Potential of patellar height measurement methods in predicting recurrent patellar dislocation incidence: a case-control study.

BACKGROUND: Recurrent patellar dislocation (RPD) is a multifactorial disease that affects young and active people. Patellar height measurements are used clinically to screen and diagnose knee conditions. However, there are no known studies that have assessed and compared the performance of patellar height indices for predicting the incidence of RPD, which could be used to recommend surgical treatment after primary patellar dislocation. This case-control study aimed to determine if the patellar height index could be used to predict the incidence of RPD, and to identify the optimal method in terms of its diagnostic ability for RPD. METHOD: Altogether, 133 patients (52 patients with RPD [Group R] and 81 sex- and age-matched controls [Group C]) were enrolled in this study. The Insall-Salvati (IS), Blackburne-Peel (BP), Caton-Deschamps (CD), and modified IS (mIS) methods were used to measure the patellar height index. The intra-observer and inter-observer reliabilities of these four methods were determined using intraclass correlation coefficients. A receiver operating characteristic curve analysis was performed to evaluate the predictive ability of each index and identify the cut-off values that indicated significantly increased risk of RPD. RESULTS: Patient demographics were similar between the two groups. The inter-observer and intra-observer reliabilities were good for all four methods. In patients with RPD, the mean index values for the four methods were significantly higher than those in the matched controls. The area under the curve (AUC) values for IS, BP, CD, and mIS were 0.91 (standard error [SE], 0.03; 95% confidence interval [CI], 0.84-0.96), 0.72 (SE, 0.05; 95% CI, 0.63-0.81), 0.86 (SE, 0.03; 95% CI, 0.79-0.92), and 0.96 (SE, 0.01; 95% CI, 0.94-0.99), respectively. CONCLUSION: Patellar height indices had high predictive performance for the incidence of RPD. The mIS method had the highest AUC.

Efficacy of neoadjuvant chemoradiotherapy followed by pancreatic resection for older patients with resectable and borderline resectable pancreatic ductal adenocarcinoma.

BACKGROUND: The benefit of preoperative treatment followed by pancreatic resection in older patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. In this retrospective analysis of prospectively collected data, we evaluated the significance and safety of preoperative treatment followed by curative resection for older PDAC patients. METHODS: We evaluated 122 patients with resectable and borderline resectable PDAC who received neoadjuvant chemoradiotherapy (NACRT) followed by curative resection between 2009 and 2019. Changes in the prognostic nutritional indices during NACRT, surgical outcomes, and prognosis were compared between older (≥75 years, n = 44) and younger patients (<75 years, n = 78). RESULTS: The completion rate, adverse event rate, changes in prognostic nutritional indices during NACRT, and prognosis were similar between the groups. In multivariate analysis, an elevated C-reactive protein/albumin ratio (CRP/Alb) ≥ 33.1% during NACRT (p = 0.035) and no postoperative adjuvant chemotherapy (p = 0.041) were identified as significant predictors of overall survival. CONCLUSIONS: NACRT followed by pancreatic resection could be safely performed in older patients, with a similar prognosis as that of younger patients, despite an increased frequency of postoperative complications. Elevated CRP/Alb during NACRT and no postoperative adjuvant chemotherapy were poor prognostic factors for older patients.

Prediction of local tumor control and recurrence-free survival in patients with pancreatic cancer undergoing curative resection after neoadjuvant chemoradiotherapy.

BACKGROUND AND OBJECTIVES: There is little data on the correlation between the reduction in fluorodeoxyglucose positron emission tomography (FDG-PET) radioactive accumulation and carbohydrate antigen 19-9 (CA19-9) levels with pathological tumor responses (PTRs) and prognosis after neoadjuvant chemoradiotherapy (NACRT) for patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: This study was a retrospective analysis of prospectively collected data from 102 patients with resectable (R-) and borderline resectable (BR-) PDAC who received NACRT, followed by curative resection. Data were prospectively collected and compared between the responders and nonresponders to NACRT. RESULTS: Patients with 60% or more reduction in maximum standardized uptake value (SUVmax) on FDG-PET, with 75% or more reduction in CA19-9 levels, or with 50%-100% of tumor cells destroyed due to NACRT had significantly better recurrence-free survival (RFS) than each of the nonresponders (p = 0.028, <0.001, and 0.022, respectively). The reduction rates of SUVmax and CA19-9 levels were correlated with PTR. The combined evaluation of these biomarkers reflected RFS. CONCLUSIONS: Reduction rates of FDG uptake and CA19-9 levels were preoperative predictors of pathological response to NACRT. These biomarkers of local response had prognostic value in R-PDAC and BR-PDAC. The combined evaluation of these biomarkers allowed for reliable prediction of RFS after surgery.

