Idiopathic left-sided ovarian vein thrombosis in a post-menopausal woman

Ovarian vein thrombosis (OVT) is a rare thromboembolic condition largely involving the right ovarian vein. Risk factors include pregnancy/ peripartum period, oestrogen therapy, recent surgery or hospitalisation, malignancy, pelvic inflammatory diseases, and thrombophilia; OVT without risk factors is considered idiopathic. We present a rare case of idiopathic left-sided OVT in a post-menopausal woman in her 60s with insignificant past medical history and no identifiable risk factors. She presented with isolated left -lower -quadrant abdominal pain ultimately found to have OVT on computed tomography (CT) scan and confirmed with magnetic resonance imaging (MRI). The patient was initially treated with low-molecular-weight heparin and then transitioned to apixaban. She remained symptom-free at 3-month follow-up. Five previous cases of idiopathic left-sided OVT have been reported to-date, but this is the first case in a postmenopausal woman that has not been associated with hypercoagulable risk factors nor further thromboembolic complications.

Characterization of PFAS air emissions from thermal application of fluoropolymer dispersions on fabrics

During thermal processes utilized in affixing fluoropolymer coatings dispersion to fibers and fabrics, coating components are vaporized. It is suspected that per- and polyfluoroalkyl substances (PFAS) from the dispersions may undergo chemical transformations at the temperatures used, leading to additional emitted PFAS thermal byproducts. It is important to characterize these emissions to support evaluation of the resulting environmental and health impacts. In this study, a bench-scale system was built to simulate this industrial process via thermal application of dispersions to fiberglass utilizing relevant temperatures and residence times in sequential drying, baking, and sintering steps. Experiments were performed with two commercially available dispersions and a simple model mixture containing a single PFAS (6:2 fluorotelomer alcohol [6:2 FTOH]). Vapor-phase emissions were sampled and characterized by several off-line and real-time mass spectrometry techniques for targeted and nontargeted PFAS. Results indicate that multiple PFAS thermal transformation products and multiple nonhalogenated organic species were emitted from the exit of the high temperature third (sintering) furnace when 6:2 FTOH was the only PFAS present in the aqueous mixture. This finding supports the hypothesis that temperatures typical of these industrial furnaces may also induce chemical transformations within the fluorinated air emissions. Experiments using the two commercial fluoropolymer dispersions indicate air emissions of part-per-million by volume (ppmv) concentrations of heptafluoropropyl-1,2,2,2-tetrafluoroethyl ether (Fluoroether E1), as well as other PFAS at operationally relevant temperatures. We suspect that E1 is a direct thermal decomposition product (via decarboxylation) of 2,3,3,3-tetrafluoro-2-(heptafluoropropoxy)propanoic acid (commonly referred to as HFPO-DA) present in the dispersions. Other thermal decomposition products, including the monomer, tetrafluoroethene, may originate from the PFAS used to stabilize the dispersion or from the polymer particles in suspension. This study represents the first researcher-built coating application simulator to report nontargeted PFAS emission characterization, real-time analyses, and the quantification of 30 volatile target PFAS.Implications: Thermal processes used to affix fluoropolymers to fabrics are believed to be a source of PFAS air emissions. These coating operations are used by many large and small manufacturers and typically do not currently require any air emissions control. This research designed and constructed a bench-scale system that simulates these processes and used several off-line and advanced real-time mass spectroscopy techniques to characterize PFAS air emissions from two commercial fluoropolymer dispersions. Further, as the compositions of commercial dispersions are largely unknown, a model three-component solution containing a single PFAS was used to characterize emissions of multiple PFAS thermal transformation products at operationally relevant conditions. This research shows that fluoropolymer fabric coating facilities can be sources of complex mixtures of PFAS air emissions that include volatile and semivolatile PFAS present in the dispersions, as well as PFAS byproducts formed by the thermal transformation of fluorocarbon and hydrocarbon species present in these dispersions.

