Effect of external beam irradiation on neointimal hyperplasia after experimental coronary artery injury

Human coronary artery restenosis after percutaneous revascularization is a response to mechanical injury. Smooth muscle cell proliferation is a major component of restenosis, resulting in obstructive neointimal hyperplasia. Because ionizing radiation inhibits cellular proliferation, this study tested in a porcine coronary injury model the hypothesis that the hyperplastic response to coronary artery injury would be attenuated by X-irradiation. Deep arterial injury was produced in 37 porcine left anterior descending coronary artery segments with overexpanded, percutaneously delivered tantalum wire coils. Three groups of pigs were irradiated with 300-kV X-rays after coil injury: Group I (n = 10), 400 cGy at 1 day; Group II (n = 10), 400 cGy at 1 day and 400 cGy at 4 days and Group III (n = 9), 800 cGy at 1 day. Eight pigs in the control group underwent identical injury but received no radiation. Treatment efficacy was histologically assessed by measuring neointimal thickness and percent area stenosis. Mean neointimal thickness in all irradiated groups was significantly higher than in the control groups and thickness was proportional to X-ray dose. X-irradiation delivered at these doses and times did not inhibit proliferative neointima. Rather, it accentuated the neointimal response to acute arterial injury and may have potentiated that injury.

Recurrence of thymoma: clinicopathological features, therapy, and prognosis

Factors influencing the recurrence or persistence of thymoma after therapy were investigated in 127 patients with thymoma, including 75 with thymoma and myasthenia gravis. The rate of recurrence or persistence was 19% (24 of 127 patients) overall, 11% (8 of 75 patients) in myasthenic thymoma, and 31% (16 of 52 patients) in nonmyasthenic thymoma. The more advanced the clinical stage, the higher the rate of recurrence or persistence. The recurrence/persistence rate for patients with the same clinical stage was higher in those with nonmyasthenic thymoma (8% in Stage I, 11% in Stage II, 36% in Stage III, and 75% in Stage IV) than in those with myasthenic thymoma (0 in Stage I, 13% in Stage II, 18% in Stage III, and 20% in Stage IV). The prognosis for patients having subtotal resection of tumor was good in myasthenic thymoma (recurrence/persistence rate, 17%) in contrast with nonmyasthenic thymoma (recurrence/persistence rate, 78%). These results suggest that nonmyasthenic thymoma is more malignant than myasthenic thymoma. Postoperative radiotherapy was effective in preventing the recurrence or persistence of thymoma after therapy.

Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months

Between 1988 and 2000, 378 cases of keloids were treated in the authors' department, and 147 keloids in 129 patients were selected for this study. Keloids that occurred at a different site in the same patient and keloids that recurred later at the same site were deemed to be different keloids. Those keloids were surgically removed, and the patients were treated postoperatively with 15-Gy electron-beam irradiation and followed for more than 18 months. The therapeutic outcomes were evaluated. Statistical analysis was performed using Fisher's exact probability test or chi-square test. Recurrence occurred in two sites on 14 earlobes (14.3 percent), in two sites on 12 necks (16.7 percent), in 22 sites on 51 anterior chest walls (43.1 percent), in 13 sites in 33 scapular regions (39.4 percent), in four sites on 15 upper limbs (26.7 percent), in four sites in 11 suprapubic regions (36.4 percent), and in one site on 11 lower limbs (9.1 percent). The overall recurrence rate was 32.7 percent. Analysis of the therapeutic outcomes showed that the recurrence rates in the sites with high stretch tension, such as the chest wall, and the scapular and suprapubic regions were statistically higher than in sites without high tension, such as the neck, earlobes, and lower limbs (41.1 percent versus 13.5 percent, p = 0.0017). The results suggested that keloid sites with a high risk of recurrence should be treated with escalated radiation doses and posttreatment self-management.