Impact of rotational errors of whole pelvis on the dose of prostate-based image-guided radiotherapy to pelvic lymph nodes and small bowel in high-risk prostate cancer.

BACKGROUND: The target volume increases when the prostate and pelvic lymph nodes (PLNs) are combined, and the fiducial markers (FMs) are placed at the edge of the irradiation field. Thus, the position of FMs may be changed by the rotational errors (REs) of "whole pelvis". The aim of this study was to examine the impact of REs of "whole pelvis" on the dose of FMs-based image-guided radiotherapy to the PLNs and the small bowel in prostate cancer including the PLNs. MATERIALS AND METHODS: We retrospectively evaluated 10 patients who underwent prostate cancer radiotherapy involving the PLNs. The position of FMs was calculated from the radiographs obtained before and after the 6D correction of pelvic REs. We simulated the delivery dose considering the daily pelvic REs and calculated the difference from the planned dose in the D98% of the PLN clinical target volume and the D2cc, and V45Gy of the small bowel. RESULT: The position of FMs strongly correlated with the pelvic REs in the pitch direction (r = 0.7788). However, the mean delivered doses to PLNs for 10 patients were not significantly different from the planned doses (p = 0.625). Although the D2cc and V45Gy of the small bowel strongly correlated with the pitch rotation of the pelvis, there was no significant difference between the delivered and planned doses (p = 0.922 and p = 0.232, respectively). CONCLUSION: The dosimetric effect of pelvic REs on the dose to PLNs and the small bowel was negligible during the treatment course.

Changes and prognostic impact of inflammatory nutritional factors during neoadjuvant chemoradiotherapy for patients with resectable and borderline resectable pancreatic cancer.

BACKGROUND: Inflammatory nutritional factors, such as the neutrophil/lymphocyte ratio (NLR), Glasgow Prognostic Score (GPS), modified GPS (mGPS), and C-reactive protein/albumin (CRP/Alb) ratio, have prognostic values in many types of cancer. In this study, the prognostic values of inflammatory nutritional scores were evaluated in the patients with resectable or borderline resectable pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant chemoradiotherapy (NACRT). METHODS: A total of 49 patients who underwent pancreatectomy after NACRT from September 2009 to May 2016 were enrolled. The NACRT consisted of hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) delivered 5 days/week for 2 weeks before pancreatectomy. Inflammatory nutritional scores were determined before and after NACRT in this series. RESULTS: The median NLR increased after NACRT (from 2.067 to 3.302), with statistical difference (p < 0.001). In multivariate analysis, high pre-NACRT mGPS (2 or 1; p = 0.0478) and significant increase in CRP/Alb ratio after NACRT (≧ 0.077; p = 0.0036) were associated with shorter overall survival. All patients were divided into two groups according to the ΔCRP/Alb ratio after NACRT: the group with high ΔCRP/Alb ratio (≧ 0.077) and the group with low ΔCRP/Alb ratio (< 0.077). The group with high ΔCRP/Alb ratio after NACRT (n = 13) not only had higher post-NACRT CRP levels (p < 0.001) but also had lower post-NACRT Alb levels (p = 0.002). Patients in the group with high ΔCRP/Alb ratio lost more body weight during NACRT (p = 0.03). CONCLUSION: In addition to pre-NACRT mGPS, ΔCRP/Alb after NACRT could provide prognostic value in the patients with PDAC treated by NACRT.

The predictors and patterns of the early recurrence of pancreatic ductal adenocarcinoma after pancreatectomy: the influence of pre- and post- operative adjuvant therapy.

