Ambulatory peri-bulbar implantation, revision and replacement of Artificial Urinary Sphincter in neurogenic and non-neurogenic male patients: A preliminary feasibility study over a one-year experience.

INTRODUCTION: Our goal was to determine the rate of complications, early revision and removal after full ambulatory implantation of bulbar AUS in men; secondly, to describe satisfaction and short-term continence rate. MATERIAL AND METHODS: Between April 2018 and April 2019, 28 consecutive patients underwent AUS implantation in a newly organised ambulatory setting. A prospective database of all included patients was established with comprehensive data collected on medical history, aetiology and severity of SUI, surgical procedures, postoperative complications and patient satisfaction. RESULTS: Twenty-eight patients were included (30 consecutive procedures: 22 primary AUS placement, 6 complete revisions, 2 partial revisions), with a mean follow up of 223±220.5 days. Fourteen patients had prior radiotherapy. Readmission rate was 6.7% in the first 30 days after surgery. Both revision and removal rates were 6.7%. Complications were reported in 26.7% of procedures, mainly Clavien-Dindo I. Patient satisfaction of ambulatory surgery organisation and experience was high (87/5% satisfied or very satisfied). Full continence & social continence were achieved for, respectively, 55.6% and 88.9% of procedures. CONCLUSION: Ambulatory placement of AUS is safe and can be performed successfully. Larger patient cohorts and randomised trials are crucial to improve knowledge on non-indications for full ambulatory AUS implantation in men.

Breast dosimetry in alternative X-ray-based imaging modalities used in current clinical practices.

In X-ray breast imaging, Digital Mammography (DM) and Digital Breast Tomosynthesis (DBT), are the standard and largely used techniques, both for diagnostic and screening purposes. Other techniques, such as dedicated Breast Computed Tomography (BCT) and Contrast Enhanced Mammography (CEM) have been developed as an alternative or a complementary technique to the established ones. The performance of these imaging techniques is being continuously assessed to improve the image quality and to reduce the radiation dose. These imaging modalities are predominantly used in the diagnostic setting to resolve incomplete or indeterminate findings detected with conventional screening examinations and could potentially be used either as an adjunct or as a primary screening tool in select populations, such as for women with dense breasts. The aim of this review is to describe the radiation dosimetry for these imaging techniques, and to compare the mean glandular dose with standard breast imaging modalities, such as DM and DBT.

X-ray dosimetry in breast cancer screening: 2D and 3D mammography.

According to the World Health Organization (WHO), at the end of 2020, 7.8 million women alive were diagnosed with breast cancer in the past 5 years, making it the world's most prevalent cancer. It is largely recognized and demonstrated that early detection represents the first strategy to follow in the fight against cancer. The effectiveness of mammography screening for early breast cancer detection has been proven in several surveys and studies over the last three decades. The estimation of the Mean Glandular Dose (MGD) is important to understand the radiation-associated risk from breast x-ray imaging exams. It continues to be the subject of numerous studies and debates, since its accuracy is directly related to risk estimation and for optimizing breast cancer screening programs. This manuscript reviews the main dosimetry formalisms used to estimate the MGD in mammography and to understand the continuing efforts to reduce the absorbed dose over the last forty years. The dosimetry protocols were formulated initially for mammography. Digital breast tomosynthesis (DBT) either in conjunction with synthesized digital mammogram (SDM) or with digital mammography (DM), is routinely used in many breast cancer screening programs and consequently the dosimetry protocols were extended for these techniques.

Assessment of the uterine dose in digital mammography and digital breast tomosynthesis.

