Multi-Institutional Outcomes of Patients Aged 75 years and Older With Pancreatic Ductal Adenocarcinoma Treated With 5-Fraction Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy (A-SMART).

PURPOSE: Treatment options for pancreatic ductal adenocarcinoma (PDAC) are commonly limited for patients with advanced age due to medical comorbidities and/or poor performance status. These patients may not be candidates for more aggressive chemotherapy regimens and/or surgical resection leaving few, if any, other effective treatments. Ablative stereotactic MRI-guided adaptive radiation therapy (A-SMART) is both efficacious and safe for PDAC and can achieve excellent long-term local control, however, the appropriateness of A-SMART for elderly patients with inoperable PDAC is not well understood. METHODS: A retrospective analysis was performed of inoperable non-metastatic PDAC patients aged 75 years or older treated on the MRIdian Linac at 2 institutions. Clinical outcomes of interest included overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional (LRC). Toxicity was graded according to Common Terminology Criteria for Adverse Events (CTCAE, v5). RESULTS: A total of 49 patients were evaluated with a median age of 81 years (range, 75-91) and a median follow-up of 14 months from diagnosis. PDAC was classified as locally advanced (46.9%), borderline resectable (36.7%), or medically inoperable (16.3%). Neoadjuvant chemotherapy was delivered to 84% of patients and all received A-SMART to a median 50 Gy (range, 40-50 Gy) in 5 fractions. 1 Year LRC, PFS, and OS were 88.9%, 53.8%, and 78.9%, respectively. Nine patients (18%) had resection after A-SMART and benefited from PFS improvement (26 vs 6 months, P = .01). ECOG PS <2 was the only predictor of improved OS on multivariate analysis. Acute and late grade 3 + toxicity rates were 8.2% and 4.1%, respectively. CONCLUSIONS: A-SMART is associated with encouraging LRC and OS in elderly patients with initially inoperable PDAC. This novel non-invasive treatment strategy appears to be well-tolerated in patients with advanced age and should be considered in this population that has limited treatment options.

Lack of Efficacy of the Neutropenic Diet in Decreasing Infections among Cancer Patients: A Systematic Review.

The objective of this systematic review is to evaluate the existing evidence supporting the effectiveness of the neutropenic diet in decreasing infection and mortality among cancer patients. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Scopus for relevant articles published from database inception until March 2019. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed for this review. Individual studies were evaluated using the Oxford Center for Evidence-Based Medicine guidelines. A total of 473 articles were identified and 11 articles were selected after assessing eligibility. Our review showed that the neutropenic diet does not decrease infection rates or mortality among cancer patients. Currently, there is no uniform definition for the neutropenic diet across different institutions. For example, some institutions follow general food safety practices while others avoid foods that increase exposure to microbes and bacteria, and some follow both. Given these differences in practice regarding what constitutes a neutropenic diet, it is advisable that safe food handling and preparation practices recommended by the Food and Drug Administration be uniformly followed for neutropenic patients.

Proton Beam Therapy in Liver Malignancies.

PURPOSE OF REVIEW: Proton beam therapy (PBT) allows for improved sparing of surrounding normal tissues compared with X-ray-based radiation therapy. This is especially important in the setting of liver malignancies, where an increase in integral dose leads to a higher risk of radiation-induced liver disease (RILD) as well as close proximity to vital gastrointestinal (GI) organs. RECENT FINDINGS: We have data from multiple centers demonstrating that PBT can safely deliver high, ablative doses of radiation therapy conferring excellent local control with good tolerance of treatment. PBT is an effective treatment with longstanding evidence of efficacy that is increasing in availability.

The spectrum of injuries from motorcycle induced road traffic accidents from level one trauma center: A prospective observational study.