Cerebellar pilocytic astrocytoma: a treatment protocol based upon analysis of 73 cases and a review of the literature

In a retrospective study of 73 patients operated on for cerebellar pilocytic astrocytomas, results of treatment, outcome and biological behaviour of residual tumour were analysed. Complete tumour resection proven by CT or MRI scans within 1 year after surgery was achieved only in 69% of cases. In 31% of cases the surgeon's opinion on the extent of surgical resection was not borne out by the result of postoperative neuroimaging. Progression of residual tumour or tumour recurrence appeared in 19% of patients. 1 patient showed metastatic spread along the craniospinal axis, and in 1 patient malignant degeneration appeared during follow-up. Stable residual tumour or regression of residual tumour was seen in 14% of patients. Outcome after surgical treatment, which was combined with irradiation in 10 patients (14%), was favourable in 80% and unfavourable in 20% of patients. This outcome of treatment was not influenced by a second operation for progression of residual tumour or recurrent tumour. Characteristics of patients with tumour progression after the first operation did not differ from those of the whole group. There were 17 reoperations for residual or recurrent tumour, 10 of which took place within 4 years after the initial surgical treatment. Surgery-related morbidity was 15% and mortality 4%. Irradiation to residual tumour in 8 patients was followed by complete regression in 1 patient, progression in 4 patients and no changes in 1 patient. For the remaining 2 patients the effect of irradiation on the residual tumour is unknown. Factors that determine the prognosis are discussed on the basis of this retrospective analysis and the data from the literature. It is concluded that optimal treatment for a cerebellar pilocytic astrocytoma does not consist solely in surgery with the aim of total tumour removal and careful tumour handling in order to avoid spread of tumour cells and subsequent metastases and additional radiation therapy is strictly selected cases, but also in posttreatment follow-up based on direct postoperative neuroimaging, preferably by MRI. An algorithm for postoperative follow-up management is presented.

Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature

BACKGROUND

Simple excision of earlobe keloids can result in recurrence rates approaching 80%. Many modalities have been suggested to reduce the risk of recurrence postoperatively, including intralesional steroids and radiotherapy.

OBJECTIVE

In order to determine the most reliable method to prevent keloid recurrence, we have conducted the first randomized, prospective trial comparing corticosteroid injections versus radiation therapy.

RESULTS

Thirty-one keloids were treated and followed for a minimum of 12.0 months. Two of 16 keloids (12.5%) recurred after surgery and radiation therapy, while 4 of 12 (33%) recurred after surgery and steroid injections. No alteration of skin pigmentation, wound dehiscence, chronic dermatitis, or neoplastic changes was observed in any patient in either group. Although a statistically significant difference was not observed, radiotherapy appeared to be more effective than steroid injections in preventing keloid recurrence.

CONCLUSIONS

Radiotherapy is a simpler treatment modality with better patient compliance, and patients were much more likely to complete treatment than with corticosteroid injections. We believe that radiotherapy can play an important role in the prevention of earlobe keloid recurrences, and that with current techniques, complications can be minimized. Further randomized study with additional patients is needed to compare the effectiveness of corticosteroid injections and radiotherapy in preventing keloid recurrence.

Intracranial meningiomas: analysis of recurrence after surgical treatment

Recurrence of intracranial meningiomas after surgery has long been recognized, but there is still no consensus about factors responsible for recurrence. To better understand such factors, we analysed data on 276 patients with meningiomas who were treated at our institution from 1976 to 1990 (mean follow-up = 5.1 years). Effects of sex, tumour histology, tumour site, and radiotherapy on recurrence were closely studied. Using World Health Organization criteria to define malignancy, 254 of the tumours were benign and 22 were atypical or malignant. For data analysis, distinction was made between "recurrence"(i.e., reappearance of tumour after total resection) and "regrowth" (i.e., tumour enlargement after subtotal removal). Recurrence was seen in 2 of 183 benign meningiomas and in 10 of 16 malignant meningiomas. Recurrence and regrowth rates for malignant meningiomas far exceeded those for benign meningiomas (p = 0.001). Neither sex nor tumour site was associated with subsequent recurrences in patients whose tumours had been completely resected. The influence of radiotherapy was studied in terms of its effects on benign versus malignant meningiomas, whether given after complete or incomplete resection, and whether given after primary resection or on reoperation. We found that radiotherapy did not decrease "recurrence" or "regrowth" regardless of when administered, either at first resection or on recurrence. This was true for benign as well as malignant meningiomas. However, due to the small number in our series, we cannot conclude that radiotherapy has no beneficial role in the treatment of meningiomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Biologically effective doses of postoperative radiotherapy in the prevention of keloids. Dose-effect relationship

PURPOSE

To review the recurrence rates of keloids after surgical excision followed by radiotherapy, and to answer the question whether after normalization of the dose, a dose-effect relationship could be derived.

