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Fathi A, Bashrum BS, Kim MS, Wang J, Mayfield CK, Thompson AA, Bolia IK, Hasan LK, Weber AE, Petrigliano FA, Liu JN. Evaluation of spin in reviews of biodegradable balloon spacers for massive irreparable rotator cuff tears. J Shoulder Elbow Surg 2024; 33:e13-e20. [PMID: 37657596 DOI: 10.1016/j.jse.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/10/2023] [Accepted: 07/21/2023] [Indexed: 09/03/2023]
Abstract
HYPOTHESIS Clinical studies are often at risk of spin, a form of bias where beneficial claims are overstated while negative findings are minimized or dismissed. Spin is often more problematic in abstracts given their brevity and can result in the misrepresentation of a study's actual findings. The goal of this study is to aggregate primary and secondary studies reporting the clinical outcomes of the use of subacromial balloon spacers in the treatment of massive irreparable rotator cuff tears to identify the incidence of spin and find any significant association with study design parameters. MATERIALS AND METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Independent searches were completed on 2 databases (PubMed and Embase) for primary studies, systematic and current concepts reviews, and meta-analyses and the results were compiled. Two authors independently screened the studies using a predetermined inclusion criteria and aggregated data including titles, publication journals and years, authors, study design, etc. Each study was independently assessed for the presence of 15 different types of spin. Statistical analysis was conducted to identify associations between study characteristics and spin. RESULTS Twenty-nine studies met the inclusion criteria for our analysis, of which 10 were reviews or meta-analyses and 19 were primary studies. Spin was identified in every study except for 2 (27/29, 93.1%). Type 3 spin, "Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention" and type 9 spin, "Conclusion claims the beneficial effect of the experimental treatment despite reporting bias" were most frequently noted in our study, both observed in 12/29 studies (41.4%). Date of publication, and adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses or "The International Prospective Register of Systematic Reviews" were study characteristics associated with a higher rate of certain types of spin. There was a statistically significant association between disclosure of external study funding source and the presence of spin type 4, but none of the other forms of spin. CONCLUSION Spin is highly prevalent in the abstracts of primary studies, systematic reviews, and meta-analyses discussing the use of subacromial balloon spacer technology in the treatment of massive irreparable rotator cuff tears. Our findings revealed that spin in the abstract tended to favor the balloon spacer intervention. Further efforts are required in the future to mitigate spin within the abstracts of published manuscripts.
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Affiliation(s)
- Amir Fathi
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Bryan S Bashrum
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Michael S Kim
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Jennifer Wang
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Cory K Mayfield
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ashley A Thompson
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Joseph N Liu
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA.
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Liu C, Jiang S, Xu W, Chen X, He R, Deng K, Su H, Yin X, Su S, Liang T, Zhu L, Hou G, Zhang Y, Shi Y, Lv W, Liu L, Guo Z, Xu Y, Xu T, Wang K. Poly-l-lactide-co-ε-caprolactone (PLCL) and poly-l-lactic acid (PLLA)/gelatin electrospun subacromial spacer improves extracellular matrix (ECM) deposition for the potential treatment of irreparable rotator cuff tears. Int J Biol Macromol 2023:125522. [PMID: 37353124 DOI: 10.1016/j.ijbiomac.2023.125522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 06/25/2023]
Abstract
Biodegradable subacromial spacer implantation has become practicable for the treatment of irreparable rotator cuff tears (IRCT). However, the relative high degradation rate and inferior tissue regeneration properties of current subacromial spacer may lead to failure regards to long-term survival. It is reported that satisfactory clinical results lie in the surrounding extracellular matrix (ECM) deposition after implantation. This study aims to develop a biological subacromial spacer that would enhance tissue regeneration properties and results in better ECM deposition. Physicochemical properties were characterized on both poly-l-lactide-co-ε-caprolactone (PLCL) dip-coating spacer (monolayer spacer, MS) and PLCL dip-coating + Poly-l-Lactic Acid (PLLA)/Gelatin electrospun spacer (Bilayer Spacer, BS). Cytocompatibility, angiogenesis, and collagen inducibility were evaluated with tendon fibroblasts and endothelial cells. Ultrasonography and histomorphology were used to analyze biodegradability and surrounding ECM deposition after the implantation in vivo. BS was successfully fabricated with the dip-coating and electrospinning technique, based on the human humeral head data. In vitro studies demonstrated that BS showed a greater cytocompatibility, and increased secretion of ECM proteins comparing to MS. In vivo studies indicated that BS promoted ECM deposition and angiogenesis in the surrounding tissue. Our research highlights that BS exhibits better ECM deposition and reveals a potential candidate for the treatment of IRCT in future.
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Affiliation(s)
- Chang Liu
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China; Department of Orthopaedic Surgery, The Lingnan Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Shihai Jiang
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig 04103, Germany
| | - Wenbin Xu
- Department of Orthopaedic Surgery, The Lingnan Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xi Chen
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Ronghan He
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Kunxue Deng
- Medprin Regenerative Medical Technologies Co., Ltd, Guangzhou 510630, China
| | - Hengxian Su
- Zhujiang Hospital of Southern Medical University, Guangzhou 510282, China
| | - XiaoPeng Yin
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Shouwen Su
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Tangzhao Liang
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Lei Zhu
- Department of Plastic and Aesthetic Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Tianhe District, Guangzhou 510630, China
| | - Gang Hou
- Department of Orthopaedic Surgery, The Lingnan Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Yuanyuan Zhang
- Obstetrics and Gynaecology, Maternal and Child Health Care Hospital of Jiaozuo, Jiaozuo 454000, China
| | - Yi Shi
- Department of Orthopedics, First Affiliated Hospital of Anhui Medical University, 230022, China
| | - Wenhao Lv
- Department of Joint Surgery, Jiaozuo Coal Industry (Group) Co. Ltd. Central Hospital, Jiaozuo 454000, China
| | - Libiao Liu
- Medprin Regenerative Medical Technologies Co., Ltd, Guangzhou 510630, China
| | - Zeyue Guo
- Medprin Regenerative Medical Technologies Co., Ltd, Guangzhou 510630, China
| | - Yichun Xu
- Department of Orthopaedic Surgery, The Lingnan Hospital of Sun Yat-sen University, Guangzhou 510630, China.
| | - Tao Xu
- Department of Mechanical Engineering, Tsinghua University, Beijing 100084, China; Center for Bio-intelligent Manufacturing and Living Matter Bioprinting, Research Institute of Tsinghua University in Shenzhen, Tsinghua University, Shenzhen 518057, China; East China Institute of Digital Medical Engineering, Shangrao 334000, China.
| | - Kun Wang
- Department of Joint and Trauma Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China.
