Prostate cancer and elective nodal radiation therapy for cN0 and pN0-a never ending story? : Recommendations from the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO)

For prostate cancer, the role of elective nodal irradiation (ENI) for cN0 or pN0 patients has been under discussion for years. Considering the recent publications of randomized controlled trials, the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO) aimed to discuss and summarize the current literature. Modern trials have been recently published for both treatment-naïve patients (POP-RT trial) and patients after surgery (SPPORT trial). Although there are more reliable data to date, we identified several limitations currently complicating the definitions of general recommendations. For patients with cN0 (conventional or PSMA-PET staging) undergoing definitive radiotherapy, only men with high-risk factors for nodal involvement (e.g., cT3a, GS ≥ 8, PSA ≥ 20 ng/ml) seem to benefit from ENI. For biochemical relapse in the postoperative situation (pN0) and no PSMA imaging, ENI may be added to patients with risk factors according to the SPPORT trial (e.g., GS ≥ 8; PSA > 0.7 ng/ml). If PSMA-PET/CT is negative, ENI may be offered for selected men with high-risk factors as an individual treatment approach.

Quality of long standing radiographs assessment of the patella position

BACKGROUND

The gold standard for evaluating leg alignment is a long leg standing radiograph (LSR). The research states that a correct LSR should have a patella that is centered and facing forward as well as a fibula head superimposition (FHS) with a tibia that is 1/3 larger than the fibula. The purpose of this study was to determine levels of quality for LSR by quantifying and correlating the patella position and fibular head superimposition.

METHOD

741 lower limbs were included using two distinct measurement techniques, we calculated the patella position's (PD) departure from the center of the knee joint (M1 and M2). To measure the inter-rater dependability in assessing PD and FHS, intraclass correlation coefficients were determined. The Bland-Altman approach was used to compare M1 with M2's performance. We created three quality groups based on the average quantity of PD.

RESULTS

The mean PD was 3.5 mm for M1 and 4.1 mm for M2, respectively. Three quality categories were created: group A for PD ≤ 5 mm, group B for PD 5-10 mm, and group C for PD of ≥10 mm. Group A takes up 70.9% of the LSR. Interestingly, group A's FHS was 21.3% than the typical value of 1/3.

CONCLUSIONS

The patella's center should be centered within a 5 mm range and the fibular head should be 1/5 covered from the tibia. This study is the first to define quantitative metrics based on LSR analysis.

LEVEL OF EVIDENCE

Level IV (diagnostic retrospective case series).

The Femoral Vein as a Long-Term Aorto-Iliac Graft for Aortic Infection and Aortitis

Background

Reconstruction of the aorto-iliac segment with femoral vein (FV) as substitute for infected synthetic grafts or mycotic aneurysms constitutes the most sustainably convenient alternative. The aim of this study was to evaluate the long-term outcome of up to 16 years of follow-up, analysing the morphologic adaption of the FV with special emphasis on the distal and proximal anastomoses.

Methods

We conducted a retrospective study of 22 patients with 109 computed tomography angiograms (CTAs) treated between August 2001 and January 2020 in case of aortic infection/aortitis. Morphologic changes like anastomotic dilatation/stenosis as well as changes of FV wall thickness were retrospectively analysed in pre- and postoperative CTAs.

Results

Elective procedure was done in 17/22 (77%) cases, and 5/22 (23%) patients required emergent surgery. The median follow-up was 91.5 months (P₂₅;P₇₅ = 21;117). Cross-sectional diameter of proximal (20.38 ± 3.77 vs 22.04 ± 3.97 mm, p = 0.007) and distal anastomoses (13.05 ± 4.23 vs 14.61 ± 5.19 mm, p = 0.05) increased significantly, as well as the proximal and distal anastomotic areas (3.36 ± 1.29 vs 4.32 ± 1.63 mm², p = 0.04 and 0.99 ± 0.48 vs 1.25 ± 0.72 mm², p = 0.023, respectively). Venous wall thickness was significantly reduced at the anastomotic site (1.74 ± 0.46 vs 1.24 ± 0.31 mm, p = 0.001). The upper thigh diameter did not differ before and after harvesting of the FV (161.6 ± 29.1 vs. 178.2 ± 23.3 mm, p = 0.326, respectively).

