Assessment of the results and hematological side effects of 3D conformal and IMRT/ARC therapies delivered during craniospinal irradiation of childhood tumors with a follow-up period of five years.

BACKGROUND: Craniospinal irradiation (CSI) of childhood tumors with the RapidArc technique is a new method of treatment. Our objective was to compare the acute hematological toxicity pattern during 3D conformal radiotherapy with the application of the novel technique. METHODS: Data from patients treated between 2007 and 2014 were collected, and seven patients were identified in both treatment groups. After establishing a general linear model, acute blood toxicity results were obtained using SPSS software. Furthermore, the exposure dose of the organs at risk was compared. Patients were followed for a minimum of 5 years, and progression-free survival and overall survival data were assessed. RESULTS: After assessment of the laboratory parameters in the two groups, it may be concluded that no significant differences were detected in terms of the mean dose exposures of the normal tissues or the acute hematological side effects during the IMRT/ARC and 3D conformal treatments. Laboratory parameters decreased significantly compared to the baseline values during the treatment weeks. Nevertheless, no significant differences were detected between the two groups. No remarkable differences were confirmed between the two groups regarding the five-year progression-free survival or overall survival, and no signs of serious organ toxicity due to irradiation were observed during the follow-up period in either of the groups. CONCLUSION: The RapidArc technique can be used safely even in the treatment of childhood tumors, as the extent of the exposure dose in normal tissues and the amount of acute hematological side effects are not higher with this technique.

Single-fraction stereotactic ablative body radiotherapy for sternal metastases in oligometastatic breast cancer: Technique and single institution experience.

INTRODUCTION: Due to size and close proximity to skin, the sternum is a complicated target for stereotactic ablative body radiotherapy (SABR). This is a retrospective case series of single-fraction SABR to sternal metastasis in patients with oligometastatic breast cancer. METHODS: Between June 2014 and June 2018, ten breast cancer patients received 20 Gy in 1 fraction to a solitary sternal metastasis. Eligible patients had Eastern Cooperative Oncology Group performance status of 0-2, oligometastatic disease (defined as 1-5 metastases) and a controlled primary site. Patients were treated with 3-dimensional conformal radiotherapy, each patient case comprising of> 6 coplanar beams and 2-6 non-coplanar beams. Local control, pain response and adverse events were retrospectively reviewed. RESULTS: The median planned target volumes were 84.75cc (range, 14.4-197.8cc). The median conformity index was 1.29 (range, 1.2-1.49). At a median follow-up of 32 months, nine patients achieved in-field control. Two patients had triple negative disease, one of them developed marginal recurrence, and the other had in-field recurrence. Seven patients had sternal pain prior to SABR, and within 3 months after SABR treatment, the pain improved (n = 3) or resolved (n = 2). Four patients developed acute grade 1 and 2 skin reactions, and two patients had late grade 1 skin reactions. There were no grade 3 or 4 toxicities. CONCLUSION: Our case series demonstrates safety of SABR with associated disease control and analgesic benefit in selected patients with oligometastatic breast cancer. The marginal recurrence observed in this cohort suggests wider margins could be beneficial to account for microscopic disease.

Low-level laser therapy versus trunk stabilization exercises on sternotomy healing after coronary artery bypass grafting: a randomized clinical trial.

The aim of this study was to investigate the effects of low-level laser therapy (LLLT) versus trunk stabilization exercises on sternotomy healing following coronary artery bypass grafting (CABG) surgery. Forty-five male patients who had acute sternal instability post-CABG surgery in the age range of 45-65 years were divided randomly into three equal groups (n = 15). The laser group received LLLT, while the exercise group received trunk stabilization exercises. The control group only received a routine cardiac rehabilitation programme, which was also provided to both the laser and the exercise groups. All groups were offered 12 sessions over 4 weeks. Sternal separation, median sternotomy photographic analysis, pain and activities of daily living (ADL) performance were evaluated pre- and post-treatment. Statistical significance was set at P < 0.05. There was a significant decrease among the laser group in upper-sternal separation, while the exercise and control groups showed a non-significant decrease. In terms of mid-sternal separation, laser and exercise groups showed a significant decrease while the control group showed a non-significant decrease. In terms of lower-sternal separation, the exercise group showed a significant decrease, while the laser and control groups showed a non-significant decrease. Post-treatment between-groups analysis showed a significant difference only among the laser and control groups with regard to upper-sternal separation, while analysis of the laser, exercise and control groups in the case of upper-sternal separation and the between-groups comparison in terms of mid- and lower-sternal separation revealed no significant differences. LLLT and trunk stabilization exercises were found to be the most effective methods for sternotomy healing post-CABG surgery, with LLLT offering superior performance in the case of the upper sternum while trunk stabilization exercises were more effective for the lower sternum.