OBJECTIVE: To observe the role of motorcycles in causing Road Traffic Accidents and assess the demographics of the drivers, the injury patterns and their outcomes. METHODS: This prospective observational study was conducted at the Surgical Unit 1, Lahore General Hospital, Lahore for a period of 6 months from November 2017 to May 2018. All patients presenting in ER with RTA secondary to motorcycle trauma were included in the study. Data of patients including demographic and medical data, helmet use, spectrum of injuries, specific injury diagnosis, and final disposition of patients was analyzed. The distribution and associations of both victim- and crash-related variables such as crash mechanism, types of involved vehicles, types of injuries, and demographic characteristics were investigated. Data were analyzed by SPSS v23. RESULTS: A total of 835 patients were included in this study with 685 (82%) being male (mean age 28.38 ± 13.89 years) and775 (92.7%) were motorcycle users. The majority of road traffic crashes, traffic accident's mechanism were motorcycle-vehicle accident 579 (69.3%), followed by collision with slow moving carts and bicycles 104 (12.5%). Inner city main roads were the site for 563 (67.4%) accidents. Only 168 (2.2%) patients were wearing helmets at the time of trauma. CONCLUSIONS: Motorcycle traffic morbidities and mortalities remain to be a major public health issue in Lahore as well as all over Pakistan. There is an urgent need for an efficacious interventional programs to decline the burden of motorcycle related morbidity and mortalities.

The evolving role of diet in prostate cancer risk and progression.

PURPOSE OF REVIEW: This overview examines the rationale for dietary interventions for prostate cancer by summarizing the current evidence base and biological mechanisms for the involvement of diet in disease incidence and progression. RECENT FINDINGS: Recent data have further solidified the association between insulin resistance and prostate cancer with the homeostatic model assessment of insulin resistance. Data also show that periprostatic adipocytes promote extracapsular extension of prostate cancer through chemokines, thereby providing a mechanistic explanation for the association observed between obesity and high-grade cancer. Regarding therapeutics, hyperinsulinemia may be the cause of resistance to phosphatidylinositol-3 kinase inhibitors in the treatment of prostate cancer, leading to new investigations combining these drugs with ketogenic diets. SUMMARY: Given the recently available data regarding insulin resistance and adipokine influence on prostate cancer, dietary strategies targeting metabolic syndrome, diabetes, and obesity should be further explored. In macronutrient-focused therapies, low carbohydrate/ketogenic diets should be favored in such interventions because of their superior impact on weight loss and metabolic parameters and encouraging clinical data. Micronutrients, including the carotenoid lycopene which is found in highest concentrations in tomatoes, may also play a role in prostate cancer prevention and prognosis through complementary metabolic mechanisms. The interplay between genetics, diet, and prostate cancer is an area of emerging focus that might help optimize therapeutic dietary response in the future through personalization.

Evaluation of Cancer Specific Mortality with Surgery versus Radiation as Primary Therapy for Localized High Grade Prostate Cancer in Men Younger Than 60 Years.

PURPOSE: The optimal primary treatment of localized high grade prostate cancer in younger men remains controversial. The objective of this project was to compare the impact of initial radical prostatectomy vs radiation therapy on survival outcomes in young men less than 60 years old with high grade prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed the records of men younger than 60 years in the SEER (Surveillance, Epidemiology and End Results) database who underwent initial surgery or radiation therapy of high grade (Gleason score 8 or greater) localized (N0M0 TNM stage) prostate cancer from 2004 to 2012. Univariate and multivariate Cox proportional hazards regression models were used to examine prostate cancer specific and overall mortality. RESULTS: A total of 2,228 men were identified, of whom 1,459 (65.5%) underwent initial surgery and had a median followup of 43 months and 769 (34.5%) underwent initial external beam radiation therapy with or without brachytherapy and had a median followup of 44 months. On multivariate analysis initial treatment with surgery was associated with improved prostate cancer specific and overall mortality compared with initial radiation treatment (HR 0.37, 95% CI 0.19-0.74, p = 0.005 vs HR 0.41, 95% CI 0.24-0.70, p = 0.001) when controlling for age, biopsy Gleason score, T stage and prostate specific antigen. CONCLUSIONS: Our data showed significant survival differences in young men treated initially with surgery vs external beam radiation therapy of high grade prostate cancer. Future prospective randomized trials are needed to confirm the long-term outcomes of these treatment approaches.

Recent advances in radiation oncology: multimodal targeting of high risk and recurrent prostate cancer.

