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The latest global health threat is the ongoing outbreak of respiratory disease, which was named COVID-19 and multiple ever-evolving neurological complications have since been reported. We present the case of a patient with a bilateral tonic pupil in the postinfectious context of COVID-19. Brain magnetic resonance imaging and laboratory tests were normal, a 0.125% pilocarpine test confirmed the diagnosis.
RESUMO
The latest global health threat is the ongoing outbreak of respiratory disease, which was named COVID-19 and multiple ever-evolving neurological complications have since been reported. We present the case of a patient with a bilateral tonic pupil in the postinfectious context of COVID 19. Brain magnetic resonance imaging and laboratory tests were normal, a 0.125% pilocarpine test confirmed the diagnosis.
Assuntos
COVID-19/complicações , Pupila Tônica/etiologia , Adulto , Feminino , HumanosRESUMO
La última amenaza para la salud a nivel mundial es el continuo brote de la enfermedad respiratoria, que recibió el nombre de COVID-19, y desde entonces se han publicado múltiples complicaciones neurológicas que están en constante evolución. Presentamos el caso de un paciente con pupila tónica bilateral en el contexto postinfeccioso de COVID-19. La resonancia magnética cerebral y los estudios analíticos fueron normales, una prueba de pilocarpina al 0,125% confirmó el diagnóstico (AU)
The latest global health threat is the ongoing outbreak of respiratory disease, which was named COVID-19 and multiple ever-evolving neurological complications have since been reported. We present the case of a patient with a bilateral tonic pupil in the postinfectious context of COVID-19. Brain magnetic resonance imaging and laboratory tests were normal, a 0.125% pilocarpine test confirmed the diagnosis (AU)
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Humanos , Feminino , Adulto , Pupila Tônica/virologia , Infecções por Coronavirus/complicações , Pandemias , Pupila Tônica/diagnóstico por imagem , Imageamento por Ressonância MagnéticaRESUMO
BACKGROUND AND PURPOSE: The FiGaRO trial assessed the feasibility and safety of using an FDG-PET-based dose-painting technique to deliver a radiotherapy (RT) boostto the FDG-avid primary tumour in patients with locally advanced high and intermediate risk oropharyngeal cancer. MATERIALS AND METHOD: Patients underwent a planning 18FDG-PET-CT scan, immobilised in the treatment position, after one cycle of induction chemotherapy. The volume of persistent FDG-avidity in the primary tumour was escalated to 71.5 Gy in30 fractions delivered using a simultaneous integrated boost Intensity Modulated RT (SIB-IMRT) technique. RT was delivered with concomitant Cisplatin following 2 cycles of induction chemotherapy. The primary outcome was the incidence of grade ≥ 3 late mucosal toxicity 12 months post-treatment, with an excess rate of >10% regarded as unacceptable. RESULTS: Twenty-nine patients were included and twenty-four were treated between 2014 and 2018, in two UK centres. Median follow-up was 36 months (range 4-56 months). Pre-defined planning target volume objectives and organ at risk dose constraints were met in all cases. There were no incidents of acute grade 4 toxicity. There were 4 cases of grade ≥ 3 mucosal toxicity at 12 months post-treatment (19.1%). There were no cases of persistent mucosal ulceration at 12 months. Overall survival at 3-years was 87.5%, 92.9% for intermediate and 70.0% for high risk patients. CONCLUSION: Late toxicity rates, although higher than anticipated, are comparable to contemporary published data for standard dose chemo-IMRT. Results suggest improved 3y survival rates for high risk patients. This approach merits further investigation. ClinicalTrials.gov Identifier: NCT02953197.
