Trimodality therapy of malignant pleural mesothelioma with helical tomotherapy.

OBJECTIVE: The purpose of this study was to determine the efficacy and tolerability of hemithoracic radiotherapy implemented with helical tomotherapy (HTT) in malignant pleural mesothelioma (MPM) patients. METHODS: Between October 2018 and December 2020, data from 11 MPM patients who received trimodality therapy, including lung-sparing surgery (pleurectomy-decortication, P/D), adjuvant chemotherapy (cisplatin+ pemetrexed), and radiotherapy, were retrospectively reviewed. HTT was used to deliver a total of 30 Gy, 50-54 Gy or 59.4-60 Gy to R2 disease with 1.8-2 Gy daily doses. Descriptive data are presented in number (percentage) or median (minimum- maximum). The Kaplan-Meier method was used to calculate survival data. In patients with toxicities, the risk organ doses were compared using the Mann-Whitney U test. RESULTS: The median follow-up was 20.5 (12-30) months. Two-year local control, disease-free, and overall survival rates were 48.5%, 49%, and 77.9%, respectively. The median prescribed dose for planning target volume (PTV) was 50.4±8.7 (30-60) Gy. Mean dose (Dmean) of total lung was 19.9±6 (10.4-26) Gy; the V20 (%) of ipsilateral and contralateral lungs were 89.±11.2 (62.7-100) and 0.7±2.1 (0.49-5.9), respectively. Esophageal Dmean and maximum doses (Dmax) were found as 21.7±8.4 (7.4-34) and 53.1±10.4 (25.4-64.4) Gy, respectively. V30 (%) and Dmean of heart were 22.3%±13.4% (3.9-47) and 21±5.7 (10.8-29.3) Gy, respectively. Dmax of medulla spinalis (MS) was 38.6± 1.3 (13.7-48) Gy. Grade 1-2 radiation pneumonitis (RP) developed in 4 (36.4%) and esophagitis in 2 (18.2%) patients. RP was found to be associated with MS and esophageal doses (p<0.05). Myelitis was diagnosed in 1 (9.1%) patient (MS Dmax: 29 Gy). CONCLUSION: HTT can be used as part of trimodality therapy for MPM patients with acceptable toxicities. MS and esophageal doses should be considered for radiation pneumonitis risk, and new dose constraints for these organs should be defined.

Utilizing shear wave elastography for the evaluation of optical nerve involvement in Behçet's disease.

In this study, we investigated the elasticity of the optic nerve using shear wave elastography (SWE) in patients with Behçet's Disease (BD) and compare findings with a healthy control group. Optic nerve measurements of 40 eyes in the BD group and 38 eyes in the control group were performed by SWE (SWE-right and SWE-left). The mean age of the individuals in the BD group was higher than controls (p = 0.022). The SWE measurement results in the right eye were significantly higher in the BD group (p = 0.005), while SWE-left values were similar in the two groups (p = 0.206). There was a moderate positive correlation between age and SWE-right (r = 0.347, p = 0.031), there was no correlation between SWE-left and age (p = 0.756). It was found that SWE-right had significant value in distinguishing between BD and healthy controls (sensitivity: 75%, specificity: 78.9%; p = 0.005); whereas, SWE-left did not (p = 0.206). In the multiple logistic regression analysis, after adjusting for age and sex, the performance of SWE-right to distinguish BD patients from controls was found to remain significant (OR: 15.045, 95% CI: 2.33-97.120, p = 0.004). Due to the fact that only SWE-right values appear to have significant discriminatory performance for BD, it is feasible to suggest that the frequency and severity of BD involvement are associated with SWE-related changes in the optic nerve. This finding indicates the need for more comprehensive studies evaluating optic nerve SWE values in this context.

Prepontine and Meckel's Cave Dermoid Cyst: MR and CT Findings with Literature Review.

Dermoid cysts (DCs) are benign, congenital tumors that comprise 0.04-0.6% of all intracranial tumors. DC rupture is a rare complication and usually occurs spontaneously. The most common localisations of intracranial DCs are the posterior fossa, and suprasellar and parasellar regions. The presentations of DCs are highly variable. They are often detected incidentally on computed tomography (CT) or magnetic resonance imaging (MRI) scans while investigating the cause of seizure or headache. Prepontine cystern is a rare localisation for intracranial DCs. To the best of our knowledge, only four cases have been reported in the literature so far. We present MRI and CT findings of a patient with DC, which ruptured into the subarachnoid space extending from the right Meckel's cave to the prepontine cistern. Key Words: Dermoid cysts, Meckel's cave, Prepontine cistern, Rupture.