PURPOSE OF REVIEW: The overview summarizes recent developments in radiation oncology for high risk and recurrent prostate cancer. RECENT FINDINGS: A number of well known phase III prostate hypofractionated radiation therapy (HFxRT) trials were finally published with long-term follow-ups. These trials demonstrate patterns of equivalent tumor control with several showing worse toxicity rates. The ASCENDE-RT randomized trial demonstrated the superiority of brachytherapy boost in intermediate and high-risk prostate cancer. Important randomized trials show a clear benefit to androgen deprivation therapy (ADT) in both intermediate-risk prostate cancer and postprostatectomy patients with rising PSA. Finally, the first randomized trial of metastasis-directed therapy showed a delay in time to ADT and biochemical failures in oligometastatic prostate cancer. SUMMARY: The use of brachytherapy boost in high-risk disease and ADT in locally recurrent cancer after prostatectomy are practice changing given the magnitude of benefit seen in the randomized trials. The benefit of metastasis-directed therapy in oligometastatic prostate cancer must be validated in a larger randomized trial. However, hypofractionated radiation therapy requires further long-term follow-up so that late toxicity risk can be accurately assessed before it becomes a standard of care in prostate cancer.

Minimal toxicity after proton beam therapy for prostate and pelvic nodal irradiation: results from the proton collaborative group REG001-09 trial.

BACKGROUND: Proton beam therapy (PBT) reduces normal organ dose compared to intensity modulated radiation therapy (IMXT) for prostate cancer patients who receive pelvic radiation therapy. It is not known whether this dosimetric advantage results in less gastrointestinal (GI) and genitourinary (GU) toxicity than would be expected from IMXT. MATERIAL AND METHODS: We evaluated treatment parameters and toxicity outcomes for non-metastatic prostate cancer patients who received pelvic radiation therapy and enrolled on the PCG REG001-09 trial. Patients who received X-ray therapy and/or brachytherapy were excluded. Of 3210 total enrolled prostate cancer patients, 85 received prostate and pelvic radiation therapy exclusively with PBT. Most had clinically and radiographically negative lymph nodes although 6 had pelvic nodal disease and one also had para-aortic involvement. Pelvic radiation therapy was delivered using either 2 fields (opposed laterals) or 3 fields (opposed laterals and a posterior beam). Median pelvic dose was 46.9 GyE (range 39.7-56) in 25 fractions (range 24-30). Median boost dose to the prostate +/- seminal vesicles was 30 GyE (range 20-41.4) in 16 fractions (range 10-24). RESULTS: Median follow-up was 14.5 months (range 2.8-49.2). Acute grade 1, 2, and 3 GI toxicity rates were 16.4, 2.4, 0%, respectively. Acute grade 1, 2, and 3 GU toxicity rates were 60, 34.1, 0%, respectively. CONCLUSIONS: Prostate cancer patients who receive pelvic radiation therapy using PBT experience significantly less acute GI toxicity than is expected using IMXT. Further investigation is warranted to confirm whether this favorable acute GI toxicity profile is related to small bowel sparing from PBT.

Interdisciplinary Collaboration in Head and Neck Cancer Care: Optimizing Oral Health Management for Patients Undergoing Radiation Therapy.

Radiation therapy (RT) plays a crucial role in the treatment of head and neck cancers (HNCs). This paper emphasizes the importance of effective communication and collaboration between radiation oncologists and dental specialists in the HNC care pathway. It also provides an overview of the role of RT in HNC treatment and illustrates the interdisciplinary collaboration between these teams to optimize patient care, expedite treatment, and prevent post-treatment oral complications. The methods utilized include a thorough analysis of existing research articles, case reports, and clinical guidelines, with terms such as 'dental management', 'oral oncology', 'head and neck cancer', and 'radiotherapy' included for this review. The findings underscore the significance of the early involvement of dental specialists in the treatment planning phase to assess and prepare patients for RT, including strategies such as prophylactic tooth extraction to mitigate potential oral complications. Furthermore, post-treatment oral health follow-up and management by dental specialists are crucial in minimizing the incidence and severity of RT-induced oral sequelae. In conclusion, these proactive measures help minimize dental and oral complications before, during, and after treatment.