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Johns WL, Ailaney N, Lacy K, Golladay GJ, Vanderbeck J, Kalore NV. Implantable Subacromial Balloon Spacers in Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review of Clinical, Biomechanical, and Financial Implications. Arthrosc Sports Med Rehabil 2020; 2:e855-e872. [PMID: 33364617 PMCID: PMC7754516 DOI: 10.1016/j.asmr.2020.06.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/21/2020] [Indexed: 01/26/2023] Open
Abstract
Purpose To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs). Methods All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies. Results In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM. Conclusions Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal. Level of Evidence IV; Systematic review of level III-IV studies.
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Affiliation(s)
- William L Johns
- School of Medicine, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Nikhil Ailaney
- School of Medicine, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Kevin Lacy
- School of Medicine, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Jennifer Vanderbeck
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Niraj V Kalore
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia, USA
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Haim Zada M, Kumar A, Elmalak O, Markovitz E, Icekson R, Domb AJ. In vitro and in vivo degradation behavior and the long-term performance of biodegradable PLCL balloon implants. Int J Pharm 2020; 574:118870. [DOI: 10.1016/j.ijpharm.2019.118870] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 02/06/2023]
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Stewart RK, Kaplin L, Parada SA, Graves BR, Verma NN, Waterman BR. Outcomes of Subacromial Balloon Spacer Implantation for Massive and Irreparable Rotator Cuff Tears: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119875717. [PMID: 31663007 PMCID: PMC6794659 DOI: 10.1177/2325967119875717] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) entails a challenging decision-making process in which surgeons must consider several factors, including duration of symptoms, tear pattern, tear size, and muscle quality, as well as patient characteristics such as age, comorbidities, shoulder dominance, and activity level. Unfortunately, no clear consensus has been reached regarding optimal management. Purpose To systematically review the published literature assessing outcomes after subacromial balloon spacer implantation for treatment of massive and irreparable RCTs. Study Design Systematic review; Level of evidence, 4. Methods A comprehensive literature search was performed in September 2018 through use of MEDLINE and the Cochrane Library electronic databases. Studies were assessed for multiple outcomes of interest including Constant score, Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) Shoulder Score, complications, and patient satisfaction. Results After applying the selection criteria, 12 clinical studies were included for data extraction and analysis. In total, 291 shoulders (in 284 patients) treated with subacromial balloon spacer implantation were pooled for evaluation, with a mean follow-up of 22.9 ± 14.9 months (range, 6-60 months). Constant scores were used as an outcome metric for 267 shoulders (91.7%; 11 studies), with improvements in mean Constant score ranging from 18.5 to 49.6 points. Patient satisfaction was assessed in 105 patients (37.0%; 5 studies), with rates of patients indicating they were satisfied or very satisfied with their treatment outcome ranging from 45.8% to 100%. A total of 6 patients (2.1%) experienced complications related to balloon spacer implantation, including transient neurapraxia of the lateral antebrachial cutaneous nerve, superficial wound infection, deep wound infection, and balloon migration. Of these, 3 patients (2 balloon migration, 1 deep wound infection) required subsequent surgeries for balloon removal. Conclusion Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure with favorable patient-reported outcomes at limited short-term follow-up. However, inherent methodological limitations and patient heterogeneity between studies may impair our ability to fully characterize the longer term efficacy, particularly relative to other potential surgical options. Further prospective randomized or comparative studies are warranted to ascertain clinical outcomes of subacromial balloon spacer in the management of massive and irreparable RCTs.
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Affiliation(s)
- Russell K Stewart
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Lisa Kaplin
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen A Parada
- Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Benjamin R Graves
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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6
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Biodegradable implantable balloons: Mechanical stability under physiological conditions. J Mech Behav Biomed Mater 2019; 100:103404. [PMID: 31473436 DOI: 10.1016/j.jmbbm.2019.103404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 08/05/2019] [Accepted: 08/24/2019] [Indexed: 11/23/2022]
Abstract
Rotator cuff tendons injuries occurs as a result of trauma, e.g. due to falling, mechanical injuries and frequent overhead activity and as natural degenerative tears in elderly people. Biodegradable balloon shaped spacer of Poly-(L-lactide-co-ε-caprolactone) (PLCL) are applied in the treatment of these injuries. This type of treatment involves insertion of inflated biodegradable implant into the tissues of the damaged region in the shoulder to avoid shoulder impingement and reduce friction between the acromion and the humeral head and propagation of inflammation. The implant must maintain integrity under significant mechanical loading in order to remain effective. However, with time, the implant is exposed to the risk of failure due to the high pressure caused by the muscular motion and the friction with the bones. We report in this study the limits of the mechanical stability of the PLCL balloon shape spacer (implant) under prolonged cyclic loading, so as to be able to predict their physical stability in vivo. We have demonstrated in an in vitro settings that the implant withstands fatigue cycles for significantly longer than 8 weeks, which provides sufficient time window for patients to perform substantial rehabilitation and recover from an injury. The data presented herein is expected to assist medical practitioners in safety and efficacy measurements and assessment following spacer implantation.
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7
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Lehrich BM, Barnes L, Mesa A, Singh K, Tokita KM. Response to "Is there a role for hydrogel spacer in post-prostatectomy radiotherapy setting?". Radiol Med 2019; 124:1304-1305. [PMID: 31428959 DOI: 10.1007/s11547-019-01071-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Brandon M Lehrich
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA.
| | - Lucy Barnes
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA
| | - Albert Mesa
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA
| | - Karan Singh
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA
| | - Kenneth M Tokita
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA.
