External evaluation of a deep learning-based approach for automated brain volumetry in patients with huntington's disease.

A crucial step in the clinical adaptation of an AI-based tool is an external, independent validation. The aim of this study was to investigate brain atrophy in patients with confirmed, progressed Huntington's disease using a certified software for automated volumetry and to compare the results with the manual measurement methods used in clinical practice as well as volume calculations of the caudate nuclei based on manual segmentations. Twenty-two patients were included retrospectively, consisting of eleven patients with Huntington's disease and caudate nucleus atrophy and an age- and sex-matched control group. To quantify caudate head atrophy, the frontal horn width to intercaudate distance ratio and the intercaudate distance to inner table width ratio were obtained. The software mdbrain was used for automated volumetry. Manually measured ratios and automatically measured volumes of the groups were compared using two-sample t-tests. Pearson correlation analyses were performed. The relative difference between automatically and manually determined volumes of the caudate nuclei was calculated. Both ratios were significantly different between the groups. The automatically and manually determined volumes of the caudate nuclei showed a high level of agreement with a mean relative discrepancy of - 2.3 ± 5.5%. The Huntington's disease group showed significantly lower volumes in a variety of supratentorial brain structures. The highest degree of atrophy was shown for the caudate nucleus, putamen, and pallidum (all p < .0001). The caudate nucleus volume and the ratios were found to be strongly correlated in both groups. In conclusion, in patients with progressed Huntington's disease, it was shown that the automatically determined caudate nucleus volume correlates strongly with measured ratios commonly used in clinical practice. Both methods allowed clear differentiation between groups in this collective. The software additionally allows radiologists to more objectively assess the involvement of a variety of brain structures that are less accessible to standard semiquantitative methods.

Image Guided Intraoperative Radiation Therapy After Surgical Resection of Brain Metastases: A First In-Human Feasibility Report.

Purpose: A correct placement of the applicator during intraoperative radiation therapy for brain metastasis is of paramount importance, to deliver a precise and safe treatment. The applicator-to-surface contact assessment cannot be performed under direct observation because the applicator itself limits the visual range. No image guided verification is currently performed intracranially. We hypothesize that image guided intraoperative radiation therapy would assure a more precise delivery in the target area. We describe our workflow in a first in-human experience. Methods and Materials: Phantom-based measurements were performed to reach the best cone beam computed tomography imaging quality possible. Once defined, a clinical feasibility study was initiated. An in-room cone beam computed tomography device is used to acquire intraoperative images after placing the applicator. Repositioning the applicator is thereafter discussed with the surgeon, according to the imaging outcomes, if required. Results: An optimal image quality was achieved with 120-kV voltage, 20-mA current, and a tube current time product of 150 mAs. An additional 0.51 mSv patient exposure was calculated for the entire procedure. The wide dynamic range (-600 HU to +600 HU) of cone beam computed tomography and a 27 HU mean computed tomography values difference between brain tissue and spherical applicator allows distinguishing both structures. In this first in-human experience, the applicator was repositioned after evidencing air gaps, assuring full applicator-to-surface contact. Conclusions: This first in-human procedure confirmed the feasibility of kilovoltage image guided intraoperative radiation therapy in a neurosurgical setting. A prospective study has been initiated and will provide further dosimetric details.

Artificial-intelligence-based MRI brain volumetry in patients with essential tremor and tremor-dominant Parkinson's disease.