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Neoplasias Orofaríngeas , Radioterapia de Intensidade Modulada , Fluordesoxiglucose F18 , Humanos , Neoplasias Orofaríngeas/diagnóstico por imagem , Neoplasias Orofaríngeas/radioterapia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Dosagem Radioterapêutica , Radioterapia de Intensidade Modulada/efeitos adversosRESUMO
PURPOSE: An accurate assessment of out-of-field dose is necessary to estimate the risk of second cancer after radiotherapy and the damage to the organs at risk surrounding the planning target volume. Although treatment planning systems (TPSs) calculate dose distributions outside the treatment field, little is known about the accuracy of these calculations. The aim of this work is to thoroughly compare the out-of-field dose distributions given by two algorithms implemented in the Monaco TPS, with measurements and full Monte Carlo simulations. METHODS: Out-of-field dose distributions predicted by the collapsed cone convolution (CCC) and Monte Carlo (MCMonaco ) algorithms, built into the commercially available Monaco version 5.11 TPS, are compared with measurements carried out on an Elekta Axesse linear accelerator. For the measurements, ion chambers, thermoluminescent dosimeters, and EBT3 film are used. The BEAMnrc code, built on the EGSnrc system, is used to create a model of the Elekta Axesse with the Agility collimation system, and the space phase file generated is scored by DOSXYZnrc to generate the dose distributions (MCEGSnrc ). Three different irradiation scenarios are considered: (a) a 10 × 10 cm2 field, (b) an IMRT prostate plan, and (c) a three-field lung plan. Monaco's calculations, experimental measurements, and Monte Carlo simulations are carried out in water and/or in an ICRP110 phantom. RESULTS: For the 10 × 10 cm2 field case, CCC underestimated the dose, compared to ion chamber measurements, by 13% (differences relative to the algorithm) on average between the 5% and the ≈2% isodoses. MCMonaco underestimated the dose only from approximately the 2% isodose for this case. Qualitatively similar results were observed for the studied IMRT case when compared to film dosimetry. For the three-field lung plan, dose underestimations of up to ≈90% for MCMonaco and ≈60% for CCC, relative to MCEGSnrc simulations, were observed in mean dose to organs located beyond the 2% isodose. CONCLUSIONS: This work shows that Monaco underestimates out-of-field doses in almost all the cases considered. Thus, it does not describe dose distribution beyond the border of the field accurately. This is in agreement with previously published works reporting similar results for other TPSs. Analytical models for out-of-field dose assessment, MC simulations or experimental measurements may be an adequate alternative for this purpose.
Assuntos
Aceleradores de Partículas , Planejamento da Radioterapia Assistida por Computador , Algoritmos , Método de Monte Carlo , Imagens de Fantasmas , Radiometria , Dosagem RadioterapêuticaRESUMO
PURPOSE: To perform a systematic and thorough assessment, using the Uncomplicated and Cancer-Free Control Probability (UCFCP) function, of a broad range of photon prostate cancer RT treatments, on the same scenario (a unique pelvic CT set). UCFCP considers, together with the probabilities of local tumour control (TCP) and deterministic (late) sequelae (NTCP), the second primary cancer risk (SPCR) due to photon and neutron peripheral doses. METHODS AND MATERIALS: Thirty-six radiotherapy plans were produced for the same CT. 6, 10, 15 and 18 MV 3DCRT, IMRT and VMAT (77.4â¯Gy in 43 fractions) and 6 and 10 MV SBRT (36.25â¯Gy in 5 fractions with flattened and FFF beams) for Elekta, Siemens and Varian Linacs plans were included. DVH and peripheral organ dosimetry were used to compute TCP, NTCP, and SPCR (the competition and LNT models) for further plan ranking. RESULTS: Biological models (and parameters) used predicted an outcome which is in agreement with epidemiological findings. SBRT plans showed the lowest SPCR and a below average NTCPrectal. High energy plans did not rank worse than the low energy ones. Intensity modulated plans were ranked above the 3D conformal techniques. CONCLUSIONS: According to UCFCP, the best plans were the10 MV SBRTs. SPCR rates were low and did not show a substantial impact on plan ranking. High energy intensity-modulated plans did not increase in excess the average of SPCR. Even more, they ranked among the best, provided that MU were efficiently managed.