MATERIAL AND METHODS

A literature search was performed to identify studies dealing with the efficacy of various irradiation regimens for the prevention of keloids after surgery. Biologically effective doses (BEDs) of the various irradiation regimens were calculated using the linear-quadratic concept. A distinction between recurrence rates of keloids in the face and neck region and those in other parts of the body was made.

RESULTS

31 reports were identified with PubMed with the search terms keloids, surgery, radiation therapy, radiotherapy. 13 reports were excluded, because no link could be found between recurrence rate and dose, or if less than ten patients per dose group. The recurrence rate for surgery only was 50-80%. For BED values > 10 Gy the recurrence rate decreased as a function of BED. For BED values > 30 Gy the recurrence rate was < 10%. For a given dose, the recurrence rates of keloids in the sites with high stretch tension were not significantly higher than in sites without stretch tension.

CONCLUSION

The results of this study indicate that for effectively treating keloids postoperatively, a relatively high dose must be applied in a short overall treatment time. The optimal treatment probably is an irradiation scheme resulting in a BED value of at least 30 Gy. A BED value of 30 Gy can be obtained with, for instance, a single acute dose of 13 Gy, two fractions of 8 Gy or three fractions of 6 Gy, or a single dose of 27 Gy at low dose rate. The radiation treatment should be administered within 2 days after surgery.

Peripheral CD4+CD25+ TREG Cell Counts and the Response to Extracorporeal Photopheresis in Lung Transplant Recipients

Extracorporeal photopheresis (ECP) has been proposed as a possible alternative therapy for patients with bronchiolitis obliterans syndrome (BOS), with some evidence of efficacy. Although the mechanism by which ECP exerts its protective effects remains to be determined, two recent studies suggest that the modulation of transplant immune rejection may depend on the capacity to increase the number of peripheral T-regulatory (Treg) cells. We evaluated the effect of ECP treatment on the number of naturally occurring CD4(+)CD25(+) Treg cells in the peripheral blood of six lung transplant recipients: in five cases after failure of augmented or changed immunosuppression for BOS, and in one case owing to persistent acute rejection in a patient who contracted chronic hepatitis C viral infection after lung transplant. A functional stabilization was observed in three of our five patients with BOS, which was accompanied by a slight increase or stabilization of the number of peripheral blood CD4(+)CD25(high) cells with in vitro features of Treg cells. On the contrary, two patients with BOS who did not experience graft functional stabilization also showed a decline in the peripheral Treg subset. In the last patient Treg cell kinetics showed stabilization during the first 5 months of ECP treatment when lung function remained stable and graft histology normalized but showed a subsequent decrease, predating BOS diagnosis. In all, our results indicate that ECP may modulate peripheral Treg cell number but the time course of peripheral Treg cells varies according to graft function.

Low-activity (2.0 GBq; 54 mCi) radioiodine post-surgical remnant ablation in thyroid cancer: comparison between hormone withdrawal and use of rhTSH in low-risk patients

OBJECTIVE

(a) To compare the efficacy of low-activity (2 GBq; 54 mCi) (131)I ablation using l-thyroxine withdrawal or rhTSH stimulation, and (b) to assess the influence of thyroid remnants volume on the ablation rate.

DESIGN

Patients underwent neck ultrasound, (131)I neck scintigraphy and radioiodine uptake. Post-therapy whole body scan (WBS) was acquired after 4-6 days. Ablation was assessed after 6-12 months by WBS, Tg and TgAb following l-thyroxine withdrawal.

METHODS

Group A: preparation by L-T(4) withdrawal (37 days); 21 patients received (131)I (2.02+/-0.22 GBq; 54.6+/-5.9 mCi) and on the day of treatment, TSH, Tg, TgAb were measured; Group B: stimulation by rhTSH; 21 patients received (131)I (1.97+/-0.18 GBq; 53.2+/-4.9 mCi) 24 h after the second injection of rhTSH (0.9 mg) and TSH, Tg and TgAb were measured after 2 days.

RESULTS

At follow-up, 90.0% of patients from group A and 85.0% of patients from group B had Tg levels <1 ng/ml; no uptake was observed in 95.2% and in 90.5% of patients from group A or B respectively, with no statistical differences for both ablation criteria. Before (131)I treatment, small thyroid remnants (<1 ml) were detected by US in <25% of all patients.