Essential tremor and Parkinson's disease patients may present with various tremor types. Overlapping tremor features can be challenging to diagnosis and misdiagnosis is common. Although underlying neurodegenerative mechanisms are suggested, neuroimaging studies arrived at controversial results and often the different tremor types were not considered. We investigated whether different tremor types displayed distinct structural brain features. Structural MRI of 61 patients with essential tremor and 29 with tremor-dominant Parkinson's disease was analysed using a fully automated artificial-intelligence-based brain volumetry to compare volumes of several cortical and subcortical regions. Furthermore, essential tremor subgroups with and without rest tremor or more pronounced postural and kinetic tremor were investigated. Deviations from an internal reference collective of age- and sex-adjusted healthy controls and volumetric differences between groups were examined; regression analysis was used to determine the contribution of disease-related factors on volumetric measurements. Compared with healthy controls, essential tremor and tremor-dominant Parkinson's disease patients displayed deviations in the occipital lobes, hippocampus, putamen, pallidum and mesencephalon while essential tremor patients exhibited decreased volumes within the nucleus caudatus and thalamus. Analysis of covariance revealed similar volumetric patterns in both diseases. Essential tremor patients without rest tremor showed a significant atrophy within the thalamus compared to tremor-dominant Parkinson's disease and atrophy of the mesencephalon and putamen were found in both subgroups compared to essential tremor with rest tremor. Disease-related factors contribute to volumes of occipital lobes in both diseases and to volumes of temporal lobes in essential tremor and the putamen in Parkinson's disease. Fully automated artificial-intelligence-based volumetry provides a fast and rater-independent method to investigate brain volumes in different neurological disorders and allows comparisons with an internal reference collective. Our results indicate that essential tremor and tremor-dominant Parkinson's disease share structural changes, indicative of neurodegenerative mechanisms, particularly of the basal-ganglia-thalamocortical circuitry. A discriminating, possibly disease-specific involvement of the thalamus was found in essential tremor patients without rest tremor and the mesencephalon and putamen in tremor-dominant Parkinson's disease and essential tremor without rest tremor.

Intraoperative or postoperative stereotactic radiotherapy for brain metastases: time to systemic treatment onset and other patient-relevant outcomes.

PURPOSE: Intraoperative radiotherapy (IORT) has become a viable treatment option for resectable brain metastases (BMs). As data on local control and radiation necrosis rates are maturing, we focus on meaningful secondary endpoints such as time to next treatment (TTNT), duration of postoperative corticosteroid treatment, and in-hospital time. METHODS: Patients prospectively recruited within an IORT study registry between November 2020 and June 2023 were compared with consecutive patients receiving adjuvant stereotactic radiotherapy (SRT) of the resection cavity within the same time frame. TTNT was defined as the number of days between BM resection and start of the next extracranial oncological therapy (systemic treatment, surgery, or radiotherapy) for each of the groups. RESULTS: Of 95 BM patients screened, IORT was feasible in 84 cases (88%) and ultimately performed in 64 (67%). The control collective consisted of 53 SRT patients. There were no relevant differences in clinical baseline features. Mean TTNT (range) was 36 (9 - 94) days for IORT patients versus 52 (11 - 126) days for SRT patients (p = 0.01). Mean duration of postoperative corticosteroid treatment was similar (8 days; p = 0.83), as was mean postoperative in-hospital time (11 versus 12 days; p = 0.97). Mean total in-hospital time for BM treatment (in- and out-patient days) was 11 days for IORT versus 19 days for SRT patients (p < 0.001). CONCLUSION: IORT for BMs results in faster completion of interdisciplinary treatment when compared to adjuvant SRT, without increasing corticosteroid intake or prolonging in-hospital times. A randomised phase III trial will determine the clinical effects of shorter TTNT.

Frequency and Characteristics of Spinal Bleeding Sources in Nontraumatic Angiogram-Negative Subarachnoid Hemorrhage.

INTRODUCTION: Angiogram-negative subarachnoid hemorrhage (AN-SAH) accounts for 5-15% of spontaneous SAH. This study aims to analyze the frequency and characteristics of spinal bleeding sources in patients with AN-SAH. METHODS: 140 patients suffering from AN-SAH treated at our institution from 2012 to 2022 were included in this retrospective cohort study. RESULTS: 52.1% were diagnosed with perimesencephalic SAH, 35.0% with non-perimesencephalic, SAH and 12.9% with CT-negative SAH (diagnosed by lumbar puncture). Additional magnetic resonance imaging (MRI) identified a spinal bleeding source in 4 patients (2.86%). These patients presented with local spine pain or neurological deficits (relative risk: 3.9706 [95% confidence interval [CI]: 0.7272-21.6792]; p < 0.001) and were younger (mean difference 14.85 years [95% CI: 0.85-28.85; p = 0.038]) compared to patients without a spinal bleeding source. CONCLUSIONS: AN-SAH caused by spinal pathology is rare. This study indicates that craniocervical and holospinal MRI should be considered in AN-SAH, especially for young patients with AN-SAH who present with back pain or neurological deficits.