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Bakti N, Bhat M, Gulihar A, Prasad V, Singh B. Subacromial Balloon Interpositional Arthroplasty for the Management of Irreparable Rotator Cuff Tears: Five-year Results. Open Orthop J 2019. [DOI: 10.2174/1874325001913010089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Management of massive irreparable rotator cuff tears can be a source of significant dilemma for the treating surgeon. This is especially true when dealing with patients with poor physiological reserves where options of tendon transfer, superior capsular repair or arthroplasty might be unsuitable. We report the five-year outcomes of 26 patients who underwent balloon interpositional arthoplasty for the management of massive irreparable rotator cuff tears.
Methods:
Fifty-four consecutive patients underwent balloon interpositional arthroplasty in our institution. Of these, 26 patients completed at least two postoperative functional outcome measures over a five-year period, which included the Visual Analogue Score (VAS), Oxford Shoulder Score (OSS) and the SF12 score. Outcome scores were obtained prospectively.
Results:
The average age at implantation was 67 years old. Our result shows statistically significant improvement in pain up to five years post-implantation of the device (p = 0.012). Function measured by the OSS and SF12 (PCS) score showed improvement up to two years post-implantation (p = 0.006). Three of the 54 patients in our cohort went on to have arthroplasty surgery for their rotator cuff tears. None of the patients in our cohort suffered from any adverse reactions following implantation.
Discussion/Conclusion:
Results from our study identify the spacer device as an option in the management of irreparable rotator cuff tears with statistical improvement in pain and function. It may also delay the need for arthoplasty surgery.
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Forgione M, Sara S, Vincent AD, Borg M, Moretti K, O'Callaghan ME. Satisfaction with care in men with prostate cancer. Eur J Cancer Care (Engl) 2019; 28:e13028. [DOI: 10.1111/ecc.13028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 12/05/2017] [Accepted: 02/01/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Michelle Forgione
- Freemasons Foundation Centre for Men's Health The University of Adelaide Adelaide South Australia Australia
| | - Sally Sara
- Urology Unit Repatriation General Hospital Daw Park South Australia Australia
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA‐PCCOC) Adelaide South Australia Australia
| | - Andrew D. Vincent
- Freemasons Foundation Centre for Men's Health The University of Adelaide Adelaide South Australia Australia
- Discipline of Medicine University of Adelaide Adelaide South Australia Australia
| | - Martin Borg
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA‐PCCOC) Adelaide South Australia Australia
- Adelaide Radiation Centre Adelaide South Australia Australia
| | - Kim Moretti
- Freemasons Foundation Centre for Men's Health The University of Adelaide Adelaide South Australia Australia
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA‐PCCOC) Adelaide South Australia Australia
- School of Medicine, Flinders Centre for Innovation in Cancer Flinders University Adelaide South Australia Australia
- Discipline of Surgery University of Adelaide Adelaide South Australia Australia
- Centre for Population Health Research University of South Australia Adelaide South Australia Australia
| | - Michael E. O'Callaghan
- Freemasons Foundation Centre for Men's Health The University of Adelaide Adelaide South Australia Australia
- Urology Unit Repatriation General Hospital Daw Park South Australia Australia
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA‐PCCOC) Adelaide South Australia Australia
- Discipline of Medicine University of Adelaide Adelaide South Australia Australia
- School of Medicine, Flinders Centre for Innovation in Cancer Flinders University Adelaide South Australia Australia
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Leiker AJ, Desai NB, Folkert MR. Rectal radiation dose-reduction techniques in prostate cancer: a focus on the rectal spacer. Future Oncol 2018; 14:2773-2788. [PMID: 29939069 DOI: 10.2217/fon-2018-0286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the most common cancer in men. External beam radiotherapy by a variety of methods is a standard treatment option with excellent disease control. However, acute and late rectal side effects remain a limiting concern in intensification of therapy in higher-risk patients and in efforts to reduce treatment burden in others. A number of techniques have emerged that allow for high-radiation dose delivery to the prostate with reduced risk of rectal toxicity, including image-guided intensity-modulated radiation therapy, endorectal balloons and various forms of rectal spacers. Image-guided radiation therapy, either intensity-modulated radiation therapy or stereotactic ablative radiation therapy, in conjunction with a rectal spacer, is an efficacious means to reduce acute and long-term rectal toxicity.
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Affiliation(s)
- Andrew J Leiker
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
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Placement of an absorbable rectal hydrogel spacer in patients undergoing low-dose-rate brachytherapy with palladium-103. Brachytherapy 2017; 17:251-258. [PMID: 29241706 DOI: 10.1016/j.brachy.2017.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 01/26/2023]
Abstract
PURPOSE Rates of rectal toxicity after low-dose-rate (LDR) brachytherapy for prostate cancer are dependent on rectal dose, which is associated with rectal distance from prostate and implanted seeds. Placement of a hydrogel spacer between the prostate and rectum has proven to reduce the volume of the rectum exposed to higher radiation dose levels in the setting of external beam radiotherapy. We present our findings with placing a rectal hydrogel spacer in patients following LDR brachytherapy, and we further assess the impact of this placement on dosimetry and acute rectal toxicity. METHODS AND MATERIALS Between January 2016 and April 2017, 74 patients had placement of a hydrogel spacer, immediately following a Pd-103 seed-implant procedure. Brachytherapy was delivered as follows: as a monotherapy to 26 (35%) patients; as part of planned combination therapy with external beam radiotherapy to 40 (54%) patients; or as a salvage monotherapy to eight (11%) patients. Postoperative MRI was used to assess separation achieved with rectal spacer. Acute toxicity was assessed retrospectively using Radiation Oncology Therapy Group radiation toxicity grading system. Rectal dosimetry was compared with a consecutive cohort of 136 patients treated with seed implantation at our institution without a spacer, using a 2-tailed paired Student's t test (p < 0.05 for statistical significance). RESULTS On average, 11.2-mm (SD 3.3) separation was achieved between the prostate and the rectum. The resultant mean rectal volume receiving 100% of prescribed dose (V100%), dose to 1 cc of rectum (D1cc), and dose to 2 cc of rectum (D2cc) were 0 (SD 0.05 cc), 25.3% (SD 12.7), and 20.5% (SD 9.9), respectively. All rectal dosimetric parameters improved significantly for the cohort with spacer placement as compared with the nonspacer cohort. Mean prostate volume, prostate V100 and dose to 90% of gland (D90) were 29.3 cc (SD 12.4), 94.0% (SD 3.81), and 112.4% (SD 12.0), respectively. Urethral D20, D5cc, and D1cc were 122.0% (SD 17.27), 133.8% (SD 22.8), and 144.0% (SD 25.4), respectively. After completing all treatments, at the time of first the followup, 7 patients reported acute rectal toxicity-6 experiencing Grade 1 rectal discomfort and 1 (with preexisting hemorrhoids) experiencing Grade 1 bleeding. CONCLUSIONS Injection of rectal spacer is feasible in the post-LDR brachytherapy setting and reduces dose to the rectum with minimal toxicity. Prostate and urethral dosimetries do not appear to be affected by the placement of a spacer. Further studies with long-term followup are warranted to assess the impact on reduction of late rectal toxicity.