Concordance in oncogenic alterations between primary and recurrent/metastatic cholangiocarcinoma pairs using targeted next-generation sequencing

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Background: The genetic background of cholangiocarcinoma (CCA) commonly involves alterations in kinase signaling, tumor suppression, oxidative stress modulation, and proto-oncogenic coupling pathways. Novel agents targeting such pathways have shown promise in systemic treatment; however, studies examining differences in the mutational landscapes between primary and recurrent, metastatic, or progressive disease after systemic therapy are lacking. The present study aimed to determine if recurrent, metastatic, or progressive disease genetically parallels the primary or not. Methods: Patients with biopsy proven CCA (primary tumor and paired recurrent/metastatic or progressive disease) from two institutions (MSKCC and Duke) were identified. Targeted next-generation sequencing (Integrated Mutation Profiling of Actionable Cancer Targets (IMPACT)) capturing single nucleotide variants, copy number alterations, and structural variants was used to compare driver alteration concordance across the paired samples. Subgroup analyses were performed based on exposure to systemic therapy in patients with disease progression and tumor type (intrahepatic versus extrahepatic). Results: Sample pairs from 65 patients with intrahepatic (ICCA, n=54) and extrahepatic CCA (ECCA, n=11) were analyzed. Median time between samples was 19.6 months (range 2.7 - 122.9). Some de novo alterations were identified in recurrent/metastatic samples, but overall concordance (70%) was demonstrated between patient pairs for common oncogenic driver genes (Table). Subgroup analyses of summative ICCA and ECCA mutations revealed concordance of 65% and 88%, respectively. Concordance was also demonstrated between pairs exposed to systemic therapy between sample collections (n=50, 71%). Conclusions: In this dataset of CCA patients, a concordance rate of 70% was identified in the genomic alterations between primary and recurrent/metastatic pairs, and this did not appear to be altered by prior treatment with systemic chemotherapy. While limited by sample size, concordance in ICCA pairs was lower than that seen in ECCA. [Table: see text]

Development of Volatility Distributions for Organic Matter in Biomass Burning Emissions

The volatility distribution of organic emissions from biomass burning and other combustion sources can determine their atmospheric evolution due to partitioning/aging. The gap between measurements and models predicting secondary organic aerosol has been partially attributed to the absence of semi- and intermediate volatility organic compounds (S/I-VOC) in models and measurements. However, S/I-VOCs emitted from these sources and typically quantified using the volatility basis framework (VBS) are not well understood. For example, the amount and composition of S/I-VOCs and their variability across different biomass burning sources such as residential woodstoves, open field burns, and laboratory simulated open burning are uncertain. To address this, a novel filter-in-tube sorbent tube sampling method collected S/I-VOC samples from biomass burning experiments for a range of fuels and combustion conditions. Filter-in-tube samples were analyzed using thermal desorption-gas chromatography-mass spectrometry (TD/GC/MS) for compounds across a wide range of volatilities (saturation concentrations; -2 ≤ logC* ≤ 6). The S/I-VOC measurements were used to calculate volatility distributions for each emissions source. The distributions were broadly consistent across the sources with IVOCs accounting for 75% - 90% of the total captured organic matter, while SVOCs and LVOCs were responsible for 6% - 13% and 1% - 12%, respectively. The distributions and predicted partitioning were generally consistent with literature. Particulate matter emission factors spanned two orders of magnitude across the sources. This work highlights the potential of inferring gas-particle partitioning behavior of biomass burning emissions using filter-in-tube sorbent samples analyzed offline. This simplifies both sampling and analysis of S/I-VOCs for studies focused on capturing the full range of organics emitted.

