Trimodality therapy for esophageal cancer: The role of surgical and radiation treatment parameters in the development of anastomotic complications.

BACKGROUND: Here, we investigated the relationship between clinical parameters, including the site of surgical anastomosis and radiation dose to the anastomotic region, and anastomotic complications in esophageal cancer patients treated with trimodality therapy. METHODS: Between 2007 and 2016, esophageal cancer patients treated with trimodality therapy at a tertiary academic cancer center were identified. Patient, treatment, and outcome parameters were collected. Radiation dose to the gastric regions were extracted. Anastomotic complication was defined as leak and/or stricture. We used Fisher's exact and Wilcoxon rank-sum tests to compare the association between clinical parameters and anastomotic complications. RESULTS: Of 89 patients identified, the median age was 63 years, 82% (n = 73) were male, and 82% had distal (n = 47) or gastroesophageal junction (n = 26) tumors. Median follow-up was 25.8 months. Esophagectomies were performed with cervical (65%, n = 58) or thoracic anastomoses (35%, n = 31). Anastomotic complications developed in 60% (n = 53). Cervical anastomosis was associated with anastomotic complications (83%, n = 44/53, p < 0.01). Radiation to any gastric substructure was not associated with anastomotic complications (p > 0.05). In the subset of patients with distal/gastroesophageal junction tumors undergoing esophagectomy with cervical anastomosis where radiation was delivered to the future neoesophagus, 80% (n = 35/44) developed anastomotic complications. In this high-risk subgroup, radiation was not associated with anastomotic complications (p > 0.05). CONCLUSIONS: Our analysis did not demonstrate an association between radiation dose to gastric substructures and anastomotic complications. However, it showed an association between esophagectomy with cervical anastomosis and anastomotic complications. Patients with distal/gastroesophageal junction tumors who undergo esophagectomy with cervical anastomosis have higher rates of anastomotic complications unrelated to radiation to gastric substructures.

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review.

PURPOSE OF REVIEW: Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease. RECENT FINDINGS: Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.

Radiologic response of chemotherapy alone versus radiation and chemotherapy in the treatment of locally-advanced or advanced thymic epithelial tumors.

BACKGROUND: Here, we investigated radiological responses following chemotherapy alone as compared to both radiation/chemotherapy (chemoRT) in patients with thymic epithelial tumors (TETs) who did not receive upfront surgery. METHODS: TETs treated at a tertiary academic cancer center between January 2007 and July 2018 were identified. Patients received chemotherapy or chemoRT as initial therapy and pre- and post-treatment scans were available. Student's t-test, Wilcoxon rank-sum tests, and Cox proportional hazards method were used to compare clinical details and survival between groups. The primary outcome was change in tumor size, which was compared between groups using linear mixed-effects regression models, adjusting for baseline tumor size, age, and histology. RESULTS: A total of 24 of 114 patients with TETs identified met the inclusion criteria. The majority of patients had 67% thymoma (67%, n = 16) and AJCC8 III-IVA disease (58%, n = 14). Median age was 58.5 years (range: 33-76), median initial tumor volume was 187.1 cc (range: 28.7-653.6) and diameter was 8.5 cm (range: 4.5-14.3). Half of the patients received upfront chemotherapy (n = 12: 83% cisplatin/adriamycin/cyclophosphamide) or chemoRT (n = 12: 58% carboplatin/paclitaxel; median RT dose: 63 Gy [range: 60-70 Gy]). At a median imaging follow-up of 15 months (range: 0-86): ChemoRT was associated with increased average radiological response compared to chemotherapy alone (volume: -47.0 cc more, P < 0.001; diameter: -0.8 cm more, P = 0.03). In eight patients who received chemotherapy, 33% saw further tumor shrinkage (median volume: -42.3%, P = 0.03; diameter: -3.0%, P = 0.049) with additional radiation/chemoradiation. Median survival increased for patients ultimately receiving surgery versus those who did not (46 month, range: 16-127 vs. 14 month, range: 6-82; P < 0.01). CONCLUSIONS: ChemoRT produced a greater radiologic response compared to chemotherapy alone in patients with TETs not suitable for upfront resection. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: We found that chemoRT was associated with a greater radiologic response compared to patients who received chemotherapy alone. WHAT THIS STUDY ADDS: What this study adds: In patients with TET not amenable to upfront resection, chemoRT may be a feasible strategy for cytoreduction.

Association Between Pain Scores and Successful Spinal Cord Stimulator Implantation.