INTRODUCTION: Digital Mammography (DM-2D) and more recently Digital Breast Tomosynthesis (DBT), are two of the most effective imaging modalities for breast cancer detection, often used in screening programmes. It may happen that exams using these two imaging modalities are inadvertently performed to pregnant women. The objective of this study is to assess the dose in the uterus due to DM-2D and DBT exams, according to two main irradiation scenarios: in the 1st scenario the exposure parameters were pre-selected directly by the imaging system, while in the 2nd scenario, the maximum exposure parameters were chosen. METHODS: The mammography equipment used was a Siemens Mammomat Inspiration. A physical anthropomorphic phantom, PMMA plates (simulating a breast thickness of 6 cm) and thermoluminescent dosimeters (TLDs) were used to measure entrance air kerma values on the phantom's breast and abdomen in order to successively estimate the mean glandular dose (MGD) and the dose in the uterus. For the two irradiation scenarios chosen, two-breast imaging modalities were selected: 1) DBT in Cranio-Caudal (CC) view (with 28 kV and 160 mAs as exposure parameters), 2) DBT and DM in Medio Lateral-Oblique (MLO) and CC views (with 34 kV and 250 mAs as exposure parameters). RESULTS: In the 1st scenario, the TLD measurements did not detect significant dose values in the abdomen whereas the MGD estimated using the D.R. Dance model was in close agreement with data available in the literature. In the 2nd scenario, there was no significant difference in MGD estimation between the different views, whereas the air kerma values in the abdomen (in DBT mode, CC and MLO) were 0.049 mGy and 0.004 mGy respectively. In CC DM-2D mode the abdomen air kerma value was 0.026 mGy, with no significant detected value in MLO view. CONCLUSIONS: For the dose in the uterus, the obtained values seem to indicate that DM-2D and DBT examinations inadvertently performed during pregnancy do not pose a significant radiological risk, even considering the case of overexposure in both breasts. IMPLICATIONS FOR PRACTICE: The accurate knowledge of the doses in DM-2D and DBT will contribute to raise the awareness among medical practitioners involved in breast imaging empowering them to provide accurate information about dose levels in the uterus, improving their radiation risk communication skills and consequently helping to reduce the anxiety of pregnant women undergoing this type of examinations.

Intercomparison of Monte Carlo calculated dose enhancement ratios for gold nanoparticles irradiated by X-rays: Assessing the uncertainty and correct methodology for extended beams.

Results of a Monte Carlo code intercomparison exercise for simulations of the dose enhancement from a gold nanoparticle (GNP) irradiated by X-rays have been recently reported. To highlight potential differences between codes, the dose enhancement ratios (DERs) were shown for the narrow-beam geometry used in the simulations, which leads to values significantly higher than unity over distances in the order of several tens of micrometers from the GNP surface. As it has come to our attention that the figures in our paper have given rise to misinterpretation as showing 'the' DERs of GNPs under diagnostic X-ray irradiation, this article presents estimates of the DERs that would have been obtained with realistic radiation field extensions and presence of secondary particle equilibrium (SPE). These DER values are much smaller than those for a narrow-beam irradiation shown in our paper, and significant dose enhancement is only found within a few hundred nanometers around the GNP. The approach used to obtain these estimates required the development of a methodology to identify and, where possible, correct results from simulations whose implementation deviated from the initial exercise definition. Based on this methodology, literature on Monte Carlo simulated DERs has been critically assessed.

Consistency checks of results from a Monte Carlo code intercomparison for emitted electron spectra and energy deposition around a single gold nanoparticle irradiated by X-rays.

Organized by the European Radiation Dosimetry Group (EURADOS), a Monte Carlo code intercomparison exercise was conducted where participants simulated the emitted electron spectra and energy deposition around a single gold nanoparticle (GNP) irradiated by X-rays. In the exercise, the participants scored energy imparted in concentric spherical shells around a spherical volume filled with gold or water as well as the spectral distribution of electrons leaving the GNP. Initially, only the ratio of energy deposition with and without GNP was to be reported. During the evaluation of the exercise, however, the data for energy deposition in the presence and absence of the GNP were also requested. A GNP size of 50 nm and 100 nm diameter was considered as well as two different X-ray spectra (50 kVp and 100kVp). This introduced a redundancy that can be used to cross-validate the internal consistency of the simulation results. In this work, evaluation of the reported results is presented in terms of integral quantities that can be benchmarked against values obtained from physical properties of the radiation spectra and materials involved. The impact of different interaction cross-section datasets and their implementation in the different Monte Carlo codes is also discussed.