Pyrolysis processing of PFAS-impacted biosolids, a pilot study

Concentrations of per- and poly-fluoroalkyl substances (PFAS) present in wastewater treatment biosolids are a growing concern. Pyrolysis is a thermal treatment technology for biosolids that can produce a useful biochar product with reduced levels of PFAS and other contaminants. In August 2020, a limited-scope study investigated target PFAS removal of a commercial pyrolysis system processing biosolid with the analysis of 41 target PFAS compounds in biosolids and biochar performed by two independent laboratories. The concentrations of 21 detected target compounds in the input biosolids ranged between approximately 2 µg/kg and 85 µg/kg. No PFAS compounds were detected in the biochar. The PFAS concentrations in the biochar were assumed to equal the compounds' minimum detection limits (MDLs). The pyrolysis system's target PFAS removal efficiencies (REs) were estimated to range between >81.3% and >99.9% (mean >97.4%) with the lowest REs being associated with the lowest detected PFAS concentrations and the highest MDLs. No information on non-target PFAS compounds in influent or effluent media or products of incomplete combustion was considered. Selected gaseous emissions were measured by Fourier transform infrared spectroscopy and gas chromatography time-of-flight mass spectrometry to provide additional information on air emissions after process controls. This limited-scope study indicated that additional research to further understand this process is warranted.Implications: Development of alternative approaches to manage PFAS-impacted biosolids is of emerging international importance. A commercially operating biosolid pyrolysis process was shown to lower target PFAS levels in produced biochar. Additional research is warranted to understand all potential PFAS transformation emission routes and optimal air pollution emissions control strategies for this technology class.

Cookstove Emissions and Performance Evaluation Using a New ISO Protocol and Comparison of Results with Previous Test Protocols

In 2018, the International Organization for Standardization (ISO) 19867-1 "Harmonized laboratory test protocols" were released for establishing improved quality and comparability for data on cookstove air pollutant emissions, efficiency, safety, and durability. This is the first study that compares emissions [carbon dioxide, carbon monoxide, total hydrocarbons, methane, nitrogen oxides, fine particulate matter (PM_2.5), organic carbon, elemental carbon, and ultrafine particles] and efficiency data between the ISO protocol and the Water Boiling Test (WBT). The study examines six stove/fuel combinations [liquefied petroleum gas (LPG), pellet, wood fan, wood rocket, three stone fire, and charcoal] tested in the same US EPA laboratory. Evaluation of the ISO protocol shows improvements over previous test protocols and that results are relatively consistent with former WBT data in terms of tier ratings for emissions and efficiency, as defined by the ISO 19867-3 "Voluntary Performance Targets." Most stove types remain similarly ranked using ISO and WBT protocols, except charcoal and LPG are in higher PM_2.5 tiers with the ISO protocol. Additionally, emissions data including polycyclic aromatic hydrocarbons are utilized to compare between the ISO and Firepower Sweep Test (FST) protocols. Compared to the FST, the ISO protocol results in generally higher PM_2.5 tier ratings.

Relative contributions of selected multigeneration products to chamber SOA formed from photooxidation of a range (C10-C17) of n-alkanes under high NO x conditions

A series of chamber experiments was conducted to investigate the composition of secondary organic aerosol (SOA) following oxidation of a range of parent n-alkanes (C10-C17) in the presence of NO x . The relative contribution of selected species representing first, second, and higher generation products to SOA mass was measured using a high-resolution aerosol mass spectrometer. Gas chromatography was also used for a limited set of amenable species. Relative contributions varied substantially across the range of investigated alkanes reflecting slight changes in SOA composition. The contribution of first-generation cyclic hemiacetal is minimal toward the small end of the investigated range and gradually increase with n-alkane size. The relative contribution of second generation and higher nitrate-containing species, in contrast, decrease with an increased alkane size. A similar trend is observed for relative contribution of organonitrates to SOA. Finally, SOA yield and composition are sensitive to water vapor concentrations. This sensitivity is limited to a narrow range (dry to ~15% RH) with little, if any, impact above 15% suggesting that this impact may be negligible under ambient conditions. The impact of water vapor also appears to decrease with increasing alkane carbon number.