Shear-Wave Elastography of Patellar Ligament and Achilles Tendon in Semiprofessional Athletes: Comparing With Nonexercising Individuals.

OBJECTIVES: To compare semiprofessional athletes and nonexercising individuals in terms of p-SWE properties of the patellar ligament and the Achilles tendon. METHODS: This case-control study was conducted in University of Health Sciences, Haseki Education and Research Hospital. A total of 58 individuals, with 29 in each group (according to power analysis), were included in the study. All relevant findings, including demographic characteristics, body mass index (BMI), and exercise (km run per week, km/w) were recorded. The MyLab 9 (Esaote, Genova, Italy) device was used for SWE. The QElaXto-p-SWE software was utilized for P-SWE interpretation and analyses. RESULTS: The mean age was 47.21 ± 12.16 years (range 22-70). Weight (P = .001) and BMI (P < .001) values were significantly higher in the nonathlete group than in the athlete group. There were no significant differences between groups in terms of age, gender, and height. Median SWE values of bilateral patellar ligaments (P < .001 and P < .001) and bilateral Achilles tendons (P < .001 and P < .001) were significantly higher in the athlete group than in the nonathlete group. CONCLUSIONS: We revealed normal p-SWE characteristics for the patellar ligament and Achilles tendon, which are frequently injured in athletes. These scores are important in early detection and follow-up of injuries in athletes.

Sacralization may be associated with facet orientation and tropism but not degenerative changes of the lumbar vertebrae.

PURPOSE: In this retrospective study, we aimed to investigate the possible effects of transitional vertebra anatomy on facet joint tropism and orientation by evaluating lumbar magnetic resonance imaging (MRI) studies performed at our institution. MATERIAL AND METHODS: We included 84 patients with sacralization of the L5 vertebra and an equal number of patients with a radiology report within normal limits as the control group in our study. We compared facet tropism (FT) and orientation between both groups. RESULTS: In both the sacralization group and the control group, the facet orientation angle showed a significant increasing trend from the L1-L2 level to the L5-S1 level (p < 0.001). The orientation angle of the L5-S1 level was higher in the sacralization group compared to the control group (p < 0.01). In the evaluation of FJ orientation between the sacralization and control groups, we found that coronal orientation was significantly more frequent at the L5-S1 level in the sacralization group. When the 2 groups were compared with regard to tropism at each spinal level, the sacralization group had a significantly higher FT frequency at the L5-S1 level (p < 0.001). CONCLUSIONS: To our knowledge, this is the first study to evaluate the relationship between sacralization and facet joint tropism. However, there were no relationships between facet degeneration, disc degeneration/herniation, and sacralization. Our results indicate that, although patients with sacralization and controls had similar characteristics in most assessments, they demonstrated significant differences at the L5-S1 level in terms of orientation and tropism.

Using CT scout view to scan illicit drug carriers may reduce radiation exposure.

OBJECTIVE: The aim of this study was to present our experience on the evaluation of suspected illicit drug carriers via computerized tomography scout view (CTSV) with analysis of detectability and features such as content, form and density. METHODS: A total of 120 individuals suspected of body packing were screened via CT in a university emergency department between January 2014 and December 2017. RESULTS: 88.3% of 120 body packing cases examined in the study were male. The median (1st quartile-3rd quartile) age of the cases was 35.5 (30-41) years. We found that solid packs have a 4.573-fold higher likelihood of detection in CTSV screening than liquid ones (95%CI: 1.879-11.134). Additionally, the number of CT scans needed were significantly associated with capsule localization (stomach) (OR:7.178, 95%CI: 2.420-21.293) and solid form packs (OR: 8.705, 95%CI: 2.318-32.692) are associated with number of CT scans. CONCLUSION: CTSVs have a successful detection rate, especially in solid form packs. Our results suggest that conclusive CTSV imaging for body packing may be recommended to delay the application of the next CT scan until the passage of the first capsule; thereby preventing unnecessary radiation exposure.

The Coexistence of Autoimmune Pancreatitis and Crohn's Disease in an Adolescent Case.

Although autoimmune pancreatitis is not seen in children frequently, it is included in the etiology of chronic pancreatitis. A 16-year-old girl who was diagnosed with chronic pancreatitis 4 months previously, presented to the outpatient clinic with abdominal pain on the epigastric region, and left lower abdominal quadrant and bloody defecation. Remarkable laboratory test results were as follows: amylase: 109 U/L, lipase: 196 U/L, Ig G:13.70 g/L, IgG4:2.117 g/L, fecal calprotectin 573 µg/g. In the MRCP examination, revealed enlarged pancreas with a heterogeneous appearance, dilated main pancreatic duct. Colonoscopic and histopathological findings were consistent with inflammatory bowel disease. The case was diagnosed as Crohn's disease coursing with autoimmune pancreatitis. Clinical and laboratory findings regressed after steroid treatment. Autoimmune pancreatitis is important in that it is rarely seen in children and though less frequently it is associated with Crohn's disease. It should be kept in mind that inflammatory bowel disease may develop in the follow-up of autoimmune pancreatitis and autoimmune pancreatitis may be present in the etiology of chronic pancreatitis.

