Rectal/urinary toxicity after hypofractionated vs. conventional radiotherapy in high risk prostate cancer: systematic review and meta analysis

OBJECTIVE

The aim of our report was to review the literature concerning the toxicity of radiation therapy in patients treated for high-risk prostate cancer, and to evaluate the differences in toxicity between conventional fractionation and hypofractionated treatments, in view of different techniques used in high-risk prostate cancer patients.

MATERIALS AND METHODS

PubMed database has been explored for studies concerning acute and late urinary/gastrointestinal toxicity in high-risk prostate cancer patients treated with radiotherapy. Prospective studies, concerning potential relationship between acute/late genitourinary (GU)/gastrointestinal (GI) toxicity and prostate radiotherapy in patients with high-risk prostate cancer, were included in the final analysis. Data collected from single arm, phase II non-randomized and randomized studies have been evaluated to perform odds ratio for toxicity risk. Furthermore, meta-analysis randomized prospective trials were considered suitable because they had recruited high-risk prostate cancer patients who didn't undergo surgery, with available data on ≥ G2 toxicity frequency.

RESULTS

The initial search provided 606 results, but only 35 manuscripts met all eligibility requirements and were included in this report. In order to perform odds ratio we observed a decrease in late gastrointestinal toxicity for patients treated with hypofractionated schemes compared to CV treated ones. Among patients who underwent conventional treatment, SIB seemed to decrease acute genitourinary side effects; SIB-Hypo treated patients suffered less toxicity than patients treated with hypofractionated- sequential boost schemes. Hypo-SIB schemes would seem less toxic in terms of acute gastrointestinal and late genitourinary side effects than CV-SIB. Therefore, our focus shifted to 6 clinical trials evaluating genitourinary and gastrointestinal toxicity in patients who had been randomized to receive conventional fractionation or hypofractionated treatment, in both cases with IMRT technology. Our meta-analysis of these randomized trials involving patients with high-risk prostate cancer showed a statistically significant increase in late genitourinary toxicity for hypo-treated patients; no difference was observed in acute genitourinary/gastrointestinal toxicity, and in late gastrointestinal toxicity.

CONCLUSIONS

Our analysis doesn't want to establish a definitive truth; very few trials assessed only high risk-class patients. Our purpose is to stimulate further randomized prospective trials focusing both on the effectiveness and toxicity profile (toxicity/effectiveness ratio), taking into account the use of different technologies and doses.

Improvement of luminescence properties of rubidium vanadate, RbVO3, phosphors by erbium doping in the crystal lattice

The thermal quenching effect of RbVO₃ phosphor was effectively improved by Er³⁺ doping into the lattice, as a result, the emission intensity of the phosphor was successfully enhanced.

CTA and DSA Evaluation of Patients with Subarachnoid Haemorrhage

We correlate digital subtraction angiography (DSA) and computed tomography with angiographic 3D reconstruction (CTA) in patients with subarachnoid haemorrhage. 45 patients were evaluated with both techniques (CTA and DSA) within 3–4 days after acute haemorrhage: source CT images, MIP and 4D-angio reconstruction and standard DSA were performed and correlated. The MIP tecnique is very easy and quick to perform and operator independent, while 4D-angio reconstruction requires at least 30 minutes to obtain good quality images.

CTA and DSA were equivalent in demonstrating the presence of all 57 aneurysms in the 45 patients. Most aneurysms were located at the level of the circle of Willis; CTA was not adequate to demonstrate the neck of aneurysms in 7 cases located in of the syphon, vertebral artery and posterior communicating artery; CTA gave a good display of the thrombus within the aneurysm.

Patients could go directly from the CT diagnostic room to the operating room in certain types of aneurysm such as those in the anterior communicating artery or middle cerebral artery in which there is a correlation between site of the haemorrhage and the aneurysm. In the future, improvements in MR technology will also exclude aneurysms in sites difficult to evaluate by CTA such as the syphon, so that DSA will be performed only in selected doubtful cases.

VERO® radiotherapy for low burden cancer: 789 patients with 957 lesions

Purpose

The aim of this retrospective study is to evaluate patient profile, feasibility, and acute toxicity of RadioTherapy (RT) delivered by VERO® in the first 20 months of clinical activity.

Methods

Inclusion criteria: 1) adult patients; 2) limited volume cancer (M0 or oligometastatic); 3) small extracranial lesions; 4) treatment between April 2012 and December 2013 and 5) written informed consent. Two techniques were employed: intensity modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT). Toxicity was evaluated using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer (RTOG/EORTC) criteria.

Results

Between April 2012 and December 2013, 789 consecutive patients (957 lesions) were treated. In 84% of them one lesion was treated and in 16% more than one lesion were treated synchronously/metachronously; first radiotherapy course in 85%, re-irradiation in 13%, and boost in 2% of cases. The treated region included pelvis 46%, thorax 38%, upper abdomen 15%, and neck 1%. Radiotherapy schedules included <5 and >5 fractions in 75% and 25% respectively. All patients completed the planned treatment and an acceptable acute toxicity was observed.