BACKGROUND: The perioperative factors predicting or influencing early pancreatic ductal adenocarcinoma recurrence are unclear. This study attempted to identify the predictive factors for early pancreatic ductal adenocarcinoma recurrence post-pancreatectomy and the influence of pre- and post- operative adjuvant therapy. METHODS: One hundred and fifteen patients undergoing curative resection for pancreatic ductal adenocarcinoma between 2000 and 2016 at our institution were retrospectively analyzed. Patients were divided into two groups: those who did (n = 34) and did not (n = 81) experience a recurrence within 6 months postoperatively. RESULTS: Multivariate analyses demonstrated postoperative CA19-9 de-normalization, no postoperative adjuvant chemotherapy, and serosal invasion were independent risk factors for early recurrence (P < 0.001, P = 0.001, and P = 0.010, respectively). A subgroup analysis showed patients with (n = 51) and without (n = 64) preoperative chemoradiotherapy had different predictors. Although postoperative adjuvant chemotherapy was not a significant indicator in patients with preoperative chemoradiotherapy, CA19-9 de-normalization and no postoperative adjuvant chemotherapy were significant indicators in patients without preoperative chemotherapy. Preoperative chemotherapy strongly prevented early local recurrence while postoperative adjuvant chemotherapy prevented early distant recurrence. CONCLUSIONS: CA19-9 de-normalization was an important predictor of early recurrence of pancreatic ductal adenocarcinoma. Although postoperative adjuvant chemotherapy was an important preventive measure against early recurrence, particularly for distant recurrence, preoperative chemoradiotherapy could strongly prevent the early local recurrence of pancreatic ductal adenocarcinoma. These perioperative adjuvant therapies could have a complementary relationship.

Long-term outcome of stereotactic body radiotherapy for patients with small hepatocellular carcinoma.

AIM: To evaluate the long-term outcome of stereotactic body radiotherapy in patients with small hepatocellular carcinoma who were ineligible for resection or ablation therapies. METHODS: A total of 65 patients with 74 hepatocellular carcinomas (median tumor size 16 mm) were enrolled in the present study. They were treated with the prescribed dose of 48 Gy in four fractions at the isocenter. We extended the observation period and analyzed long-term outcomes, including overall survival, progression-free survival, local control, and various prognostic factors, in these patients. RESULTS: The median follow-up period was 41 months for all patients and 62 months for surviving patients. The 3- and 5-year overall survival rates were 56.3% (95% confidence interval, 44.1-68.5%) and 41.4% (95% confidence interval, 28.7-54.1%), respectively. The 3- and 5-year progression-free survival rates were 25.4% (95% confidence interval, 14.0-36.8%) and 10.6% (95% confidence interval, 1.5-19.8%), respectively. The 3- and 5-year local control rates were both 100% (95% confidence interval 100%). Liver toxicities exceeding grade 3 were observed in 15 patients (23.1%). The proportion of patients who had grade ≥3 toxicities did not increase. Adverse effects (grade ≤2) presented as significant prognostic factors of overall survival, while TNM stage (T1N0M0) was a significant prognostic factor of progression-free survival after multivariate analysis. CONCLUSIONS: Stereotactic body radiotherapy was effective for patients with small hepatocellular carcinomas who were ineligible for resection or ablation therapies. The incidence of grade ≥3 adverse effects did not increase, even after longer follow-up times.

A Prospective Phase II Trial of Neoadjuvant S-1 with Concurrent Hypofractionated Radiotherapy in Patients with Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma.

BACKGROUND: The ideal neoadjuvant treatment protocol for patients with pancreatic cancer (PDAC) remains unclear. We evaluated the efficacy and safety of neoadjuvant hypofractionated chemoradiotherapy with S-1 for patients with resectable (R) and borderline resectable (BR) PDAC. METHODS: Eligibility criteria included patients with R and BR PDAC, performance status 0-1, and age 20-85 years. Hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) was delivered 5 days/week for 2 weeks prior to pancreatectomy. RESULTS: Fifty-seven patients were enrolled in this study, including 33 R and 24 BR [19 BR tumors with portal vein contact (BR-PV) and 5 BR tumors with arterial contact (BR-A)]. The total rates of protocol treatment completion and resection were 91% (50/57) and 96% (55/57), respectively. Seven patients failed to complete S-1 due to cholangitis (n = 5) or neutropenia (n = 2). The most common grade 3 toxicities [Common Terminology Criteria for Adverse Events (CTCAE) version 4.0] were anorexia (7%), nausea (5%), neutropenia (4%), and leukopenia (4%). No patient experienced grade 4 toxicity. Pathologically negative margins (R0) were achieved in 54 of 55 patients (98%) who underwent pancreatectomy. Pathological response was classified as Evans grade I in 8 patients (15%), IIa in 31 patients (56%), IIb in 14 patients (25%), III in 1 patient (2%), and IV in 1 patient (2%), and operative morbidity (Clavien-Dindo grade IIIb or less) was observed in 4 patients (8%). The 1- and 2-year overall survival (OS) rates were 91 and 83% in R patients, respectively, and 77 and 58% in BR patients, respectively (p = 0.03). CONCLUSION: Neoadjuvant S-1 with concurrent hypofractionated radiotherapy is tolerable and appears promising for patients with R and BR PDAC.