MRgFUS of the nucleus ventralis intermedius in essential tremor modulates functional connectivity within the classical tremor network and beyond.

BACKGROUND: Magnetic resonance-guided focused ultrasound (MRgFUS) of the thalamic ventral intermediate nucleus is an incisionless lesional treatment for essential tremor. OBJECTIVE: To examine relationships between tremor severity and functional connectivity in patients with essential tremor and to assess long-term changes in the tremor network after sonication of the ventral intermediate nucleus. METHODS: Twenty-one patients with essential tremor (70.33 ± 11.32 years) were included in the final analysis and underwent resting state functional magnetic resonance imaging at 3 T before and 6 months after treatment. Tremor severity (Fahn-Tolosa-Marin Clinical Rating Scale) was evaluated and functional connectivity was investigated using independent component analysis. RESULTS: MRgFUS of the thalamic ventral intermediate nucleus reduced contralateral tremor effectively. Multiple regression analysis revealed exclusively negative correlations between FC and tremor severity, notably in the right cerebellar lobe VI and the left cerebellar lobe VIIIa (cerebellar network), in the left occipital fusiform gyrus (lateral visual network), the anterior division of the left superior temporal gyrus (fronto-parieto-temporal network), and in the posterior division of the left parahippocampal gyrus and the bilateral lingual gyri (default mode network). Six months after treatment, increased functional connectivity was observed in almost all tremor-associated clusters, except the cluster localized in the left cerebellum. CONCLUSIONS: Our findings suggest that tremor-related activity in essential tremor extends beyond the classical cerebellar network, additionally involving areas related to visual processing. Functional restoration of network activity after sonication of the ventral intermediate nucleus is observed within the classical tremor network (cerebellum) and notably also in visual processing areas.

Barrier films for the prevention of acute radiation dermatitis in breast cancer: A systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Radiation dermatitis (RD) is the most common side effect of adjuvant whole-breast or chest wall irradiation, majorly impacting quality of life in numerous patients. The use of barrier films (polyurethane dressings such as Hydrofilm® and Mepitel® film remaining on the skin for the duration of the radiation treatment) has been investigated as a prophylactic measure in several prospective trials. Here, we critically appraise the available evidence behind preventive barrier film application in the context of breast cancer treatment. METHODS: International literature was reviewed and high-quality randomised controlled trials (RCTs) were included in this meta-analysis. RESULTS: The results of 5 RCTs (663 patients; >90% Caucasian) were analysed. Overall, barrier films lead to improved clinician- and patient-reported outcomes: fewer grade ≥2 RD (11% vs. 42%; OR = 0.16; p < 0.001) and moist desquamation (2% vs. 16%; OR = 0.12; p = 0.006), as well as less patient-reported pain (standardised mean difference [SMD] -0.51; p < 0.001), itching (SMD -0.52; p = 0.001), burning (SMD -0.41; p = 0.011), and limitations in daily activities (SMD -0.20; p = 0.007). Furthermore, barrier films have a high acceptance rate among patients, as well as a favourable cost-benefit ratio. Possible side effects due to its application are mild and mostly self-limiting. Overall, there was a lack of information on the radiation treatment techniques used. CONCLUSION: The evidence presented in this meta-analysis suggests that barrier films are an excellent tool in the prevention of RD among Caucasian patients receiving whole-breast or chest wall irradiation. Its use should therefore be considered routinely in these patients.

Correlation between Blood Type 0 and Risk of Chronic Subdural Hematoma Recurrence: A Single Center Retrospective Cohort Study.