Conclusion

This long-term CTA follow-up study showed that the FV wall becomes thinner at the anastomotic site, and the anastomoses dilate with time without rupture. The FV is a durable conductor after replacement of the aorto-iliac segment due to aortic infection. Further CTA studies from more centres are warranted to evaluate the risk of vein rupture.

Impacted Steel Sleeves for a minimally invasive approach in intramedullary nailing

A custom-made instrument set of Steel Sleeves was developed to assist the insertion of reamers and intramedullary devices for fixation of long bone fractures or lengthening procedures with intramedullary nails. By use of the Steel Sleeves, migration of the entry point is prevented and protection of the bone and soft tissue at the entry point is guaranteed. In addition, the principle of a closed working channel for trans-articular approaches can be provided. In this article, a description of properties and clinical application of custom-made steel sleeve instrument set is provided.

Intraoperative customization of intramedullary nails - First results

INTRODUCTION

Intramedullary nailing is a valuable treatment option for many types of fractures. Furthermore nailing is applicable for osteosynthesis following osteotomy in deformity correction. For intraoperative fine-tuning of alignment in intramedullary (IM) nailing procedures, a bending device for customization of IM nails under sterile conditions was developed. We have performed a retrospective clinical study to analyze and describe the technical requirements, indications and limitations for intraoperative customization of IM nails.

MATERIALS AND METHODS

In 41 cases of deformity correction with IM nailing, we applied intraoperative sterile bending of IM nails. The patient age ranged from 13 to 64 years. We evaluated the radiological outcome (precision of the intervention) of 31 completed cases, comparing the preoperative planning with the final result on long-standing radiographs (LSR). The diameter of the nails ranged from 8,5mm to 13mm. Cases with fracture or non-union treatment with intraoperative application of the bending device were excluded and analyzed separately.

RESULTS

All removed implants were examined - none of them showed any signs of material fatigue. The amount of intraoperative bending of the nails was 1° to 12°. A high level of precision was achieved, with a median postoperative axis deviation to the preoperative planning of 3,5mm. In a polio patient with limited bone quality, the implant removal caused an undisplaced cortical crack. There were no other complications. There was uneventful and fast bone healing in all patients.

CONCLUSIONS

Intraoperative customization of intramedullary nails is a valuable technique for precise alignment control with IM nailing. With this technique, the benefits of IM nailing can be used for a wide range of indications, including deformity correction. The sterile bending device is safe and easy to handle. It is strong enough to bend all commercially available IM nails. Monofocal or linear bending in multiple planes is possible. However, when defining the site of bending, one must consider the removal of the implant in the future.

Portal Vein Thrombosis and Thrombocytopenia in Eosinophilic Granulomatosis with Polyangiitis: A Paradox?

A 36-year-old woman with eosinophilic granulomatosis with polyangiitis (EGPA) presented with necrotic skin lesions and pulmonary infiltrates. There was eosinophilic vasculitis on skin biopsy, and substantial tissue eosinophilia in her bone marrow. She had unexplained worsening thrombocytopenia, which prompted a thrombophilia work-up. However, abnormalities in liver enzymes led to the extraordinary finding of portal vein thrombosis. Thrombocytopenia resolved with treatment with low molecular weight heparin. This case highlights the risk of hypercoagulability in eosinophilia specifically, and in EGPA. We suggest that thrombosis should be ruled out in all cases of EGPA.

99mTc-Labelled Polyclonal Human Immunoglobulin for Localization of Inflammatory Sites - Early in vitro-Results