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Fótons/uso terapêutico , Neoplasias da Próstata/radioterapia , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia Conformacional , Humanos , Masculino , Probabilidade , Neoplasias da Próstata/diagnóstico por imagem , Dosagem Radioterapêutica , Radioterapia de Intensidade Modulada , Tomografia Computadorizada por Raios XRESUMO
There is a growing interest in the combined use of Stereotactic Body Radiation Therapy (SBRT) with Flattening Filter Free (FFF) due to the high local control rates and reduced treatment times, compared to conventionally fractionated treatments. It has been suggested that they may also provide a better radiation protection to radiotherapy patients as a consequence of the expected decrease in peripheral doses. This work aims to determine this reduction in unattended out-of-field regions, where no CT information is available but an important percentage of second primary cancers occur. For that purpose, ten different cases suitable for SBRT were chosen. Thus, 142 different treatment plans including SBRT, as well as 3D-CRT, IMRT and VMAT (with standard fractionation) in low and high energies for Varian (FF and FFF), Siemens and Elekta machines were created. Then, photon and neutron peripheral dose in 14 organs were assessed and compared using two analytical models. For the prostate case, uncomplicated and cancer free control probability estimation was also carried out. As a general behavior, SBRT plans led to the lowest peripheral doses followed by 3D-CRT, VMAT and IMRT, in this order. Unflattened beams proved to be the most effective in reducing peripheral doses, especially for 10 MV. The obtained results suggest that FFF beams for SBRT with 10 MV represent the best compromise between dose delivery efficiency and peripheral dose reduction.
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Filtração/instrumentação , Segunda Neoplasia Primária/epidemiologia , Neoplasias/cirurgia , Radiocirurgia/métodos , Planejamento da Radioterapia Assistida por Computador/métodos , Filtração/métodos , Humanos , Incidência , Neoplasias/classificação , Neoplasias/patologia , Segunda Neoplasia Primária/diagnóstico , Órgãos em Risco/efeitos da radiação , Prognóstico , Dosagem Radioterapêutica , Espanha/epidemiologiaRESUMO
Cancer of unknown primary (CUP) is defined as a heterogeneous group of tumours that present with metastasis, and in which attempts to identify the original site have failed. They differ from other primary tumours in their biological features and how they spread, which means that they can be considered a separate entity. There are several hypotheses regarding their origin, but the most plausible explanation for their aggressiveness and chemoresistance seems to involve chromosomal instability. Depending on the type of study done, CUP can account for 2-9% of all cancer patients, mostly 60-75 years old. This article reviews the main clinical, pathological, and molecular studies conducted to analyse and determine the origin of CUP. The main strategies for patient management and treatment, by both clinicians and pathologists, are also addressed
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Humanos , Neoplasias Primárias Desconhecidas/diagnóstico , Metástase Neoplásica/patologia , Neoplasias/classificação , Neoplasias Primárias Desconhecidas/terapia , Padrões de Prática Médica , Consenso , Imuno-Histoquímica , Biópsia , Biomarcadores Tumorais/análiseRESUMO
Cancer of unknown primary (CUP) is defined as a heterogeneous group of tumours that present with metastasis, and in which attempts to identify the original site have failed. They differ from other primary tumours in their biological features and how they spread, which means that they can be considered a separate entity. There are several hypotheses regarding their origin, but the most plausible explanation for their aggressiveness and chemoresistance seems to involve chromosomal instability. Depending on the type of study done, CUP can account for 2-9% of all cancer patients, mostly 60-75 years old. This article reviews the main clinical, pathological, and molecular studies conducted to analyse and determine the origin of CUP. The main strategies for patient management and treatment, by both clinicians and pathologists, are also addressed.