Chronic subdural hematoma (cSDH) is a common disease in the neurological and neurosurgical world. The recommended treatment for cSDH patients with moderate or severe neurological symptoms is surgical evacuation, but cSDH frequently recurs. The patient's ABO blood type may influence the outcome. This study aims to evaluate the correlation between cSDH recurrence and blood type O. We performed a retrospective analysis of the data of patients with cSDH who were surgically treated. Recurrence was defined as the need for re-operation within the first 12 weeks after the initial surgery. We analyzed standard demographic data, duration and type of surgery, ABO blood types, and the re-operation rate. Univariate and multivariate analyses were conducted. A total of 229 patients were included. The recurrence of hematoma was identified in 20.5% of patients. Blood type O was found to be significantly associated with cSDH recurrence leading to re-operation within 12 weeks (p = 0.02, OR 1.9, 95% CI 1.1-3.5). Thrombocyte aggregation inhibition and oral anticoagulants were not predictors of cSDH recurrence. Patients with blood type O in our cohort were identified to be at higher risk of cSDH recurrence and may, therefore, be a more vulnerable patient group. This finding needs further evaluation in larger cohorts.

Brain Volume Changes after COVID-19 Compared to Healthy Controls by Artificial Intelligence-Based MRI Volumetry.

Cohort studies that quantify volumetric brain data among individuals with different levels of COVID-19 severity are presently limited. It is still uncertain whether there exists a potential correlation between disease severity and the effects of COVID-19 on brain integrity. Our objective was to assess the potential impact of COVID-19 on measured brain volume in patients with asymptomatic/mild and severe disease after recovery from infection, compared with healthy controls, using artificial intelligence (AI)-based MRI volumetry. A total of 155 participants were prospectively enrolled in this IRB-approved analysis of three cohorts with a mild course of COVID-19 (n = 51, MILD), a severe hospitalised course (n = 48, SEV), and healthy controls (n = 56, CTL) all undergoing a standardised MRI protocol of the brain. Automated AI-based determination of various brain volumes in mL and calculation of normalised percentiles of brain volume was performed with mdbrain software, using a 3D T1-weighted magnetisation-prepared rapid gradient echo (MPRAGE) sequence. The automatically measured brain volumes and percentiles were analysed for differences between groups. The estimated influence of COVID-19 and demographic/clinical variables on brain volume was determined using multivariate analysis. There were statistically significant differences in measured brain volumes and percentiles of various brain regions among groups, even after the exclusion of patients undergoing intensive care, with significant volume reductions in COVID-19 patients, which increased with disease severity (SEV > MILD > CTL) and mainly affected the supratentorial grey matter, frontal and parietal lobes, and right thalamus. Severe COVID-19 infection, in addition to established demographic parameters such as age and sex, was a significant predictor of brain volume loss upon multivariate analysis. In conclusion, neocortical brain degeneration was detected in patients who had recovered from SARS-CoV-2 infection compared to healthy controls, worsening with greater initial COVID-19 severity and mainly affecting the fronto-parietal brain and right thalamus, regardless of ICU treatment. This suggests a direct link between COVID-19 infection and subsequent brain atrophy, which may have major implications for clinical management and future cognitive rehabilitation strategies.

Five-Fraction Stereotactic Radiotherapy for Brain Metastases-A Retrospective Analysis.

PURPOSE: To determine the safety and outcome profile of five-fraction stereotactic radiotherapy (FSRT) for brain metastases (BM), either as a definitive or adjuvant treatment. METHODS: We assessed clinical data of patients receiving five fractions of 7 Gy each (cumulative physical dose of 35 Gy) to BM or surgical cavities. The primary endpoints were toxicity and radiation necrosis (RN) rates. Secondary endpoints were 1-year cumulative local control rate (LCR) and estimated overall survival (OS). RESULTS: A total of 36 eligible patients receiving FSRT to a total of 49 targets were identified and included. The median follow up was 9 (1.1-56.2) months. The median age was 64.5 (34-92) years, the median ECOG score was 1, and the median Diagnostic-Specific Graded Prognostic Assessment (DS-GPA) score was 2. Treatment was well tolerated and there were no grade 3 adverse events or higher. The overall RN rate was 14.3% and the median time to RN was 12.9 (1.8-23.8) months. RN occurrence was associated with immunotherapy, young age (≤45 years), and large PTV. The cumulative 1-year local control rate was 83.1% and the estimated median local progression free-survival was 18.8 months. The estimated median overall survival was 11 (1.1-56.2) months and significantly superior in those patients presenting with RN. CONCLUSIONS: FSRT with 5 × 7 Gy represents a feasible, safe, and efficient fast track approach of intensified FSRT with acceptable LC and comparable RN rates for both the adjuvant and definitive RT settings.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis.

