Pancreatic cancer outcome-local treatment with radiation using MRI-LINAC.

Introduction: Stereotactic MR-guided on-table adaptive radiotherapy (SMART) allows the precise delivery of high-dose radiation to tumors in great proximity to radiation-sensitive organs. The aim of this study is to evaluate the toxicity and clinical outcome in locally advanced or recurrent pancreatic tumors, with or without prior irradiation, treated with SMART. Methods: Patients were treated for pancreatic cancer (PC) using SMART technology to a prescribed dose of 50 Gy (BED10, 100 Gy) in five fractions, with daily on-table adaptation of treatment plan. Endpoints were acute and late toxicities, local control, local disease-free period, and overall survival. Results: A total of 54 PC patients were treated between August 2019 and September 2022, with a median follow-up of 8.9 months from SMART. The median age was 70.4 (45.2-86.9) years. A total of 40 patients had upfront inoperable PC (55% were locally advanced and 45% metastatic), and 14 had local recurrence following prior pancreatectomy (six patients also had prior adjuvant RT). Of the patients, 87% received at least one chemotherapy regimen (Oxaliplatin based, 72.2%), and 25.9% received ≥2 regimens. Except from lower CA 19-9 serum level at the time of diagnosis and 6 weeks prior to SMART in previously operated patients, there were no significant differences in baseline parameters between prior pancreatectomy and the inoperable group. On-table adaptive replanning was performed for 100% of the fractions. No patient reported grade ≥2 acute GI toxicity. All previously irradiated patients reported only low-grade toxicities during RT. A total of 48 patients (88.9%) were available for evaluation. Complete local control was achieved in 21.7% (10 patients) for a median of 9 months (2.8-28.8); three had later local progression. Eight patients had regional or marginal recurrence. Six- and 12-month OS were 75.0% and 52.1%, respectively. Apart from mild diarrhea 1-3 months after SMART and general fatigue, there were no significant differences in toxicity and outcomes between post-pancreatectomy and inoperable groups. Conclusion: SMART allows safe delivery of an ablative dose of radiotherapy, with minimal treatment-related toxicity, even in previously resected or irradiated patients. In this real-world cohort, local control with complete response was achieved by 20% of the patients. Further studies are needed to evaluate long-term outcome and late toxicity.

Outcome of the first 200 patients with prostate cancer treated with MRI-Linac at Assuta MC.

Background: We present our experience with MR-guided stereotactic body radiotherapy (SBRT) for 200 consecutive patients with prostate cancer with minimum 3-month follow-up. Methods: Treatment planning included fusion of the 0.35-Tesla planning MRI with multiparametric MRI and PET-PSMA for Group Grade (GG) 2 or higher and contour review with an expert MRI radiologist. No fiducials or rectal spacers were used. Prescription dose was 36.25 Gy in 5 fractions over 2 weeks to the entire prostate with 3-mm margins. Daily plan was adapted if tumor and organs at risk (OAR) doses differed significantly from the original plan. The prostate was monitored during treatment that was automatically interrupted if the target moved out of the PTV range. Results: Mean age was 72 years. Clinical stage was T1c, 85.5%; T2, 13%; and T3, 1.5%. In addition, 20% were GG1, 50% were GG2, 14.5% were GG3, 13% were GG4, and one patient was GG5. PSA ranged from 1 to 77 (median, 6.2). Median prostate volume was 57cc, and 888/1000 (88%) fractions required plan adaptation. The most common acute GU toxicity was Grade I, 31%; dysuria and acute gastrointestinal toxicity were rare. Three patients required temporary catheterization. Prostate size of over 100cc was associated with acute fatigue, urinary hesitance, and catheter insertion. Prostate Specific Antigen (PSA) decreased in 99% of patients, and one patient had regional recurrence. Conclusion: MR-guided prostate SBRT shows low acute toxicity and excellent short-term outcomes. Real-time MRI ensures accurate positioning and SBRT delivery.

