Comparison of technical success and safety of transbronchial versus percutaneous CT-guided fiducial placement for SBRT of lung tumors.

OBJECTIVE: To evaluate the technical success and safety of transbronchial (bronchoscopic) fiducial placement compared to percutaneous CT-guided fiducial placement for stereotactic body radiotherapy (SBRT) of lung tumors. MATERIALS AND METHODS: This IRB-approved, HIPAA-compliant retrospective study was performed at a single tertiary institution. Consecutive patients undergoing lung fiducial placement for purposes of guiding SBRT (CyberKnife®, Accuray, Inc.) between September 2005 to January 2013 were included in the study. Fiducial seeds were placed percutaneously with CT guidance or transbronchially with bronchoscopic guidance. We compared procedure-related complications (pneumothorax, chest tube placement), technical success (defined as implantation enabling adequate treatment planning with CT simulation) and migration rate. The need for repeat procedures and their mode was noted. Statistical analysis was performed using Fisher exact and Chi square probability tests. RESULTS: Two hundred and forty-four patients with lung tumors and 272 fiducial seed placements were included in the study. Two hundred and twenty-one of the 272 (81.2%) fiducial markers were placed percutaneously and 51/272 (18.8%) were placed transbronchially. Pneumothorax was seen in 73/221 (33%) of percutaneously-placed fiducials and in 4/51 (7.8%) of transbronchial placements (p<0.001). No significant difference was seen in the rate of chest tube placement between the two groups: 20/221 (9%) of percutaneously placed fiducials and 2/51 (3.9%) of transbronchially placed fiducials (p=0.39). Fifteen of the 51 (29%) of fiducial placements with transbronchial approach were unsuccessful, as discovered at radiotherapy planning session, and required a repeat procedure. Nine of the 15 (60%) of repeat procedures were performed percutaneously, 5/15 (33%) were placed during repeat bronchoscopy, and 1/15 (7%) was placed at transesophageal endoscopic ultrasound. No repeat fiducial placements were required for patients who had the fiducials placed percutaneously (p<0.001), with a technical success rate of 100%. CONCLUSION: Transbronchial fiducial marker placement has a significantly higher rate of failed seed placements requiring repeat procedures in comparison to percutaneous placement. Complication rate of pneumothorax requiring chest drain placement is similar between the two approaches.

Prevalence and clinical significance of chondromalacia isolated to the anterior margin of the lateral femoral condyle as a component of patellofemoral disease: observations at MR imaging.

OBJECTIVE: To determine the prevalence of chondromalacia isolated to the anterior margin of the lateral femoral condyle as a component of patellofemoral disease in patients with anterior knee pain and to correlate it with patient demographics, patellar shape, and patellofemoral alignment. MATERIALS AND METHODS: Retrospective study over a 1-year period reviewing the MR knee examinations of all patients who were referred for assessment of anterior knee pain. Only patients with isolated lateral patellofemoral disease were included. Age, gender, distribution of lateral patellofemoral chondromalacia, and grade of cartilaginous defects were documented for each patient. Correlation between the distribution of lateral patellofemoral chondromalacia and patient demographics, patellar shape, and indices of patellar alignment (femoral sulcus angle and modified Q angle) was then ascertained. RESULTS: There were 50 patients (22 males, 28 females) with anterior knee pain and isolated patellofemoral disease. The majority of the patients (78 %) had co-existent disease with grade 1 chondromalacia. No significant correlation was found between patients with chondromalacia isolated to the anterior margin of the lateral femoral condyle and age, gender, patellar shape, or modified Q angle (p > 0.05). However, patients with chondromalacia isolated to the anterior margin of the lateral femoral condyle had a shallower femoral sulcus angle (mean 141.8°) compared to the patients with lateral patellar facet disease (mean 133.8°) (p = 0.002). CONCLUSIONS: A small percentage of patients with anterior knee pain have chondromalacia isolated to the anterior margin of the lateral femoral condyle. This was associated with a shallower femoral sulcus angle.

Sentinel lymph node biopsy in elderly irish patients with malignant melanoma.

In patients with malignant melanoma, Breslow depth increases with age. However, studies suggest that the frequency of sentinel lymph node metastases in malignant melanoma decreases with age. We investigated whether this applied to the cohort of patients undergoing sentinel lymph node biopsy (SLNB) in our institution. In a prospectively accrued database we identified 149 patients undergoing SLNB from 1997 to 2005. Tumour thickness as measured by Breslow depth was assessed in stratified age groups. We assessed the relationship between SLNB positivity and age using the Chi-square for trend. We directly examined the relationship between SLNB positivity in patients aged less than 65 and aged 65 years of age and over. Disease-free and overall survival in patients aged less than 65 and aged 65 years of age and over were also assessed. Comparing the age groups, there was no significant difference identified in Breslow depth (<65 years, median Breslow > or = 1.2 mm (range 0.2-9.7); > or =65 years, median Breslow > or = 1.4 mm (range 0.12-8.5); p > or = 0.06, Mann-Whitney U). Chi-square for trend identified no significant relationship between SLNB positivity and age. We found n=120 patients <65 had SLNB, of which 26 (21.7%) were positive. In patients =65, n=29 had SLNB of which 3 (10.3%) were positive. These differences were not statistically significant (Fisher's exact test, p > or = 0.2). There was no difference in disease-free or overall survival between patients aged <65 or > or =65 who had SLNB (median follow-up 37.5 months (range 5-70); disease-free survival, p > 0.08; overall survival, p > or = 0.3, Logrank test). We did not find that elderly patients with malignant melanoma had a demonstrable difference in tumour thickness when compared to younger patients. In those patients who underwent SLNB there was no significant difference in node positivity between the age groups. Disease-free and overall survival were not significantly different between the age groups. Further study and longer follow-up will help establish the relationship between age and SLNB positivity.