Proton therapy of iris melanoma with 50 CGE : Influence of target volume on clinical outcome

PURPOSE

The aim of this study was to evaluate local tumour control, incidence of radiation-induced glaucoma and associated interventions of sector-based and whole anterior segment proton beam therapy (PBT) for the treatment of iris melanoma.

PATIENTS AND METHODS

We retrospectively analysed the data of 77 patients with iris melanoma who underwent PBT applied as 50 CGE in four daily fractions. Of the patients, 47 received PBT with a circular-shaped collimator and 30 with a conformal sector-shaped target volume. Local control, eye preservation and secondary glaucoma were evaluated.

RESULTS

Median follow-up time was 54.9 months. Local tumour control was 100% in patients receiving whole anterior segment irradiation. Two patients developed pigment dispersion in the non-irradiated area after sector-based PBT and received whole anterior segment salvage PBT. The mean volume of ciliary body irradiated was 89.0% and 34.9% for whole anterior segment and lesion-based irradiation, respectively. At the end of follow-up, secondary glaucoma was found in 74.3% of the patients with whole anterior segment irradiation and in 19.2% with sector-based irradiation. Patients with sector-based PBT had a stable visual acuity of logMAR 0.1, while it declined from logMAR 0.1 to 0.4 after whole anterior segment irradiation.

CONCLUSION

We found a significant reduction in radiation-induced secondary glaucoma and glaucoma-associated surgical interventions and stable visual acuity after sector-based irradiation compared with whole anterior segment irradiation. Sector-based irradiation revealed a higher risk for local recurrence, but selected patients with well-circumscribed iris melanoma benefit from applying a lesion-based target volume when treated with sector-based PBT.

Proton beam radiotherapy of diffuse iris melanoma in 54 patients

BACKGROUND

Treatment modalities in iris melanoma include excision, plaque radiotherapy, photon or proton beam therapy and enucleation. In extensive tumours and diffuse seeding, radiotherapy remains as an alternative to enucleation.

METHODS

This study is a retrospective, consecutive, interventional, single-institutional case series. 54 patients with a diffuse and non-resectable iris melanoma diagnosed from September 1998 to June 2012 were included. A 68-megaelectron volt proton beam was used to treat the anterior segment with a total dose of 4×12.5 cobalt grey equivalent. The cases were evaluated for local tumour control, eye retention, functional outcome and local complications after treatment.

RESULTS

During a mean follow-up of 62.7 months (median 54.8 months, range 5.5-159.6 months), local tumour control was achieved in 96.3% of the patients. Cataract and glaucoma were the main complications developing after irradiation in 42.6% and 55.6%, respectively. In 34 of 44 patients (77.3%) who underwent cataract removal, a visual acuity of 20/40 or better following surgery was preserved. Enucleation was performed in three patients. The reason was suspected tumour recurrence in one and glaucoma in two. Hepatic metastasis occurred in one patient.

CONCLUSIONS

As an alternative to enucleation, whole anterior segment fractionated proton beam radiotherapy offered excellent local tumour control in diffuse iris melanoma. Given the limited alternatives, the rate of complications appears acceptable and visual function could be preserved in the majority of the patients during follow-up.

Intraindividual, randomized comparison of the macrocyclic contrast agents gadobutrol and gadoterate meglumine in breast magnetic resonance imaging

OBJECTIVES

To compare intraindividually two macrocyclic contrast agents - gadobutrol and gadoterate meglumine (Gd-DOTA) - for dynamic and quantitative assessment of relative enhancement (RE) in benign and malignant breast lesions.

METHODS

This was an ethically approved, prospective, single-centre, randomized, crossover study in 52 women with suspected breast lesions referred for magnetic resonance imaging (MRI). Each patient underwent one examination with gadobutrol and one with Gd-DOTA (0.1 mmol/kg BW) on a 1.5 T system 1 - 7 days apart. Dynamic, T1-weighted, 3D gradient echo sequences were acquired under identical conditions. Quantitative evaluation with at least three regions of interest (ROI) per lesion was performed. Primary endpoint was RE during the initial postcontrast phase after the first and second dynamic acquisition, and peak RE. All lesions were histologically proven; differences between the examinations were evaluated.

