Selective Ophthalmic Artery Chemotherapy with Melphalan in the Management of Unilateral Retinoblastoma: A Prospective Study.

PURPOSE: To determine prospectively the efficacy and to assess potential side effects of melphalan selective ophthalmic artery chemotherapy (SOAC) as first-line treatment for unilateral retinoblastoma. DESIGN: Phase 2 nonrandomized, prospective study. PARTICIPANTS: Patients with unilateral retinoblastoma group B, C, or D of the International Classification for Intraocular Retinoblastoma (IRC). Group D eyes with massive vitreous seeding were not eligible. METHODS: Melphalan SOAC associated with diode laser thermotherapy, cryotherapy, or both at 4-week intervals (3-6 cycles). For persistent vitreous seeding, intravitreal melphalan chemotherapy also was used. MAIN OUTCOME MEASURES: The primary outcome was globe preservation rate. Secondary outcomes were tumor relapse rate, occurrence of ocular or systemic adverse events, and measurement of the dose area product (DAP). RESULTS: Between 2012 and 2017, 39 patients (39 eyes) with unilateral retinoblastoma were included prospectively. Three included patients did not receive SOAC (2 catheterization failures and 1 case of viral syndrome) and were considered failures. At diagnosis, IRC groups for the 36 treated patients were: B, n = 4 (11%); C, n = 13 (36%); and D, n = 19 (53%); median age was 21.5 months (range, 3.2-61.6 months). Median number of SOAC cycles was 3.9 (range, 1-6 cycles), and median melphalan dose was 4.9 mg/procedure. The median DAP was 1.24 Gy.cm2/procedure. Median follow-up was 63 months (range, 34-93 months). SOAC was associated with local treatments for 31 patients (86%): diode laser thermotherapy for all of them and cryotherapy or intravitreal chemotherapy for 10 (32%) and 9 patients (25%), respectively. SOAC treatment was interrupted in 5 patients because of severe ophthalmic (ptosis, n = 2; retinal ischemia, n = 2) or systemic (hypotension, n = 1) adverse events. At the cutoff date analysis, all patients were alive without metastasis. The 18-month eye preservation rate was 80% (range, 68.6%-94.6%). After a follow-up of at least 30 months, the ocular preservation rate was 69% (n = 24 preservations). CONCLUSIONS: This first prospective trial demonstrated that SOAC with melphalan alone as first-line treatment for retinoblastoma is efficient and well tolerated with no metastatic events, although ocular ischemic complications were observed.

Patient dose evaluation in computed tomography: A French national study based on clinical indications.

PURPOSE: A national survey was performed to assess patient dose indicators based on clinical indication and on patient morphology for most common adult computed tomography (CT) examinations in France. METHODS: Seventeen groups of clinical indications (GCIs) for diagnostic CT in adult patients were considered based on their frequency and on image quality requirements. Data was collected for 15-30 consecutive examinations performed between 2015 and 2017, per CT scanner and GCI. Distributions of total examination Dose-Length Product (DLP) and Volume CT Dose Index (CTDIvol) were assessed for each GCI as a function of patient gender or patient Body Mass Index (BMI) for head/neck and trunk examinations, respectively. RESULTS: 6610 examinations were analysed. Median total exam DLP values were higher for men compared to women patients for head and neck examinations: difference ranged from 6% for ear trauma indication (577 vs 543 mGy·cm, p = 0.01) to 35% for brain tumour GCI (1472 vs 1093 mGy·cm, p < 0.01). For trunk examinations, total exam DLP increased consistently with patient's BMI. For normal-BMI patients, median CTDIvol and DLP differed significantly between different GCIs for single-phase CT of the chest (3 mGy and 112 mGy·cm, respectively, for chronic obstructive pulmonary disease group vs 5.8 mGy and 207 mGy·cm for pulmonary embolism group, p < 0.05) and of the abdomen-pelvis (5.6 mGy and 284 mGy·cm, respectively, in renal colic group vs 9.5 mGy and 463 mGy·cm in occlusive syndrome group, p < 0.05). CONCLUSION: This study provides morphological- and clinical-based patient dose indicators in CT as a practical tool for clinical practices optimisation.

Experimental evaluation of seven quality control phantoms for digital breast tomosynthesis.