Patient radiation protection covers for head CT scans - a clinical evaluation of their effectiveness.

PURPOSE: Although the use of thyroid shields for patients for head CT examinations is reasonable and even required by German regulations, so far available shields are often not used due to difficult applicability. New shields that are easier to use and therefore may gain wider acceptance and more frequent use are now available. In this work two new patient shields are investigated regarding their dose reduction effectiveness and applicability and compared to a thyroid/sternum shield typically used as a part of personal protective equipment. MATERIALS AND METHODS: The reduction of organ doses for thyroid, sternum and mamma were measured with thermoluminescence detectors in an anthropomorphic female phantom. Additionally, the influence of the length or position of the overview scan at the beginning of the CT examination was taken into account. RESULTS: Depending on the patient shield, a reduction of the organ doses for thyroid of 5 - 24 %, for sternum of 25 - 48 % and for mamma of 25 - 70 % could be found. A shift of 25 mm in the cranial direction for the overview scan resulted in a reduction of these organ doses of 12 - 15 %. CONCLUSION: Patient shields for cranial CT examinations provide a considerable dose reduction. New models are easily applied and no decrease in image quality through reconstruction artifacts could be found. Therefore, it is advised to use shields which are applied upon the patient without the need to be wrapped around the neck and the overview scan should be positioned as close as possible to the examined region. KEY POINTS: • New shields provide a compromise between usability and radiation protection.• Patient shields reduce organ doses even when not directly exposed.• The overview scan contributes considerably to out of field organ doses.• Shielding factors are greatly influenced by the positioning of the examination field.

Profuse mediastinal hemorrhage due to mediastinitis after a sternal infection.

A 79-year-old female patient was admitted because of profuse bleeding from a skin defect in the anterior chest due to a deep sternal wound infection. Eighteen years earlier, she had undergone irradiation to treat a sternal metastasis from breast cancer. Computed tomography (CT) showed the extravasation of iodinated contrast material from the ascending aorta. The patient underwent an immediate thoracotomy and recovered. This report presents a very rare case of massive bleeding from the thoracic aorta due to a mediastinal infection after irradiation for sternal metastasis from breast cancer.

Two cases of valve surgery through right anterior minithoracotomy in presence of severe postmastectomy irradiation sternal damage.

High dose postmastectomy radiation therapy for breast cancer can lead to severe postirradiation sternal damage. Under these circumstances, median sternotomy may be associated with a prohibitive risk of postoperative deep sternal wound infection and alternative approaches have to be evaluated. We report herein the use of a right anterior minithoracotomy through the third intercostal space for isolated aortic valve replacement in one and combined aortic and mitral valve replacement in combination with mitral ring decalcification and coronary artery bypass grafting to the proximal right coronary artery in another patient.

Tocopherol succinate: modulation of antioxidant enzymes and oncogene expression, and hematopoietic recovery.

PURPOSE: A class of naturally occurring isoforms of tocopherol (tocols) was shown to have varying degrees of protection when administered before radiation exposure. We recently demonstrated that α-tocopherol succinate (TS) is a potential radiation prophylactic agent. Our objective in this study was to further investigate the mechanism of action of TS in mice exposed to (60)Co γ-radiation. METHODS AND MATERIALS: We evaluated the effects of TS on expression of antioxidant enzymes and oncogenes by quantitative RT-PCR in bone marrow cells of (60)Co γ-irradiated mice. Further, we tested the ability of TS to rescue and repopulate hematopoietic stem cells by analyzing bone marrow cellularity and spleen colony forming unit in spleen of TS-injected and irradiated mice. RESULTS: Our results demonstrate that TS modulated the expression of antioxidant enzymes and inhibited expression of oncogenes in irradiated mice at different time points. TS also increased colony forming unit-spleen numbers and bone marrow cellularity in irradiated mice. CONCLUSIONS: Results provide additional support for the observed radioprotective efficacy of TS and insight into mechanisms.

Radiation-induced osteosarcoma 17 years after mediastinal irradiation following surgical removal of thymoma.