Conclusions

RT delivered by VERO® was administrated predominantly to thoracic and pelvic lesions (lung and urologic tumours) using hypofractionation. It is a feasible approach for limited burden cancer offering short and well accepted treatment with favourable acute toxicity profile. Further investigation including dose escalation and other available VERO® functionalities such as real-time dynamic tumour tracking is warranted in order to fully evaluate this innovative radiotherapy system.

Posterior Fossa Arteriovenous Pial Fistula: Diagnostic and Endovascular Therapeutic Features

Intracranial arteriovenous fistulas (AVFs) are rare vascular cerebral lesions composed of one or more corticalpial arterial feeders directly connected with a single draining vein. They differ from the other AV malformations in that they lack a nidus and are located outside the dural leaflets. Because of high flow and pressure AVFs have a high risk of hemorrhage and if untreated cause death in up to 63% of cases. Treatment can be endovascular or microneurosurgical. We describe an infant with hydrocephalus and raised intracranial pressure and MRI findings of a single dilated venous vessel with a proximal varix in the perimedullary spaces confirmed by CT angiography and DSA that found a single artery-single vein fistula we successfully occluded with GDC coils.

Biomechanics of the Spine

Biomechanics of the spine is a vast area of research that has generated numerous studiesin recent years on the part of doctors (mainly orthopaedic surgeons), bioengineers and physicists. This paper is a short introduction to some of the topics of major interest in spine biomechanics.

The first topic is the development of the spine with a “mechanical” explanation of the physiological curvatures. As the spine is a multiarticular complex structure, understanding the mechanism responsible for its dynamics requires in-depth knowledge of the spine's basic components: the vertebrae and their architecture, the intervertebral joints, the ligaments and muscles. A short morphofunctional description of each of these anatomical parts is given mentioning their biomechanical features.

Of particular interest, in relation to spinal trauma, is the architecture of the cancellous bone of the vertebrae responsible for most resistance to compressive weight loads. This specific characteristic is gradually lost over the years either due to disease or to a progressive resorption of the horizontal lamellae and thinning of the vertical columns typical of osteoporosis.

Numerous studies have been conducted in vivo and in vitro to shed light on the mechanisms leading to particular traumatic lesions or degenerative arthrosis. These have given rise to various theories formulated to account for the distribution of loads and strength in the elements making up the functional spinal unit. These theories include the old “two vertical columns” theory, subsequently replaced by the “three columns theory”, and the latest “four columns” model which divides the spine longitudinally depending on carrying strength. The latest theory was formulated in the wake of in vivo CT studies using an axial loading device which allows axial loads to be applied even though patients are in a supine position.

A short mention is made of the possible biomechanical applications of neuroradiological techniques, namely cine-MR scans, which allow detailed study of the ligaments, muscles and disc, especially the cervical spine under dynamic conditions.

Lastly, the controversial concept of spinal stability and instability is discussed. Further studies are necessary to establish appropriate criteria for treatment of traumatic or degenerative lesions since an impairment to spine statics can result in permanent neurological damage.

Non-Discal Lumbar Radiculopathy: Combined Diagnostic Approach by CT and MR

The goal of this paper was to evaluate the different causes of non-discal radiculopathies and to determine the different sensitivity and specificity of CT and MR.

We reviewed 450 patients with non-discal radiculopathy; CT was performed in all patients while MR was done only in 95 cases. MR was obtained only in case of polyradiculopathy, or if there was a discrepancy between clinical evaluation and CT findings or when sphincteral symptoms were present.

The most frequent cause of non-discal radiculopathy was degenerative disk disease associated with facet joint abnormality and secondary central and lateral spinal canal stenosis. Other causes were neoplastic lesions, traumas, malformations, inflammatory processes and vascular abnormality.

CT was more sensitive and specific in degenerative disc disease while MR was better at evaluating other pathology.

CT still represents a satisfactory technique in evaluating patients with non-discal radiculopathy; MR must be also performed in case of discrepancy between clinical evaluation and CT findings.

Directly MR examination should be reserved for patients presenting sphincteral symptoms.

Percutaneous Treatment of Herniated Lumbar Disc by Intradiscal Oxygen-Ozone Injection

We report our experience of treating lumbar herniated disc by intradiscal injection of an oxygen-ozone mixture. Ozone (03, MW = 48) is a triatomic molecule, having antiviral, disinfectant and antiseptic properties. Several mechanisms of action have been proposed to explain the efficacy of the treatment:

analgesic action; anti-inflammatory action; oxidant action on the proteoglycan in the nucleus pulposus.

We treated 93 patients (50 women, 43 men) aged from 24 to 45 yrs (average age 38 yrs) from June 1996 to April 1998.

All patients presented sciatica and/or low back pain, lasting two or more months; patients had in the mean time received both medical and physical therapy with mild or no benefit.