Mutagenicity- and pollutant-emission factors of pellet-fueled gasifier cookstoves: Comparison with other combustion sources

Emissions from solid-fuel burning cookstoves are associated with 3 to 4 million premature deaths annually and contribute significantly to impacts on climate. Pellet-fueled gasifier stoves have some emission factors (EFs) approaching those of gas-fuel (liquid petroleum gas) stoves; however, their emissions have not been evaluated for biological effects. Here we used a new International Organization for Standardization (ISO) testing protocol to determine pollutant- and mutagenicity-EFs for a stove designed for pellet fuel, the Mimi Moto, and for two other forced-draft stoves, Xunda and Philips HD4012, burning pellets of hardwood or peanut hulls. The Salmonella assay-based mutagenicity-EFs (revertants/megajouledelivered) spanned three orders of magnitude and correlated highly (r = 0.99; n = 5) with EFs of the sum of 32 particle-phase polycyclic aromatic hydrocarbons (PAHs). The Mimi Moto/hardwood pellet combination had total-PAH- and mutagenicity-EFs 99.2 and 96.6% lower, respectively, compared to data published previously for the Philips stove burning non-pelletized hardwood, and 100 and 99.8% lower, respectively, compared to those of a wood-fueled three-stone fire. The Xunda burning peanut hull pellets had the highest fuel energy-based mutagenicity-EF (revertants/megajoulethermal) of the pellet stove/fuel combinations tested, which was between that of diesel exhaust, a known human carcinogen, and a natural-draft wood stove. Although the Mimi Moto burning hardwood pellets had the lowest fuel energy-based mutagenicity-EF, this value was between that of utility coal and utility wood boilers. This advanced stove/fuel combination has the potential to greatly reduce emissions in contrast to a traditional stove, but adequate ventilation is required to approach acceptable levels of indoor air quality.

Improved long-term patient-reported health and well-being outcomes of early-stage breast cancer treated with partial breast proton therapy

Background

Because early‐stage breast cancer can be treated successfully by a variety of breast‐conservation approaches, long‐term quality of life (QoL) is an important consideration in assessing treatment outcomes for these patients. This study compares patient‐reported QoL outcomes among women with stage 0‐2 disease treated via lumpectomy followed by whole breast irradiation (WBI) or partial breast proton irradiation (PBPT).

Methods

In this cross‐sectional study, 129 participants evaluated QoL several years post‐treatment by responding to subjective instruments, including established scalar questionnaires and self‐report measures. Responses were averaged between the two groups.

Results

At 6.5 years (median) postdiagnosis, participants’ demographic, and clinical characteristics were similar. Patient‐reported outcomes were reported as mean scale scores for the two groups, all displaying significant differences favoring PBPT, including: cosmetic breast cancer treatment outcome scale (BCTOS) (PBPT mean 1.45, WBI mean 1.88, P < 0.001); breast pain (PBPT mean 1.30, WBI mean 1.67, P < 0.05); breast texture (BPT mean 1.44, WBI mean 1.91, P < 0.001); clothing fit (PBPT mean 1.06, WBI 1.46, P < 0.001); fatigue (PBPT mean 2.24, WBI mean 3.77, P < 0.002); impact of daily life fatigue on personal relations (OBPT mean 0.83, WBI mean 2.15, P < 0.001); and self‐consciousness (appearance dissatisfaction) (PBPT mean 1.38, WBI mean 1.77, P < 0.004).

Conclusion

Patients’ responses suggest that PBPT is associated with improved overall QoL compared to standard whole breast treatment. These self‐perceptions are reported by patients who are 5‐10 years post‐treatment, and that PBPT may enhance QoL in a multitude of interrelated ways.