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12
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Farah S, Anderson DG, Langer R. Physical and mechanical properties of PLA, and their functions in widespread applications - A comprehensive review. Adv Drug Deliv Rev 2016; 107:367-392. [PMID: 27356150 DOI: 10.1016/j.addr.2016.06.012] [Citation(s) in RCA: 1047] [Impact Index Per Article: 130.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 12/28/2022]
Abstract
Poly(lactic acid) (PLA), so far, is the most extensively researched and utilized biodegradable aliphatic polyester in human history. Due to its merits, PLA is a leading biomaterial for numerous applications in medicine as well as in industry replacing conventional petrochemical-based polymers. The main purpose of this review is to elaborate the mechanical and physical properties that affect its stability, processability, degradation, PLA-other polymers immiscibility, aging and recyclability, and therefore its potential suitability to fulfill specific application requirements. This review also summarizes variations in these properties during PLA processing (i.e. thermal degradation and recyclability), biodegradation, packaging and sterilization, and aging (i.e. weathering and hygrothermal). In addition, we discuss up-to-date strategies for PLA properties improvements including components and plasticizer blending, nucleation agent addition, and PLA modifications and nanoformulations. Incorporating better understanding of the role of these properties with available improvement strategies is the key for successful utilization of PLA and its copolymers/composites/blends to maximize their fit with worldwide application needs.
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13
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Basu A, Haim-Zada M, Domb AJ. Biodegradable inflatable balloons for tissue separation. Biomaterials 2016; 105:109-116. [DOI: 10.1016/j.biomaterials.2016.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/27/2022]
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14
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Trifiletti DM, Garda AE, Showalter TN. Implanted spacer approaches for pelvic radiation therapy. Expert Rev Med Devices 2016; 13:633-40. [DOI: 10.1080/17434440.2016.1195682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Daniel M. Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Allison E. Garda
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Pinkawa M. Current role of spacers for prostate cancer radiotherapy. World J Clin Oncol 2015; 6:189-193. [PMID: 26677428 PMCID: PMC4675900 DOI: 10.5306/wjco.v6.i6.189] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/12/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
Radiotherapy is an established curative treatment method for prostate cancer. Optimal tumor control rates can only be achieved with high local doses, associated with a considerable risk of rectal toxicity. Apart from already widely adapted technical advances, as intensity-modulated radiation therapy, the application of spacers placed between the prostate and rectum has been increasingly used in the last years. Biodegradable spacers, including hydrogel, hyaluronic acid, collagen or an implantable balloon, can be injected or inserted in a short procedure under transrectal ultrasound guidance via a transperineal approach. A distance of about 1.0-1.5 cm is usually achieved between the rectum and prostate, excluding the rectal wall from the high isodoses. Several studies have shown well tolerated injection procedures and treatments. Apart from considerable reduction of rectal irradiation, a prospective randomized trial demonstrated a reduction of rectal toxicity after hydrogel injection in men undergoing prostate image-guided intensity-modulated radiation therapy. The results are encouraging for continuing evaluation in dose escalation, hypofractionation, stereotactic radiotherapy or re-irradiation trials in the future.
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Heikkilä VP. PEG spacer gel and adaptive planning vs single plan in external prostate radiotherapy--clinical dosimetry evaluation. Br J Radiol 2015; 88:20150421. [PMID: 26370300 DOI: 10.1259/bjr.20150421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Spacer gel is used to reduce the rectal dose in prostate radiotherapy. It is injected to increase the distance between the prostate and rectum. During the course of external radiotherapy treatment, physiological changes in rectal volume exist. When using polyethylene glycol material, such as DuraSeal(®) (Covidien, Mansfield, MA), gel resorption also occurs. Together, these factors alter the original dose plan distribution. METHODS External dose planning and calculations were simulated using images acquired from 10 patients who were treated with brachytherapy and gel. The CT series was taken relative to gel injection: pre 1 day, post 1 day, post 1 month and post 2 months. Adaptive planning was compared with a single plan. RESULTS Adaptive planning shows better results compared with the single plan used in the total treatment course; however, the effect is minor. CONCLUSION Gel usage is clearly favourable to rectal DVH. Using adaptive planning with gel improves rectal DVH but is not necessary according to this study. ADVANCES IN KNOWLEDGE Spacer gel is used in prostate radiotherapy to increase distance between the prostate and the rectum, thus reducing the rectal doses. During the treatment course, gel resorption exists which affects the rectal doses. The usefulness of adaptive planning to compensate this resorption effect has not been studied before.