Magnetic resonance imaging of the quadriceps fat pad oedema pattern in relation to patellofemoral joint pathologies.

PURPOSE: Quadriceps fat pad is located posterior to the quadriceps tendon. Increased signal intensity of this fat pad is seen on routine knee magnetic resonance imaging (MRI) examinations, but the exact mechanism and related pathologies are not clear. In this study we aimed to evaluate the relationship between MRI signal intensity and morphological features of quadriceps fat pad, as well as various pathologies of the patellofemoral joint. MATERIAL AND METHODS: Sixty-one knees with quadriceps fat pad oedema out of 457 knee MRI examinations were included. Quadriceps fat pad signal intensity, dimensions, posterior indentation, and various parameters related to patellofemoral joint such as trochlear facet asymmetry, trochlear depth and sulcus angle, and the Insall-Salvati ratio were evaluated. RESULTS: There was no statistically significant correlation between quadriceps fat pad oedema intensity and its dimensions, but it was significant when compared to posterior indentation. There was no correlation between fat pad oedema and each of the pathologies. However, there was a significant correlation between the presence of fat pad oedema and the presence of at least one of the pathologies related to patellofemoral joint. CONCLUSIONS: Quadriceps fat pad oedema detected in MRI examinations should warn the radiologist against the presence of various pathologies related to the patellofemoral joint.

Volumetric decrease of pancreas after abdominal irradiation, it is time to consider pancreas as an organ at risk for radiotherapy planning.

BACKGROUND: Volumetric shrinkage of normal tissues such as salivary glands, kidneys, hippocampus are observed after radiotherapy. We aimed to assess the alterations in pancreatic volume of patients who received abdominal radiotherapy and define pancreas as an organ at risk for radiation treatment planning. MATERIAL-METHODS: Forty-nine patients operated for gastric adenocarcinoma who received adjuvant abdominal radiotherapy were in the study group, 27 patients with early stage disease who did not need adjuvant treatment after surgery comprised the control group. An experienced radiologist contoured the pancreas of all the patients from computed tomographies imported to the planning system obtained either for radiation planning purpose or for follow-up after surgery. The same procedure was repeated one year later for both groups. Measured volume of the pancreas was expressed in cm3. RESULTS: Mean pancreatic volumes were similar in both groups at the onset of the study, 51,34 ± 20,33 cm3, and 50,12 ± 23,75 cm3 in the irradiated and the control groups respectively (p = 0,63). One year later, mean pancreatic volumes were significantly decreased in each group; 22,48 ± 10,53 cm3, 44,18 ± 23,08 cm3 respectively, p < 0,001. However, the decrease in pancreatic volume was significantly more pronounced in the irradiated group in comparison to the control group, p < 0,001. CONCLUSION: Volumetric decrease in normal tissues after radiotherapy is responsible for loss of organ function and radiation related late side effects. Although pancreas is a radiation sensitive organ losing its volume and function after radiation exposure, it is not yet considered as an organ at risk for radiation treatment planning. Pancreas should be contoured as an organ at risk, dose-volume histogram for the organ should be created, and safe organ doses should be determined. This is the first study declaring pancreas as an organ at risk for radiation toxicity and the necessity of defining dose constraints for the organ.

Osteoporosis development and vertebral fractures after abdominal irradiation in patients with gastric cancer.

BACKGROUND: Decrease in bone mineral density, osteoporosis development, bone toxicity and resulting insufficiency fractures as late effect of radiotherapy are not well known. Osteoporosis development related to radiotherapy has not been investigated properly and insufficiency fractures are rarely reported for vertebral bones. METHODS: Ninety-seven patients with gastric adenocarcinoma were evaluated for adjuvant treatment after surgery. While 73 out of 97 patients treated with adjuvant chemoradiotherapy comprised the study group, 24 out of 97 patients with early stage disease without need of adjuvant treatment comprised the control group. Bone mineral densities (BMD) of lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry after surgery, and one year later in both groups. RESULTS: There was statistically significant decline in BMDs after one year in each group itself, however the decline in BMDs of the patients in the irradiated group was more pronounced when compared with the patients in the control group; p values were 0.02 for the decline in BMDs of lumbar spine, and 0.01 for femoral neck respectively. Insufficiency fractures were observed only in the irradiated patients (7 out of 73 patients) with a cumulative incidence of 9.6%. CONCLUSIONS: Abdominal irradiation as in the adjuvant treatment of gastric cancer results in decrease in BMD and osteoporosis. Insufficiency fracture risk in the radiation exposed vertabral bones is increased. Calcium and vitamin D replacement and other measures for prevention of osteoporosis and insufficiency fractures should be considered after abdominal irradiation.

