients. No human anti-mouse antibody response was observed after the diagnosis dose; however, 10 of the 13 treated patients developed human anti-mouse antibody approximately 3 months later. Two treated patients presented extrahepatic metastases at the time of RIT (one bone and one abdominal node) and two relapsed within 3 months of RIT (one in the lung and the other in the liver). Two patients are still alive, and one of these is disease-free at 93 months after resection. At a median follow-up of 127 months, the median disease-free survival is 12 months and the median overall survival is 50 months. CONCLUSION: RIT is feasible in an adjuvant setting after complete resection of LM from colorectal cancer and should be considered for future trials, possibly in combination with chemotherapy, because of the generally poor prognosis of these patients.

[Positive sentinel node biopsy in breast cancer: is axillary surgery necessary in all cases?]. / Biopsie du ganglion sentinelle positive dans le cancer du sein: place du curage axillaire de complément?

Our retrospective study analyzes various factors to evaluate the risk of invasion of the not sentinel node when the sentinel node biopsy is positive in the infiltrated breast cancers. We compared in single varied then multivaried analysis, various parameters between two groups: positive not sentinel nodes and negative not sentinel nodes among 180 cases of positive sentinel node biopsy between 2001 and 2004. At the time of the single varied analysis, seem to be risk factors of non sentinel node involvement: the histopronostic SBRIII rank, positive a HER2neu status, the presence of extracapsulal node extension and infiltration of the sentinel node by a macrometastasis. The tumoral embol, the absence of hormonal receivers, a tumoral size > 10 mm and the number of sentinel node taken appear at the limit of the significativity. In multivaried analysis, SBRIII rank and the presence of an extracapsular node extension remain related to non sentinel node involvement. The histological type, association with a CIS, the size of the sentinel nodes, the number of positive sentinel nodes and the year of surgery are nonsignificant. Additional axillairy clearing out at the time of a positive node sentinel biopsy should be discussed according to different criteria determined by a precise histological analysis.

Intraoperative radiotherapy given as a boost for early breast cancer: long-term clinical and cosmetic results.

PURPOSE: The standard radiotherapy (RT) of breast cancer consists of 50 Gy external beam RT (EBRT) to the whole breast followed by an electron boost of 10-16 Gy to the tumor bed, but this has several cosmetic disadvantages. Intraoperative radiotherapy (IORT) could be an alternative to overcome these. METHODS AND MATERIALS: We evaluated 50 women with early breast cancer operated on in a dedicated IORT facility. Median dose of 10 Gy was delivered using 9-MeV electron beams. All patients received postoperative EBRT (50 Gy in 2 Gy fractions). Late toxicity and cosmetic results were assessed independently by two physicians according to the Common Terminology Criteria for Adverse Event v3.0 grading system and the European Organization for Research and Treatment of Cancer questionnaires. RESULTS: After a median follow-up of 9.1 years (range, 5-15 years), two local recurrences were observed within the primary tumor bed. At the time of analysis, 45 patients are alive with (n = 1) or without disease. Among the 42 disease-free remaining patients, 6 experienced Grade 2 late subcutaneous fibrosis within the boost area. Overall, the scores indicated a very good quality of life and cosmesis was good to excellent in the evaluated patients. CONCLUSION: Our results confirm that IORT given as a boost after breast-conserving surgery is a reliable alternative to conventional postoperative fractionated boost radiation.

Surgery for esophageal cancer after concomitant radiochemotherapy: oncologic and functional results.

The aim of this study was to evaluate the results of surgery after preoperative radiochemotherapy (PRCT) for esophageal cancer. This retrospective study included 88 patients scan between 1992 and 2000. The median follow-up was 55.7 months (3.3-104.1 months). Surgical mortality was 15.9%. Multivariate analysis found that the following were risk factors for surgical mortality: gamma-glutamyltransferase level > 75 UI/ml (p = 0.007), weight loss = 10% (p = 0.05), and digestive toxicity World Health Organization grade III or IV during PRCT (p = 0.019). The median overall survival was 24.9 months. The 5-year overall survival (OS) and disease-free survival (DFS) were, respectively, 33.1% and 33.2%. Complete responder patients had a 71.8% 5-year OS (p = 0.01) and a 71.8% 5-year DFS (p = 0.009). The rate of recurrence was 37.5%. Multivariate analysis found that female gender (p = 0.03), weight loss = 10% (p = 0.03), preoperative computed tomography scan bronchial contact (p = 0.01), and N+ status (pN+) at pathology examination (p = 0.0001) were predictors of poor oncologic results. Patients with high preoperative risk of surgical mortality need to be selected for intensive perioperative management. In association with surgery, PRCT improves the local control, DFS, and OS of responder patients. Morphologic evaluation for staging esophageal cancer in predicting the pathologic response after PRCT is poor or controversial. Only surgical resection can provide accurate prognostic information for staging esophageal cancer and improving local control.