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Affiliation(s)
- Vesa-Pekka Heikkilä
- Department of Oncology and Radiotherapy, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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17
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Long-term Local and Systemic Safety of Poly(l-lactide-co-epsilon-caprolactone) after Subcutaneous and Intra-articular Implantation in Rats. Toxicol Pathol 2015; 43:1127-40. [DOI: 10.1177/0192623315600275] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The use of biodegradable materials is gaining popularity in medicine, especially in orthopedic applications. However, preclinical evaluation of biodegradable materials can be challenging, since they are located in close contact with host tissues and might be implanted for a long period of time. Evaluation of these compounds requires biodegradability and biocompatibility studies and meticulous pathology examination. We describe 2 preclinical studies performed on Sprague-Dawley rats for 52 weeks, to evaluate clinical pathology, biocompatibility, biodegradability, and systemic toxicity after implantation of 2-layered films or saline-inflated balloon-shaped implants of downsized InSpace™ devices (termed “test device”). The test devices are made from a copolymer of poly-l-lactide-co-∊-caprolactone in a 70:30 ratio, identical to the device used in humans, intended for the treatment of rotator cuff tears. Intra-articular film implantation and subcutaneous implantation of the downsized device showed favorable local and systemic tolerability. Although the implanted materials have no inherent toxic or tumorigenic properties, one animal developed a fibrosarcoma at the implantation site, an event that is associated with a rodent-predilection response where solid materials cause mesenchymal neoplasms. This effect is discussed in the context of biodegradable materials along with a detailed description of expected pathology for biodegradable materials in long-term rodent studies.
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Wolf F, Gaisberger C, Ziegler I, Krenn E, Scherer P, Hruby S, Schätz T, Forstner R, Holzinger J, Vaszi A, Kametriser G, Steininger P, Deutschmann H, Sedlmayer F. Comparison of two different rectal spacers in prostate cancer external beam radiotherapy in terms of rectal sparing and volume consistency. Radiother Oncol 2015; 116:221-5. [PMID: 26232129 DOI: 10.1016/j.radonc.2015.07.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/03/2015] [Accepted: 07/05/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE In external beam radiation (EBRT) of the prostate, the rectum is the dose-limiting organ at risk, and sparing of the anterior rectal wall is a prerequisite for safe delivery of doses beyond 70 Gy. Spatial sparing of the rectum can be achieved by introducing a spacer material into the retroprostatic space, thus separating the anterior rectal wall from the PTV. MATERIALS AND METHODS Two spacer technologies, Spacer OAR, a polyethylene glycol gel and ProSpace, a saline inflated balloon, were compared in terms of spacer volume, stability, and dose reduction to the anterior rectum wall in 78 patients. RESULTS Both spacer systems significantly reduced the rectum surface encompassed by the 95% isodose (gel: -35%, p<0.01; balloon -63.4%, p<0.001) compared to a control group. The balloon spacer was superior in reducing rectum dose (-27.7%, p=0.034), but exhibited an average volume loss of >50% during the full course of treatment of 37-40 fractions, while the volume of gel spacers remained fairly constant. CONCLUSIONS In choosing between the two spacer technologies, the advantageous dose reduction of the balloon needs to be weighed up against the better volume consistency of the gel spacer with respect to the duration of hypofractionated vs normofractionated regimens.
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Affiliation(s)
- Frank Wolf
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria.
| | - Christoph Gaisberger
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Ingrid Ziegler
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Elisabeth Krenn
- Salzburg University of Applied Sciences, Paracelsus Medical University of Salzburg, Austria
| | - Philipp Scherer
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Stephan Hruby
- Dpt. of Urology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Tobias Schätz
- Dpt. of Urology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Rosemarie Forstner
- Dpt. of Radiology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Josef Holzinger
- Dept. of Surgery, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Andrea Vaszi
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Gerhard Kametriser
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Philipp Steininger
- Institute for Research and Development on Advanced Radiation Technologies (radART), St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Heinz Deutschmann
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria; Institute for Research and Development on Advanced Radiation Technologies (radART), St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Felix Sedlmayer
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria; Institute for Research and Development on Advanced Radiation Technologies (radART), St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
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A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers. Prostate Cancer Prostatic Dis 2015; 18:96-103. [PMID: 25687401 DOI: 10.1038/pcan.2015.4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/02/2014] [Accepted: 12/10/2014] [Indexed: 01/15/2023]
Abstract
Permanent radioactive seed implantation provides highly effective treatment for prostate cancer that typically includes multidisciplinary collaboration between urologists and radiation oncologists. Low dose-rate (LDR) prostate brachytherapy offers excellent tumor control rates and has equivalent rates of rectal toxicity when compared with external beam radiotherapy. Owing to its proximity to the anterior rectal wall, a small portion of the rectum is often exposed to high doses of ionizing radiation from this procedure. Although rare, some patients develop transfusion-dependent rectal bleeding, ulcers or fistulas. These complications occasionally require permanent colostomy and thus can significantly impact a patient's quality of life. Aside from proper technique, a promising strategy has emerged that can help avoid these complications. By injecting biodegradable materials behind Denonviller's fascia, brachytherpists can increase the distance between the rectum and the radioactive sources to significantly decrease the rectal dose. This review summarizes the progress in this area and its applicability for use in combination with permanent LDR brachytherapy.
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20
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Abstract
Definitive radiotherapy is a well-recognized treatment option for localized prostate cancer. Rectum toxicity is the dose-limiting toxicity. Dose-volume correlations have been reported in many studies. The application of a spacer to increase the distance between the prostate and anterior rectal wall is an innovative technique, considerably reducing the dose to the rectum. Hyaluronic acid, human collagen, an inflatable balloon or hydrogel are potential materials to create the desired effect. The number of clinical studies is rapidly increasing. Well-tolerated injection or implantation techniques and low rectal treatment-related toxicity have been demonstrated in prospective studies. Long-term clinical results and the results of randomized studies are needed to better define the beneficial effect for the patient.
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Affiliation(s)
- Michael Pinkawa
- *Department of Radiation Oncology, Rheinisch-Westfaelische Technische Hochschule Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany;
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Mok G, Benz E, Vallee JP, Miralbell R, Zilli T. Optimization of radiation therapy techniques for prostate cancer with prostate-rectum spacers: a systematic review. Int J Radiat Oncol Biol Phys 2014; 90:278-88. [PMID: 25304788 DOI: 10.1016/j.ijrobp.2014.06.044] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/12/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
Dose-escalated radiation therapy for localized prostate cancer improves disease control but is also associated with worse rectal toxicity. A spacer placed between the prostate and rectum can be used to displace the anterior rectal wall outside of the high-dose radiation regions and potentially minimize radiation-induced rectal toxicity. This systematic review focuses on the published data regarding the different types of commercially available prostate-rectum spacers. Dosimetric results and preliminary clinical data using prostate-rectum spacers in patients with localized prostate cancer treated by curative radiation therapy are compared and discussed.