CONCLUSIONS

The use of rhTSH for the preparation of low-risk patients to ablation therapy with low activities of (131)I (2 GBq; 54 mCi) is safe and effective and avoids hypothyroidism. The presence of thyroid remnants smaller than 1 ml at US evaluation had no effect on the ablation rate.

Three-Dimensional Conformal Radiotherapy for Localized Prostate Cancer in Kidney Transplant Recipients

BACKGROUND

This is the first report of graft function and prostate cancer control in renal transplant recipients subjected to modern conformal radiotherapy.

METHODS

Eight kidney transplant recipients were treated with three-dimensional conformal radiotherapy. All patients but one were subjected to transitory hormonal deprivation. A three-dimensional radiotherapy-planning system (Pinnacle, Philips Medical System, Bothell, WA) was used to delineate anatomic contours on pretreatment computed tomography and for dose computation. The clinical target volume encompassed the prostate and was expanded with a 10-mm wide margin in all directions to obtain the planning target volume. The irradiation technique consisted of a nine-field arrangement delivering 70 Gy in 2-Gy fractions, with 18-MV photon beams. Biochemical recurrence was defined as two consecutive increases in prostate-specific antigen (>1.5 ng/mL). Graft function was monitored by creatinine clearance. Excretory profiles were assessed by furosemide-stimulated diethylenetriaminepentaacetic acid renography. All patients were subjected to hip magnetic resonance imaging to assess for avascular hip necrosis.

RESULTS

After a mean follow-up of 28 months, two patients showed isolated biochemical recurrence and six patients remained free of recurrence. In seven patients with functional allografts, the creatinine clearance was unimpaired by treatment. However, significant obstruction of the terminal ureter was revealed in two patients by furosemide-stimulated diethylenetriaminepentaacetic acid renograms. The doses delivered to the uretero-neocystostomy were calculated to range from less than 20 Gy to more than 45 Gy depending on bladder repletion.

CONCLUSIONS

Adequate cancer control was achieved at the expense of infraclinical ureteral obstruction. The doses delivered to the uretero-neocystostomy may be reduced by having a full bladder at the time of irradiation. No avascular hip necrosis was observed.

The prevention of heterotopic bone formation following total hip arthroplasty using 600 rad in a single dose

While postoperative irradiation has been shown to lower the incidence of heterotopic ossification effectively in high-risk patients following total hip arthroplasty, patients in multiple-dose protocols continue to develop some heterotopic ossification despite therapy. Sixteen patients (17 hips) received single-dose exposure to 600 rad delivered within 3 days of total hip arthroplasty. The patients were considered at high risk for development of heterotopic ossification because of hypertrophic osteoarthritis, posttraumatic arthritis, or the presence of previously formed ectopic bone. Thirty-five percent of the patients underwent excision of preexisting ectopic bone at the time of arthroplasty. The average follow-up period was 11.8 months (range, 6-24 months). At follow-up study, all hips were classified as Brooker class O or I, compared to a 17% incidence of Brooker class II and III for previously reported multiple-dose protocols. All patients were asymptomatic at last follow-up study, and no component demonstrated subsidence or radiolucent lines indicative of loosening. The authors conclude that low-dose, single-fraction radiotherapy is more cost-effective and convenient and as efficacious as current multiple-dose regimens.

Breast conservation therapy after augmentation mammaplasty: is it appropriate?

Breast conservation therapy, consisting of lumpectomy, axillary node dissection, whole-breast irradiation, and a boost to the tumor bed, is an increasingly popular option for the treatment of breast cancer. Among patients with stage I and stage II disease, breast conservation therapy yields survival rates equivalent to those for mastectomy. The cosmetic results of radiotherapy are usually good, and this approach preserves an intact, sensate breast. Most studies on breast conservation therapy, however, have been performed in nonaugmented patients. Relatively little has been published regarding breast conservation therapy in the presence of silicone implants. Between 1981 and 1994, we treated 33 augmented patients with breast conservation therapy. Among 26 individuals for whom complete follow-up data were available, 17 (65 percent) developed significant capsular contracture on the irradiated side. Thus far 8 patients with radiation-induced contracture have undergone corrective surgery. In our experience, augmented breast cancer patients treated with breast conservation therapy have less satisfactory cosmetic results than nonaugmented women. In addition, mammographic follow-up, critical for identifying local recurrence, may be impaired by the presence of an implant and capsular contracture. On the basis of these considerations, breast conservation therapy may be less than optimal in augmented cancer patients unless explantation is performed before treatment.