Radiation-induced osteosarcoma is a rare complication after irradiation of primary malignancies. In the chest wall, it is usually secondary to radiotherapy for breast cancer or lymphoma. We report a rare case of radiation-induced osteosarcoma of the sternum after mediastinal irradiation of a thymoma. A 49-year-old woman presented with a sternal tumor 17 years after surgery plus mediastinal irradiation (50 Gy) for a stage III thymoma. On biopsy, this second tumor was diagnosed as a radiation-induced osteosarcoma. Systemic survey revealed additional metastatic spread to vertebrae and pelvis. Despite intensive combination chemotherapy that initially stabilized her disease, the patient died 2 years after the diagnosis was made. Because thymoma patients receiving mediastinal irradiation are thus at additional risk of radiation-induced secondary malignancy, long-term follow-up is advisable.

Simultaneous surgery of the aortic valve and sternal osteomyelitis.

A 64-year-old man was referred for aortic valve replacement due to severe stenosis. He also suffered chronic sternal osteomyelitis with skin fistula subsequent to radiation therapy. Both pathologies were approached simultaneously by sternal resection, omental plasty, and valve replacement, which led to favorable primary and mid-term result.

No effect of ketoprofen and meloxicam on bone graft ingrowth: a bone chamber study in goats.

BACKGROUND AND PURPOSE: There is increasing awareness that non-steroidal anti-inflammatory drugs (NSAIDs), and especially the cyclooxygenase-2 (COX-2) selective ones, may retard bone healing. We have used NSAIDs (indomethacin for at least 7 days) to prevent heterotopic ossification after acetabular reconstructions using impacted bone grafts. The long-term clinical results have been satisfying, making it difficult to believe that there is an important negative effect of NSAIDs on graft incorporation. We studied the effect of two different NSAIDs on bone and tissue ingrowth in a bone chamber model in goats, using autograft, rinsed allograft, and allograft that had been rinsed and subsequently irradiated. METHODS: 9 goats received no NSAIDs, 9 received ketoprofen, and 9 received meloxicam--all for 6 weeks. In each goat 6 bone chambers were implanted: 2 filled with autograft, 2 with rinsed allograft, and 2 with allograft that had been rinsed and irradiated. The amount of bone ingrowth and total tissue ingrowth was compared between the groups. RESULTS: There were no statistically significant differences in bone ingrowth between the different groups. Also, no differences in bone ingrowth were found with respect to the type of graft used. Furthermore, there was no statistically significant difference in the total amount of ingrowth of fibrous tissue between the treatment groups. INTERPRETATION: No differences in bone ingrowth in titanium bone chambers could be detected with both ketoprofen and meloxicam compared to untreated control animals. This confirms our hypothesis that the effect of NSAIDs on the incorporation and ingrowth of bone graft is limited.

A case of radiation-induced sternal malignant fibrous histiocytoma treated with neoadjuvant chemotherapy and surgical resection.

BACKGROUND: Primary sternal malignant fibrous histiyocytoma (MFH) is highly rare. Effective treatment modality is surgical resection with wide margins. However, to date, the effects of radiotherapy or chemotherapy has not been clearly defined. CASE PRESENTATION: Herein, we aimed to present a 50-year old female patient with MFH occurred in the radiotherapy field who had had surgical procedure for breast cancer 19 years ago and had followed by radiotherapy. Neoadjuvant chemotherapy was applied for MFH due to cardiac and mediastinal vascular invasion. Wide resection was carried out for the mass after having been decreased in size following neoadjuvant chemotherapy. CONCLUSION: Neoadjuvant chemotherapy was an effective method. In planning the surgical resection, the size of the tumor before chemotherapy should be considered as the initial size and surgical margins should be determined accordingly.

Irradiation has no effect on the incorporation of impacted morselized bone: a bone chamber study in goats.

BACKGROUND: Gamma irradiation has been widely used for sterilization of bone allografts. However, gamma irradiation alters proteins. This is favorable when it reduces immunogenicity, but is undesirable when osteoinductive proteins are damaged. Although the effect of gamma irradiation on BMPs has been studied, the effect of irradiation on the process of incorporation of morselized bone chips remains unclear. We studied the effects of sterilization by gamma irradiation on the incorporation of impacted morselized allografts. METHODS: Bone chambers with impacted allografts, rinsed impacted allografts, allografts that were rinsed and subsequently irradiated, and an empty control were implanted in proximal medial tibiae of goats. Incorporation was evaluated using histology and histomorphometry. RESULTS: Histology revealed evidence of bone graft incorporation, which proceeded in a similar way in unprocessed, rinsed, and both rinsed and irradiated bone grafts. After 12 weeks, no difference in bone and tissue ingrowth was found between the unprocessed, the rinsed, and the rinsed and subsequently irradiated allografts. The amount of unresorbed graft remnant was highest in the unprocessed bone grafts. INTERPRETATION: We conclude that sterilization with gamma irradiation does not influence the incorporation of impacted rinsed bone allografts.