Keratoconus Progression After Corneal Cross-Linking in Eyes With Preoperative Maximum Keratometry Values of 58 Diopters and Steeper.

PURPOSE: To evaluate the effectiveness of cross-linking (CXL) in treating keratoconus eyes with Kmax values ≥58.0 D. METHODS: Retrospective analysis of outcomes of standard Dresden epi-off CXL in progressive keratoconus with preoperative Kmax ≥58.0 Diopters (D). Inclusion criteria were Kmax ≥58.0 D and minimum follow-up of 1 year. Corneal topography and tomography were performed preoperatively and at 1 and 2 years. Sixty-one eyes of 56 patients with mean age of 24.9 ± 8.6 years (mean ± SD, range 12-57 years) had 1-year follow-up. Fifty of these eyes had 2-year follow-up. The definition of progression was an increase in Kmax of ≥1.0 D over 1 year. RESULTS: Mean Kmax was 63.9 ± 6.1 D (mean ± SD, range 58.2-87.0 D) preoperatively (n = 61) and 62.9 ± 5.9 D (range 54.6-82.5 D) after 1 year. This represented a significant decrease in steepness (P = 0.0029). Mean pachymetry decreased significantly from 433.7 ± 44.8 µm preoperatively to 423.0 ± 41.8 µm (P = 0.001) at 1 year. Progression occurred in 14 of the 61 eyes (23%) at 1 year, and 5 (8.2%) steepened more than 2.0 D. In the group with 2-year follow-up, mean Kmax was 63.0 ± 5.0 D (range 58.2-87 D) before CXL and decreased to 61.5 ± 4.8 D (range 53.6-78.3 D) at 2 years (P = 0.001). Nine of the 50 eyes (18%) showed an increase of Kmax of ≥ 1 D. CONCLUSIONS: The incidence of progression (23% at 1 and 18% at 2 years, respectively) is considerably higher than in previously reported results of CXL in eyes with mean Kmax ≥58.0 D. To the best of our knowledge, this study represents the largest number of such steep corneas analyzed with respect to long-term progression after CXL.

Spine radiosurgery: lessons learned from the first 100 treatment sessions.

OBJECTIVE Local therapy to spine tumors has been shown to be effective in selected cases. Spinal radiosurgery (SRS) is an evolving radiotherapy regimen allowing for noninvasive, highly efficacious local treatment. The learning curve can compromise the results of any newly employed technology and should be studied to minimize its effects. In this paper the first 100 SRSs performed at several medical centers are presented and analyzed for the effects of the learning curve on outcome. METHODS A retrospective analysis was undertaken to evaluate data from patients treated with SRS at Sheba Medical Center and Assuta Medical Centers in the period from September 2011 to February 2016. Medical history, clinical and neurological findings, pathological diagnoses, SRS variables, complications, and follow-up data were collected and analyzed. Local control rates were calculated, and local treatment failure cases were qualitatively studied. RESULTS One hundred treatment sessions were performed for 118 lesions at 179 spinal levels in 80 patients. The complication rate was low and did not correlate with a learning curve. Mean follow-up time was 302 days, and the overall local control rate was 95%. The local control rate was dose dependent and increased from 87% (among 35 patients receiving a dose of 16 Gy) to 97% (among 65 patients receiving a dose of 18 Gy). The 6 treatment failure cases are discussed in detail. CONCLUSIONS Spinal radiosurgery is a safe and effective treatment. Comprehensive education of the treating team and continuous communication are essential to limit the effects of the learning curve on outcome.

Extra-peritoneal pressure packing without external pelvic fixation: A life-saving stand-alone surgical treatment.