PURPOSES: The introduction of digital breast tomosynthesis (DBT) into the French breast cancer screening program is forecast by the authorities. The aim of the present study was to evaluate image quality phantoms to be used as internal quality controls. METHODS: Seven breast phantoms dedicated to quality control in mammography were evaluated on reconstructed DBT images: ACR Model 015, BR3D, DBT QC model 021, Mam/Digi-EPQC, MTM100, TOMOMAM® and TOMOPHAN®. Two representative image parameters of DBT images were studied: image score and z-resolution, when inserts were included in the phantom, on five DBT systems of three different brands. Three observers were involved. RESULTS: The MTM100, Mam/Digi-EPQC, BR3D, DBT QC model 021 phantoms' images presented artefacts affecting the image score. The ACR Model 015, TOMOMAM® and TOMOPHAN® phantoms appeared to be pertinent for DBT image score analysis. Due to saturation artefacts, Z-resolution results were not coherent with the theory for all phantoms except by using aluminium beads in the TOMOMAM® phantom. CONCLUSIONS: Phantom manufacturers should be encouraged to collaborate with DBT system manufacturers in order to design universal phantoms suitable for all systems for more complete quality control. From our study we can propose several specifications for an ideal and universal phantom designed for internal quality control in DBT. Phantoms should allow sensitive image score measurements. The background structure should be realistic to avoid artefacts. Phantoms should have a standard breast-like shape and size.

Inferring postimplant dose distribution of salvage permanent prostate implant (PPI) after primary PPI on CT images.

PURPOSE: To evaluate the dose distribution of additional radioactive seeds implanted during salvage permanent prostate implant (sPPI) after a primary permanent prostate implant (pPPI). METHODS AND MATERIALS: Patients with localized prostate cancer were primarily implanted with iodine-125 seeds and had a dosimetric assessment based on day 30 postimplant CT (CT1). After an average of 6 years, these patients underwent sPPI followed by the same CT-based evaluation of dosimetry (CT2). Radioactive seeds on each CT were detected. The detected primary seeds on CT1 and CT2 were registered and then removed from CT2 referred as a modified CT2 (mCT2). Dosimetry evaluations (D90 and V100) of sPPI were performed with dedicated planning software on CT2 and mCT2. Indeed, prostate volume, D90, and V100 differences between CT2 and either CT1 or mCT2 were calculated, and values were expressed as mean (standard deviation). RESULTS: The mean prostate volume difference between sPPI and pPPI over the 6 patients was 9.85 (7.32) cm3. The average D90 and V100 assessed on CT2 were 486.5 Gy (58.9) and 100.0% (0.0), respectively, whereas it was 161.3 Gy (47.5) and 77.3% (25.2) on mCT2 (p = 0.031 each time). The average D90 the day of sPPI [145.4 Gy (11.2)] was not significantly different from that observed on mCT2 (p = 0.56). CONCLUSION: Postimplant D90 and V100 of sPPI after pPPI can be estimated on CT images after removing the primary seeds.

Focal brachytherapy for localized prostate cancer: Urinary toxicity depends on tumor location.

PURPOSE: To evaluate whether patients with prostate cancer have worse functional urinary recovery with focal brachytherapy (FBT) at the base versus the apex of the prostate. METHODS AND MATERIALS: The functional outcomes of patients treated with FBT at the base of the prostate were compared with those of patients treated with FBT at the apex. Urinary symptoms, continence, and erectile dysfunction were measured using the International Prostate Symptom Score (IPSS), International Continence Score (ICS), and International Index of Erectile Function (IIEF-5) questionnaires, respectively, at baseline and at 6, 12, and 24 months after treatment. RESULTS: Twenty-eight and 13 patients were treated with FBT at the apex and the base, respectively, of the prostate. A significant difference between groups was found in the IPSS score at 6 months (mean IPSS: apex 6.4 ± 4.7, base 10.6 ± 5.7; p = 0.02), but not at baseline or at 12 and 24 months after treatment. On multivariate analysis, only FBT at the base of the prostate remained an independent predictor of worsening urinary symptoms (odds ratio, 5.8; p = 0.04). CONCLUSIONS: At 6 months after FBT, significantly less urinary toxicity was found in patients who underwent FBT at the apex versus the base of the prostate. Continence and sexual side effects were minimal in all patients.

Medical physics personnel for medical imaging: requirements, conditions of involvement and staffing levels-French recommendations.

The French regulations concerning the involvement of medical physicists in medical imaging procedures are relatively vague. In May 2013, the ASN and the SFPM issued recommendations regarding Medical Physics Personnel for Medical Imaging: Requirements, Conditions of Involvement and Staffing Levels. In these recommendations, the various areas of activity of medical physicists in radiology and nuclear medicine have been identified and described, and the time required to perform each task has been evaluated. Criteria for defining medical physics staffing levels are thus proposed. These criteria are defined according to the technical platform, the procedures and techniques practised on it, the number of patients treated and the number of persons in the medical and paramedical teams requiring periodic training. The result of this work is an aid available to each medical establishment to determine their own needs in terms of medical physics.

Focal brachytherapy for selected low-risk prostate cancers: a pilot study.