Relationship between patellar mobility and patellofemoral joint cartilage degeneration after anterior cruciate ligament reconstruction.

Patellofemoral cartilage degeneration is a potential complication of anterior cruciate ligament reconstruction (ACLR) surgery. Hypomobility of the patella in the coronal plane is often observed after ACLR. Few studies, however, have examined the relationship between cartilage degeneration in the patellofemoral joint and mobility after ACLR. The present study investigated 1) the coronal mobility of the patella after ACLR, 2) the relationship between patellar mobility and cartilage degeneration of the patellofemoral joint, and 3) the relationship between patellar mobility and knee joint function after ACLR. Forty patients who underwent medial hamstring-based ACLR participated in the study. Lateral and medial patellar displacements were assessed with a modified patellofemoral arthrometer, and the absolute values of the displacements were normalized to patient height. The International Cartilage Repair Society (ICRS) cartilage injury classification of the patellar and femoral (trochlear) surfaces, and the Lysholm Knee Scoring Scale were used to evaluate knee function. Lateral and medial patellar displacements were reduced compared with the non-operated knee at the second-look arthroscopy and bone staple extraction operation (second operation; 24.4 ± 7.9 months after ACLR, P<0.01). The ICRS grades of the patellofemoral joint (patella and trochlea) were significantly worse than those pre-ACLR. Neither lateral nor medial patellar mobility, however, were significantly correlated with the ICRS grade or the Lysholm score. Although patellar mobility at approximately 2 years after ACLR was decreased compared to the non-operated knee, small displacement of the patella was not related to cartilage degeneration or knee joint function at the time of the second operation.

Relationship between dose-volume parameters and pulmonary complications after neoadjuvant chemoradiotherapy followed by surgery for lung cancer.

PURPOSE: This study evaluated the relationship between dose-volume histogram (DVH) parameters and pulmonary complications after neoadjuvant chemoradiotherapy (NACRT) followed by surgery for lung cancer. We also examined a new DVH parameter, because the unresected lung should be more spared than the later resected lung. PATIENTS AND METHODS: Data from 43 non-small cell lung cancer patients were retrospectively analyzed. The DVH parameters of the lung were calculated from the total bilateral lung volume minus (1) the gross tumor volume (DVHg) or (2) the later resected lung volume (DVHr). Radiation pneumonitis (RP) and fistula, including bronchopleural and pulmonary fistula, were graded as the pulmonary complications. Factors affecting the incidences of grade 2 or higher RP (≥G2 RP) and fistula were analyzed. RESULTS: Sixteen patients (37 %) experienced ≥G2 RP and a V20 value of the total lung minus the later resected lung (V20r) ≥ 12 % was a significant factor affecting the incidence of ≥G2 RP (p = 0.032). Six patients (14 %) developed a fistula and a V35 value of the total lung minus the gross tumor (V35g) ≥ 19 % and a V40g ≥ 16 % were significant factors affecting the incidence of fistula (p = 0.002 and 0.009, respectively). CONCLUSION: These DVH parameters may be related to the incidences of ≥G2 RP and fistula.

Impact of Pelvic Rotational Setup Error on Lymph Nodal Dose in Whole Pelvic IMRT Using Fiducial Markers.