Temperature and Driving Cycle Significantly Affect Carbonaceous Gas and Particle Matter Emissions from Diesel Trucks

The present study examines the effects of fuel [an ultralow sulfur diesel (ULSD) versus a 20% v/v soy-based biodiesel-80% v/v petroleum blend (B20)], temperature, load, vehicle, driving cycle, and active regeneration technology on gas- and particle-phase carbon emissions from light and medium heavy-duty diesel vehicles (L/MHDDV). The study is performed using chassis dynamometer facilities that support low-temperature operation (-6.7 °C versus 21.7 °C) and heavy loads up to 12 000 kg. Organic and elemental carbon (OC-EC) composition of aerosol particles is determined using a thermal-optical technique. Gas- and particle-phase semivolatile organic compound (SVOC) emissions collected using traditional filter and polyurethane foam sampling media are analyzed using advanced gas chromatograpy/mass spectrometry methods. Study-wide OC and EC emissions are 0.735 and 0.733 mg/km, on average. The emissions factors for diesel vehicles vary widely, and use of a catalyzed diesel particle filter (CDPF) device generally mutes the carbon particle emissions in the exhaust, which contains ~90% w/w gas-phase matter. Interestingly, replacing ULSD with B20 did not significantly influence SVOC emissions, for which sums range from 0.030 to 9.4 mg/km for the L/MHDDVs. However, both low temperature and vehicle cold-starts significantly increase SVOCs in the exhaust. Real-time particle measurements indicate vehicle regeneration technology did influence emissions, although regeneration effects went unresolved using bulk chemistry techniques. A multistudy comparison of the toxic particle-phase polycyclic aromatic hydrocarbons (PAHs; molecular weight (MW) ≥ 252 amu) in diesel exhaust indicates emission factors that span up to 8 orders of magnitude over the past several decades. This study observes conditions under which PAH compounds with MW ≥ 252 amu appear in diesel particles downstream of the CDPF and can even reach low-end concentrations reported earlier for much larger HDDVs with poorly controlled exhaust streams. This rare observation suggests that analysis of PAHs in particles emitted from modern L/MHDDVs may be more complex than recognized previously.

Characterization of emissions and residues from simulations of the Deepwater Horizon surface oil burns

The surface oil burns conducted by the U.S. Coast Guard from April to July 2010 during the Deepwater Horizon disaster in the Gulf of Mexico were simulated by small scale burns to characterize the pollutants, determine emission factors, and gather particulate matter for subsequent toxicity testing. A representative crude oil was burned in ocean-salinity seawater, and emissions were collected from the plume by means of a crane-suspended sampling platform. Emissions included particulate matter, aromatic hydrocarbons, polychlorinated dibenzodioxins/dibenzofurans, elements, and others, the sum of which accounted for over 92% by mass of the combustion products. The unburned oil mass was 29% of the original crude oil mass, significantly higher than typically reported. Analysis of alkanes, elements, and PAHs in the floating residual oil and water accounted for over 51% of the gathered mass. These emission factors, along with toxicity data, will be important toward examining impacts of future spill burning operations.

Mutagenicity and oxidative damage induced by an organic extract of the particulate emissions from a simulation of the deepwater horizon surface oil burns

Emissions from oil fires associated with the "Deepwater Horizon" explosion and oil discharge that began on April 20, 2010 in the Gulf of Mexico were analyzed chemically to only a limited extent at the time but were shown to induce oxidative damage in vitro and in mice. To extend this work, we burned oil floating on sea water and performed extensive chemical analyses of the emissions (Gullett et al., Marine Pollut Bull, in press, ). Here, we examine the ability of a dichloromethane extract of the particulate material with an aerodynamic size ≤ 2.5 µm (PM2.5 ) from those emissions to induce oxidative damage in human lung cells in vitro and mutagenicity in 6 strains of Salmonella. The extract had a percentage of extractable organic material (EOM) of 7.0% and increased expression of the heme oxygenase (HMOX1) gene in BEAS-2B cells after exposure for 4 hr at 20 µg of EOM/ml. However, the extract did not alter mitochondrial respiration rate as measured by extracellular flux analysis. The extract was most mutagenic in TA100 +S9, indicative of a role for polycyclic aromatic hydrocarbons (PAHs), reflective of the high concentrations of PAHs in the emissions (1 g/kg of oil consumed). The extract had a mutagenicity emission factor of 1.8 ± 0.1 × 105 revertants/megajoulethermal in TA98 +S9, which was greater than that of diesel exhaust and within an order of magnitude of open burning of wood and plastic. Thus, organics from PM2.5 of burning oil can induce oxidative responses in human airway epithelial cells and are highly mutagenic. Environ. Mol. Mutagen. 58:162-171, 2017. © 2017 Wiley Periodicals, Inc.