Objective: Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS). Methods: Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality. Results: Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified "PMV > 24 hrs" (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke's R2 0.38). Conclusions: Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

MAC-spinal meningioma score: A proposal for a quick-to-use scoring sheet of the MIB-1 index in sporadic spinal meningiomas.

Objective: MIB-1 index is an important predictor of meningioma progression. However, MIB-1 index is not available in the preoperative tailored medical decision-making process. A preoperative scoring sheet independently estimating MIB-1 indices in spinal meningioma (SM) patients has not been investigated so far. Methods: Between 2000 and 2020, 128 patients with clinical data, tumor imaging data, inflammatory laboratory (plasma fibrinogen, serum C-reactive protein) data, and neuropathological reports (MIB-1, mitotic count, CD68 staining) underwent surgery for spinal WHO grade 1 and 2 meningioma. Results: An optimal MIB-1 index cut-off value (≥5/<5) predicting recurrence was calculated by ROC curve analysis (AUC: 0.83; 95%CI: 0.71-0.96). An increased MIB-1 index (≥5%) was observed in 55 patients (43.0%) and multivariable analysis revealed significant associations with baseline Modified McCormick Scale ≥2, age ≥65, and absence of calcification. A four-point scoring sheet (MAC-Spinal Meningioma) based on Modified McCormick, Age, and Calcification facilitates prediction of the MIB-1 index (sensitivity 71.1%, specificity 60.0%). Among those patients with a preoperative MAC-Meningioma Score ≥3, the probability of a MIB-1 index ≥5% was 81.3%. Conclusion: This novel score (MAC-Spinal Meningioma) supports the preoperative estimation of an increased MIB-1 index, which might support preoperative patient-surgeon consultation, surgical decision making and enable a tailored follow-up schedule or an individual watch-and-wait strategy.

Benchmarking Safety Indicators of Surgical Treatment of Brain Metastases Combined with Intraoperative Radiotherapy: Results of Prospective Observational Study with Comparative Matched-Pair Analysis.

Intraoperative radiotherapy (IORT) of the operative cavity for surgically treated brain metastasis (BM) has gained increasing prominence with respect to improved local tumor control. However, IORT immediately performed at the time of surgery might be associated with increased levels of perioperative adverse events (PAEs). In the present study, we performed safety metric profiling in patients who had undergone surgery for BM with and without IORT in order to comparatively analyze feasibility of IORT as an adjuvant radiation approach. Between November 2020 and October 2021, 35 patients were surgically treated for BM with IORT at our neuro-oncological center. Perioperative complication profiles were collected in a prospective observational cohort study by means of patient safety indicators (PSIs), hospital-acquired conditions (HACs), and specific cranial-surgery-related complications (CSCs) as high-standard quality metric tools and compared to those of an institutional cohort of 388 patients with BM resection without IORT in a balanced comparative matched-pair analysis. Overall, 4 out of 35 patients (11%) with IORT in the course BM resection suffered from PAEs, accounting for 3 PSIs (9%) and 1 HAC (3%). Balanced matched-pair analysis did not reveal significant differences in the perioperative complication profiles between the cohorts of patients with and without IORT (p = 0.44). Thirty-day mortality rates were 6% for patients with IORT versus 8% for patients without IORT (p = 0.73). The present study demonstrates that IORT constitutes a safe and clinically feasible adjuvant treatment modality in patients undergoing surgical resection of BM.

Detection of Degenerative Changes on MR Images of the Lumbar Spine with a Convolutional Neural Network: A Feasibility Study.