The protective effects of different treatments on rat salivary glands after radiotherapy.

This study was aimed to evaluate the efficacy of treatment modalities for minimizing salivary gland damage caused by radiotherapy. Forty rats were divided into five groups. Group 1 had no irradiation or any treatment. Group 2 underwent only 15 Gy single dose radiotherapy. N-acetylcysteine, dexamethasone, hyperbaric oxygen treatment were given, respectively to the group 3, 4 and 5 for 5 days. 15 Gy single dose radiotherapy was applied to the group 3, 4 and 5 on the second day. Pyknosis, lysis, and vacuolization were examined in ductal cells and pyknosis, lysis, vacuolization, inflammation and collective duct damage in acinar cells. Dexamethasone and hyperbaric oxygen did not prove to have a positive effect on acinar and ductal cell. N-acetylcysteine-applied group had statistically significantly lower amount of damage. We determined that the decrease of ductal and acinar cell damage in parotid glands of N-acetylcysteine-applied rats was more distinct and statistically.

Acute toxicity in nasopharyngeal carcinoma patients treated with IMRT/VMAT.

PURPOSE: To evaluate acute toxicity in nasopharyngeal cancer (NPC) patients treated with intensity modulated radiotherapy (IMRT)/volumetric modulated arc therapy (VMAT) with or without cisplatin-based chemotherapy. MATERIALS AND METHODS: A total of 45 newly diagnosed, histologically proven non-metastatic NPC patients treated with IMRT between May 2010 and December 2012, were evaluated retrospectively, 37 planned with Eclipse and 8 with Prowess Panther treatment planning system. The doses to the planning target volumes of primary tumor and involved lymph nodes, high risk region, and uninvolved regional nodal areas were 70 Gy, 60 Gy, and 54 Gy respectively and delivered simultaneously over 33 fractions to 39 patients. Another 6 patients irradiated with sequential boost technique. Some 84.4% of patients received chemotherapy. Acute toxicities were graded according to the Radiation Therapy Oncology Group scoring criteria and Common Terminology Criteria for Adverse Events (CTCAE) for chemotherapy side effects. RESULTS: Median age was 43 years (14-79) and all patients were WHO type II. Grade 1 mucositis and dysphagia were observed in 17 (37.8%), and 10 (22.2%) patients, respectively. The incidence of acute grade 2 mucositis and dysphagia was 55.6% and 68.9%, respectively. The most common chemoradiotherapy related acute toxicities were nausea, leucopenia and thrombocytopenia. Grade 3 toxicity was detected in 13 (28.8%) cases. No grade 4 toxicity was occurred. Mean weight loss was 9%. None of the patients required the insertion of percutaneous endoscopic gastrostomy for nutritional support. Radiation therapy was completed without interruption in all patients. CONCLUSIONS: IMRT is a safe and effective treatment modality, and well tolerated by patients in the treatment of nasopharyngeal carcinoma. No unexpected side effects were observed.

The Efficacy of Probiotic (Lactobacillus rhamnosus GG) and 5-ASA (Aminosalicylic Acid) in the Treatment of Experimental Radiation Proctitis in Rats.

The aims of the study are to demonstrate the effect of probiotic use on the healing of radiation proctitis (RP) and evaluate the efficiency of fecal biomarkers at follow-up of the treatment. Thirty-two male/female rats were randomly separated into four groups of eight rats. The first group (control) was not radiated. RP was created by 17.5 Gy single dose rectal irradiation. The second group (RP) was subjected to RP, but not treated. The third group (RP+ASA) was treated with 5-aminosalicylic acid (5-ASA) 250 mg/kg daily by gastric lavage for 14 days after the irradiation, and the forth group (RP+LGG) was treated with Lactobacillus GG (LGG) 25 × 100 million CFU daily. Feces samples were taken at the 7th and 14th day of the treatment for fecal biomarkers. Rectums of the rats were resected at the 14th day by laparotomy. Samples were evaluated both macroscopically and microscopically. RP was achieved both macroscopically and microscopically. Weight loss of RP group is statistically significant (p < 0.005) than other groups. The healing ratio of RP+ASA and RP+LGG groups was significantly better than the RP group (p < 0.005) both macroscopically and microscopically. But there was no significant difference between ASA and LGG groups. Biochemically, fecal calprotectin was found to be more effective than fecal myeloperoxidase and fecal lactoferrin to show the efficacy of treatment of radiation proctitis. The results of our study demonstrate that probiotic is as effective as 5-aminosalicylic in the treatment of radiation proctitis, and fecal calprotectin is a useful biomarker in determining the response to the treatment.