99mTc-labelled polyclonal human immunoglobulin (HIG) has been shown to be able to localize inflammatory sites. Hypothetically these immunoglobulins bind directly to bacteria, HIG binds directly to Fc-receptors on the surface membrane of leucocytes or HIG simply passes vessels of increased permeability. To collect further information experiments were carried out in vitro with the blood of human volunteers. 0.5 mg 99mTc-HIG, 2 mg 99mTc-human albumin and 0.5 mg 99mTc-labelled murine monoclonal antigranulocyte antibodies were added to in vitro isolated human “mixed” leucocyte pellets and to 30 ml whole blood of 6 healthy volunteers. The whole blood and the directly labelled leucocyte pellet were layered and separated on a discontinuous Percoll®/ plasma gradient. The activity distribution was measured within the gradient. The 99mTc-HIG labelled gradients showed a significant uptake of the activity within the monocyte band whereas the 99mTc-albumin gradients showed no specific albumin uptake in any cellular band. The 99mTc-antibody labelled gradients showed a significantly increased uptake on granulocytes . It is concluded that in man a specific monocyte-associated uptake and binding mechanism of 99mTc-HIG plays an important role in the localisation of inflamed sites.

Kinetics of 99mTc-Labelled Antibodies against CD4 (T-Helper) Lymphocytes in Man

Die Verfügbarkeit 99mTc-markierter CD4-Antikörper erlaubt das Studium ihres kinetischen Verhaltens bei rheumatischen Patienten. Prospektiv wurden Patienten mit rheumatoider Arthritis untersucht. Drei dieser Patienten erhielten 250 µg eines mit 555 MBq 99mTc markierten CD4-Antikörpers (MAX16H5) injiziert. Ein Patient erhielt in vitro mit 99mTc markierte Lymphozyten. 4% der Aktivität wurden renal eliminiert. Von 4 nach 24 h p. i. fiel der Milzuptake von 7,5 auf 4%, der Leberuptake stieg von 25 auf 30%, der Knochemarkuptake blieb vergleichbar (50%), während der Uptake über einem großen erkrankten Gelenk von 2 geringfügig auf 2,5% stieg. 15 bis 30 min nach der Antikörperinjektion war eine Umverteilung von Aktivität zu registrieren, die einer Lymphozytenredistribution vergleichbar war. Die Recoveryrate (0-1 h) der in vivo markierten Zellen betrug 30%, die der in vitro markierten Zellen 19%. Ein Patient wurde mit in vitro CD4-Antikörper-markierten Lymphozyten untersucht. Ein signifikanter Unterschied der Kinetik beider Präparationen war nicht zu registrieren. Zusammenfassend schließen die Autoren, daß zirkulierende CD4-exprimierende Lymphozyten mit CD4-Antikörpern markiert werden können. Die kinetischen Daten erinnern an jene rezirkulierender Lymphozyten.

Diagxxnostic Accuracy of 99mTc-Anti-CEA Immuno- scintigraphy in Patients with Liver Metastases from Colorectal Carcinoma

17 Patienten mit 43 Lebermetastasen kolorektaler Karzinome wurden der Immunszintigraphie (IS) mit 99mTc-markierten monoklonalen Anti-CEA-Antikörpern (BW 431/26) unterzogen. Im Hinblick auf die Gesamtzahl der Raumforderungen wurden Sensitivität und diagnostische Treffsicherheit mit 21% bestimmt, bezogen auf die Patientenzahl betrugen sie 47% (mindestens eine positive Darstellung bei multiplen Metastasen) bzw. 77% bei nur einer Solitärmetastase. Die Sensitivität wurde durch Verwendung der SPECT- Technik nicht wesentlich verbessert. Eine Korrelation mit den Serum-CEA- Spiegeln ließ sich nicht nachweisen. Am besten schienen sich Lebermetastasen mittlerer Größe mit mäßiger Tumornekrose darzustellen. Die Ursache für die geringe Sensitivität ist vor allem in der ausgeprägten unspezifischen Anreicherung 99mTc-markierter Antikörper im RES der Leber zu sehen. Im Augenblick scheint die Immunszintigraphie lediglich eine ergänzende Methode zu konventionellen diagnostischen Maßnahmen darzustellen.