PURPOSE: Traditional maneuvers aim to decrease retroperitoneal bleeding in hemodynamically unstable multi-trauma patients with unstable pelvic fractures, are reportedly successful in approximately only 50%. The life-saving effect of extra-peritoneal pressure packing (EPPP) is based on direct compression and control of both venous and arterial retroperitoneal bleeders. This study describes the safety and efficacy of emergent EPPP employment, as a stand-alone surgical treatment, that is, carried out without external pelvic fixation or emergent angiography. MATERIALS AND METHODS: A retrospective chart review of all hemodynamic unstable, multi-trauma patients with mechanically unstable pelvic fractures treated by the EPPP technique at our medical center between the years 2005 and 2011. Survival rates, clinical, and physiological outcomes were followed prospectively. RESULTS: Twenty-five of the 181 pelvic fracture patients had biomechanically unstable fractures that required surgical fixation. Fourteen of those 25 patients had deteriorating hemodynamic instability from massive pelvic bleeding which was resistant to resuscitation, and they underwent EPPP, as a stand-alone treatment. The procedure successfully achieved hemodynamic stability in all 14 patients and obviated the early mortality associated with massive pelvic bleeding. Three of these patients eventually succumbed to their multiple injuries. CONCLUSION: Implementation of EPPP improved all measured physiological outcome parameters and survival rates of hemodynamically unstable multi-trauma patients with unstable pelvic fractures in our trauma center. It provided the unique advantage of directly compressing the life-threatening retroperitoneal bleeders by applying direct pressure and causing a tamponade effect to stanch venous and arterial pelvic blood flow and obviate the early mortality associated with massive pelvic bleeding.

Refractive, topographic, tomographic, and aberrometric analysis of keratoconic eyes undergoing corneal cross-linking.

PURPOSE: To report refractive, topographic, tomographic, and aberrometric outcomes 12 months after corneal cross-linking (CXL) in eyes with progressive advanced keratoconus. DESIGN: Prospective, nonrandomized, single-center clinical study. PARTICIPANTS: Twenty-eight eyes undergoing CXL between April and June 2006. INTERVENTION: Riboflavin-ultraviolet A (UVA)-induced CXL included instillation of 0.1% riboflavin-20% dextrane solution 30 minutes before UVA irradiation and every 5 minutes for an additional 30 minutes during irradiation. MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), sphere and cylinder refraction, topography, tomography, aberrometry, and endothelial cell count were evaluated at baseline and at 1, 3, 6, and 12 months follow-up. RESULTS: Mean baseline UCVA and BSCVA were 0.17+/-0.09 and 0.52+/-0.17, respectively; 12-month mean UCVA and BSCVA were 0.27+/-0.08 and 0.72+/-0.16, a statistically significant difference (P<0.05). Mean spherical equivalent refraction showed a significant decrease of 0.41 diopters (D). Mean baseline simulated keratometry (SIM K) flattest and steepest meridians and SIM K average were 46.10, 50.37, and 48.08 D, respectively; at 12 months, 40.22, 44.21, and 42.01 D, respectively, were recorded, a difference that was significant for all 3 indices (P<0.05). Mean average pupillary power (APP) changed significantly from 47.50 to 41.04 D at 12 months (P<0.05) and apical keratometry (AK) from 58.94 to 55.18 D (P<0.05). The treated eyes showed no deterioration of the Klyce indices at 6 months postoperatively, whereas the untreated (contralateral) eyes did show deterioration. For a 3-mm pupil, there was a significant reduction (P<0.05) in whole eye (total), corneal, higher order, and astigmatic wavefront aberrations. A significant difference (P<0.05) in total coma and total spherical aberration after CXL was also observed. Mean baseline pupil center pachymetry and total corneal volume decreased significantly (P<0.05) to 470.09+/-29.01 microm and 57.17+/-3.21 mm(3) from baseline values of 490.68+/-30.69 microm and 59.37+/-4.36 mm(3), respectively. Endothelial cell counts did not changed significantly (P=0.13). CONCLUSIONS: Corneal cross-linking seems to be effective in improving UCVA and BSCVA in eyes with progressive keratoconus by significantly reducing corneal APP, AK, and corneal and total wavefront aberrations at 1 year postoperatively.