Efficacy of total lymphoid irradiation for chronic allograft rejection following bilateral lung transplantation

PURPOSE

To assess the safety and efficacy of total lymphoid irradiation (TLI) in patients experiencing chronic rejection following bilateral lung transplantation (BLT).

PATIENTS AND MATERIALS

Eleven patients received TLI for chronic allograft rejection (bronchiolitis obliterans syndrome) refractory to conventional treatment modalities. Radiation therapy (RT) was prescribed as 8 Gy delivered in 10 0.8-Gy fractions, 2 fractions/week, via mantle, paraaortic, and inverted-Y fields. Serial pre- and post-RT pulmonary function values, complete blood counts, and immunosuppressive augmentation requirements [use of methylprednisolone, murine anti-human mature T-cell monoclonal antibody (OKT3), polyclonal antithymocyte globulin (ATG), and tacrolimus] were monitored.

RESULTS

In the 3 months preceding TLI, the average decrease in forced expiratory volume in 1 s (FEV1) was 34% (range 0-75%) and the median number of immunosuppression augmentations was 3 (range 0-5). Only 4 of 11 patients completed all 10 TLI treatment fractions. Reasons for discontinuation included progressive pulmonary decline (four patients), worsening pulmonary infection (two patients), and persistent thrombocytopenia (one patient). Seven of the 11 patients failed within 8 weeks of treatment cessation. One patient had unabated rejection and received bilateral living related-donor transplants; he is alive and well. Six patients died. Two of these deaths were due to pulmonary infection from organisms isolated prior to the start of RT; the other four deaths were from progressive pulmonary decline. The four remaining patients had durable positive responses to TLI (mean follow-up of 47 weeks; range 24-72). Comparing the 3 months preceding RT to the 3 months following treatment, these four patients had improvements in average FEV1 (40% decline vs. 1% improvement) and fewer median number of immunosuppressive augmentations (3.5 vs. 0). None of these patients has developed lymphoproliferative disease or has died. Features suggestive of a positive response to TLI included longer interval from transplant to RT, higher FEV1 at initiation of RT, and absence of preexisting pulmonary infection.

CONCLUSION

Total lymphoid irradiation for chronic allograft rejection refractory to conventional medical management following BLT was tolerable. A subset of patients experienced durable preservation of pulmonary function and decreased immunosuppressive requirements. Patients with rapidly progressive allograft rejection, low FEV1, or preexisting infection were least likely to benefit from irradiation. Early initiation of TLI for patients experiencing chronic allograft rejection following BLT may be warranted.

Radiotherapy in the management of vaginal intraepithelial neoplasia after hysterectomy

Intravaginal radium was used to treat 11 patients who were found to have vaginal intraepithelial neoplasia (VAIN) following hysterectomy for cervical intraepithelial neoplasia. All were discovered by cytological follow-up, were colposcopically assessed and diagnosis was confirmed by histological examination before treatment. Nine of 10 patients questioned continue to enjoy satisfactory sexual intercourse after treatment but 6 of 8 premenopausal patients subsequently became oestrogen deficient and required hormone replacement therapy. No other significant morbidity has been observed. All remain cytologically and colposcopically free of disease after a median follow-up of 26 months. We conclude that radiotherapy is an effective treatment of VAIN following hysterectomy.

ERCP in infants, children, and adolescents-Different roles of the methods in different age groups

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is seldom used in children, and published series have limited numbers of pediatric patients. The aim of this retrospective observational study was to assess the efficacy and safety of pediatric ERCP in a large group of children.

METHODS

Data were evaluated from 626 children with biliopancreatic disorders admitted to University Hospital Motol, Prague, between January 1999 and January 2018. Clinical data were obtained by retrospective evaluation of our database of pediatric ERCP procedures and from clinical records.