Our objective was to evaluate the diagnostic performance of a convolutional neural network (CNN) trained on multiple MR imaging features of the lumbar spine, to detect a variety of different degenerative changes of the lumbar spine. One hundred and forty-six consecutive patients underwent routine clinical MRI of the lumbar spine including T2-weighted imaging and were retrospectively analyzed using a CNN for detection and labeling of vertebrae, disc segments, as well as presence of disc herniation, disc bulging, spinal canal stenosis, nerve root compression, and spondylolisthesis. The assessment of a radiologist served as the diagnostic reference standard. We assessed the CNN's diagnostic accuracy and consistency using confusion matrices and McNemar's test. In our data, 77 disc herniations (thereof 46 further classified as extrusions), 133 disc bulgings, 35 spinal canal stenoses, 59 nerve root compressions, and 20 segments with spondylolisthesis were present in a total of 888 lumbar spine segments. The CNN yielded a perfect accuracy score for intervertebral disc detection and labeling (100%), and moderate to high diagnostic accuracy for the detection of disc herniations (87%; 95% CI: 0.84, 0.89), extrusions (86%; 95% CI: 0.84, 0.89), bulgings (76%; 95% CI: 0.73, 0.78), spinal canal stenoses (98%; 95% CI: 0.97, 0.99), nerve root compressions (91%; 95% CI: 0.89, 0.92), and spondylolisthesis (87.61%; 95% CI: 85.26, 89.21), respectively. Our data suggest that automatic diagnosis of multiple different degenerative changes of the lumbar spine is feasible using a single comprehensive CNN. The CNN provides high diagnostic accuracy for intervertebral disc labeling and detection of clinically relevant degenerative changes such as spinal canal stenosis and disc extrusion of the lumbar spine.

Sudden paraparesis due to spinal cord ischemia with initial contrast enhancement of the cauda equina and time-delayed owl-eyes sign on follow-up MR imaging: a case report.

We report on a case of a 52-year-old male with sudden paraparesis. The initial MRI showed contrast enhancement of the conus medullaris and the complete cauda equina. Follow-up MRI revealed a spinal ischemia in the anterior portion of the spinal cord. Only a few reports with similar findings have been published. We suggest that contrast enhancement of the conus medullaris and descending nerve roots can be a potential first indicator of a spinal cord ischemia.

Diagnostic Accuracy of Quantitative Imaging Biomarkers in the Differentiation of Benign and Malignant Vertebral Lesions : Combination of Diffusion-Weighted and Proton Density Fat Fraction Spine MRI.

PURPOSE: To compare and combine the diagnostic performance of the apparent diffusion coefficient (ADC) derived from diffusion-weighted imaging (DWI) and proton density fat fraction (PDFF) derived from chemical-shift encoding (CSE)-based water-fat magnetic resonance imaging (MRI) for distinguishing benign and malignant vertebral bone marrow lesions (VBML). METHODS: A total of 55 consecutive patients with 53 benign (traumatic, inflammatory and primary) and 36 malignant (metastatic and hematologic) previously untreated VBMLs were prospectively enrolled in this IRB-approved study and underwent sagittal DWI (single-shot spin-echo echo-planar with multi-slice short TI inversion recovery fat suppression) and CSE-based MRI (gradient-echo 6­point modified Dixon) in addition to routine clinical spine MRI at 1.5 T or 3.0 T. Diagnostic reference standard was established according to histopathology or imaging follow-up. The ADC = ADC (0, 800) and PDFF = fat / (water + fat) were calculated voxel-wise and examined for differences between benign and malignant lesions. RESULTS: The ADC and PDFF values of malignant lesions were significantly lower compared to benign lesions (mean ADC 861â€¯× 10-6 mm2/s vs. 1323â€¯× 10-6 mm2/s, p < 0.001; mean PDFF 3.1% vs. 28.2%, p < 0.001). The areas under the curve (AUC) and diagnostic accuracies were 0.847 (p < 0.001) and 85.4% (cut-off at 1084.4â€¯× 10-6 mm2/s) for ADC and 0.940 (p < 0.001) and 89.9% for PDFF (cut-off at 7.8%), respectively. The combined use of ADC and PDFF improved the diagnostic accuracy to 96.6% (malignancy if ADC ≤ 1118.2â€¯× 10-6 mm2/s and PDFF ≤ 20.0%, otherwise benign). CONCLUSION: Quantitative evaluation of both ADC and PDFF was useful in differentiating benign VBMLs from malignancy. The combination of ADC and PDFF improved the diagnostic performance and yielded high diagnostic accuracy for the differentiation of benign and malignant VBMLs.