Diagnostic tests in all patients included plain film x-ray, CT and/or MR at the level of the lumbar spine disclasing a herniated or protruded disc with nerve root or thecal sac compression.

We divided patients to be treated in to two groups: the first one group included 35 patients already selected for surgery who presented herniated or protruded disc with radicular pain with associated neurological deficit (hypoesthesia and partial loss of reflex). Those patients had already had medical and physical therapy for two or more months and agreed to try the percutaneous treatment before surgery. CT or MR in this group demonstrated the presence of intraforaminal, extra or sub-ligamentary and sequestrated herniated disc. The second group included 58 patients with radicular pain but without neurological deficit; patients in this group had received medical and/or physical therapy for two or more months and CT showed the presence of a small subligamentary herniated or protruded disc.

We considered the results according to the modified MacNab method.

In the first group we had “failure” in all patients; in seven cases the symptoms improved for one month, but recurred later on. In the second group 45 patients had “success” showing complete clinical recovery within five to six days after treatment, all remained without symptoms up to six months or more of follow-up. The remaining 13 patients presented the same symptoms again within three months after a temporary clinical recovery. The goal of this study was to present this new technique that can also be compared with a previous study of different percutaneous treatment. Clinical and neuroradiological indications and the contraindications are well known, and must be followed to achieve good results and avoid complications.

Development of an E-learning System for the Endoscopic Diagnosis of Early Gastric Cancer: An International Multicenter Randomized Controlled Trial

Background

In many countries, gastric cancer is not diagnosed until an advanced stage. An Internet-based e-learning system to improve the ability of endoscopists to diagnose gastric cancer at an early stage was developed and was evaluated for its effectiveness.

Methods

The study was designed as a randomized controlled trial. After receiving a pre-test, participants were randomly allocated to either an e-learning or non-e-learning group. Only those in the e-learning group gained access to the e-learning system. Two months after the pre-test, both groups received a post-test. The primary endpoint was the difference between the two groups regarding the rate of improvement of their test results.

Findings

515 endoscopists from 35 countries were assessed for eligibility, and 332 were enrolled in the study, with 166 allocated to each group. Of these, 151 participants in the e-learning group and 144 in the non-e-learning group were included in the analysis. The mean improvement rate (standard deviation) in the e-learning and non-e-learning groups was 1·24 (0·26) and 1·00 (0·16), respectively (P < 0·001).

Interpretation

This global study clearly demonstrated the efficacy of an e-learning system to expand knowledge and provide invaluable experience regarding the endoscopic detection of early gastric cancer (R000012039).

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This report establishes that an e-learning system on the Internet can improve the diagnostic ability of endoscopists.

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Countless endoscopists worldwide can access the system to learn how to make an endoscopic diagnosis of early gastric cancer.

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The e-learning system could be modified to provide education regarding endoscopic diagnosis in other organs.

This is the first report to demonstrate how an e-learning system based on the Internet can improve the diagnostic ability of gastrointestinal endoscopists worldwide. There is no limit to the number of endoscopists who can access the system and benefit from this opportunity to learn how to make an endoscopic diagnosis of early gastric cancer. This e-learning system could be modified to provide education regarding endoscopic diagnosis in other organs such as the large intestine and the esophagus, as well as the stomach. It may contribute to human welfare and health by reducing the mortality from gastrointestinal cancer.

Proton pump inhibitor after endoscopic resection for esophageal squamous cell cancer: multicenter prospective randomized controlled trial

BACKGROUND

Whether proton pump inhibitors (PPIs) relieve heartburn or precordial pain after endoscopic resection (ER) for esophageal squamous cell carcinoma (ESCC) remains unclear. The aim of this study was to investigate the efficacy of PPI therapy for these symptoms after ER for ESCC.

METHODS

We conducted a multicenter prospective randomized controlled trial among 15 hospitals in Japan. In total, 229 patients with cT1a ESCC were randomly assigned to receive PPI therapy for 5 weeks after ER (the PPI group, n = 115) or follow-up without PPI therapy (the non-PPI group, n = 114). The primary end point was the incidence of gastroesophageal reflux disease (GERD)-like symptoms after ER from a self-reported questionnaire (Frequency Scale for Symptoms of GERD). Secondary end points were ulcer healing rate at 5 weeks, incidence of pain, improvement rate of symptoms in those who started PPI therapy because of GERD-like symptoms in the non-PPI group, and adverse events.

RESULTS

No significant difference was observed in the incidence of GERD-like symptoms after ER between the non-PPI and PPI groups (30 % vs 34 %, respectively). No significant differences were observed in the ulcer healing rate at 5 weeks (84 % vs 85 %) and incidence of pain within 1 week (36 % vs 45 %). In nine of ten patients (90 %) who started PPI therapy because of GERD-like symptoms in the non-PPI group, PPI administration relieved GERD-like symptoms. No adverse events related to PPI administration were observed.

CONCLUSION

PPI therapy is not efficacious in reducing symptoms and did not promote healing of ulcers in patients undergoing ER for ESCC.