RESULTS

We performed 856 ERCPs on 626 pediatric patients; of these procedures, 59% were therapeutic and 41% were diagnostic. We achieved 96% technical success. Indications for ERCP and pathological findings differed in different age groups. The main role of ERCP was in excluding biliary atresia in those aged less than one year. In children aged 1 to 6 years, the most frequent diagnoses were choledochal cyst followed by choledocholithiasis. In children aged 7 to 12 years and 13 to 19 years, the most frequent diagnoses were choledocholithiasis followed by pancreatic pathology. The overall complication rate found in this study was similar to rates observed in adult populations.

CONCLUSIONS

Our study shows the efficacy and safety of diagnostic and therapeutic ERCP in a large series of infants and children with technical success and complication rates comparable to those in adults. Our data show that ERCP had different roles in different age groups of children.

Optimal time for postoperative irradiation of pterygia

A prospective study of the optimal time for postoperative beta irradiation of pterygia in 54 eyes of 54 patients suggested that immediate postoperative irradiation, given as a single dose of 2000 rad, was associated with a lower rate of recurrence than a similar dose given 4 days postoperatively. The authors suggest that patients with recurrent pterygia, selected to have postoperative beta radiation, receive the radiation as a single dose of 2000 rad at the end of the surgical procedure.

Postoperative hip irradiation in prevention of heterotopic ossification: causes of treatment failure

Over 4 years, 33 patients (mean age, 52 years) underwent hip surgery followed by single-fraction 700-cGy radiation therapy (RT). Records, port films, and plain radiographs were reviewed to assign Brooker classification levels for severity of heterotopic ossification (HO) and assess the amount of new HO developing after surgery. Nineteen patients (58%) developed radiographic evidence of new HO after surgery. All five patients with three or more risk factors and none of 12 with postoperative Brooker level 0 (no radiographic HO) developed new HO. Ten of 16 treated on postoperative day 1, six of 10 on postoperative day 2, none of three on day 3, two of three on day 4, and one of one on day 5 developed new HO. New HO developed outside the irradiated volume in 11 patients. Surgeons should remove all heterotopic bone whenever possible; RT should be administered within 3 days after surgery; portals should cover all potentially involved soft tissue; and future studies should evaluate larger single fractions (900-1,000 cGy) for prevention of HO in patients with three or more risk factors and/or radiographic evidence of residual HO.

Surgical management and outcomes of petroclival meningiomas: a single-center case series of 259 patients

BACKGROUND

Surgical management of petroclival meningiomas is challenging. Various and inconsistent outcome and prognostic factors of the lesions have been evaluated previously. In the present study, the surgical outcome, philosophy, and experience of petroclival meningiomas are detailed based on a large patient series.

METHODS

A series of 259 patients with petroclival meningiomas (70 males and 189 females) were surgically treated. Clinical charts and radiographs were reviewed. Follow-up results were evaluated.

RESULTS

The preoperative Karnofsky Performance Scale (KPS) score was 74.2 ± 10.5. The mean tumor size was 4.3 ± 1.0 cm. The gross total resection (GTR) rate was 52.5%. During a mean follow-up period of 55.3 months, recurrence/progression (R/P) occurred in 11 patients. The recent KPS score was 78.4 ± 22.7, it improved in 139 (57.2%) patients and stabilized in 53 (21.8%) patients, and 201 (82.7%) patients lived independently. The risk factors affecting the KPS score included (but were not limited to) age ≥ 60, preoperative KPS ≤ 60, and brainstem edema. The adverse factors contributing to R/P-free survival included (but were not limited to) non-total resection and the absence of the subarachnoid space. The R/P-free survival rate was 94.5% at 5 years and 91.2% at 9 years. The overall survival rate was 94.7% at 5 years and 94.7% at 9 years.

CONCLUSIONS

Favorable outcomes from petroclival meningiomas could be achieved by microsurgery. Neurological function and quality of life were prioritized, and GTR was attempted. Risk factors should be considered in surgical schemes, and tumor recurrence should be aggressively monitored and treated.