Proton Density Fat Fraction Spine MRI for Differentiation of Erosive Vertebral Endplate Degeneration and Infectious Spondylitis.

Vertebral Modic type 1 (MT1) degeneration may mimic infectious disease on conventional spine magnetic resonance imaging (MRI), potentially leading to additional costly and invasive investigations. This study evaluated the diagnostic performance of the proton density fat fraction (PDFF) for distinguishing MT1 degenerative endplate changes from infectious spondylitis. A total of 31 and 22 patients with equivocal diagnosis of MT1 degeneration and infectious spondylitis, respectively, were retrospectively enrolled in this IRB-approved retrospective study and examined with a chemical-shift encoding (CSE)-based water-fat 3D six-echo modified Dixon sequence in addition to routine clinical spine MRI. Diagnostic reference standard was established according to histopathology or clinical and imaging follow-up. Intravertebral PDFF [%] and PDFFratio (i.e., vertebral endplate PDFF/normal vertebrae PDFF) were calculated voxel-wise within the single most prominent edematous bone marrow lesion per patient and examined for differences between MT1 degeneration and infectious spondylitis. Mean PDFF and PDFFratio of infectious spondylitis were significantly lower compared to MT1 degenerative changes (mean PDFF, 4.28 ± 3.12% vs. 35.29 ± 17.15% [p < 0.001]; PDFFratio, 0.09 ± 0.06 vs. 0.67 ± 0.37 [p < 0.001]). The areas under the curve (AUC) and diagnostic accuracies were 0.977 (p < 0.001) and 98.1% (cut-off at 12.9%) for PDFF and 0.971 (p < 0.001) and 98.1% (cut-off at 0.27) for PDFFratio. Our data suggest that quantitative evaluation of vertebral PDFF can provide a high diagnostic accuracy for differentiating erosive MT1 endplate changes from infectious spondylitis.

Objective Evaluation of Risk Factors for Radiation Dermatitis in Whole-Breast Irradiation Using the Spectrophotometric L*a*b Color-Space.

Background: Radiation-induced dermatitis (RID) is frequent in breast cancer patients undergoing radiotherapy (RT). Spectrophotometry (SP) is an objective and reliable tool for assessing RID severity. Despite intensive research efforts during the past decades, no sustainable prophylactic and treatment strategies have been found. Estimation of new and reevaluation of established risk factors leading to severe RID is therefore of major importance. Methods: 142 early breast cancer patients underwent whole-breast irradiation following breast-conserving surgery. RID was evaluated by physician-assessed Common Terminology Criteria of Adverse Events (CTCAE v4.03). Spectrophotometers provided additional semi quantification of RID using the L*a*b color-space. A total of 24 patient- and treatment-related parameters as well as subjective patient-assessed symptoms were analyzed. Results: Values for a*max strongly correlated with the assessment of RID severity by physicians. Breast volume, initial darker skin, boost administration, and treatment technique were identified as risk factors for severe RID. RID severity positively correlated with the patients' perception of pain, burning, and reduction of everyday activities. Conclusions: Physician-assessed RID gradings correlate with objective SP skin measurements. Treatment technique and high breast volumes were identified as objective and significant predictors of RID. Our data provide a solid benchmark for future studies on RID with objective SP.

Acute radiation-induced skin toxicity in hypofractionated vs. conventional whole-breast irradiation: An objective, randomized multicenter assessment using spectrophotometry.