Intercomparison of dose enhancement ratio and secondary electron spectra for gold nanoparticles irradiated by X-rays calculated using multiple Monte Carlo simulation codes.

PURPOSE: Targeted radiation therapy has seen an increased interest in the past decade. In vitro and in vivo experiments showed enhanced radiation doses due to gold nanoparticles (GNPs) to tumors in mice and demonstrated a high potential for clinical application. However, finding a functionalized molecular formulation for actively targeting GNPs in tumor cells is challenging. Furthermore, the enhanced energy deposition by secondary electrons around GNPs, particularly by short-ranged Auger electrons is difficult to measure. Computational models, such as Monte Carlo (MC) radiation transport codes, have been used to estimate the physical quantities and effects of GNPs. However, as these codes differ from one to another, the reliability of physical and dosimetric quantities needs to be established at cellular and molecular levels, so that the subsequent biological effects can be assessed quantitatively. METHODS: In this work, irradiation of single GNPs of 50 nm and 100 nm diameter by X-ray spectra generated by 50 and 100 peak kilovoltages was simulated for a defined geometry setup, by applying multiple MC codes in the EURADOS framework. RESULTS: The mean dose enhancement ratio of the first 10 nm-thick water shell around a 100 nm GNP ranges from 400 for 100 kVp X-rays to 600 for 50 kVp X-rays with large uncertainty factors up to 2.3. CONCLUSIONS: It is concluded that the absolute dose enhancement effects have large uncertainties and need an inter-code intercomparison for a high quality assurance; relative properties may be a better measure until more experimental data is available to constrain the models.

Monte Carlo dose distribution calculation at nuclear level for Auger-emitting radionuclide energies.

The distribution of radiopharmaceuticals in tumor cells represents a fundamental aspect for a successful molecular targeted radiotherapy. It was largely demonstrated at microscopic level that only a fraction of cells in tumoral tissues incorporate the radiolabel. In addition, the distribution of the radionuclides at sub-cellular level, namely inside each nucleus, should also be investigated for accurate dosimetry estimation. The most used method to perform cellular dosimetry is the MIRD one, where S-values are able to estimate cellular absorbed doses for several electron energies, nucleus diameters, and considering homogeneous source distributions. However the radionuclide distribution inside nuclei can be also highly non-homogeneous. The aim of this study is to show in what extent a non-accurate cellular dosimetry could lead to misinterpretations of surviving cell fraction vs dose relationship; in this context, a dosimetric case study with 99mTc is also presented. METHODS: The state-of-art MCNP6 Monte Carlo simulation was used in order to model cell structures both in MIRD geometry (MG) and MIRD modified geometries (MMG), where also entire mitotic chromosome volumes were considered (each structure was modeled as liquid water material). In order to simulate a wide energy range of Auger emitting radionuclides, four mono energetic electron emissions were considered, namely 213eV, 6keV, 11keV and 20keV. A dosimetric calculation for 99mTc undergoing inhomogeneous nuclear internalization was also performed. RESULTS: After a successful validation step between MIRD and our computed S-values for three Auger-emitting radionuclides (99mTc, 125I and 64Cu), absorbed dose results showed that the standard MG could differ from the MMG from one to three orders of magnitude. These results were also confirmed by considering the 99mTc spectrum emission (Auger and internal conversion electrons). Moreover, considering an inhomogeneous radionuclide distribution, the average electron energy that maximizes the absorbed dose was found to be different for MG and MMG. CONCLUSIONS: The modeling of realistic radionuclide localization inside cells, including a inhomogeneous nuclear distribution, revealed that i) a strong bias in surviving cell fraction vs dose relationships (taking to different radiobiological models) can arise; ii) the alternative models might contribute to a more accurate prediction of the radiobiological effects inherent to more specific molecular targeted radiotherapy strategies.