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Affiliation(s)
- Gary Mok
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Radiation Oncology, Centre Intégré de Cancérologie de Laval, Centre de Santé et de Services Sociaux de Laval, Laval, Québec, Canada; Department of Radiology, Radiation Oncology, and Nuclear Medicine, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - Eileen Benz
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Paul Vallee
- Department of Radiology, Geneva University Hospital, Geneva, Switzerland
| | - Raymond Miralbell
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.
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22
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Heikkilä VP, Kärnä A, Vaarala MH. DuraSeal as a spacer to reduce rectal doses in low-dose rate brachytherapy for prostate cancer. Radiother Oncol 2014; 112:233-6. [PMID: 25201125 DOI: 10.1016/j.radonc.2014.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/28/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
Abstract
The purpose of this study was to evaluate the utility of off-label use of DuraSeal polyethylene glycol (PEG) gel in low-dose rate (LDR) prostate brachytherapy seed implantation to reduce rectal doses. Diluted DuraSeal was easy to use and, in spite of a clearance effect, useful in decreasing D₂cc rectal doses.
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Affiliation(s)
| | - Aarno Kärnä
- Department of Radiotherapy, Oulu University Hospital, Finland
| | - Markku H Vaarala
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
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23
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Gervasi E, Cautero E, Dekel A. Fluoroscopy-guided implantation of subacromial "biodegradable spacer" using local anesthesia in patients with irreparable rotator cuff tear. Arthrosc Tech 2014; 3:e455-8. [PMID: 25264508 PMCID: PMC4175154 DOI: 10.1016/j.eats.2014.05.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/08/2014] [Indexed: 02/03/2023] Open
Abstract
Treatment of massive rotator cuff tears can be challenging, especially when tears are considered irreparable or, when repaired, at significant risk of retear. A surgical technique is described using a biodegradable subacromial balloon-shaped spacer (InSpace; Ortho-Space, Caesarea, Israel) that, when implanted between the humeral head and acromion, permits smooth, frictionless gliding, supporting shoulder biomechanics. The specific insertion technique described herein is a simple procedure that can be performed in a day-care or outpatient setting with patients under local anesthesia, thus providing a treatment option for patients with multiple comorbidities complicating or contraindicating surgery, such as reverse arthroplasty under general anesthesia.
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Affiliation(s)
- Enrico Gervasi
- Department of Orthopedic Surgery, Latisana Civil Hospital, Latisana, Italy,Address correspondence to Enrico Gervasi, M.D., Department of Orthopaedic Surgery, Latisana Civil Hospital, Via Sabbionera 45, 33053 Latisana, Udine, Italy.
| | - Enrico Cautero
- Department of Orthopedic Surgery, Latisana Civil Hospital, Latisana, Italy
| | - Assaf Dekel
- Advanced Orthopedic Clinic, Assuta Medical Center, Tel Aviv, Israel
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24
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[Prostate-rectum spacers: optimization of prostate cancer irradiation]. Cancer Radiother 2014; 18:215-21; quiz 243-4, 247. [PMID: 24746454 DOI: 10.1016/j.canrad.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 03/03/2014] [Indexed: 12/20/2022]
Abstract
In the curative radiotherapy of localized prostate cancer, improvements in biochemical control observed with dose escalation have been counterbalanced by an increase in radiation-induced toxicity. The injection of biodegradable spacers between prostate and rectum represents a new frontier in the optimization of radiotherapy treatments for patients with localized disease. Transperineal injection of different types of spacers under transrectal ultrasound guidance allows creating a 7-to-20 mm additional space between the prostate and the anterior rectal wall lasting 3 to 12 months. Dosimetrically, a relative reduction in the rectal volume receiving at least 70 Gy (V70) in the order of 43% to 84% is observed with all types of spacers, regardless of the radiotherapy technique used. Preliminary clinical results show for all spacers a good tolerance and a possible reduction in the acute side effects rate. The aim of the present systematic review of the literature is to report on indications as well as dosimetric and clinical advantages of the different types of prostate-rectum spacers commercially available (hydrogel, hyaluronic acid, collagen, biodegradable balloon).
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25
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Tsurumi T, Fuse M. Enhancement of Apatite Precipitation on an Alkaline Hydrolyzed Poly (Lactic acid-ε-Caprolactone) Film in Simulated Body Fluid. J HARD TISSUE BIOL 2014. [DOI: 10.2485/jhtb.23.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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26
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Tree A, Alexander E, Van As N, Dearnaley D, Khoo V. Biological Dose Escalation and Hypofractionation: What is There to be Gained and How Will it Best be Done? Clin Oncol (R Coll Radiol) 2013; 25:483-98. [DOI: 10.1016/j.clon.2013.05.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 05/09/2013] [Indexed: 12/12/2022]
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27
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Valdagni R, Rancati T. Reducing rectal injury during external beam radiotherapy for prostate cancer. Nat Rev Urol 2013; 10:345-57. [PMID: 23670182 DOI: 10.1038/nrurol.2013.96] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Rectal bleeding and faecal incontinence are serious injuries that men with prostate cancer who receive radiotherapy can experience. Although technical advances--including the use of intensity-modulated radiotherapy coupled with image-guided radiotherapy--have enabled the delivery of dose distributions that conform to the shape of the tumour target with steep dose gradients that reduce the dose given to surrounding tissues, radiotherapy-associated toxicity can not be avoided completely. Many large-scale prospective studies have analysed the correlations of patient-related and treatment-related parameters with acute and late toxicity to optimize patient selection and treatment planning. The careful application of dose-volume constraints and the tuning of these constraints to the individual patient's characteristics are now considered the most effective ways of reducing rectal morbidity. Additionally, the use of endorectal balloons (to reduce the margins between the clinical target volume and planning target volume) and the insertion of tissue spacers into the region between the prostate and anterior rectal wall have been investigated as means to further reduce late rectal injury. Finally, some drugs and other compounds are also being considered to help protect healthy tissue. Overall, a number of approaches exist that must be fully explored in large prospective trials to address the important issue of rectal toxicity in prostate cancer radiotherapy.
