Stereotactic body radiotherapy using helical tomotherapy for hepatocellular carcinoma: clinical outcome and dosimetric comparison of Hi-ART vs. Radixact.

Background: Helical tomotherapy (HT), a unique rotational dose delivery machine, has been updated from Hi-ART to Radixact. We retrospectively evaluated the treatment outcomes of stereotactic body radiotherapy (SBRT) using HT for hepatocellular carcinoma (HCC) and compared the dosimetric details of Hi-ART and Radixact. Methods: Between April 2014 and November 2020, 28 patients with HCC were treated with SBRT using HT for a cure at Soonchunhyang University College of Medicine, Bucheon. According to the Barcelona Clinic Liver Cancer classification, 9 patients had stage 0 disease, 12 had stage A, 4 had stage B, and 3 had stage C. The tumor size ranged from 1 cm to 8 cm (median, 2 cm). The SBRT dose ranged from 40 to 60 Gy (median, 48 Gy) with 4 fractions. Twenty-three patients were treated with Hi-ART and 5 patients were treated with Radixact. To compare the dosimetric parameters between Hi-ART and Radixact, we created treatment plans with the same constraints, pitch, modulation factor, and field width for the same patient in pairs. Results: The median follow-up time from the date of SBRT administration was 24 months (range, 3-67 months). The local failure-free survival and intrahepatic failure-free survival rates were 96% and 58% at 1 year, 84% and 36% at 2 years, and 76% and 18% at 3 years, respectively. The overall survival rate was 93% at 1 year, 93% at 2 years, and 53% at 3 years, respectively. When the paired treatment plans were reviewed, the beam-on time and intermediate dose-spillage were found to be significantly reduced in Radixact than Hi-ART (P<0.001). With regard to normal organ sparing, the irradiated dose to the total liver, normal liver, heart, and kidney was significantly lower with Radixact (P<0.001). Conclusions: SBRT using HT for HCC showed favorable treatment outcomes. Radixact, the latest version, physically improved treatment efficiency by reducing treatment time and provided better organ sparing than Hi-ART.

Treatment outcomes of helical tomotherapy for hepatocellular carcinoma in terms of intermediate-dose spillage.

BACKGROUND: Although helical tomotherapy (HT) tends to increase intermediate-dose spillage by increasing of low-dose region, this has not been fully determined in the clinical setting. Therefore, we investigated treatment outcomes of HT for hepatocellular carcinoma (HCC) with respect to intermediate-dose spillage. METHODS: We retrospectively reviewed 20 HCC patients, who received high-dose radiotherapy (RT) using HT with radical intent between April 2014 and September 2017. In accordance with the Barcelona Clinic Liver Cancer (BCLC) classification, stage was 0 in 7 patients, A in 3 patients, B in 5 patients, and C in 5 patients. Baseline Child-Pugh class was A in 18 patients and B in 2 patients. The median tumor size was 2.5 cm (range, 1-11 cm). Helical intensity-modulated radiotherapy (IMRT) technique was applied in all patients: among these, 13 patients were treated with stereotactic body radiotherapy (SBRT). The median fraction size was 12 Gy (range, 2-15 Gy), and the median total dose was 50 Gy (range, 44-60 Gy). Intermediate-dose spillage was assessed by the Radiation Therapy Oncology Group recommendation from 22 HT planning data, as follows: R50% means the ratio of the 50% prescription isodose volume to the planning target volume (PTV). RESULTS: The median follow-up period after HT was 22 months. The local progression-free survival (LPFS) and progression-free survival (PFS) rates were 89% and 59% at 1 year, and 82% and 30% at 2 years, respectively. The overall survival rate was 100% at 1 year and 85% at 2 years, respectively. In terms of intermediate-dose spillage, minor or major deviations were noted in the R50% of 20 HT plans (91%). However, 1 patient (5%) experienced classic radiation-induced liver disease, and severe toxicity ≥ grade 3 was not reported. CONCLUSIONS: Although HT for HCC tends to increase intermediate-dose spillage, the treatment results were favorable with that reported in other published studies.

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery.

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p = .003) and Lauge-Hansen classification (p = .003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p = .044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.

Pop-up messages in order communication systems can increase awareness of osteoporosis among physicians and improve osteoporosis treatment.