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Oncologia/normas , Neoplasias Primárias Desconhecidas/diagnóstico , Neoplasias Primárias Desconhecidas/terapia , Patologia Clínica/normas , Idoso , Consenso , Humanos , Oncologia/organização & administração , Pessoa de Meia-Idade , Patologia Clínica/organização & administração , Sociedades Médicas/organização & administração , Sociedades Médicas/normas , EspanhaRESUMO
PURPOSE: Neutron peripheral contamination in high-energy radiotherapy implies an increase of secondary radiation-induced cancer risk. Although peripheral neutron dose (PND) has been evaluated in organs, few studies have been performed regarding patient size. This work aims to improve an existing methodology for adult patient PND estimations to generalize it to young and children, for its implementation in treatment planning systems (TPS). METHODS: As a first step, we aimed to generalize the previous model to be usable with any thermal neutron detector. Then, taking into account total neutron spectra and dose-to-point thermal neutron fluence measurements for three phantom sizes (adult, teen and child) and two common treatment locations (H&N and abdomen), the new model was proposed. It represents an upgraded parameterization and extension of the existing one, including patient anatomy. Finally, comparison between estimations and measurements, as well as validation against the original model, was carried out for 510 measured patients. RESULTS: Concordance found between experimental and theoretical estimations makes us confident about later implementation in treatment planning systems. Comparison among the previous and upgraded models shows no significant differences for the adult case. However, an important underestimation (34.1% on average) can be observed regarding child case for the original one. CONCLUSIONS: An improved generalization of an existing PND model, considering patient anatomy has been validated and used in real patients. The final methodology is easily implementable in clinical routine and TPS thanks to the ready availability of input parameters (patient height and weight, high-energy MU and facility characterization).
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Modelos Teóricos , Nêutrons/uso terapêutico , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia , Adolescente , Adulto , Criança , Simulação por Computador , Humanos , Método de Monte Carlo , Neoplasias Induzidas por Radiação/prevenção & controle , Fótons/uso terapêutico , Radioterapia/instrumentaçãoRESUMO
One of the major causes of secondary malignancies after radiotherapy treatments are peripheral doses, known to increase for some newer techniques (such as IMRT or VMAT). For accelerators operating above 10MV, neutrons can represent important contribution to peripheral doses. This neutron contamination can be measured using different passive or active techniques, available in the literature. As far as active (or direct-reading) procedures are concerned, a major issue is represented by their parasitic photon sensitivity, which can significantly affect the measurement when the point of test is located near to the field-edge. This work proposes a simple method to estimate the unwanted photon contribution to these neutrons. As a relevant case study, the use of a recently neutron sensor for "in-phantom" measurements in high-energy machines was considered. The method, called "Dual Energy Photon Subtraction" (DEPS), requires pairs of measurements performed for the same treatment, in low-energy (6MV) and high energy (e.g. 15MV) fields. It assumes that the peripheral photon dose (PPD) at a fixed point in a phantom, normalized to the unit photon dose at the isocenter, does not depend on the treatment energy. Measurements with ionization chamber and Monte Carlo simulations were used to evaluate the validity of this hypothesis. DEPS method was compared to already published correction methods, such as the use of neutron absorber materials. In addition to its simplicity, an advantage of DEPs procedure is that it can be applied to any radiotherapy machine.
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Nêutrons Rápidos , Fótons , Radiometria/métodos , Dosagem Radioterapêutica , Simulação por Computador , Nêutrons Rápidos/efeitos adversos , Humanos , Método de Monte Carlo , Neoplasias Induzidas por Radiação/etiologia , Segunda Neoplasia Primária/etiologia , Imagens de Fantasmas , Fótons/efeitos adversos , Radiometria/instrumentação , Radiometria/estatística & dados numéricos , Radioterapia de Intensidade Modulada/efeitos adversos , Espalhamento de RadiaçãoRESUMO
This article analyses the potential use of double emulsions as silicon delivery systems with reference to the influence of the composition of the inner aqueous phase (W1, containing NaCl and sodium caseinate or gelatin) on silicon encapsulation and physicochemical properties of food-grade W1/O/W2. Irrespective of W1, DEs initially showed a well-defined monomodal distribution, with the widest range registering in the sample with gelatin. All samples developed a bimodal distribution during storage (3 ± 2 °C). Heating increased the range of droplet size distribution. DEs exhibited high physical stability (creaming), decreasing over storage; this behaviour was generally unaffected by W1 composition, which maintained similar stability (95-96%) at the end of storage. Viscosity was generally unaffected by formulation, storage time or heating treatment. Si encapsulation efficiency (72.4 and 78.3%) was not affected by W1 composition, while Si encapsulation stability was generally unaffected by either storage or heating. These DEs can be used as potential ingredient (with lower fat content, better fatty acid profile and with the potential Si health benefits) for the development of healthier foods including meat products.