Polycyclic Aromatic Hydrocarbons in Fine Particulate Matter Emitted from Burning Kerosene, Liquid Petroleum Gas, and Wood Fuels in Household Cookstoves

This study measures polycyclic aromatic hydrocarbon (PAH) compositions in particulate matter emissions from residential cookstoves. A variety of fuel and cookstove combinations are investigated, including: (i) liquid petroleum gas (LPG), (ii) kerosene in a wick stove, (iii) wood (10 and 30% moisture content on a wet basis) in a forced-draft fan stove, and (iv) wood in a natural-draft rocket cookstove. The wood burning in the natural-draft stove had the highest PAH emissions followed by the wood combustion in the forced-draft stove and kerosene burning. LPG combustion has the highest thermal efficiency (∼57%) and the lowest PAH emissions per unit fuel energy, resulting in the lowest PAH emissions per useful energy delivered (in the unit of megajoule delivered, MJd). Compared with the wood combustion emissions, LPG burning also emits a lower fraction of higher molecular weight PAHs. In rural regions where LPG and kerosene are unavailable or unaffordable, the forced-draft fan stove is expected to be an alternative because its benzo[a]pyrene (B[a]P) emission factor (5.17-8.24 μg B[a]P/MJd) and emission rate (0.522-0.583 μg B[a]P/min) are similar to those of kerosene burning (5.36 μg B[a]P/MJd and 0.452 μg B[a]P/min). Relatively large PAH emission variability for LPG suggests a need for additional future tests to identify the major factors influencing these combustion emissions. These future tests should also account for different LPG fuel formulations and stove burner types.

Effects of Cold Temperature and Ethanol Content on VOC Emissions from Light-Duty Gasoline Vehicles

Emissions of speciated volatile organic compounds (VOCs), including mobile source air toxics (MSATs), were measured in vehicle exhaust from three light-duty spark ignition vehicles operating on summer and winter grade gasoline (E0) and ethanol blended (E10 and E85) fuels. Vehicle testing was conducted using a three-phase LA92 driving cycle in a temperature-controlled chassis dynamometer at two ambient temperatures (-7 and 24 °C). The cold start driving phase and cold ambient temperature increased VOC and MSAT emissions up to several orders of magnitude compared to emissions during other vehicle operation phases and warm ambient temperature testing, respectively. As a result, calculated ozone formation potentials (OFPs) were 7 to 21 times greater for the cold starts during cold temperature tests than comparable warm temperature tests. The use of E85 fuel generally led to substantial reductions in hydrocarbons and increases in oxygenates such as ethanol and acetaldehyde compared to E0 and E10 fuels. However, at the same ambient temperature, the VOC emissions from the E0 and E10 fuels and OFPs from all fuels were not significantly different. Cold temperature effects on cold start MSAT emissions varied by individual MSAT compound, but were consistent over a range of modern spark ignition vehicles.