The role of post-operative radiation in the prevention of heterotopic ossification in patients with post-traumatic acetabular fracture

Heterotopic ossification (HO) with subsequent pain and limitation of motion of the lower extremity is a common and significant problem for patients who suffer traumatic acetabular fracture (TAF). The incidence of heterotopic ossification is markedly increased for patients requiring surgical repair depending on the degree of trauma and the type of surgical repair necessary. Radiation therapy (RT) has proven to be the most effective surgical adjunct for the prevention of heterotopic ossification in patients undergoing total hip replacement (THR), but has not been reported in patients with traumatic fracture and repair. This report details an experience with patients treated at a Shock Trauma Center with extensile repair and immediate (within 48 hr) post-operative radiation therapy given as 5 daily fractions of 2 Gy in 5 to 7 days to a total dose of 10 Gy using megavoltage radiation therapy. A total of 30 consecutive patients (RT group) have been treated at our institution since June 1985. The last 20 patients treated with surgery only (non-RT group) prior to initiation of this study were used as a control group. Heterotopic ossification was seen to some degree in 50% of all radiation therapy patients, but was severe in only three of 30 (10%) of cases [three (10%) had Brooker III HO and no patients had ankylosis (Brooker IV HO)]. In contrast, some degree of heterotopic ossification was seen in 90% of the non-radiation therapy patients, and was severe in 10 of 20 (50%) of patients [seven (35%) had Brooker III HO whereas three (15%) had ankylosis (Brooker IV)]. This difference is significant for both total incidence and incidence of severe cases (p less than 0.01). This reduction in heterotopic ossification incidence approaches the magnitude reported for high-risk patients with total hip replacement. Even though the incidence of severe heterotopic ossification after radiation therapy for total hip replacement is approximately 5% and for traumatic acetabular fracture patients it is double (10%), the actual incidence of heterotopic ossification without radiation therapy is different in the two conditions. For total hip replacement, the incidence is about 30% and for traumatic acetabular fracture it is 50%. Radiation therapy has again proven itself to be an excellent surgical adjunct to prevent heterotopic ossification, this time in traumatic acetabular fracture patients.

Inhibition of epidural scar tissue formation after spinal surgery: external irradiation vs. spinal membrane application

PURPOSE

The scar tissue that forms after lumbar dissection is a severe complication and a cause of lumbar and radicular pain. It was recently shown that radiotherapy could inhibit peridural fibrosis after laminectomy. In this study, the efficiency of external irradiation was compared with spinal membrane application.

METHOD AND MATERIALS

Thirty male New Zealand rabbits underwent L5 laminectomy. Ten rabbits each received a single fraction of 900-cGy external irradiation administered by 9-MeV electron beam 24 h after the surgery. Ten other rabbits each had spinal membrane applied during laminectomy. The remaining 10 rabbits constituted the control group. All of the rabbits were killed 30 days after the laminectomy. Axial histologic sections through the laminectomy defect were evaluated. Each specimen was scored for the extent and density of fibrosis and arachnoidal adherence.

RESULTS

The extent and density of fibrosis and arachnoidal adherence differed significantly between the control group and the treatment groups (p < 0.05). However, the extent and density of fibrosis and arachnoidal adherence did not differ significantly between the spinal membrane and irradiation groups (p > 0.05).

CONCLUSION

This preliminary study showed that high-single-fraction/low-total-dose administered postoperatively can successfully inhibit postsurgical epidural fibrosis as effectively as applied spinal membrane.

Lymphatic Fistulas: Obliteration by Low-Dose Radiotherapy

BACKGROUND

Lymphatic drainage from the surgical wound is an uncommon but challenging complication of surgical intervention. Protracted lymphorrhea contributes to morbidity, favors infections and results in a prolonged hospital stay. Treatment options include surgical ligation and, more conservatively, leg elevation, continuous local pressure, subatmospheric pressure dressings, and low-dose radiotherapy. This study examines the efficacy of low-dose radiotherapy.

PATIENTS AND METHODS

17 patients (19 fistulas) with lymphorrhea following vena saphena harvesting (n = 7), femoropopliteal bypass (n = 3), varicose vein surgery (n = 2), hip arthroplasty (n = 3; five fistulas), shunt surgery (n = 1), and piercing (n = 1) were referred for external radiotherapy. Depending on the depth of the fistula, orthovoltage (n = 12), electrons (4-11 MeV; n = 2) or photons (8 MV; n = 3) were used. Fractions between 0.3 Gy and 2 Gy were applied; the individual total dose depended on the success of the radiotherapy, i. e., the obliteration of the lymph fistula, and varied from 1 to 12 Gy.