Localization and Activity of Inflammatory Bowel Disease Using 111ln Leukocyte Imaging

A prospective study was initiated to compare the clinically proven results concerning localization/extent and activity of inflammatory bowel diseases with those of 111ln-oxine leukocyte imaging. All patients studied were completely examined with barium enema x-ray, clinical and laboratory investigations, and endoscopy with histopathology. A total of 31 leukocyte scans were performed in 15 patients (12 with Crohn’s disease, 3 with ulcerative colitis). The scans were graded by comparing the cell uptake of a lesion (when present) and a bone marrow area providing a count ratio (CR). The inflammatory lesions were correctly localized on 26 leukocyte scans, and in 21 scans the scintigraphically estimated extent of disease was identical to endoscopy. In 5 cases the disease extent was underestimated, 4 scans in patients with relapse of Crohn’s disease were falsely negative, and in one patient with remission truly negative. The scintigraphically assessed disease activity was also in a good agreement with clinical disease activity based on histopathology in all cases. We conclude that leukocyte imaging provides valuable information about localization and activity of inflammatory bowel disease.

Somatostatin Receptor Expression in the Thyroid Demonstrated with 111In-Octreotide Scintigraphy

Neuroendocrine tumors with somatostatin receptor expression may be localized by 111ln-octreotide scintigraphy. This study examines those thyroid conditions where 111 ln-octreotide uptake could be observed also in the thyroid gland. 26 consecutive patients who underwent 111 ln-octreotide scintigraphy for tumor localization were additionally examined for thyroid disease by sonography and 99mTc-pertechnetate scintigraphy. 12 of these patients had no significant thyroid uptake and had an euthyroid normal-sized thyroid gland. 14 patiens with 111ln thyroid uptakes had endemic goiters, two of them with thyroid autonomy and one with Graves’ disease. Thus, 111 ln-octreotide thyroid uptake was predominantly seen in patients with endemic goiter with or without thyroid autonomy.

Tc-99m DTPA Perfusion Scintigraphy and Color Coded Duplex Sonography in the Evaluation of Minimal Renal Allograft Perfusion

Aim: The clinical impact of perfusion scintigraphy versus color coded Duplex sonography was evaluated, with respect to their potential in assessing minimal allograft perfusion in vitally threatened kidney transplants, i.e. oligoanuric allografts suspected to have either severe rejection or thrombosis of the renal vein or artery. Methods: From July 1990 to August 1994 the grafts of 15 out of a total of 315 patients were vitally threatened. Technetium-99m DTPA scintigraphy and color coded Duplex sonography were performed in all patients. For scintigraphic evaluation of transplant perfusion analog scans up to 60 min postinjection, and time-activity curves over the first 60 sec after injection of 370-440 MBq Tc-99m diethylenetriaminepentaacetate acid (DTPA) were used and classified by a perfusion score, the time between renal and iliac artery peaks (TDiff) and the washout of the renogram curve. Additionally, evaluation of excretion function and assessment of vascular or urinary leaks were performed. By color coded Duplex sonography the perfusion in all sections of the graft as well as the vascular anastomoses were examined and the maximal blood flow velocity (Vmax) and the resistive index (Rl) in the renal artery were determined by means of the pulsed Doppler device. Pathologic-anatomical diagnosis was achieved by either biopsy or post-explant histology in all grafts. Results: Scintigraphy and color coded Duplex sonography could reliably differentiate minimal (8/15) and not perfused (7/15) renal allografts. The results were confirmed either by angiography in digital subtraction technique (DSA) or the clinical follow up. Conclusion: In summary, perfusion scintigraphy and color coded Duplex sonography are comparable modalities to assess kidney graft perfusion. In clinical practice scintigraphy and color-coded Doppler sonography can replace digital subtraction angiography in the evaluation of minimal allograft perfusion.

Minimal contribution of cell-bound antibodies to the immunoscintigraphy of inflamed joints with 99mTc-anti-CD4 monoclonal antibodies