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Affiliation(s)
- Riccardo Valdagni
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan 20133, Italy
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28
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Gez E, Cytron S, Ben Yosef R, London D, Corn BW, Alani S, Scarzello G, Dal Moro F, Sotti G, Zattoni F, Koziol I, Torre T, Bassignani M, Kalnicki S, Ghavamian R, Blakaj D, Anscher M, Sommerauer M, Jocham D, Melchert C, Huttenlocher S, Kovacs G, Garg M. Application of an interstitial and biodegradable balloon system for prostate-rectum separation during prostate cancer radiotherapy: a prospective multi-center study. Radiat Oncol 2013; 8:96. [PMID: 23618548 PMCID: PMC3643836 DOI: 10.1186/1748-717x-8-96] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 03/28/2013] [Indexed: 12/21/2022] Open
Abstract
Background and purpose Rectal toxicity presents a significant limiting factor in prostate radiotherapy regimens. This study evaluated the safety and efficacy of an implantable and biodegradable balloon specifically designed to protect rectal tissue during radiotherapy by increasing the prostate–rectum interspace. Patients and methods Balloons were transperineally implanted, under transrectal ultrasound guidance, into the prostate–rectum interspace in 27 patients with localized prostate cancer scheduled to undergo radiotherapy. Patients underwent two simulations for radiotherapy planning--the first simulation before implant, and the second simulation seven days post implant. The balloon position, the dimensions of the prostate, and the distance between the prostate and rectum were evaluated by CT/US examinations 1 week after the implant, weekly during the radiotherapy period, and at 3 and 6 months post implant. Dose-volume histograms of pre and post implantation were compared. Adverse events were recorded throughout the study period. Results Four of 27 patients were excluded from the evaluation. One was excluded due to a technical failure during implant, and three patients were excluded because the balloon prematurely deflated. The balloon status was evaluated for the duration of the radiotherapy period in 23 patients. With the balloon implant, the distance between the prostate and rectum increased 10-fold, from a mean 0.22 ± 0.2 cm to 2.47 ± 0.47 cm. During the radiotherapy period the balloon length changed from 4.25 ± 0.49 cm to 3.81 ± 0.84 cm and the balloon height from 1.86 ± 0.24 cm to 1.67 ± 0.22 cm. But the prostate-rectum interspace distance remained constant from beginning to end of radiotherapy: 2.47 ± 0.47 cm and 2.41 ± 0.43 cm, respectively. A significant mean reduction in calculated rectal radiation exposure was achieved. The implant procedure was well tolerated. The adverse events included mild pain at the perineal skin and in the anus. Three patients experienced acute urinary retention which resolved in a few hours following conservative treatment. No infections or thromboembolic events occurred during the implant procedure or during the radiotherapy period. Conclusion The transperineal implantation of the biodegradable balloon in patients scheduled to receive radiotherapy was safe and achieved a significant and constant gap between the prostate and rectum. This separation resulted in an important reduction in the rectal radiation dose. A prospective study to evaluate the acute and late rectal toxicity is needed.
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Kouloulias V, Kalogeropoulos T, Platoni K, Georgakopoulos J, Matsopoulos G, Chaldeopoulos D, Beli I, Pantelakos P, Asimakopoulos C, Kouvaris J, Kelekis N. Feasibility and radiation induced toxicity regarding the first application of transperineal implementation of biocompatible balloon for high dose radiotherapy in patients with prostate carcinoma. Radiat Oncol 2013; 8:82. [PMID: 23566526 PMCID: PMC3679742 DOI: 10.1186/1748-717x-8-82] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/01/2013] [Indexed: 12/13/2022] Open
Abstract
Objective To evaluate the feasibility of the transperineal implementation of biocompatible balloon (Prospace) and the acute toxicity of high dose 3DCRT in patients with localized low risk prostate cancer. Materials and methods Between December 2011 and April 2012, fifteen patients were treated with external 3DCRT consisted of 76–78 Gy in 38–39 daily fractions (2.0 Gy/ fraction). Before 3DCRT, we placed the Prospace though the perineum by a minimally invasive procedure in the intermediate space between the rectum and the prostate. The primary study endpoint was the evaluation of acute toxicity according to the EORTC/RTOG radiation toxicity scale. Erectile function was evaluated with the IIEF-5 questionnaire. Rectosigmoidoscopy was performed at baseline, at the end of 3DCRT and 3 months thereafter in order to assess also the rectal toxicity according to Subjective-RectoSigmoid (S-RS) scale. The evaluation of pain related to Prospace implementation was done with the visual analogue score (VAS). Results The acute toxicities were as follows: grade I GI toxicity in two patients and for GU toxicity, three patients with grade I of nocturia, four patients with grade I of frequency, two patients with grade I and two patients with grade II of dysouria. The mean score of rectal toxicity according to S-RS score was 1.8(±0.6). The mean VAS score related to Prospace was 1.4(±0.5). Erectile function was unchanged. The Prospace device was found stable in sequential CTs during irradiation. Conclusions The implementation of PROSPACE was feasible, while the acute radiation toxicity was low and comparable with IMRT techniques.
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Affiliation(s)
- Vassilis Kouloulias
- 2nd Department of Radiology, Radiotherapy Unit, ATTIKON University hospital, Xaidari, Greece.