Racial disparities in clinical presentation, surgical procedures, and hospital outcomes among patients with hepatocellular carcinoma in the United States.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States (US), with substantial disparities observed in cancer incidence and survival among racial groups. This study provides analyses on race and ethnicity disparities for patients with HCC. METHODS: This is a cross-sectional analysis of data from the National Inpatient Sample (NIS) between 2011 and 2016, utilizing the STROBE guidelines. Multivariate logistic regression analyses were used to examine the risk-adjusted associations between race and pre-treatment clinical presentation, surgical procedure allocation, and post-treatment hospital outcomes. All clinical parameters were identified using ICD-9-CM and ICD-10-CM diagnosis and procedure codes. RESULTS: 83,876 weighted HCC hospitalizations were reported during the study period. Patient demographics were divided according to NIS racial/ethnic categorization, which includes Caucasian (57.3%), African American (16.9%), Hispanic (15.7%), Asian or Pacific Islanders (9.3%), and Native American (0.8%). Association between greater odds of hospitalization and Elixhauser Comorbidity Index > 4 was significantly higher among Native Americans (aOR=1.79; 95% CI: 1.23-2.73), African Americans (aOR=1.24; 95% CI: 1.12-1.38), and Hispanics (aOR=1.11; 95% CI, 1.01-1.24). Risk-adjusted association between race and receipt of surgical procedures demonstrated that the odds of having surgery was significantly lower for African Americans (aOR=0.64; 95% CI: 0.55-0.73) and Hispanics (aOR=0.70; 95% CI: 0.59-0.82), while significantly higher for Asians/Pacific Islanders (aOR=1.36; 95% CI: 1.28-1.63). Post-operative complications were significantly lower for African Americans (aOR=0.68; 95% CI: 0.55-0.86) while the odds of in-hospital mortality were significantly higher for African Americans (aOR=1.28; 95% CI: 1.11-1.49) and Asians/Pacific Islanders (aOR=1.26; 95% CI: 1.13-1.62). CONCLUSIONS: After controlling for potential confounders, there were significant racial disparities in pre-treatment presentations, surgical procedure allocations, and post-treatment outcomes among patients with HCC. Further studies are needed to determine the underlying factors for these disparities to develop targeted interventions to reduce these disparities of care.

Dosimetric comparison of magnetic resonance-guided radiation therapy, intensity-modulated proton therapy and volumetric-modulated arc therapy for distal esophageal cancer.

Advances in radiotherapy (RT) technologies permit significant decreases in the dose delivered to organs at risk (OARs) for patients with esophageal cancer (EC). Novel RT modalities such as proton beam therapy (PBT) and magnetic resonance-guided radiotherapy (MRgRT), as well as motion management techniques including breath hold (BH) are expected to further improve the therapeutic ratio. However, to our knowledge, the dosimetric benefits of PBT vs MRgRT vs volumetric-modulated arc therapy (VMAT) have not been directly compared for EC. We performed a retrospective in silico evaluation using the images and datasets of nine distal EC patients who were treated at our institution with a 0.35-Tesla MR linac to 50.4 Gy in 28 fractions in mid-inspiration BH (BH-MRgRT). Comparison free-breathing (FB) intensity-modulated PBT (FB-IMPT) and FB-VMAT plans were retrospectively created using the same prescription dose, target volume coverage goals, and OAR constraints. A 5 mm setup margin was used for all plans. BH-IMPT and BH-VMAT plans were not evaluated as they would not reflect our institutional practice. Planners were blinded to the results of the treatment plans created using different radiation modalities. The primary objective was to compare plan quality, target volume coverage, and OAR doses. All treatment plans met pre-defined target volume coverage and OAR constraints. The median conformity and homogeneity indices between FB-IMPT, BH-MRgRT and FB-VMAT were 1.13, 1.25, and 1.43 (PITV) and 1.04, 1.15, 1.04 (HI), respectively. For FB-IMPT, BH-MRgRT and FB-VMAT the median heart dose metrics were 52.8, 79.3, 146.8 (V30Gy, cc), 35.5, 43.8, 77.5 (V40Gy, cc), 16.9, 16.9, 32.5 (V50Gy, cc) and 6.5, 14.9, 17.3 (mean, Gy), respectively. Lung dose metrics were 8.6, 7.9, 18.5 (V20Gy, %), and 4.3, 6.3, 11.2 (mean, Gy), respectively. The mean liver dose (Gy) was 6.5, 19.6, 22.2 respectively. Both FB-IMPT and BH-MRgRT achieve substantial reductions in heart, lung, and liver dose compared to FB-VMAT. We plan to evaluate dosimetric outcomes across these RT modalities assuming consistent use of BH.

Causes of Death Among Patients With Initially Inoperable Pancreas Cancer After Induction Chemotherapy and Ablative 5-fraction Stereotactic Magnetic Resonance Image Guided Adaptive Radiation Therapy.