RESULTS

Forty-five patients with a total of 11 benign and 34 malignant lesions were assessed. Mean RE was significantly higher for gadobutrol than Gd-DOTA (p < 0.0001). Gadobutrol showed significantly less washout (64.4 %) than Gd-DOTA (75.4 %) in malignant lesions (p = 0.048) CONCLUSIONS: Gadobutrol has higher RE values compared with Gd-DOTA, whereas Gd-DOTA shows more marked washout in malignant lesions. This might improve the detection of breast lesions and influence the specificity of breast MRI-imaging.

Linking on-farm dairy management practices to storm-flow fecal coliform loading for California coastal watersheds

How and where to improve water quality within an agricultural watershed requires data at a spatial scale that corresponds with individual management decision units on an agricultural operation. This is particularly true in the context of water quality regulations, such as Total Maximum Daily Loads (TMDLs), that identify agriculture as one source of non-point source pollution through larger tributary watershed scale and above and below water quality investigations. We have conducted a systems approach study of 10 coastal dairies and ranches to document fecal coliform concentration and loading to surface waters at the management decision unit scale. Water quality samples were collected on a storm event basis from loading units that included: manure management systems; gutters; storm drains; pastures; and corrals and lots. In addition, in-stream samples were collected above and below the dairy facilities and from a control watershed, managed for light grazing and without a dairy facility or human residence and corresponding septic system. Samples were analyzed for fecal coliform concentration by membrane filtration. Instantaneous discharge was measured for each collected sample. Storm runoff was also calculated using the curve number method (SCS, 1985). Results for a representative dairy as well as the entire 10 dairy data set are presented. Fecal coliform concentrations demonstrate high variability both within and between loading units. Fecal coliform concentrations for pastures range from 206 to 2,288,888 cfu/100 ml and for lots from 1,933 to 166,105,000 cfu/100 ml. Mean concentrations for pastures and lots are 121,298 (SE = 62,222) and 3,155,584 (SE = 1,902,713) cfu/100 ml, respectively. Fecal coliform load from units of concentrated animals and manure are significantly more than units such as pastures while storm flow amounts were significantly less. Compared with results from earlier tributary scale studies in the watershed, this systems approach has generated water quality data that is beneficial for management decisions because of its scale and representation of current management activities. These results are facilitating on-farm changes through the cooperative efforts of dairy managers, regulatory agency staff, and sources of technical and financial assistance.

Kahnbeinfrakturen - wann operativ, wann konservativ? CT-basierte Klassifikation

Traditionally acute scaphoid fractures were treated by immobilization. As a consequence we have to deal with a high number of scaphoid non-unions or SNAC wrists. A study of 30 patients with scaphoid non-union showed that only 30% (9 patients) have not seen a doctor, while the majority of the patients (70%, 21 patients) were treated by a physician after trauma. In 15 (71.4%) of these 21 patients a missed diagnosis and in 6 (28.6%) a failed conservative treatment of the scaphoid fracture were the reasons for scaphoid non-union. Therefore, improvements in the diagnosis and therapy of scaphoid fractures are urgently needed. Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type seen on X-ray. Differentiation between stable and unstable fractures sometimes is difficult from conventional X-rays. In these cases we recommend a CT bone scan in the long axis of the scaphoid. According to the CT scan we modified Herbert's classification: undisplaced waist fractures are classified as stable and can be treated conservatively or can be stabilized percutaneously using minimally invasive procedures. Comminuted or displaced fractures are classified as unstable and need operative treatment because of the increased risk of scaphoid non-union after plaster immobilization. Fractures of the proximal pole of the scaphoid should be treated operatively by internal fixation, even if they are not displaced, because of the reduced perfusion. We recommend a CT scan of the scaphoid, if there is any doubt about the diagnosis or the stability of the scaphoid fracture. In any case, a CT scan has to be ordered to justify a conservative treatment.

Der posttraumatische karpale Kollaps

PURPOSE

Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid.

METHOD AND MATERIAL

37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically.

RESULTS

The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain.