Carbonaceous aerosols emitted from light-duty vehicles operating on gasoline and ethanol fuel blends

This study examines the chemical properties of carbonaceous aerosols emitted from three light-duty gasoline vehicles (LDVs) operating on gasoline (e0) and ethanol-gasoline fuel blends (e10 and e85). Vehicle road load simulations were performed on a chassis dynamometer using the three-phase LA-92 unified driving cycle (UDC). Effects of LDV operating conditions and ambient temperature (-7 and 24 °C) on particle-phase semivolatile organic compounds (SVOCs) and organic and elemental carbon (OC and EC) emissions were investigated. SVOC concentrations and OC and EC fractions were determined with thermal extraction-gas chromatography-mass spectrometry (TE-GC-MS) and thermal-optical analysis (TOA), respectively. LDV aerosol emissions were predominantly carbonaceous, and EC/PM (w/w) decreased linearly with increasing fuel ethanol content. TE-GC-MS analysis accounted for up to 4% of the fine particle (PM2.5) mass, showing the UDC phase-integrated sum of identified SVOC emissions ranging from 0.703 μg km(-1) to 18.8 μg km(-1). Generally, higher SVOC emissions were associated with low temperature (-7 °C) and engine ignition; mixed regression models suggest these emissions rate differences are significant. Use of e85 significantly reduced the emissions of lower molecular weight PAH. However, a reduction in higher molecular weight PAH entities in PM was not observed. Individual SVOC emissions from the Tier 2 LDVs and fuel technologies tested are substantially lower and distributed differently than those values populating the United States emissions inventories currently. Hence, this study is likely to influence future apportionment, climate, and air quality model predictions that rely on source combustion measurements of SVOCs in PM.

Proton radiation for treatment of cancer of the oropharynx: Early experience at Loma Linda University Medical Center using a concomitant boost technique

PURPOSE

To assess accelerated fractionation using photon and proton radiation to improve local control and reduce complications in treating locally advanced oropharyngeal cancer.

METHODS AND MATERIALS

Twenty-nine patients with localized Stage II-IV oropharyngeal cancer received accelerated photon and proton radiation, 75.9 GyE in 45 fractions/5.5 weeks, to the primary disease, involved lymph nodes, and potential areas of subclinical spread. Follow-up ranged from 2 to 96 months.

RESULTS

Five-year actuarial control for local disease was 88%, and for neck node disease, 96%; yielding a 84% locoregional control rate at 5 years. Four patients developed distant metastases. The 5-year actuarial locoregional control rate was 84%. The actuarial 2-year disease-free survival rate was 81%; at 5 years, it was 65%. All patients completed the prescribed treatment; though aggressive nutritional and anesthetic support was necessary. Late Grade 3 toxicity was seen in 3 patients.

CONCLUSIONS

Protons used as a concomitant boost with photons effectively delivered an accelerated time-dose schedule to the cancer with a more tolerable schedule to surrounding normal tissues. Preliminary results reveal increased locoregional control without increased toxicity. Future studies must evaluate the optimum time-dose schedule.

Reducing Toxicity from Craniospinal Irradiation

PURPOSE

We report on a radiation treatment technique that has reduced the dose to critical normal structures in children with medulloblastoma.

PATIENTS AND METHODS

Three children between the ages of 3 and 4 with stage M2 or M3 medulloblastoma were treated between 2001 and 2003 with craniospinal irradiation using protons. Patients received 36 cobalt gray equivalent to the craniospinal axis, then 18 cobalt gray equivalent to the posterior fossa. The cranium was treated with opposed lateral fields. The spine was treated with three matched posteroanterior fields, with the beam stopping just beyond the thecal sac. The posterior fossa was then treated with alternating posteroanterior, right posterior oblique, and left posterior oblique fields, with the beam stopping just proximal to the cochlea. The use of general anesthesia and pre-porting with diagnostic-quality x-rays allowed precise patient positioning.

RESULTS

Craniospinal irradiation delivered via conformal proton irradiation substantially reduced the dose to the cochlea and vertebral bodies and virtually eliminated the exit dose through thorax, abdomen, and pelvis. Despite concurrent chemotherapy, a clinically significant lymphocyte count reduction was not seen. Patients tolerated treatment well; acute side effects (e.g., nausea, decreased appetite, and odynophagia) were mild. All patients completed therapy without interruption.