Dosimetric evaluation of nasopharyngeal carcinomas irradiated with different IMRT techniques.

PURPOSE: To evaluate the performance of volumetric arc therapy (VMAT), dynamic intensity modulated radiotherapy (IMRT) and step-and-shoot IMRT techniques in nasopharyngeal cancer (NPC) patients. METHODS: IMRT plans of 48 NPC patients treated between May 2010 and December 2012, were evaluated. Twenty two patients were planned with VMAT, 18 with dynamic IMRT and 8 with step-and-shoot IMRT. Conformity index (CI) and homogeneity index (HI), the dosimetry of the planning target volumes (PTVs) and organs at risk (OARs) and the monitor units (MU) were evaluated for each IMRT modality. RESULTS: The conformity indices of VMAT and dynamic IMRT were better than step-and-shoot IMRT plans (p<0.05). Step-and-shoot IMRT plans provided better homogeneity than VMAT (p=0.01). MUs for dynamic IMRT were much higher compared to VMAT (p<0.01) and step and- shoot IMRT (p<0.01). There was no significant difference between the 3 techniques in terms of PTV70 mean doses. When compared with step-and-shoot IMRT, VMAT and dynamic IMRT had a better sparing effect on optic nerves, eyes and optic chiasm (p<0.05). VMAT plans performed better sparing for brain stem than dynamic IMRT (p=0.01). There was a remarkable decrease in the maximum doses of VMAT to the eye. CONCLUSIONS: VMAT outperforms dynamic IMRT by effectively reducing the MU and the dose to some OARs, with adequate PTV coverage. Also, VMAT provides better sparing of normal tissue and conformity than step-and-shoot IMRT. Differences between step-and-shoot IMRT and dynamic IMRT are thought to be due to technical differences of linear accelerator devices like fiber size, variable fiber, dose rate and gantry.

Long-term treatment results in soft tissue sarcomas of the thoracic wall treated with pre-or-postoperative radiotherapy--a single institution experience.

OBJECTIVE: To evaluate the long term results among patients with soft tissue sarcoma of the thoracic wall. MATERIALS AND METHODS: Twenty-six patients who were treated with pre-or postoperative radiotherapy between December 1980-December 2007, with a diagnosis of soft tissue sarcoma of the thoracic wall were retrospectively evaluated. RESULTS: The median age was 44 years (14-85 years) and 15 of them were male. A total of 50% of patients were grade 3. The most common histologic type of tumor was undifferentiated pleomorphic sarcoma (26.9%). Tumor size varied between 2-25 cm (median 6.5 cm). Seventeen of the cases had marginal and 9 had wide local resection. Four cases received preoperative radiotherapy and 22 postoperative radiotherapy. Six of the patients with large and high grade tumors received chemotherapy. Median follow-up time was 82 months (9-309 months). Local recurrence and metastasis was detected in 34.6% and 42.3% of patients, respectively. Five- year local control (LC), disease-free survival (DFS), overall survival (OS), and disease-specific survival (DSS) were 62%, 38%, 69%, and 76% respectively. On univariate analysis, the patients with positive surgical margins had a markedly lower 5-year LC rate than patients with negative surgical margin, but the difference was not significant (43% vs 78%, p=0.1). Five-year DFS (66% vs 17%) and DSS (92% vs 60%) rates were significantly worse for the patients who had high grade tumors (p=0.01, p=0.008 respectively). CONCLUSIONS: Tumor grade and surgical margin are essential parameters for determining the prognosis of thoracic wall soft tissue sarcoma both in our series and the literature.

Symplastic leiomyoma in the suprarenal inferior vena cava.

Leiomyomas are benign tumors of the soft tissue and may develop in any location where smooth muscle is present. Leiomyoma in the inferior vena cava is a rarely seen pathology, and symplastic leiomyoma is also a rare histological variant of leiomyoma. In this case, we present a rare histological variant of symplastic leiomyoma in the inferior vena cava (IVC). This is the first radiologically reported case of a symplastic leiomyoma of the IVC.