CONCLUSION

Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

[Functional outcome and quality of life after ray amputation versus amputation through the proximal phalanx of the index finger]

Little data is available about the long-term functional outcome and quality of life after ray amputation or amputation at the level of the proximal phalanx of the index finger. The purpose of this study was to evaluate the functional outcome and postoperative quality of life after ray amputation or amputation through the proximal phalanx to create a database which is helpful in the decision whether to amputate a digital ray or to preserve a stump.58 patients with amputation of the second ray and 12 patients with amputation through the proximal phalanx of the index finger between 1987 and 1996 were included in the study and examined with respect to hand strength, sensibility, range of motion, pain, and aesthetic result of the hand. Subjective functional outcome was evaluated using the DASH-questionnaire. The majority of patients were male (78 % with ray amputation/83 % with amputation through the proximal phalanx). In 55 %/58 % the operation was performed on the dominant hand. Average age was 45 years and average follow-up was 44.2 months after ray resection and 22.1 months after amputation through the proximal phalanx. Patients lost an average of 10.7 weeks of work after ray amputation and 8.1 weeks after digital amputation. There was no significant loss of grip strength after ray amputation (29 % to 34 % loss of grip strength, 32 % loss of pinch grip) compared with patients after amputation through the proximal phalanx (21 % to 28 % loss of grip strength, 17 % to 35 % loss of pinch grip). DASH-score was 31.3 after ray amputation and 21.7 after digital amputation. Patients with amputation through the proximal phalanx reached a significantly better result in part B of the DASH-questionnaire. 65.5 % of the patients after ray amputation and 91.7 % after digital amputation complained of postoperative pain in the operated hand. Decreased sensibility was found in 55.2 % after ray resection and in 33.3 % after digital amputation. All patients after amputation through the proximal phalanx but only 82.8 % after ray amputation showed a free range of motion of the operated hand. The aesthetic appearance of the operated hand was rated higher after ray amputation. The results show that there is no significant loss of strength after ray amputation compared to amputation through the proximal phalanx as mentioned in the literature. Patients with amputation through the proximal phalanx demonstrate a better functional outcome, while the aesthetic appearance was rated higher after ray amputation. A significant difference was only found in part B of the DASH-questionnaire. This should be considered when the indication for ray amputation is pending.

Early dynamic motion versus postoperative immobilization in patients with extensor indicis proprius transfer to restore thumb extension: a prospective randomized study

Transfer of the extensor indicis proprius is the gold standard for reconstruction of the extensor pollicis longus tendon to restore thumb extension. Twenty patients were included to a prospective randomized trial to assess whether an early dynamic motion protocol yields a better outcome than immobilization. Evaluation included postoperative range of motion, grip strength, duration of treatment, and time off work. Ten patients of each group had the thumb immobilized in an extension thumb spica cast for 3 weeks after surgery or underwent an early dynamic motion protocol. Follow-up examinations were performed 3, 4, 6, and 8 weeks after surgery. At 3 weeks total range of motion of the interphalangeal joint was almost twice as good (59 degrees ) in the dynamic motion group compared with immobilized patients (31 degrees ). At 6 weeks no significant differences between the groups were found. A similar pattern for grip strength and pinch grip was found after 3 weeks, when patients undergoing the motion protocol had significantly better results than the immobilized group. Although the dynamic motion group still had better results after 4 weeks, hand function was similar in both groups after 6 and 8 weeks. Patients with early dynamic motion recovered their hand function more rapidly than immobilized patients, shortening total rehabilitation time and making dynamic motion treatment highly cost-effective.

[Reconstruction of defects of the anterior abdominal wall]

Reconstruction of the abdominal wall is of importance in many clinical situations, but may require the entire spectrum of plastic and reconstructive surgery. Indications for particular procedures depend on the clinical situation and the patient's individual profile. One has to differentiate between life-saving primary measures and secondary corrections to improve form or function. The article outlines current actual concepts of plastic surgical defect reconstruction with which the general/visceral surgeon should be acquainted, in order to integrate these concepts into a multi-disciplinary approach in pertinent clinical situations.

[Treatment strategy in complex hand injuries]

There are no clear definitions of serious or complex hand injuries in the literature. Multistructural injuries involving a vital risk to the affected part of the body part are usually classified as complex. The quality of the reconstruction, based on sound management principles, determines the aesthetic and functional outcome for the patient. The strategies basically consist of: Careful radical dbridement, thorough analysis of the defect and evaluation of lost functions, injury classification, Patient oriented reconstructive procedures, careful and realistic explanation of perspectives and risks to the patient. Following these principles will most likely achieve the planned objectives of treatment, such as, best possible restoration of form and function, cost-effective therapy, and early professional and social reintegration. Algorithmic approaches are an important aid in the clinical approach to these kinds of problems, making it possible to reach clear reproducible decisions that are amenable to standardization. Despite all individual decisions necessary to achieve optimal care, this standard theoretical framework will be able to improve the quality of care.