RESULTS

In 13 out of 17 patients complete obliteration of the fistula was achieved. Interestingly, this was achieved in nine of the ten patients irradiated with total doses of </=3 Gy and with fraction sizes ranging from 0.3 to 0.5 Gy. In one patient with hip arthroplasty, only two out of three fistulas disappeared after 12 Gy and in a further three cases no distinct benefit was observed after 2.4 Gy, 8 Gy, and 10.5 Gy, respectively. No treatment-related side effects occurred.

CONCLUSION

Radiotherapy represents an efficacious and economical treatment option in cases of persistent lymphorrhea and is able to reduce the risk of secondary infection, to decrease the duration of hospitalization, and to reduce overall costs for the individual patient. Daily scoring of treatment efficacy is recommended, because radiotherapy can be terminated as soon as lymphorrhea has stopped. Very low total doses with 0.3-0.5 Gy fraction size are recommended up to a maximum of 10-12 Gy in nonresponders.

Pterygium and beta irradiation

The results of the combined use of Beta Irradiation, topical Thio-Tepa and dexamethasone in the post-operative treatment of pterygium in 169 patients (213 eyes) are reported. The recurrence rate has been evaluated statistically only in eyes with true pterygia, and for this purpose the material has been divided into 3 groups: group 1 includes all the bilateral cases who either had both eyes treated with Beta therapy or not, group 2 includes all the unilateral cases, and group 3 is made up of the total number of eyes operated. In the group comprising the bilateral cases, the recurrence rate was 2/60 in the eyes treated with Beta rays and 4/18 in the non-treated ones (P less than 0.10). In the group comprising the unilateral cases, the recurrence rate was 8/73 in the Beta rays treated eyes and 18/41 in the non-treated ones (P less than 0.025). When the total number of eyes was considered, the recurrence rate was 10/135 in the eyes treated with Beta rays and 22/61 in the non-treated ones (P less than 0.05). The difference in the recurrence rate between the eyes submitted to Beta therapy and those not submitted is considered statistically significant.

External beam radiation therapy for bronchial stump recurrence of non-small-cell lung cancer after complete resection

BACKGROUND AND PURPOSE

External beam radiation therapy (EBRT) is occasionally used in the treatment of bronchial stump recurrences after complete surgical resection in patients with non-small-cell lung cancer (NSCLC), but no prospective study exists, so far. The objective of this review is to determine effectiveness of high-dose EBRT in this disease.

METHODS

A systematic review was undertaken using electronic databases, reference lists and hand searching of journals to identify potentially eligible studies. Selection criteria included studies that provided outcome after high-dose EBRT in this disease. Six retrospective studies were reviewed, including a total of 54 patients.

RESULTS AND CONCLUSION

High-dose EBRT appears to be an effective treatment modality for recurrent NSCLC confined to the bronchial stump after curative resection with a median survival time of approximately 30 months and 5-year survival of approximately 30%. Although small patient numbers and unclear indications for radical versus palliative EBRT may obscure the overall conclusions, among patients with intrathoracic recurrence those with bronchial stump recurrence only do better than those with non-stump recurrence. It seems there is a dose-response effect in this patient population and a predominantly local pattern of failure, both observations having an implication for future studies. The optimal dose/fractionation pattern or treatment fields must be further investigated in the future. Identification of an unfavourable subset of patients may help optimize treatment in the future by omitting high-dose, curative RT in those patients who may be best treated with palliative RT. Prospective studies on EBRT in both bronchial stump and other post-surgical recurrences are urgently needed.

Para-articular ossification in total hip replacement: an indication for irradiation therapy

The results of postoperative irradiation therapy after total hip replacement or resection of para-articular ossification in 25 patients are reported. The patients were kept under radiological observation for an average period of 26 months and clinical observation for an average period of 31 months after surgery. There were only two clinically relevant recurrences of para-articular ossification. The earlier radiotherapy with a total dose of 2000 rads (2000 cGy) was begun, the better was the effect. In this small population sample statistical significance could not be calculated. No side effects were detected.

Radiation therapy for heterotopic ossification

Heterotopic ossification is a common complication after bone and joint surgery. If the disease progresses, it may cause pain and disability, eventually defeating the purpose of surgery in the first place. Today, prophylactic treatment is indicated after surgery. Both nonsteroidal antiinflammatory drugs and radiation therapy are effective. Radiation therapy is associated with fewer side effects and is preferred. Single-dose postoperative irradiation has been found to be as effective as fractionated radiation therapy.