Inflammatory sternal metastasis heralding lung cancer: two cases.

Bone pain due to bone metastases is a frequent presenting symptom of lung cancer. However, sternal metastases are unusual. We report two patients with inflammatory sternal metastases mimicking osteitis and indicating lung cancer. Chest computed tomography scan showed lytic lesion of the sternal manubrium invading anterior soft tissue. Diagnosis relied on histological examination of sternal biopsy and negative bacteriologic cultures. Local radiotherapy resulted in resolution of local signs.

[Organ doses from CT examinations in children]. / Evaluation des doses d'irradiation aux organes en scanographie pédiatrique.

PURPOSE: To estimate radiation doses from routine pediatric CT scans (body) and to propose dose reduction protocols. MATERIAL AND METHODS: [corrected] Study performed with a phantom equivalent to the body of 5 year old child with evaluation of doses delivered to breast, gonads, bone marrow (sternum, T12) and thyroid for CT examinations of the chest, abdomen, pelvis and spine. Extrapolation is made to estimate the doses for 1 year old and 10 year old children. Finally, dose reduction protocols are evaluated. RESULTS: CT of the chest delivers significant doses to breast tissue and bone marrow, CT of the abdomen and pelvis delivers significant doses to the ovaries and CT pf the spine delivers significant doses to thyroid and bone marrow. Optimization can be achieved without degradation of the image quality, by reducing Kv and mAs within reasonable limits. This study may be used in order to evaluate the doses delivered by multi-detector CT units.

In vivo determination of extra-target doses received from serial tomotherapy.

BACKGROUND AND PURPOSE: The purpose of this study was to perform in-vivo measurements of extracranial doses received by patients undergoing serial tomotherapy of the head and neck. MATERIAL AND METHODS: Intensity modulated radiotherapy treatment (IMRT) plans were designed for nine patients using the CORVUS treatment planning system (NOMOS Corp.). These plans were delivered using a tertiary collimator dedicated for serial tomotherapy attached to a 10-MV linear accelerator. For each patient, one optically stimulated luminescence dosimeter (OSLD) was placed on the sternum and one on the lower abdomen. The OSLDs were then processed, thereby estimating the in vivo absorbed doses to the sternum and gonads as a function of distance from the treatment site. RESULTS: The OSLDs were shown to measure known doses to within 5%, thereby validating their accuracy for this dose and energy range. In the patient studies, the dose received by the OSLDs varied in direct proportion to the number of monitor units delivered and inversely with the distance from the target volume; the patient dose at a distance of 15 cm from the target is approximately 0.4% of the total monitor units delivered, and drops to below 0.1% of the total MUs at approximately 40 cm from the center of the target. The average sternal dose was 1353 mSv and the average abdominal dose was 327 mSv for an average prescribed dose of 60.1 Gy. This can be attributed, at least partially, to the inefficient treatment delivery that on average required 9.9 MU/0.01 Gy. CONCLUSIONS: While IMRT reduces the normal tissue volume in the high-dose region, it also increases the overall monitor units delivered, and hence the whole-body dose, when compared with conventional treatment delivery. As has been noted in existing literature, these increases in whole-body dose from radiotherapy delivery may increase the likelihood of a radiation-induced secondary malignancy. Therefore, it is important to assess the risk of secondary malignancies from IMRT delivery, and compare this relative risk against the potential benefits of decreased normal tissue complication probabilities.

Post radiation inflammatory malignant fibrous histiocytoma arising from the chest wall.

A 59-year-old man who underwent radiation therapy (41 Gy) to the mediastinum through the anterior chest for Hodgkin's disease presented with a painful anterior chest wall tumor 18 years later. The tumor originated from the left parasternal region and was excised with the sternum. Chest wall reconstruction was performed. The tumor measured 45 x 45 mm and invaded the sternum. The pathologic diagnosis was malignant fibrous histiocytoma. Early and complete excision of the tumor is indicated.

Comparison of kilovoltage x-ray and electron beam dose distributions for radiotherapy of the sternum.

The dose distributions for a patient with cancer involving the sternum were calculated for both a kilovoltage x-ray beam and a megavoltage electron beam. The minimum target dose and dose uniformity over the target volume were significantly better using electrons (90%-101%) than kilovoltage x-rays (68%-119%). The calculated lung dose and integral patient dose were also less for electrons than kilovoltage x-rays. For treating cancers of the sternum with radical intent, megavoltage electrons are recommended as the treatment mode of choice rather than kilovoltage x-rays.