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The increasing interest of the medical community to radioinduced second malignancies due to photoneutrons in patients undergoing high-energy radiotherapy, has stimulated in recent years the study of peripheral doses, including the development of some dedicated active detectors. Although these devices are designed to respond to neutrons only, their parasitic photon response is usually not identically zero and anisotropic. The impact of these facts on measurement accuracy can be important, especially in points close to the photon field-edge. A simple method to estimate the photon contribution to detector readings is to cover it with a thermal neutron absorber with reduced secondary photon emission, such as a borated rubber. This technique was applied to the TNRD (Thermal Neutron Rate Detector), recently validated for thermal neutron measurements in high-energy photon radiotherapy. The positive results, together with the accessibility of the method, encourage its application to other detectors and different clinical scenarios.
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Nêutrons , Radiometria , Radioterapia de Alta Energia , Humanos , FótonsRESUMO
Active thermal neutron detectors are used in a wide range of measuring devices in medicine, industry and research. For many applications, the long-term stability of these devices is crucial, so that very well controlled neutron fields are needed to perform calibrations and repeatability tests. A way to achieve such reference neutron fields, relying on a 3 MV Tandem Pelletron accelerator available at the CNA (Seville, Spain), is reported here. This paper shows thermal neutron field production and reproducibility characteristics over few days.
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Nêutrons , Aceleradores de Partículas , Calibragem , Desenho de Equipamento , Humanos , Radiometria/instrumentação , Radiometria/estatística & dados numéricos , Reprodutibilidade dos Testes , EspanhaRESUMO
PURPOSE: Knowing the contribution of neutron to collateral effects in treatments is both a complex and a mandatory task. This work aims to present an operative procedure for neutron estimates in any facility using a neutron digital detector. METHODS: The authors' previous work established a linear relationship between the total second cancer risk due to neutrons (TR(n)) and the number of MU of the treatment. Given that the digital detector also presents linearity with MU, its response can be used to determine the TR(n) per unit MU, denoted as m, normally associated to a generic Linac model and radiotherapy facility. Thus, from the number of MU of each patient treatment, the associated risk can be estimated. The feasibility of the procedure was tested by applying it in eight facilities; patients were evaluated as well. RESULTS: From the reading of the detector under selected irradiation conditions, m values were obtained for different machines, ranging from 0.25 × 10(-4)% per MU for an Elekta Axesse at 10 MV to 6.5 × 10(-4)% per MU for a Varian Clinac at 18 MV. Using these values, TR(n) of patients was estimated in each facility and compared to that from the individual evaluation. Differences were within the range of uncertainty of the authors' methodology of equivalent dose and risk estimations. CONCLUSIONS: The procedure presented here allows an easy estimation of the second cancer risk due to neutrons for any patient, given the number of MU of the treatment. It will enable the consideration of this information when selecting the optimal treatment for a patient by its implementation in the treatment planning system.