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Smeenk RJ, van Lin ENJT. Application of anorectal sparing devices in prostate radiotherapy. Radiother Oncol 2013; 106:155-6. [PMID: 23474285 DOI: 10.1016/j.radonc.2013.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 02/11/2013] [Accepted: 02/11/2013] [Indexed: 11/27/2022]
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31
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Melchert C, Gez E, Bohlen G, Scarzello G, Koziol I, Anscher M, Cytron S, Paz A, Torre T, Bassignani M, Dal Moro F, Jocham D, Yosef RB, Corn BW, Kovács G. Interstitial biodegradable balloon for reduced rectal dose during prostate radiotherapy: results of a virtual planning investigation based on the pre- and post-implant imaging data of an international multicenter study. Radiother Oncol 2013; 106:210-4. [PMID: 23484879 DOI: 10.1016/j.radonc.2013.01.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 12/27/2012] [Accepted: 01/27/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate dose reduction caused by the implantation of an interstitial inflatable and biodegradable balloon device aiming to achieve lower rectal doses with virtual 3D conformal external beam radiation treatment. MATERIALS AND METHODS An inflatable balloon device was placed, interstitially and under transrectal ultrasound guidance, into the rectal-prostate interspace prior treatment initiation of 26 patients with localized prostate cancer, who elected to be treated with radiotherapy (3D CRT or IMRT). The pre- and post-implant CT imaging data of twenty two patients were collected (44 images) for the purpose of the 3D conformal virtual planning presented herein. RESULTS The dorsal prostate-ventral rectal wall separation resulted in an average reduction of the rectal V70% by 55.3% (± 16.8%), V80% by 64.0% (± 17.7%), V90% by 72.0% (± 17.1%), and V100% by 82.3% (± 24.1%). In parallel, rectal D2 ml and D0.1 ml were reduced by 15.8% (± 11.4%) and 3.9% (± 6.4%), respectively. CONCLUSIONS Insertion of the biodegradable balloon into the prostate-rectum interspace is similar to other published invasive procedures. In this virtual dose distribution analysis, the balloon insertion resulted in a remarkable reduction of rectal volume exposed to high radiation doses. This effect has the potential to keep the rectal dose lower especially when higher than usual prostate dose escalation protocols or hypo-fractionated regimes are used. Further prospective clinical investigations on larger cohorts and more conformal radiation techniques will be necessary to define the clinical advantage of the biodegradable interstitial tissue separation device.
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Affiliation(s)
- Corinna Melchert
- Department of Interdisciplinary Brachytherapy, University of Lübeck, Germany
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Srivastava SP, Das IJ, Kumar A, Johnstone PAS, Cheng CW. Impact of rectal balloon-filling materials on the dosimetry of prostate and organs at risk in photon beam therapy. J Appl Clin Med Phys 2013; 14:3993. [PMID: 23318385 PMCID: PMC5713667 DOI: 10.1120/jacmp.v14i1.3993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 08/25/2012] [Accepted: 08/16/2012] [Indexed: 11/23/2022] Open
Abstract
The use of rectal balloon in radiotherapy of prostate cancer is shown to be effective in reducing prostate motion and minimizing rectal volume, thus reducing rectal toxicity. Air‐filled rectal balloon has been used most commonly, but creates dose perturbation at the air‐tissue interface. In this study, we evaluate the effects of rectal balloon‐filling materials on the dose distribution to the target and organs at risk. The dosimetric impact of rectal balloon filling was studied in detail for a typical prostate patient, and the general effect of the balloon filling was investigated from a study of ten prostate patients covering a wide range of anterior–posterior and left–right separations, as well as rectal and bladder volumes. Hounsfield units (HU) of the rectal balloon filling was changed from −1000 HU to 1000 HU at an interval of 250 HU, and the corresponding changes in the relative electron density (RED) was calculated. For each of the HU of the rectal balloon filling, a seven‐field IMRT plan was generated with 6 MV and 15 MV photon beams, respectively. Dosimetric evaluation was performed with the AAA algorithm for inhomogeneity corrections. A detailed study of the rectal balloon filling shows that the GTV, PTV, rectal, and bladder mean dose decreased with increasing values of RED in the rectal balloon. There is significant underdosage in the target volume at the rectum–prostate interface with an air‐filled balloon as compared to that with a water‐filled balloon for both 6 MV and 15 MV beams. While the dosimetric effect of the rectal balloon filling is reduced when averaged over ten patients, generally an air‐filled balloon results in lower minimum dose and lower mean dose in the overlap region (and possibly the PTV) compared to those produced by water‐filled or contrast‐filled balloons. Dose inhomogeneity in the target volume is increased with an air‐filled rectal balloon. Thus a water‐filled or contrast‐filled rectal balloon is preferred to an air‐filled rectal balloon in EBRT of prostate treatment. PACS numbers: 87.55.D‐, 87.55.de, 87.55.dk, 87.55.Gh, 87.55.kd
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Affiliation(s)
- Shiv P Srivastava
- Department of Health Sciences, Purdue University, West Lafayette, IN 47907-2051, USA.
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Gandhi PJ, Murthy ZVP. Investigation of Different Drug Deposition Techniques on Drug Releasing Properties of Cardiovascular Drug Coated Balloons. Ind Eng Chem Res 2012. [DOI: 10.1021/ie3006676] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Pankaj J. Gandhi
- Department
of Chemical Engineering, Sardar Vallabhbhai National Institute of Technology, Surat
395 007, Gujarat, India
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Savarese E, Romeo R. New solution for massive, irreparable rotator cuff tears: the subacromial "biodegradable spacer". Arthrosc Tech 2012; 1:e69-74. [PMID: 23766979 PMCID: PMC3678622 DOI: 10.1016/j.eats.2012.02.002] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 02/24/2012] [Indexed: 02/03/2023] Open
Abstract
Massive, irreparable rotator cuff tears are a source of pain and disability. Although most rotator cuff tears can be completely repaired, a significant number are considered massive and irreparable. Numerous operative techniques have been described for the treatment of these kinds of tears including arthroscopic debridement, biceps tenotomy, tendon transfer, grafting, and reverse arthroplasty. We describe a surgical technique using a biodegradable subacromial balloon spacer (InSpace; OrthoSpace, Kfar Saba, Israel) implanted between the humeral head and acromion that permits smooth, frictionless gliding, restoring the shoulder biomechanics. The technique is easy to perform and is less invasive than the conventional surgical techniques available, and it may potentially serve as a bridging option in patients with massive, irreparable tears who are normally candidates for reverse arthroplasty.
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Affiliation(s)
- Eugenio Savarese
- Address correspondence to Eugenio Savarese, M.D., Ph.D., San Carlo Hospital, Potito Petrone, 85100, Potenza, Italy
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