PURPOSE: The aim of this study was to investigate the impact of pelvic rotational setup error on lymph nodal dose in the whole pelvic intensity-modulated radiation therapy using the fiducial marker. METHODS: The dose differences of clinical target volume for pelvic lymph node (CTVLN) due to isocenter (IC) shift and pelvic rotation were evaluated using the radiation treatment planning system. The rotated computed tomography (CT) images were created for the simulation of the pelvic rotation. The original CT images were rotated around the IC of the original plan in the pitch and roll directions up to±3.0 deg. at 1.0 deg. intervals. As simulated plans, IC positions were shifted in the anterior-posterior and superior-inferior directions up to±10 mm at 2 mm intervals in the original and rotated CT images, and the dose distributions were calculated. The dose calculation was performed for each CT image while keeping the movement of multi leaf collimator and the monitor unit of the original plan. The differences between D98% of CTVLN in the original plan and simulated plans were calculated. RESULTS: In the posterior direction shifts of 4, 6, 8, and 10 mm, the dose reduction of 0.7, 2.1, 6.1, and 11.9% from the original plan were found for D98% of CTVLN, respectively. The dose reductions due to the rotation of pitch direction were greater than the rotation of roll direction. In the posterior direction shifts of 4, 6, 8, and 10 mm with 3.0 deg. rotation of pitch direction, the dose reduction of 2.2, 6.8, 12.8, and 19.0% from the original plan were found, respectively. CONCLUSION: The dose reduction of CTVLN might be occurred due to the rotational setup error of pitch direction.

Stereotactic body radiotherapy for patients with small hepatocellular carcinoma ineligible for resection or ablation therapies.

AIM: To evaluate the efficacy and safety of stereotactic body radiotherapy (SBRT) in patients with small hepatocellular carcinoma (HCC) who were ineligible for resection or ablation therapies. METHODS: Overall, 65 patients with 74 HCC (median tumor size, 16 mm) were enrolled. They were treated at the prescribed dose of 48 Gy in four fractions at the isocenter. Child-Turcotte-Pugh (CTP) scoring was used to classify 56 and nine patients into classes A and B, respectively. Local progression was defined as irradiated tumor growth on a dynamic computed tomography follow up. The median follow-up period was 26 months. Tumor responses were assessed according to the modified Response Evaluation Criteria in Solid Tumors. Treatment-related toxicities were evaluated according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS: The 2-year overall survival, progression-free survival and local control rates were 76.0% (95% confidence interval [CI], 65.4-86.7%), 40.0% (95% CI, 27.6-52.3%) and 100% (95% CI, 100%), respectively. At 6-12 months after SBRT, grade 3 or higher toxicities was observed in 15 (23.1%) patients. The incidence of grade 3 or higher toxicities was higher in CTP class B than in class A (P = 0.0127). CONCLUSION: SBRT was effective and relatively safe for patients with small HCC who were ineligible for resection or ablation therapies.

Case reports of portal vein thrombosis and bile duct stenosis after stereotactic body radiation therapy for hepatocellular carcinoma.

The aim of this study was to evaluate portal vein and bile duct toxicity after stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC). We retrospectively reviewed 63 patients who were administrated SBRT once for HCC. The prescribed doses were from 48 Gy in four fractions to 60 Gy in eight fractions. Portal vein thrombosis and bile duct stenosis were evaluated. The dose received by 2% of the volume (D2 ) of the portal vein and bile duct was calculated. Portal vein thrombosis was observed in three patients (4.8%). Common points of these patients were Child-Pugh class B and D2 of the portal vein 40 Gy or more (BED3 ≥200 Gy). Bile duct stenosis was observed in one patient (1.6%). The patient had a history of cholangiocarcinoma and left hepatic lobectomy. Portal vein thrombosis may be necessary to be considered when SBRT for HCC is administrated to patients in higher Child-Pugh class with higher D2 of the portal vein.

Double-bundle anterior cruciate ligament reconstruction in patients aged 60 years and older.

Background: This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years. Methods: Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60-73 years). The mean time from injury to surgery was 80.5 months (range, 1-480 months), and the mean follow-up time was 26.2 months (range, 24-42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren-Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up. Results: The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2-8 mm) to 0.9 mm (range, 0-2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74-116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren-Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients. Conclusions: Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years. Level of evidence: A retrospective study, case series (IV).

Short- and Long-Term Outcomes of Neoadjuvant Chemoradiotherapy Followed by Pancreatoduodenectomy in Elderly Patients with Resectable and Borderline Resectable Pancreatic Cancer: A Retrospective Study.