Histomorphometric evaluation of (198)Au endovascular brachytherapy in a renal artery restenosis model in rabbits.

OBJECTIVE: The main mid-term complication of percutaneous transluminal angioplasty of the renal artery is restenosis, which occurs in up to 50% of patients. Although no pharmacologic agent to date has been effective in preventing restenosis, both beta-ray emitters and gamma-ray emitters used in endovascular brachytherapy have been shown to reduce coronary restenosis. The objectives of this study were to evaluate the efficacy of (198)Au endovascular brachytherapy in preventing restenosis after percutaneous transluminal renal angioplasty and to determine the radiation dose to the operator. MATERIALS AND METHODS: Twenty-one New Zealand white rabbits (10 females and 11 males) weighing an average of 3.5 kg (range, 3.2-3.8 kg) who had been fed a normal diet underwent bilateral 33% overdilatation with deendothelialization of the renal arteries. After 7 weeks, the induced renal artery stenoses were treated by percutaneous transluminal renal angioplasty. The rabbits were randomly assigned to one of three groups before receiving endovascular 25-Gy irradiation at a radial 2.0-mm depth with a 0.5 x 15 mm (198)Au wire (106 MBq). The right renal artery was irradiated in group A; the left, in group B. The rabbits in group C randomly received a right- or left-sided dummy wire. Operator exposure to radiation was measured using thermoluminescent dosimeters and ionization chambers. The rabbits were sacrificed after 3 weeks. The aorta and renal arteries were perfusion-fixed. The renal arteries were removed for histologic and histomorphometric study. RESULTS: Forty-two renal arteries were cut into a series of 4- micro m-thick slices. Five arteries were thrombosed (two in the irradiated group and three in the control group, p > 0.05). In the patent arteries (n = 37), the average neointimal area was 0.068 mm(2) (range, 0.009-0.234 mm(2)) in 15 irradiated segments (315 slices total), whereas the average neointimal area was 0.135 mm(2) (range, 0.016-0.324 mm(2)) in 22 control segments (462 slices total) (analysis of variance, p < 0.009), showing a percentage area of restenosis of 10.4% in irradiated arteries and 43.4% in non-irradiated arteries (p < 0.0003). Radiation dose per procedure to the operator was 0.034 mSv in the index finger, 0.024 mSv in the wrist, and undectable in the body. CONCLUSION: Endovascular brachytherapy with (198)Au appears to inhibit early renal artery restenosis and exposes the operator to a safe level of radiation.

Restorative and nonrestorative surgery for low rectal cancer after high-dose radiation: long-term oncologic and functional results.

PURPOSE: This prospective, nonrandomized study evaluates, with a seven-year median follow-up, the morbidity and the functional and oncologic results of conservative surgery after high-dose radiation for cancer of the lower third of the rectum of patients who would otherwise have undergone abdominoperineal resection. METHODS: Between June 1990 and June 1996, 43 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 50 (range, 25-60) mm, and none of the tumors was fixed (15 percent T2N0, 53 percent T3N0, 32 percent T3N1). RESULTS: Postoperative mortality (2 percent) and morbidity (35 percent) were not increased by high-dose preoperative radiation. Conservative surgery was done in 30 patients (70 percent: 26 coloanal anastomoses and 4 low stapled anastomoses). After conservative surgery, long-term functional results showed 30 percent complete continence and 20 percent serious incontinence. Four patients had local recurrence as first development (13 percent). The seven-year overall survival rate was 53 percent, 62 percent after conservative surgery and 31 percent after abdominoperineal resection. The univariate analysis underscores the tumor response impact on long-term survival (pT<3 = 81 percent; pT3 = 35 percent; P = 0.0008). CONCLUSIONS: These long-term results confirm the feasibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective multicentric trial began in France in June 1996 to evaluate the reproducibility of these results.