Aim: The cellular joint infiltrate in rheumatoid arthritis patients is rich in CD4-positive T-helper lymphocytes and macrophages, rendering anti-CD4 monoclonal antibodies (mAbs) suitable for specific immunoscintigraphy of human/ experimental arthritis. Following intravenous injection, however, mAbs are present both in the free form and bound to CD4-positive, circulating monocytes and T-cells. Thus, the present study aimed at analyzing the relative contribution of the free and the cell-bound component to the imaging of inflamed joints in experimental adjuvant arthritis (AA). Methods: AA rat peritoneal macrophages or lymph node T-cells were incubated in vitro with saturating amounts of 99mTc-anti-CD4 mAb (W3/25) and injected i.v. into rats with AA. Results: In vitro release of 99mTc-anti-CD4 mAb from the cells was limited (on average 1.57%/h for macrophages and 0.84%/h for T-cells). Following i.v. injection, whole body/joint scans and tissue measurements showed only negligible accumulation of radioactivity in inflamed ankle joints (tissue: 0.22 and 0.34% of the injected activity, respectively), whereas the radioactivity was concentrated in liver (tissue: 79% and 71%, respectively), kidney, and urinary bladder. Unlike macrophages, however, anti-CD4 mAb-coated T-cells significantly accumulated in lymphoid organs, the inflamed synovial membrane of the ankle joints, as well as in elbow and knee joints. Conclusion: While the overall contribution of cell-bound mAbs to the imaging of arthritic joints with anti-CD4 mAbs is minimal, differential accumulation of macrophages and T-cells in lymphoid organs and the inflamed synovial membrane indicates preferential migration patterns of these 2 cell populations in arthritic rats. Although only validated for 99mTc-anti-CD4 mAbs, extrapolation of the results to other anticellular mAbs with similar affinity for their antigen may be possible.

Endovascular stroke therapy in Austria: a nationwide 1-year experience

BACKGROUND AND PURPOSE

Based on a tight network of stroke units (SUs) and interventional centres, endovascular treatment of acute major intracranial vessel occlusion has been widely implemented in Austria. Documentation of all patients in the nationwide SU registry has thereby become mandatory.

METHODS

Demographic, clinical and interventional characteristics of patients who underwent endovascular treatment for acute ischaemic stroke in 11 Austrian interventional centres between 1 October 2013 and 30 September 2014 were analysed.

RESULTS

In total, 301 patients (50.5% women; median age 70.5 years; median National Institutes of Health Stroke Scale score 17) were identified.193 patients (64.1%) additionally received intravenous thrombolysis. The most frequent vessel occlusion sites were the M1 segment of the middle cerebral artery (n = 161, 53.5%), the intracranial internal carotid artery (n = 60, 19.9%) and the basilar artery (n = 40, 13.3%). Stent retrievers were used in 235 patients (78.1%) and adequate reperfusion (modified Thrombolysis in Cerebral Infarction scores 2b and 3, median onset to reperfusion time 254 min) was achieved in 242 patients (81.4%). Symptomatic intracranial haemorrhage occurred in 7%. 43.8% of patients (n = 132) had good functional outcome (modified Rankin Scale score 0-2) and the mortality rate was 20.9% (n = 63) after 3 months. Compared to the anterior circulation, vertebrobasilar stroke patients had higher mortality. Patients with secondary hospital transportation had better outcomes after 3 months than in-house treated patients.

CONCLUSION

Our results document nationwide favourable outcome and safety rates of endovascular stroke treatment comparable to recent randomized trials. The ability to provide such data and the need to further optimize such an approach also underscore the contribution of respective registries.

Endovascular repair of thoracoabdominal aortic aneurysms with a novel multibranch stent-graft design: preliminary experience

AIM

The aim of this paper was to report our preliminary experience in outcome, safety and mid-term results in the treatment of thoracoabdominal aortic aneurysms (TAAA) with a novel multibranchstentgraft (E-xtra DESIGN ENGINEERING, JOTEC, Germany).

METHODS

Eight patients (mean age 66 years, 2 female) with TAAA (Crawford type I: 2 cases, type III: 3 cases, type IV: 3 cases), mean aneurysm diameter 61 mm, growth over 5 mm per year were treated. Implantation was performed under general anesthesia and surgical exposition of the common femoral artery. Brachial access was percutaneous in 5/8 patients. Balloon-expandable (Advanta V12) bridging stent-grafts were employed and lined with self-expanding nitinol stents. All patients except type IV TAAA received a spinal drainage catheter.