Background: The efficacy of neoadjuvant chemoradiotherapy (NACRT) followed by pancreatoduodenectomy (PD) in elderly patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: This retrospective analysis of prospectively collected data examined the effect of NACRT followed by PD in elderly patients with PDAC. A total of 112 patients with resectable (R-) and borderline resectable (BR-) PDAC, who were planned for PD and received NACRT between 2009 and 2022, were assessed. Changes induced by NACRT, surgical outcomes, nutritional status, renal and endocrine functions, and prognosis were compared between elderly (≥75 years, n = 43) and non-elderly (<75 years, n = 69) patients over two years following PD. Results: Completion and adverse event rates during NACRT, nutritional status, renal function, endocrine function over two years postoperatively, and prognosis did not significantly differ between the two groups. Low prognostic index after NACRT and the absence of postoperative adjuvant chemotherapy may be adverse prognostic indicators for elderly patients undergoing NACRT for R- and BR-PDAC. Conclusions: Despite a higher incidence of postoperative complications, NACRT followed by PD can be safely performed in elderly patients, resulting in a prognosis similar to that in non-elderly patients.

Dynamic computed tomography appearance of tumor response after stereotactic body radiation therapy for hepatocellular carcinoma: How should we evaluate treatment effects?

AIM: To evaluate the dynamic computed tomography (CT) appearance of tumor response after stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) and reconsider response evaluation criteria for SBRT that determine treatment outcomes. METHODS: Fifty-nine patients with 67 tumors were included in the study. Of these, 56 patients with 63 tumors underwent transarterial chemoembolization using lipiodol prior to SBRT that was performed using a 3-D conformal method (median, 48 Gy/four fractions). Dynamic CT scans were performed in four phases, and tumor response was evaluated by comparing tumor appearance on CT prior SBRT and at least 6 months after SBRT. The median follow-up time was 12 months. RESULTS: The dynamic CT appearance of tumor response was classified into the following: type 1, continuous lipiodol accumulation without early arterial enhancement (26 lesions, 38.8%); type 2, residual early arterial enhancement within 3 months after SBRT (17 lesions, 25.3%); type 3, residual early arterial enhancement more than 3 months after SBRT (19 lesions, 28.4%); and type 4, shrinking low-density area without early arterial enhancement (five lesions, 7.5%). Only two tumors with residual early arterial enhancement did not demonstrate remission more than 6 months after SBRT. CONCLUSION: The dynamic CT appearance after SBRT for HCC was classified into four types. Residual early arterial enhancement disappeared within 6 months in most type 3 cases; therefore, early assessment within 3 months may result in a misleading response evaluation.

Observation of the same asbestos body by both phase contrast microscope and analytical transmission electron microscope.

The amount of asbestos body (AB) in the human lungs is used as an index to assess asbestos lung cancer (ALC). This study reports a new method to observe the same AB previously observed by analytical transmission electron microscope (ATEM) by phase contrast microscope (PCM) or the contrary order. Four kinds of specimens were prepared from the lung tissue of an asbestos related worker: ordinary PCM specimen (A); PCM specimen (B) of which the cover glass was stripped off and ashed at a low temperature; transmission electron microscope (TEM) specimen (C); and PCM specimen (D) covered a TEM specimen (C) with immersion liquid and cover glass. These specimens were all observed by PCM, and the specimen (C) by analytical TEM (ATEM). The results showed that the TEM specimen (C) is transparent in visible light and we can also see the particles by PCM. The image by PCM of the TEM specimen (C) showed very similar features to that of PCM specimens (A) and (B). Accordingly, we could observe various same particles by both ATEM and PCM. In conclusion, the method observing the same AB by both PCM and ATEM will contribute to standardize the recognition of AB for PCM analysts.

Preoperative Loss of Knee Extension Affects Knee Extension Deficit in Patients After Anterior Cruciate Ligament Reconstruction.

Background: Loss of knee extension (LOE) after anterior cruciate ligament reconstruction (ACLR) is associated with limited knee joint function and increased risk for knee osteoarthritis. Hypothesis: Preoperative LOE will affect postoperative LOE for up to 12 months after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Included were patients who underwent anatomic ACLR between June 2014 and December 2018. In all patients, the postoperative rehabilitation protocol was the same. A heel height difference (HHD) ≥2 cm between the affected and the contralateral leg was used as a measure of LOE. Based on preoperative HHD, patients were divided into LOE and no-LOE groups. The HHD was reevaluated at 1, 3, 4, 6, 9, and 12 months postoperatively. Proportional hazards analysis was used, with the dependent variable being whether a postoperative HHD <2 cm was achieved; the independent variables being the presence or absence of preoperative LOE; and the adjusted variables being age, sex, time to surgery, and presence of meniscal sutures. Results: A total of 389 patients (208 female, 181 male; median age, 21.0 years) were included in the study. There were 55 patients in the LOE group and 334 patients in the no-LOE group. The incidence of LOE at 12 months after ACLR was 13.8% in the no-LOE group and 38.2% in the LOE group (P < .001), with an absolute risk difference of 24.4%. The hazard ratio for achieving postoperative HHD <2 cm was 2.79 for the LOE group versus the no-LOE group (P < .001). Conclusion: Patients with preoperative LOE were nearly 3 times more likely than those without LOE to have LOE at 12 months after ACLR.