Purpose: Nearly all patients with pancreatic ductal adenocarcinoma (PDAC) eventually die of progressive cancer after exhausting treatment options. Although distant metastases (DMs) are a common cause of death, autopsy studies have shown that locoregional progression may be directly responsible for up to one-third of PDAC-related deaths. Ablative stereotactic magnetic resonance-guided adaptive radiation therapy (A-SMART) is a novel treatment strategy that appears to improve locoregional control compared with nonablative radiation therapy, potentially leading to improved overall survival. Methods and Materials: A single-institution retrospective analysis was performed of patients with nonmetastatic inoperable PDAC treated between 2018 to 2020 using the MRIdian Linac with induction chemotherapy, followed by 5-fraction A-SMART. We identified causes of death that occurred after A-SMART. Results: A total of 62 patients were evaluated, of whom 42 (67.7%) had died. The median follow-up time was 18.6 months from diagnosis and 11.0 months from A-SMART. Patients had locally advanced (72.6%), borderline resectable (22.6%), or resectable but medically inoperable PDAC (4.8%). All patients received induction chemotherapy, typically leucovorin calcium (folinic acid), fluorouracil, irinotecan hydrochloride, and oxaliplatin (69.4%) or gemcitabine/nab-paclitaxel (24.2%). The median prescribed dose was 50 Gy (range, 40-50), corresponding to a median biologically effective dose of 100 Gy10. Post-SMART therapy included surgery (22.6%), irreversible electroporation (9.7%), and/or chemotherapy (51.6%). Death was attributed to locoregional progression, DMs, cancer-related cachexia/malnutrition, surgery/irreversible electroporation complications, other reasons not due to cancer progression, or unknown causes in 7.1%, 45.2%, 11.9%, 9.5%, 11.9%, and 14.3% of patients, respectively. Intra-abdominal metastases of the liver and peritoneum were responsible for 84.2% of deaths from DMs. Conclusions: To our knowledge, this is the first contemporary evaluation of causes of death in patients with PDAC receiving dose-escalated radiation therapy. We demonstrated that the predominant cause of PDAC-related death was from liver and peritoneal metastases; therefore novel treatment strategies are indicated to address occult micrometastatic disease at these sites.

ENSEAL® Hemorrhoidectomy, a Novel Technique, Versus Conventional Open Method for the Management of Grade III and IV Hemorrhoids.

Background Surgical removal of hemorrhoids is the gold-standard treatment for symptomatic grade III and IV hemorrhoid disease. There are numerous ways the hemorrhoidectomy surgical procedure is done but the most effective and least painful way is still to be elucidated. Objective To compare the outcomes of ENSEAL® (Ethicon, Inc., Raritan, USA) versus gold standard Milligan-Morgan hemorrhoidectomy in patients presenting with grade-III and IV hemorrhoids Materials and methods After ethical approval, the Randomized Controlled Trial was conducted at the Department of Surgery, Unit III, Lahore General Hospital, Lahore, Pakistan, between January 2020 and January 2022. In this study, 140 patients who met the inclusion criteria were recruited after informed consent. Patients were split randomly into two equal groups using a lottery technique. In group A, hemorrhoidectomy was carried out with ENSEAL®, whereas in group B, open hemorrhoidectomy was performed by the Milligan-Morgan method. the surgery duration and blood loss were noted. After the operation, patients were transferred to and discharged from the post-anesthesia recovery room. Patients were further followed up for pain scores after 24 hours. Data was analyzed by using Statistical Package for Social Sciences (SPSS) v25 (IBM Corp., Armonk, USA). Data was categorized for age, gender, body mass index (BMI), degree of hemorrhoids, and duration of hemorrhoids. A p-value <0.05 was considered significant. Results 140 patients were included in this study. Group A patients underwent ENSEAL® hemorrhoidectomy, and group B was formed from those who underwent the Milligan-Morgan procedure. In group A, there were 41 (58.5%) males and 29 (41.4%) females, while in group B, there were 43 (61.4%) males and 27 (38.5%) females. The mean age of group A patients was 49.97 ± 7.36 years and 43.2 ± 8.01 years in group B. In group A, the mean operative time was 20.87 ± 3.05 min, while 27.10 ± 3.42 min in group B, which is statistically significant with a p-value of <0.001. In group A, mean blood loss was 9.79 ± 2.87 ml, while 13.36 ± 3.73 ml in group B, which is statistically significant with a p-value of <0.001. In group A, the mean pain score was 2.7 ± 1.08, while 3.34 ± 1.16 in group B, which is statistically significant with a p-value of <0.001. Conclusion When considering the length of the procedure and blood loss, ENSEAL® hemorrhoidectomy has been determined to be an effective treatment that the patients tolerated well. Therefore, ENSEAL® hemorrhoidectomy can be a safe and efficient alternative to conventional treatment for hemorrhoids that are causing symptoms.