PURPOSE: To evaluate the feasibility and the early toxicity of focal brachytherapy in highly selected localized prostate cancer patients. METHODS AND MATERIALS: Twenty-one patients underwent a focal brachytherapy between February 2010 and March 2012, representing 3.7% of the cases treated by our group during this period. Patient selection was based on (at least) two series of prostate biopsies and a high-resolution MRI. Only patients with very limited and localized tumors, according to strict criteria, were selected for the procedure. The technique used a real-time procedure with the implantation of free (125)I seeds and dynamic dose calculation. The prescribed dose for the focal volume was 145Gy. RESULTS: The treated volume corresponded to a mean value of 34% of the total prostatic volume (range, 20-48%). For the focal volume, the mean D90 and V100 was 183.2Gy (range, 176-188Gy) and 99.3% (range, 98.8-100%), respectively. The technique was performed in an hour and a half. When compared with a previous cohort treated by whole-prostate brachytherapy, urinary toxicity (International Prostate Symptom Score) was borderline reduced (p = 0.04) at 6 months only, whereas the recovery of the International Index of Erectile Function 5 was better (p = 0.014). The International Continence Score was nil in almost all cases as well as rectal toxicity. CONCLUSION: Focal treatment by brachytherapy is easily feasible with little acute toxicity. Further investigation is needed to assess the results in terms of tumor control and long-term toxicity.

One-step customized transurethral resection of the prostate and permanent implant brachytherapy for selected prostate cancer patients: technically feasible but too toxic.

INTRODUCTION: Patients with prominent median lobe hyperplasia and/or high International Prostate Symptom Score (IPSS) are often contraindicated for prostate brachytherapy, mainly because of the risk of post-implant urinary retention. We evaluated an approach combining in the same operative step a limited transurethral resection (TURP) of the median lobe, immediately followed by permanent implant-free seed brachytherapy. METHODS AND MATERIALS: From January 2007 to November 2008, 22 patients underwent a customized limited TURP of their median lobe immediately before brachytherapy. All patients fulfilled our criteria for permanent implant brachytherapy, but presented with a more or less prominent median lobe and/or a high IPSS. RESULTS: The procedure appeared to be technically feasible, with only 0.3% of migrating seeds, a mean post-implant D90 of 173.4 Gy and a mean post-implant V100 of 96.6%. However, 5 patients (23%) experienced a urinary retention, with two patients having to undergo a complementary post-implant TURP. Moreover, urinary toxicity was more pronounced than in our current experience, with high IPSS at 2 months (mean 19.2) and 6 months (mean 15.8). CONCLUSION: Although technically feasible, with relatively few migrating seeds and satisfactory post-implant dosimetric parameters, one-step TURP and brachytherapy was found to be poorly tolerated, with higher than usual urinary retention and urinary toxicity rates. Considering those results, our group is presently evaluating a two-step procedure, with a customized TURP followed after 4-6 months by brachytherapy.

Assessment of organ absorbed doses and estimation of effective doses from pediatric anthropomorphic phantom measurements for multi-detector row CT with and without automatic exposure control.

This study was designed to measure organ absorbed doses from multi-detector row computed tomography (MDCT) on pediatric anthropomorphic phantoms, calculate the corresponding effective doses, and assess the influence of automatic exposure control (AEC) in terms of organ dose variations. Four anthropomorphic phantoms (phantoms represent the equivalent of a newborn, 1-, 5-, and 10-y-old child) were scanned with a four-channel MDCT coupled with a z-axis-based AEC system. Two CT torso protocols were compared: a first protocol without AEC and constant tube current-time product and a second protocol with AEC using age-adjusted noise indices. Organ absorbed doses were monitored by thermoluminescent dosimeters (LiF: Mg, Cu, P). Effective doses were calculated according to the tissue weighting factors of the International Commission on Radiological Protection (). For fixed mA acquisitions, organ doses normalized to the volume CT dose index in a 16-cm head phantom (CTDIvol16) ranged from 0.6 to 1.5 and effective doses ranged from 8.4 to 13.5 mSv. For the newborn-equivalent phantom, the AEC-modulated scan showed almost no significant dose variation compared to the fixed mA scan. For the 1-, 5- and 10-y equivalent phantoms, the use of AEC induced a significant dose decrease on chest organs (ranging from 61 to 31% for thyroid, 37 to 21% for lung, 34 to 17% for esophagus, and 39 to 10% for breast). However, AEC also induced a significant dose increase (ranging from 28 to 48% for salivary glands, 22 to 51% for bladder, and 24 to 70% for ovaries) related to the high density of skull base and pelvic bones. These dose increases should be considered before using AEC as a dose optimization tool in children.