RATIONALE, AIMS AND OBJECTIVES: The purpose of this study was to verify the effect of pop-up messages (regarding a history of dual-energy X-ray absorptiometry [DXA]) on the identification and management of osteoporosis after osteoporotic hip or spine fractures. We hypothesized that these pop-up messages would increase the awareness and management of osteoporosis among clinicians and patients. METHODS: We introduced pop-up messages regarding a history of DXA in our Order Communication System (March 2012) and evaluated the records of 404 patients who were treated between January 2011 and December 2012. The patients were categorized as being treated without the pop-up messages (Group I, before March 2012) or with the pop-up messages (Group II, after March 2012). We compared their rates of DXA prescription, osteoporosis medication, exercise, mortality and subsequent refractures during a 2-year follow-up. RESULTS: After introducing the pop-up messages, the DXA prescription rate increased from 35.1 to 57.1% (P < 0.001), the osteoporosis medication rate increased from 21.1 to 25.2% (P = 0.05) and the exercise rate increased from 35.6 to 40.5% (P = 0.018). During the 2-year follow-up, the mortality rates were 4.64% in Group I and 6.67% in Group II (P = 0.4). Subsequent refractures were found in 12.9% of Group I patients and 9.52% of Group II patients (P = 0.87). CONCLUSION: The pop-up messages positively affected the behaviours of orthopaedic surgeons and were associated with increased rates of prescription of DXA, osteoporosis medication, and might affect the behaviour of patient, increased exercise rate. Therefore, we recommend using this simple and effective method to improve physicians' awareness of osteoporosis.

A Randomized Trial Among Compression Plus Nonsteroidal Antiinflammatory Drugs, Aspiration, and Aspiration With Steroid Injection for Nonseptic Olecranon Bursitis.

BACKGROUND: Olecranon bursitis might be a minor problem in the outpatient clinic but relatively be common to occur. However, there are few well-designed studies comparing approaches to treatment. QUESTIONS/PURPOSES: (1) Which treatment (compression bandaging with nonsteroidal antiinflammatory drugs [NSAIDs], aspiration, or aspiration with steroid injections) is associated with the highest likelihood of resolution of nonseptic olecranon bursitis? (2) Which treatment is associated with earliest resolution of symptoms? (3) What factors are associated with treatment failure by 4 weeks? METHODS: We enrolled 133 patients from two centers; after applying prespecified exclusions (septic bursitis or concomitant inflammatory arthritis, intraarticular elbow pathology, recent aspiration or steroid injection done elsewhere, and refusal to participate), 90 patients were randomly allocated to receive compression bandaging with NSAIDs (C), aspiration (A), or aspiration with steroid injection (AS) groups (30 patients in each). The groups were similar at baseline in terms of age and gender. Seven patients (four from Group A and three from Group AS) were lost to followup. All patients were followed up weekly for 4 weeks, and the same treatment procedure was repeated if the bursitis recurred with any substantial fluid collection. At 4 weeks, the state of resolution and pain visual analog scale (VAS) were evaluated. Failed resolution was defined as presence of persistent olecranon bursal fluid collection at Week 4 after the initiation of the treatment; on the contrary, if bursal fluid collection was clinically reduced or completely disappeared by the end of Week 4, the treatment was considered successful. We compared the proportion of resolution by Week 4 and the median times to resolution among the treatment groups. In addition, we evaluated whether the resolution affected pain VAS and what factors were associated with the resolution. RESULTS: There were no differences in the proportion of patients whose bursitis resolved by Week 4 among the three treatment groups (Group C: 25 of 30 [83%], relative risk of resolution failure: 0.68 [95% confidence interval {CI}, 0.27-1.72], p = 0.580; Group A: 17 of 26 [65%], relative risk of resolution failure: 2.19 [95% CI, 0.98-4.87], p = 0.083; Group AS: 23 of 27 [85%], relative risk of resolution failure: 0.59 [95% CI, 0.22-1.63], p = 0.398) (p = 0.073). Steroid injection after aspiration (Group AS) was associated with the earliest resolution (2.3 weeks [range, 1-4 weeks]) when compared with aspiration alone (Group A; 3.1 weeks [range, 2-4 weeks]) and compression bandaging with NSAIDs (Group C; 3.2 weeks [range, 2-4 weeks]), p = 0.015). Longer duration of symptoms before treatment was the only factor associated with treatment failure by 4 weeks (failed resolution: 6 weeks [range, 2-9 weeks]; successful resolution: 4 weeks [range, 0.4-6 weeks]; p = 0.008). CONCLUSIONS: With the numbers available, there were no differences in efficacy when compression bandaging with NSAIDs, aspiration, and aspiration with steroid injection were compared. However, we were powered only to detect a 30% difference, meaning that if there were a smaller difference in efficacy among the groups, we might not have detected it in a study of this size. Our data can be used as pilot data to power future prospective (and likely multicenter) trials. Because olecranon bursitis can recur, and because treatments like aspiration and aspiration with steroid injection can cause complications, unless future trials demonstrate clear efficacy advantages of aspiration and/or injection both at short and longer terms, we suggest that compression bandaging and a short course of NSAIDs may offer the most appropriate balance of safety and efficacy. LEVEL OF EVIDENCE: Level II, therapeutic study.

Effect of jaw size in megavoltage CT on image quality and dose.