Comparative Efficacy of Topical Metronidazole and Glyceryl Trinitrate Versus Topical Glyceryl Trinitrate Alone in the Treatment of Acute Anal Fissure: A Randomized Clinical Trial.

Background and objective An anal fissure is a longitudinal, oval lesion in the anal canal. In over 90% of instances, the anal fissures are located posterior to the midline and produce discomfort upon defecation and/or bleeding owing to spasms of the internal anal sphincter that leads to ischemia. This research aimed to determine if topical metronidazole treatment when combined with glyceryl trinitrate 0.2% (GTN), is more successful than GTN alone in reducing the time for an acute anal fissure to heal. Material and methods This study was a single-blinded, randomized controlled trial conducted at the DHQ Hospital Okara from January 2022 to August 2022. Patients of both genders, aged 18 to 70 years, with acute anal fissures, were included. One hundred forty patients who satisfied the inclusion criteria were randomized through the lottery technique and were divided into two groups (70 in each group). Group A contained patients who got metronidazole combination with GTN, while in Group B, patients treated with GTN alone without metronidazole. The primary endpoint was fissure healing, confirmed as finding a scar where the fissure was. While the secondary endpoint was maximum pain on defecation assessed by the Visual Analogue Scale (VAS). Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) v24. Chi-Square and Fisher's Exact tests were done for statistical analysis, and p < 0.05 was considered significant. Results Three patients lost the follow-up. Out of the remaining 137, 70 (51.1%) patients were male. The patient's ages ranged from 22 to 68 years, with a mean age of 39.18 ± 11.52. One hundred twenty six (92%) complained of pain on defecation with a mean VAS of 6.01 ± 2.35. 80 (58.4%) patients complained of perianal itching, while 25 (18.2%) patients complained of bleeding on defecation. On week 1 follow-up, in group A out of 69 patients, 27 (39.1%) had complete healing, 38 (55.1%) had partial healing, while in group B out of 68 patients, one (1.4%) had complete healing, 43 (63.2%) had partial healing (p = < 0.001, significant).  On week 3 follow-up, in group A out of 69 patients, 47 (68.1%) had complete healing, and 22 (31.8%) had partial healing, while in group B out of 68 patients, 16 (23.5%) had complete healing, 49 (72%) had partial healing (p = < 0.001, significant). Mean VAS score of group A was 0.61 ± 1.38 while that of group B was 2.57 ± 2.50 (p = < 0.001, significant). Conclusion Using topical metronidazole as an addition to standard therapy may reduce the chronicity of acute anal fissures and prevent surgical treatments with high rates of complications.

Cowper's Syringocele: A Literature Review.

Cowper's syringocele is a rare but underdiagnosed cystic dilatation of the main ducts of Cowper's gland. It is becoming more widely known in the adult population. Recent research proposes that syringoceles should be categorized according to the intraductal pressures causing ductal dilatation from mild to gross ultimately involving the gland itself. Although there may be some overlap in the clinical manifestations of different syringoceles, mildly dilated ducts are frequently asymptomatic. Moreover, moderate to gross duct dilatations can manifest as lower urinary tract symptoms (LUTS) or obstructive symptoms. A valid differential diagnosis is essential because these symptoms can be found in a wide range of severe illnesses. Syringocele can be diagnosed by ultrasonography in combination with voiding retrograde/antegrade cystourethrogram (VCUG), nevertheless, other procedures like cystourethroscopy, CT scan, and MRI scans can be helpful. Initially, conservative surveillance is advised, but if necessary, endoscopic marsupialization or surgical excision is the preferred treatment modality to address persistent problems.

A Comparison Between the Postoperative Complications of Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (RNYGB) in Patients With Morbid Obesity: A Meta-Analysis.