Assuntos
Modelos Biológicos , Segunda Neoplasia Primária/etiologia , Nêutrons/efeitos adversos , Radiocirurgia/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Segunda Neoplasia Primária/epidemiologia , Radiometria , RiscoRESUMO
PURPOSE: Peripheral dose in radiotherapy treatments represents a potential source of secondary neoplasic processes. As in the last few years, there has been a fast-growing concern on neutron collateral effects, this work focuses on this component. A previous established methodology to estimate peripheral neutron equivalent doses relied on passive (TLD, CR39) neutron detectors exposed in-phantom, in parallel to an active [static random access memory (SRAMnd)] thermal neutron detector exposed ex-phantom. A newly miniaturized, quick, and reliable active thermal neutron detector (TNRD, Thermal Neutron Rate Detector) was validated for both procedures. This first miniaturized active system eliminates the long postprocessing, required for passive detectors, giving thermal neutron fluences in real time. METHODS: To validate TNRD for the established methodology, intrinsic characteristics, characterization of 4 facilities [to correlate monitor value (MU) with risk], and a cohort of 200 real patients (for second cancer risk estimates) were evaluated and compared with the well-established SRAMnd device. Finally, TNRD was compared to TLD pairs for 3 generic radiotherapy treatments through 16 strategic points inside an anthropomorphic phantom. RESULTS: The performed tests indicate similar linear dependence with dose for both detectors, TNRD and SRAMnd, while a slightly better reproducibility has been obtained for TNRD (1.7% vs 2.2%). Risk estimates when delivering 1000 MU are in good agreement between both detectors (mean deviation of TNRD measurements with respect to the ones of SRAMnd is 0.07 cases per 1000, with differences always smaller than 0.08 cases per 1000). As far as the in-phantom measurements are concerned, a mean deviation smaller than 1.7% was obtained. CONCLUSIONS: The results obtained indicate that direct evaluation of equivalent dose estimation in organs, both in phantom and patients, is perfectly feasible with this new detector. This will open the door to an easy implementation of specific peripheral neutron dose models for any type of treatment and facility.
Assuntos
Nêutrons , Radiometria/instrumentação , Radiometria/métodos , Radioterapia/métodos , Antropometria , Calibragem , Estudos de Coortes , Desenho de Equipamento , Humanos , Modelos Estatísticos , Neoplasias/diagnóstico , Neoplasias/diagnóstico por imagem , Neoplasias/radioterapia , Imagens de Fantasmas , Doses de Radiação , Radiografia , Dosagem Radioterapêutica , Análise de Regressão , Reprodutibilidade dos Testes , Medição de RiscoRESUMO
Data from a divergent experiment for birthweight (BrW) environmental variability were used to estimate genetic parameters for BrW trait and its environmental variability by fitting both homoscedastic (HO) and heteroscedastic (HE) models. A total of 5 475 records of BrW from animals born from inbred dams, and 7 140 pedigree records were used. The heritability of BrW using the model HO was 0.27, with the litter effect much more important, 0.43. The model HE provided a genetic correlation between the trait and its environmental variability that was very high and negative, -0.97, and a high value for the additive genetic variance for environmental variability, suggesting an artefact in the model. The residual skewness was found to be essentially null. A model considering the genetic correlation null was also fitted, and used to obtain the breeding values for the selection process. Moreover, the trait was considered as maternal resulting in similar estimates under the model HO, but more reasonable for the genetic correlation between the trait and its environmental variability of 0.48 with a value of 0.25 for the additive genetic variance regarding environmental variability under the model HE. This led to the conclusion that environmental variability of BrW in mice must be selected via dams. Estimated parameters in a reduced dataset without inbred animals did not substantially change this conclusion.
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Peso ao Nascer/genética , Meio Ambiente , Modelos Genéticos , Animais , Feminino , Endogamia , Masculino , Camundongos , MãesRESUMO
El síndrome de uñas amarillas es una enfermedad muy poco frecuente, con alrededor de 200 casos comunicados hasta la actualidad, que se caracteriza por la presencia de dos o más de las siguientes manifestaciones: uñas amarillas, afectación pulmonar y afectación linfática con linfedema. Es una entidad poco conocida y, por lo tanto, poco diagnosticada. Por su rareza, presentamos un nuevo caso de síndrome de las uñas amarillas en un varón de 56 años de edad con bronquiectasias infectadas y mielopatía cervical (AU)
The yellow nail syndrome is a very rare disease, with about 200 cases repoted to date, which is characterized by the presence of two or more of the following manifestations: yellow nails, lung involvement and lymphatic involvement with lymphedema. It is a barely known and therefore not diagnosed. We present a new case of yellow nail syndrome in a 56 year old man with infected bronchiestasis and cervical myelopaty (AU)