Cancer risk estimation in Digital Breast Tomosynthesis using GEANT4 Monte Carlo simulations and voxel phantoms.

The aim of this work was to estimate the risk of radiation induced cancer following the Portuguese breast screening recommendations for Digital Mammography (DM) when applied to Digital Breast Tomosynthesis (DBT) and to evaluate how the risk to induce cancer could influence the energy used in breast diagnostic exams. The organ doses were calculated by Monte Carlo simulations using a female voxel phantom and considering the acquisition of 25 projection images. Single organ cancer incidence risks were calculated in order to assess the total effective radiation induced cancer risk. The screening strategy techniques considered were: DBT in Cranio-Caudal (CC) view and two-view DM (CC and Mediolateral Oblique (MLO)). The risk of cancer incidence following the Portuguese screening guidelines (screening every two years in the age range of 50-80years) was calculated by assuming a single CC DBT acquisition view as standalone screening strategy and compared with two-view DM. The difference in the total effective risk between DBT and DM is quite low. Nevertheless in DBT an increase of risk for the lung is observed with respect to DM. The lung is also the organ that is mainly affected when non-optimal beam energy (in terms of image quality and absorbed dose) is used instead of an optimal one. The use of non-optimal energies could increase the risk of lung cancer incidence by a factor of about 2.

Paediatric CT exposures: comparison between CTDI vol and SSDE methods using measurements and Monte Carlo simulations.

Computed tomography (CT) is one of the most used techniques in medical diagnosis, and its use has become one of the main sources of exposure of the population to ionising radiation. This work concentrates on the paediatric patients, since children exhibit higher radiosensitivity than adults. Nowadays, patient doses are estimated through two standard CT dose index (CTDI) phantoms as a reference to calculate CTDI volume (CTDI vol) values. This study aims at improving the knowledge about the radiation exposure to children and to better assess the accuracy of the CTDI vol method. The effectiveness of the CTDI vol method for patient dose estimation was then investigated through a sensitive study, taking into account the doses obtained by three methods: CTDI vol measured, CTDI vol values simulated with Monte Carlo (MC) code MCNPX and the recent proposed method Size-Specific Dose Estimate (SSDE). In order to assess organ doses, MC simulations were executed with paediatric voxel phantoms.

Determination of backscatter factors in breast tomosynthesis using MCNPX simulations and measurements.

The perspective of adding digital breast tomosynthesis (DBT) to standard mammography in screening raises concerns regarding the dose absorbed by the fibroglandular breast tissue. Thus, it is important to estimate accurately the mean glandular dose (MGD), although there are no standard protocols for dosimetry, concerning DBT. This study aims at introducing backscatter factors (BSF) to calculate the entrance surface air kerma (ESAK), directly on patients or phantoms, in order to be introduced in the formalism proposed by Dance et al. MCNPX simulations were performed, to mimic a DBT acquisition, for a wide range of X-ray spectra. A homogeneous breast phantom with 50 % of glandular tissue was considered and several thicknesses were evaluated. Dose measurements were performed, to validate and support the simulation results. The BSF may indicate a real MGD estimation in vivo for DBT examinations and contribute for the improvement of the current guidelines used in these applications.

Effect of the glandular composition on digital breast tomosynthesis image quality and dose optimisation.

In the image quality assessment for digital breast tomosynthesis (DBT), a breast phantom with an average percentage of 50 % glandular tissue is seldom used, which may not be representative of the breast tissue composition of the women undergoing such examination. This work aims at studying the effect of the glandular composition of the breast on the image quality taking into consideration different sizes of lesions. Monte Carlo simulations were performed using the state-of-the-art computer program PENELOPE to validate the image acquisition system of the DBT equipment as well as to calculate the mean glandular dose for each projection image and for different breast compositions. The integrated PENELOPE imaging tool (PenEasy) was used to calculate, in mammography, for each clinical detection task the X-ray energy that maximises the figure of merit. All the 2D cranial-caudal projections for DBT were simulated and then underwent the reconstruction process applying the Simultaneous Algebraic Reconstruction Technique. Finally, through signal-to-noise ratio analysis, the image quality in DBT was assessed.