The most successful method for treating obesity is bariatric surgery. The two most common surgeries for treating morbid obesity are the laparoscopic Roux-en-Y gastric bypass (RNYGB) and the laparoscopic sleeve gastrectomy (LSG). However, there has not been a thorough analysis of the differences in their adverse effects. The aim of this study was to analyze if RNYGB and LSG had comparable postoperative complications and mortality. To that end, results from trials comparing those who underwent RNYGB and those who underwent LSG were combined. We explored the Cochrane Library, PubMed, EMBASE, and Web of Science databases for collecting pertinent data, and 10 RCTs were included in the study. Standard deviations were used to determine the risk ratio (RR) and the 95% confidence interval (CI). No substantial difference in mortality was observed between the two procedures. However, our pooled analysis showed that patients who underwent RNYGB needed some reoperation at a higher rate compared to those who had LSG, with a pooled RR of 0.64 (95% CI: 0.42-0.98; p=0.04). Patients who had LSG suffered from fewer postoperative sequelae. While the risk of other complications was higher in RNYGB, our analysis showed that the frequency of gastroesophageal reflux disease (GERD) after LSG was greater than after RNYGB, with a pooled RR of 4.00 (95% CI: 2.55-6.28; p<0.001). Based on the above-mentioned findings, RNYGB and LSG had comparable mortality rates; however, patients who underwent LSG had a reduced risk of complications and reoperations after surgery compared to those who had RNYGB.

Submandibular gland transfer for the prevention of radiation-induced xerostomia in oropharyngeal cancer: Dosimetric impact in the intensity modulated radiotherapy era.

BACKGROUND: Submandibular gland (SMG) transfer decreased radiation-associated xerostomia in the 2/3-dimensional radiotherapy era. We evaluated the dosimetric implications of SMG transfer on modern intensity modulated radiotherapy (IMRT) plans. METHODS: Eighteen oropharynx cancer patients underwent SMG transfer followed by IMRT; reoptimized plans using the baseline SMG location were generated. Mean salivary gland, oral cavity, and larynx doses were compared between clinical plans and reoptimized plans. RESULTS: No statistically significant difference in mean SMG dose (27.53 Gy vs. 29.61 Gy) or total salivary gland dose (26.12 Gy vs. 26.41 Gy) was observed with or without SMG transfer (all p > 0.05). Mean oral cavity and larynx doses were not statistically different. Neither tumor site, target volume crossing midline, stage, nor salivary gland volumes were associated with mean doses. CONCLUSIONS: Salivary gland doses were similar with or without SMG transfer. IMRT likely decreases the benefit of SMG transfer on the risk of radiation-associated xerostomia.

Dose-Escalated Magnetic Resonance Image-Guided Abdominopelvic Reirradiation With Continuous Intrafraction Visualization, Soft Tissue Tracking, and Automatic Beam Gating.

PURPOSE: Compared with computed tomography, magnetic resonance (MR) image guidance offers significant advantages for radiation therapy (RT) that may be particularly beneficial for reirradiation (reRT). However, clinical outcomes of MR-guided reRT are not well described in the published literature. METHODS AND MATERIALS: We performed a single-institution retrospective safety and efficacy analysis of reRT patients treated on the MRIdian Linac to targets within the abdomen or pelvis using continuous intrafraction MR-based motion management with automatic beam triggering. Fiducial markers were not used. RESULTS: We evaluated 11 patients who received prior RT to a median of 50 Gy (range, 30-58.8 Gy) in 25 fractions (range, 5-28 fractions). The median interval to reRT was 26.8 months. The most frequently retreated sites were nodal metastases (36.4%) and pancreatic cancer (27.3%). The median reRT dose was 40 Gy (range, 25-54 Gy) in 6 fractions (range, 5-36 fractions); ultrahypofractionation (63.6%) was more common than hyperfractionation (36.4%). Daily on-table adaptive replanning was used for 3 patients (27.3%). With a median of 14 months' follow-up from reRT completion (range, 6-32 months), the median and 1-year freedom from local progression were 29 months and 88.9%, respectively, and the median and 1-year overall survival were 17.5 months and 70.0%, respectively. One patient (9.1%) experienced acute grade 2 toxic effects; there were no acute or late treatment-related toxic effects of grade 3 or greater. CONCLUSIONS: Magnetic resonance-guided reRT appeared to be feasible and may facilitate safe dose escalation. Additional follow-up is needed to better assess long-term efficacy and late toxic effects. Prospective evaluation of this novel treatment strategy is warranted.