Avoiding Dosimetric Risk Factors for Complications in Neoadjuvant Chemoradiotherapy for Lung Cancer: Conventional Radiotherapy Versus Intensity-modulated Radiotherapy.

BACKGROUND/AIM: We compared three-dimensional conformal radiotherapy (3D-CRT) with intensity-modulated radiotherapy (IMRT) for avoiding dosimetric risk factors related to pulmonary complications after neoadjuvant chemoradiotherapy followed by surgery (NACRT-S) for non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: We performed simulations in 11 patients with dosimetric risk factors during their treatment with NACRT-S for NSCLC. Radiation treatment plans were generated using 3D-CRT and IMRT to avoid dosimetric risk factors. Regarding dose-volume histogram (DVH) parameters, we calculated the percentage of lung volume that received more than x Gy (Vx) using 1) the total lung volume minus gross tumor volume (DVHg), 2) the lung volume remaining after surgery (DVHr), and 3) the contralateral lung volume (DVHc). We analyzed the dosimetric differences between 3D-CRT and IMRT. RESULTS: V35g and V40g were significantly lower with IMRT than with 3D-CRT (p=0.001 each); the median V35g and V40g were 16.1% and 14.9% with 3D-CRT versus 12.0% and 9.2% with IMRT, respectively. Overall, 0% and 55% of the patients were able to avoid all dosimetric risk factors with 3D-CRT and IMRT, respectively (p=0.006). Even with IMRT, tumor location and length of the planning target volume (PTV) significantly affected the avoidance of all dosimetric risk factors (p=0.015 and 0.022, respectively). CONCLUSION: IMRT is more useful than 3D-CRT for avoiding dosimetric risk factors in NACRT-S for NSCLC. For further improvements in avoiding these factors, respiratory motion managements to reduce the length of the PTV may be required for patients with middle or lower lobe tumors.

A Prospective Study of Intensity-modulated Radiation Therapy Using a Standard Radiation Dose for High-grade Glioma.

BACKGROUND/AIM: We evaluated the treatment outcomes of intensity-modulated radiation therapy (IMRT) using a standard radiation dose in patients with high-grade glioma (HGG). PATIENTS AND METHODS: We conducted a prospective, single-institutional, single-arm trial. Patients aged 20-75 years with histologically proven HGG were enrolled. Surgical procedures and chemotherapy regimens were not regulated. The prescribed dose of postoperative IMRT was 60 Gy in 30 fractions over six weeks. The primary endpoint was overall survival (OS). Secondary endpoints were progression-free survival (PFS), completion rate of IMRT, and Grade 3 or higher non-hematological toxicity. RESULTS: Between 2016 and 2019, 20 patients were enrolled. According to the World Health Organization 2016 Classification, glioblastoma, anaplastic astrocytoma, and anaplastic oligodendroglioma were present in nine, six, and five of the recruited patients, respectively. Gross total resection, partial resection, and biopsy were performed in four, nine, and seven patients, respectively. All patients received concurrent and adjuvant chemotherapy using temozolomide with or without bevacizumab. The completion rate of IMRT was 100%. The median follow-up period was 29 months (range=6-68 months). Median OS and PFS were 30 and 14 months, respectively. No patients experienced Grade 3 or higher non-hematological toxicity. The 2-year OS rates were 100%, 57%, and 33% in Radiation Therapy Oncology Group-Recursive Partitioning Analysis (RTOG-RPA) classes I/II, IV, and V, respectively (p=0.002; log-rank test). CONCLUSION: IMRT using the standard radiation dose in patients with HGG can be carried out safely. RTOG-RPA class appears to be useful to estimate patient prognoses.