CONCLUSION

Our proton-beam technique for craniospinal irradiation of pediatric medulloblastoma has successfully reduced normal-tissue doses and acute treatment-related sequelae. This technique may be especially advantageous in children with a history of myelosuppression, who might not other wise tolerate irradiation.

Proton therapy for prostate cancer: the initial Loma Linda University experience

PURPOSE

We analyzed results of conformal proton radiation therapy for localized prostate cancer, with emphasis on biochemical freedom from relapse.

METHODS AND MATERIALS

Analyses were performed for 1255 patients treated between October 1991 and December 1997. Outcomes were measured on primarily in terms of biochemical relapse and toxicity.

RESULTS

The overall biochemical disease-free survival rate was 73%, and was 90% in patients with initial PSA <or=4.0; it was 87% in patients with posttreatment PSA nadirs <or=0.50. Rates dropped with rises in initial and nadir PSA values. Long-term survival outcomes were comparable with those reported for other modalities intended for cure.

CONCLUSIONS

Conformal proton radiation therapy at the reported dose levels yielded disease-free survival rates comparable with other forms of local therapy, and with minimal morbidity. Dose-escalation strategies are being implemented to further improve long-term results.

What is the role of radiation in the treatment of subfoveal membranes: review of radiobiologic, pathologic, and other considerations to initiate a multimodality discussion

BACKGROUND

Single-dose-fraction conformal proton beam and multiple-fraction X ray dose schedules have been used to treat subfoveal neovascular membranes. All schedules successfully controlled membrane progression, stabilized vision in most patients, and increased visual acuity in some. Conformal protons also decreased the radiation dose to healthy tissues outside the designated volume (16 mm in diameter). It appears that radiation therapy could be useful and cost-effective, but neither the optimal time-dose schedule single or multiple dose fractions nor the type of radiation proton conformal beam or x-ray therapy are defined.

METHODS

By means of an extensive literature survey, we reviewed the rationale for using radiation to treat subfoveal neovascularization, examined a paradigm of radiation interaction with tissue, reviewed the histopathology of neovascular membranes, and documented the role of growth factors in the pathophysiology of the disease. Accepting that the eye is an extracranial brain extension, and that its microvasculature has properties similar to brain microvessels, we reviewed the radiobiologic response of brain microvessels. We also revisited the controversy concerning the efficacy of single-dose-fraction vs. multifraction schedules.

RESULTS

This paper outlines parameters within which radiation therapy's role might be defined, and proposes a clinical radiation-biology scoring program to evaluate radiation effects, based on the SOMA concept.

CONCLUSION

A prospective, controlled clinical trial is feasible and is indicated to determine radiation therapy's role in managing the proliferative component of age-related macular degeneration.

The proton treatment center at Loma Linda University Medical Center: rationale for and description of its development

Proton radiation, a continuation of radiation oncology's historic search for an optimum dose distribution, offers superior characteristics for clinical radiation therapy. A complete facility for clinical proton radiation therapy has been designed for and constructed at Loma Linda University Medical Center. To bring about this achievement, a consortium of engineers, physicists, and physicians interested in the clinical applications of protons was necessary. The accelerator, the beam transport and delivery systems, the building, and the personnel who operate the system were all brought together to fully exploit the properties of protons for patient treatments, which are now underway.

Proton beam therapy: a promising method of locoregional cancer control

Proton beams offer superior characteristics for clinical radiation therapy, including the capability to localize precisely the dose to the desired target volume. Such precision enables the radiation therapist to give higher doses to the tumor while avoiding intolerable doses to adjacent normal tissues. Locoregional control is thus increased, and treatment morbidity and side effects are decreased. When it opens in late spring 1990, Loma Linda University Medical Center's proton treatment facility will feature the world's first accelerator and proton therapy system designed for patient care. During the next decade, other similarly-designed proton therapy systems will be built in Canada, England, France, Belgium, Germany, Japan, and South Africa, as well as at Massachusetts General Hospital in the United States.