RESULTS

The device was successfully deployed in 8/8 patients. 29/32 visceral branches were engaged. One stenosed celiac trunk was left untreated without further consequences, two renal arteries which could not be cannulated were revascularized with iliorenal bypass. One patient needed surgical revision of groin hematoma, one patient suffered from permanent protopathic sensory deficit. No renal complications occurred. Since the primary implantation was deliberately kept short and amount of contrast agent was minimised, four patients needed a secondary percutaneous procedure (Palmaz stent implantation for type I endoleak, re-PTA or additional bridging stent-graft implantation for type III endoleak). The assisted primary success rate was 8/8. Mean follow-up was 18 months. Success was stable in 7/8 patients, one patient shows type V endoleak with 5mm sac expansion. No mortality or complication occurred during follow-up.

CONCLUSION

The JOTEC E-xtra DESIGN ENGINEERING multibranch stent-graft is a promising new candidate for endovascular TAAA treatment with sufficient safety and efficacy. Its short delivery time suggests its use in patients with rapid aneurysm growth or high anxiety.

Hypomagnesaemia in patients hospitalised in internal medicine is associated with increased mortality

BACKGROUND

Magnesium is the major intracellular divalent cation. Hypomagnesaemia is common among critically ill patients; it's prevalence is not known in patients admitted to general internal medicine. We sought to quantify hypomagnesaemia, and attempted to correlate it with clinical outcomes in internal medicine patients.

MATERIALS AND METHODS

Retrospective chart review. Hypomagnesaemic patients admitted from 1 October 2010 through 18 November 2010 compared with normomagnesaemic patients. Laboratory tests, medical and demographic data were analysed.

RESULTS

In 627 consecutive admissions, overall frequency of hypomagnesaemia was 20.1% (87 patients). Hypomagnesaemic patients were a little older (mean age of 75) and more likely to be women (62%). There was a significant difference in mortality between the normomagnesaemic group (7.2%) and the hypomagnesaemic group (17.2%) (p = 0.0067). There was also a significant difference for length of stay (5.00 ± 5.3 vs. 7.0 ± 8.2, p = 0.0001).

CONCLUSION

The prevalence of hypomagnesaemia in internal medicine is very high. It is associated with higher mortality and longer hospital stay in our population. It can be a useful tool in predicting morbidity and mortality. Although no causal role can be defined for it at present, the low cost and minimal discomfort of measuring magnesium justifies its routine measurement and replacement in patients hospitalised in internal medicine.

Optimisation of occupational exposures during site remediation at WISMU

Since 1991 the national corporation WISMUT GmbH has been charged with the rehabilitation of the sites of former Uranium mining and milling in East Germany. Since decommissioning and site remediation are carried out at places with enhanced dose rates and high concentrations of airborne radioactivity (Rn-222, long-lived alpha emitters), a large part of the employees is classified as occupational exposed radiation workers. Thus, in 2002, 1,073 workers were engaged with relevant works in radiation protection areas aboveground (radiation exposed workers of category B; mean effective dose: 0.3 mSv; maximum dose: 2.2 mSv), and 514 workers still prepared by underground activities the flooding of the Uranium mines (category A; mean effective dose: 0.9 mSv; maximum effective dose: 4.9 mSv). The paper presents the measures taken by WISMUT to optimise the occupational exposure. The need for implementing appropriate ALARA methods in the field of occupational exposure is last but not least caused by the fact that for a number of employees the integral exposure over the total working life time has exceeded already the 400 mSv figure.

[Clinical relevance and indications for cardiac magnetic resonance imaging 2013: an interdisciplinary expert statement]

During the last years the indications of Cardiac Magnetic Resonance Imaging (CMRI) have been continuously expanded. However, the acceptance of the method by cardiologists and radiologists does not correlate with respect to the diagnostic potential. Several factors, such as expensive equipment, relatively long examination times, high technical know how and lack of remuneration, limit the application of CMRI in everyday clinical practice. Furthermore, doctors tend to apply more conventional, well established diagnostic procedures, the access to the method is still limited and there exist difficulties in the interdisciplinary collaboration. The interdisciplinary Austrian approach to Cardiac Imaging is aimed to improve the aforementioned problems and to support the implementation of CMRI in the diagnostic tree of cardiac diseases thus enabling a cost efficient management of patients in cardiology.