PURPOSE: Recently, the jaw size for the TomoTherapy Hi-Art II(®) (TomoTherapy Inc., Madison, WI) was reduced from 4 mm (J4) to 1 mm (J1) to improve the longitudinal (IEC-Y) resolution in megavoltage computed tomography (MVCT) images. This study evaluated the effect of jaw size on the image quality and dose, as well as the dose delivered to the lens of the eye, which is a highly radiosensitive tissue. METHODS: MVCT image quality (image noise, uniformity, contrast linearity, high-contrast resolution, and full width at half-maximum) and multiple scan average dose (MSAD) were measured at different jaw sizes. A head phantom and photoluminescence glass dosimeters (PLDs) were used to measure the exposed lens dose (cGy). Different MVCT scan modes (pitch = 1, 2, and 3) and scan lengths (108 mm, 156 mm, and 204 mm) were applied in the MSAD and PLDs measurements. RESULTS: The change in jaw size from J4 to J1 produced no change or only a slight improvement in image noise, uniformity, contrast linearity, and high-contrast resolution. However, the full-width at half-maximum reduced from approximately 7.2 at J4 to 4.5 mm at J1, which represents an enhancement in the longitudinal resolution. The MSAD at the center point changed from approximately 0.69-2.32 cGy (peripheral: 0.83-2.49 cGy) at J4 to 0.85-2.81 cGy (peripheral: 1.05-2.86 cGy) at J1. The measured lens dose increased from 0.92-3.36 cGy at J4 to 1.06-3.91 cGy at J1. CONCLUSIONS: The change in jaw size improved longitudinal resolution. The MVCT imaging dose of approximately 3.86 cGy, 1.92 cGy, and 1.22 cGy was delivered at a pitch of 1, 2, and 3, respectively, per fraction in the head and neck treatment plans. Therefore, allowance for an approximately 15% increase in lens dose over that with J4 should be provided with J1.

Spatial measurement for safe placement of screws within the scaphoid using three-dimensional analysis.

The placement of a headless screw within the scaphoid is important for successful fixation of fractured scaphoids. We ascertained the safe position of a screw using virtual collision experiments on a three-dimensionally reconstructed scaphoid bone and screw model, and applied measured angles to simple radiographs. We used images from computed tomograms of the wrists taken from 13 men to reconstruct a three-dimensional cortical image of the scaphoid. Inside the bone, we inserted a virtually reconstructed Herbert screw model and calculated the safe angle along the long axis of the scaphoid at which the screw did not collide with the bone in any sample, then applied measured safe angles to simple anteroposterior and lateral radiographs. In all experiments, the safe angle between the screw and the anteroposterior scaphoid line (defined from the most distal portion of the scaphoid where it met the capitate to the proximal position where the lunate and capitate meet) ranged from 8° to 27° in the anteroposterior view, and the safe angle between the screw and the lateral scaphoid line (defined from the most volar portion of the scaphoid tuberosity to the volar position where the scaphoid faced the radius) ranged from 2° to 26° in the lateral view. These ranges can be used as a guide for a safe position of the screw within the scaphoid in volar percutaneous fixation of screws in scaphoid fractures.

The clinicopathological features of biliary intraductal papillary neoplasms according to the location of tumors.

BACKGROUND AND AIM: In this study, we analyzed the clinical and pathological features of biliary intraductal papillary neoplasms (IPN-B) according to the location of the tumors. METHODS: A total of 55 patients with IPN-B were analyzed. We divided them into three groups: common bile duct (CBD), hilar, and intrahepatic duct (IHD) groups. The clinical and laboratory findings, cell types, depth of invasion, malignancy, existence of stones, lymph node metastasis, recurrence, and survival rate were analyzed. RESULTS: There was no difference in the depth of invasion, lymph node metastasis, and coexistence of stones between the three groups. There were four different cell types; the intestinal cell type was the most common type in each group. The gastric cell type was prevalent in the IHD and hilar groups (58.3% and 33.3%, respectively). Invasive colloid carcinoma mainly showed the intestinal cell type, and tubular carcinoma showed the pancreaticobiliary cell type. There was a trend that malignancy was more prevalent in the CBD group (94.1%) than in the hilar group (64.3%) and IHD group (79.2%), but there was no statistically significant difference. There was no difference in the recurrence rate and the 3-year survival rate between the three groups. CONCLUSION: IPN-B showed no difference in the malignancy and survival rates according to the location of the tumors. Because IPN-B show good prognosis after surgery, aggressive surgical resection for the treatment of IPN-B is recommended.

[Factors associated with malignancy in gallbladder polyps without gallbladder stone].