PURPOSE: Radiation dermatitis represents one of the most frequent side effects in breast cancer patients undergoing adjuvant whole-breast irradiation (WBI). Whether hypofractionated WBI induces comparable or less acute radiation-induced skin reactions than conventional WBI is still not fully clarified, as randomized evidence and objective assessments are limited. The aim of this study was to objectively determine frequency and severity of acute radiation-induced skin reactions during hypofractionated vs. conventionally fractionated adjuvant WBI. METHODS: In this randomized multicenter study, a total of 140 breast cancer patients underwent either hypofractionated or conventional WBI following breast-preserving surgery. Maximum radiation dermatitis severity was assessed at completion and during follow-up by physician-assessed CTCAE v4.03 and the patient-reported RISRAS scale. Additionally, photospectrometric skin readings were performed to objectify skin color differences between both treatment arms. RESULTS: Radiation dermatitis severity was significantly lower in patients receiving hypofractionation compared with conventional fractionation (mean 1.05 vs. 1.43, p = .024). Grade 0 radiation dermatitis occurred in 21.43% vs. 4.28%, grade ≥2 in 27.14% vs. 42.91% and grade ≥3 in 0% vs. 4.34% of patients following hypofractionated and conventional WBI, respectively. Objective photospectrometric measurements (n = 4200) showed both decreased erythema severity (p = .008) and hyperpigmentation (p = .002) in the hypofractionation arm. Patients allocated to hypofractionated WBI also reported less pain (p = .006), less hyperpigmentation (p = <0.001) and less limitations of day-to-day activities (p = <0.001). CONCLUSION: Physician and patient-assessed toxicity scorings as well as objective photospectrometric skin measurements revealed that hypofractionated WBI yielded lower rates and severity of acute radiation-induced skin toxicity.

Total body irradiation: Significant dose sparing of lung tissue achievable by helical tomotherapy.

PURPOSE: Total body irradiation (TBI) is an important procedure in the conditioning for bone marrow and hematopoietic stem cell transplantation. Doses up to 12Gy are delivered in hyperfractionated regimes. TBI performed with helical Tomotherapy® (Accuray, Madison, Wisconsin, USA) is an alternative to conventional techniques to deliver dose in extended target volumes with the possibility of simultaneous dose sparing to organs at risk. In this study we focused on maximum dose reduction to the lungs in TBI using helical Tomotherapy®. MATERIAL AND METHODS: Forty treatment plans of patients who received TBI were calculated with TomoH® (Accuray, Madison, Wisconsin, USA, Version 2.0.4) with a dose of 12Gy delivered in six equal fractions (2×2Gy/day). Planning iterations necessary to accomplish ICRU 83 report should be less than 250. Treatment time should be practicable in daily routine (<60min.). Besides the usual contouring of organs at risk special contouring was required for optimization processes which focused on maximum dose sparing in the central lung tissue. Dose constraints (D2, D98, D99) were predefined for target volumes (i.e. PTV TBI D99: 90% of prescribed dose). Homogeneity index <0.15 was defined for acceptability of the treatment plan. RESULTS: For all patients acceptable treatment plan fulfilling the predefined constraints were achievable. An average time of 46min is required for treatment. Thirty-four of forty patients fulfilled D2 in the PTV TBI. Four patients failed D2 due to a high BMI >28 (maximum dose 13.76Gy=114.7%). The D98 in the PTV TBI was not reached by 2/40 patients due to BMI>31 (minimum dose 11.31Gy=dose coverage of 94.2%). Also these two patients failed the homogeneity index <0.15. The mean lung dose over all patients of the right lung was 7.18Gy (range 6.4-9.5Gy). The left lung showed a median (D50) dose of 7.9Gy (range 6.7-9.3Gy). Central lung dose showed a mean dose (D50) of 5.16Gy (range 4.02-7.29Gy). The D80 of the central lung showed an average dose of 3.87Gy. CONCLUSIONS: Total body irradiation using helical Tomotherapy® can be delivered with maximum lung tissue sparing (<6Gy) but without compromise in adjacent PTV TBI structures (i.e. ribs, heart). High conformity and homogeneity in extended radiation volumes can be reached with this technique in an acceptable planning and treatment time. Limitations may occurred in patients with high body mass index.