Induction Chemotherapy and Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy for Inoperable Pancreas Cancer.

Background: Radiation therapy (RT) dose for inoperable pancreatic ductal adenocarcinoma (PDAC) has historically been non-ablative to avoid injuring gastrointestinal (GI) organs at risk (OARs). Accruing data suggest that dose escalation, in select patients, may significantly improve clinical outcomes. Early results of ablative stereotactic magnetic resonance image-guided adaptive radiation therapy (A-SMART) have been encouraging, although long-term outcomes are not well understood. Methods: A single institution retrospective analysis was performed of inoperable non-metastatic PDAC patients who received induction chemotherapy then 5-fraction A-SMART on a 0.35T-MR Linac from 2018-2021. Results: Sixty-two patients were evaluated with a median age of 66 years (range 35-91) and nearly all achieved Eastern Cooperative Oncology Group (ECOG) performance status 0-1 (96.8%). Locally advanced disease was common (72.6%), otherwise borderline resectable (22.6%), or medically inoperable (4.8%). All received induction chemotherapy for a median 4.2 months (range, 0.2-13.3) most commonly FOLFIRINOX (n=43; 69.4%). Median prescribed dose was 50 Gy (range 40-50); median biologically effective dose (BED10) was 100 Gy10. The median local control (LC), progression-free survival (PFS), and overall survival (OS) from diagnosis were not reached, 20 months, and 23 months, respectively. Also, 2-year LC, PFS, and OS were 68.8%, 40.0%, and 45.5%, respectively. Acute and late grade 3+ toxicity rates were 4.8% and 4.8%, respectively. Conclusions: To our knowledge, this is the largest series of induction chemotherapy followed by ablative 5-fraction SMART delivered on an MR Linac for inoperable PDAC. The potential for this novel treatment strategy is to achieve long-term LC and OS, compared to chemotherapy alone, and warrants prospective evaluation.

Multi-Institutional Outcomes of Stereotactic Magnetic Resonance Image Guided Adaptive Radiation Therapy With a Median Biologically Effective Dose of 100 Gy10 for Non-bone Oligometastases.

Purpose: Randomized data show a survival benefit of stereotactic ablative body radiation therapy in selected patients with oligometastases (OM). Stereotactic magnetic resonance guided adaptive radiation therapy (SMART) may facilitate the delivery of ablative dose for OM lesions, especially those adjacent to historically dose-limiting organs at risk, where conventional approaches preclude ablative dosing. Methods and Materials: The RSSearch Registry was queried for OM patients (1-5 metastatic lesions) treated with SMART. Freedom from local progression (FFLP), freedom from distant progression (FFDP), progression-free survival (PFS), and overall survival (LS) were estimated using the Kaplan-Meier method. FFLP was evaluated using RECIST 1.1 criteria. Toxicity was evaluated using Common Terminology Criteria for Adverse Events version 4 criteria. Results: Ninety-six patients with 108 OM lesions were treated on a 0.35 T MR Linac at 2 institutions between 2018 and 2020. SMART was delivered to mostly abdominal or pelvic lymph nodes (48.1%), lung (18.5%), liver and intrahepatic bile ducts (16.7%), and adrenal gland (11.1%). The median prescribed radiation therapy dose was 48.5 Gy (range, 30-60 Gy) in 5 fractions (range, 3-15). The median biologically effective dose corrected using an alpha/beta value of 10 was 100 Gy10 (range, 48-180). No acute or late grade 3+ toxicities were observed with median 10 months (range, 3-25) follow-up. Estimated 1-year FFLP, FFDP, PFS, and OS were 92.3%, 41.1%, 39.3%, and 89.6%, respectively. Median FFDP and PFS were 8.9 months (95% confidence interval, 5.2-12.6 months) and 7.6 months (95% confidence interval, 4.5-10.6 months), respectively. Conclusions: To our knowledge, this represents the largest analysis of SMART using ablative dosing for non-bone OM. A median prescribed biologically effective dose of 100 Gy10 resulted in excellent early FFLP and no significant toxicity, likely facilitated by continuous intrafraction MR visualization, breath hold delivery, and online adaptive replanning. Additional prospective evaluation of dose-escalated SMART for OM is warranted.