BACKGROUND/AIMS: The purpose of this study was to find the factors predicting the neoplastic polyp of gallbladder and analyze the size criteria associated with malignancy. METHODS: A total of 354 subjects with gallbladder polyps confirmed by tissue pathology were included for the analysis. The clinical and radiological features of the polyps were compared between the two groups (neoplastic vs. non-neoplastic) and in the three groups (non-neoplastic vs. adenoma vs. adenocarcinoma). The independent factors associated with malignancy were studied. RESULTS: Of 354 patients, non-neoplastic polyps were observed in 229 (64.7%) patents, adenoma in 85 (24.0%) and adenocarcinoma in 40 (11.3%). The mean diameter of non-neoplastic polyp, adenoma, and adenocarcinoma were 11.3+/-2.8 mm, 16.0+/-7.2 mm, and 27.0+/-8.9 mm, respectively. The mean age of patients with non-neoplastic polyp, adenoma, and adenocarcinoma were 44.8+/-11.3, 49.9+/-12.5, and 60.8+/-9.6, respectively. Age, size of polyp, number of polyp, presence of diabetes, and presence of symptom showed statistically significant difference between the neoplastic polyp and non-neoplastic polyp groups. But only age, size of polyp, number of polyp were statistically independent factors associated with neoplastic polyp (p<0.05). To predict the neoplastic polyp, sensitivity was 94.4%, but specificity was 18.3% on the basis of 10 mm criteria. whereas sensitivity and specificity was 76.0% and 55.5% on the 12 mm-criteria. CONCLUSIONS: On the basis of our analysis, the size of polyp is the most important factor to predict the malignancy. In the 10 mm criteria, sensitivity is satisfactory but specificity is very low. Therefore 10 mm size should not be considered to be the absolute size-criterion for surgery.

[A case of serous cystadenoma of the pancreas communicating with the pancreatic duct].

Serous cystadenoma of the pancreas is a rare disease and is usually benign. Mucinous cystadenoma, another cystic neoplasm of the pancreas, has a malignant potential. Serous cystadenoma is usually composed of many small cysts lined by small, cuboidal or flattened cells containing abundant glycogen. With the finding of endoscopic retrograde pancreatography, a communication between the cyst and pancreatic duct is observed occasionally in the mucinous cystadenoma, but rarely in the case of serous cystadenoma of the pancreas. We experienced a case of serous cystadenoma of the pancreas that had a communication between a cyst and the pancreatic duct.

[Mesenchymal hamartoma of the liver in adults].

Mesenchymal hamartoma of the liver (MHL) is a rare benign tumor usually found in childhood, especially during the first two years. MHL is extremely rare in adults. Most reported cases present with a slow growing abdominal mass. It is thought to be a developmental anomaly and consists of bile ducts, hepatocytes and mesenchymal tissue. We report a case of mesenchymal hamartoma of the liver in an adult male with a brief review of the literature.

Two Cases of Aspergillus Endocarditis in Patients with Acute Lymphoblastic Leukemia

Although Aspergillus endocarditis has rarely been reported, it can cause fatal complications in hematologic malignancy patients and allogeneic stem cell transplant recipients. We experienced two cases of aspergillus endocarditis developed in acute lymphoblastic leukemia patients. Case; A 19-year-old patient developed Aspergillus endocarditis after allogenic hemopoietic stem cell transplantation. He was treated with surgical intervention and liposomal amphotericin B. He died of recurred Aspergillus endocarditis and cerebral hemorrhage probably related with aspergillosis of central nervous system. Case 2; A 23-year-old patient developed invasive Aspergillus endocarditis after induction chemotherapy. Aspergillus endocarditis was successfully treated by surgical intervention and amphotericin B. He died of refractory neutropenic fever and sepsis after the third relapse of leukemia and repetitive chemotherapy. He probably had invasive pulmonary aspergillosis without evidence of endocarditis recurrence. Because the mortality of Aspergillus endocarditis is very high, early diagnosis and surgical intervention are very important for better outcome.

Two Cases of Aspergillus Endocarditis in Patients with Acute Lymphoblastic Leukemia

Although Aspergillus endocarditis has rarely been reported, it can cause fatal complications in hematologic malignancy patients and allogeneic stem cell transplant recipients. We experienced two cases of aspergillus endocarditis developed in acute lymphoblastic leukemia patients. Case; A 19-year-old patient developed Aspergillus endocarditis after allogenic hemopoietic stem cell transplantation. He was treated with surgical intervention and liposomal amphotericin B. He died of recurred Aspergillus endocarditis and cerebral hemorrhage probably related with aspergillosis of central nervous system. Case 2; A 23-year-old patient developed invasive Aspergillus endocarditis after induction chemotherapy. Aspergillus endocarditis was successfully treated by surgical intervention and amphotericin B. He died of refractory neutropenic fever and sepsis after the third relapse of leukemia and repetitive chemotherapy. He probably had invasive pulmonary aspergillosis without evidence of endocarditis recurrence. Because the mortality of Aspergillus endocarditis is very high, early diagnosis and surgical intervention are very important for better outcome.