INTRODUCTION: Determining reduction in pain score during spinal cord stimulation (SCS) trial is important prior to permanent SCS implantation. However, this association remains elusive. We investigate the association between post-SCS pain scores and successful permanent SCS implants. MATERIALS AND METHODS: This IRB-approved, retrospective study identified patients who underwent SCS trials and implantation. Predictive modeling with nonparametric regression and margins plot analysis was used to determine the threshold for post-SCS trial pain scores associated with successful permanent SCS implant (defined as >50% pain relief). Nonparametric sensitivity and specificity analysis was performed. p < 0.05 was considered significant. RESULTS: Eighty-eight patients with SCS trials were retrospectively identified (57.95% female, median age 52.5 ± 15.5 years). Of the total cohort, 79% had successful permanent SCS implantation. Post-SCS trial pain scores less than or equal to 4.9 had greater than 50% probability of a successful permanent SCS implant (97.14% sensitivity, 44.44% specificity, ROC = 0.71). Post-SCS trial pain scores between 4 and 7 were associated with a significantly higher probability of a successful SCS implant among patients without spine surgery compared with those with a history of spine surgery. Compared with males, females with pain scores between 5 and 7 had a higher probability of a successful SCS implant. CONCLUSION: Low pain scores after SCS trial are predictive of successful SCS implants with high sensitivity. Males and surgical patients with higher pain scores had a lower probability of successful SCS implant than their counterparts. Larger studies are needed to further elucidate this relationship.

Establishing a threshold for 131I bioassay in nuclear medicine personnel.

Since the late 1970's, manufacturers in nuclear medicine have reformulated the I solution to reduce the volatility of the iodine. There has also been an increase in use of the iodide in encapsulated form. Per the requirement of the current U.S. Nuclear Regulatory Commission (U.S. NRC) regulation, with the available results on the volatility of the reformulated radioiodine, we review the I bioassay program for nuclear medicine workers. Our analysis shows the threshold quantity for bioassay monitoring for the routine use of I in nuclear medicine is much higher than the criteria set in U.S. NRC Regulatory Guide 8.20. The latter is a broad bioassay guideline for the general usage of radioactive iodine. For treatment of thyroid carcinoma and hyperthyroidism, a single therapeutic I dose large enough to yield a detectable thyroid burden is very unlikely to occur in a nuclear medicine clinic. Accidental ingestion or inhalation would be an exception to our conclusion. Based on this analysis, we propose a new bioassay policy for the routine use of I in nuclear medicine clinics.

Dose indices of radiation to skin in fluoroscopically guided invasive cardiology procedures.

Tissue injury depends on the extent as well as the intensity of the assault. It would be helpful to develop skin dose indices that are more descriptive of the skin area receiving radiation above a threshold value of potential injury. For monitoring radiation exposure to patients, radiochromic film was placed close to the skin of a patient undergoing cardiac catheterization procedures. With the approval of the Institutional Review Board, films from 36 patients were scanned. Contours were drawn at the increment of 100 cGy in air kerma. Using each contour value as a threshold, the area exceeding this threshold and the average dose within this area were computed. For the four patients who had skin doses exceeding the 200 cGy threshold, the peak entrance doses have a range from 230 cGy to 409 cGy. However, these high radiation exposures were confined to limited skin areas and support the absence of any significant skin injury in these patients. The area exceeding a chosen threshold value and the average dose within the area circumscribed might therefore serve as helpful measures of the assault to the skin. This investigation has demonstrated the technical feasibility of providing such dose indices.

Skin entrance radiation dose in an interventional radiology procedure.

Monitoring of skin entrance radiation exposure in lengthy interventional procedures has been recommended because of the potential for skin injury. Fluoroscopy duration and dose-area product (DAP) are readily available real-time measurements. It would be of interest to study the correlation of these parameters and skin entrance radiation. Twenty neurological interventional procedures performed through the aortic arch were monitored. Two pieces of GafChromic XR Type R film were placed between the patient and the examination table. An observer recorded the fluoroscopy duration and DAP for each phase of the procedure. Each film was scanned post-procedure in RBG mode, and then the image was analyzed for peak skin entrance radiation dose (in air kerma). All DAP values were corrected according to a calibration with an ion chamber. With the DAP values for the respective phases of a procedure, the effective dose in a Reference Man was calculated. For these twenty cases, the means and standard deviations were 17.2+/-6.4 min for x ray on-time, 256+/-65 Gy cm (-2) for DAP, 94+/-34 cGy for peak skin entrance dose in air kerma, and 19.2+/-5.0 mSv for effective dose, respectively. The peak skin entrance dose was correlated to fluoroscopy duration, DAP, and effective dose with the r(2)-values of 0.48, 0.46, and 0.09, respectively. The correlation with DAP or fluoroscopy duration was not sufficiently strong to infer skin entrance dose from either of these parameters. Therefore, skin entrance dose should be determined directly.