Evaluation of the radiation field and shielding assessment of the experimental area of HIE-ISOLDE.

The ISOLDE facility at CERN is one of the first facilities in the world dedicated to the production of the radioactive ion beams (RIB) and during all its working time underwent several upgrades. The goal of the latest proposed upgrade, 'The High Intensity and Energy ISOLDE' (HIE-ISOLDE), is to provide a higher performance facility in order to approximate it to the level of the next generation ISOL facilities, like EURISOL. The HIE-ISOLDE aims to improve significantly the quality of the produced RIB and for this reason the increasing of the primary beam power is one of the main objectives of the project. An increase in the nominal beam current (from 2 to 6 µA proton beam intensity) and energy (from 1.4 GeV to 2 GeV) of the primary proton beam will be possible due to the upgrade of CERN's accelerator infrastructure. The current upgrade means reassessment of the radiation protection and the radiation safety of the facility. However, an evaluation of the existing shielding configuration and access restrictions to the experimental and supply areas must be carried out. Monte Carlo calculations were performed in order to evaluate the radiation protection of the facility as well as radiation shielding assessment and design. The FLUKA-Monte Carlo code was used in this study to calculate the ambient dose rate distribution and particle fluxes in the most important areas, such as the experimental hall of the facility. The results indicate a significant increase in the ambient dose equivalent rate in some areas of the experimental hall when an upgrade configuration of the primary proton beam is considered. Special attention is required for the shielding of the target area once it is the main and very intensive radiation source, especially under the upgrade conditions. In this study, the access points to the beam extraction and beam maintenance areas, such as the mass separator rooms and the high voltage room, are identified as the most sensitive for the experimental hall from the radiation protection point of view.

Optimal photon energy comparison between digital breast tomosynthesis and mammography: a case study.

A comparison, in terms of the optimal energy that maximizes the image quality between digital breast tomosynthesis (DBT) and digital mammography (DM) was performed in a MAMMOMAT Inspiration system (Siemens) based on amorphous selenium flat panel detector. In this paper we measured the image quality by the signal difference-to-noise ratio (SDNR), and the patient risk by the mean glandular dose (MGD). Using these quantities we compared the optimal voltage that maximizes the image quality both in breast tomosynthesis and standard mammography acquisition mode. The comparison for the two acquisition modes was performed for a W/Rh anode filter combinations by using a 4.5 cm tissue equivalent mammography phantom. Moreover, in order to check if the used equipment was quantum noise limited, the relation of the relative noise with respect to the detector dose was evaluated. Results showed that in the tomosynthesis acquisition mode the optimal voltage is 28 kV, whereas in standard mammography the optimal voltage is 30 kV. The automatic exposure control (AEC) of the system selects 28 kV as optimal voltage both for DBT and DM. Monte Carlo simulations showed a qualitative agreement with the AEC selection system, since an optimal monochromatic energy of 20 keV was found both for DBT and DM. Moreover, the check about the noise showed that the system is not completely quantum noise limited, and this issue could explain the experimental slight difference in terms of optimal voltage between DBT and DM. According to these results, the use of higher voltage settings is not justified for the improvement of the image quality during a DBT examination.

Radiation protection, radiation safety and radiation shielding assessment of HIE-ISOLDE.

The high intensity and energy ISOLDE (HIE-ISOLDE) project is an upgrade to the existing ISOLDE facility at CERN. The foreseen increase in the nominal intensity and the energy of the primary proton beam of the existing ISOLDE facility aims at increasing the intensity of the produced radioactive ion beams (RIBs). The currently existing ISOLDE facility uses the proton beam from the proton-synchrotron booster with an energy of 1.4 GeV and an intensity up to 2 µA. After upgrade (final stage), the HIE-ISOLDE facility is supposed to run at an energy up to 2 GeV and an intensity up to 4 µA. The foreseen upgrade imposes constrains, from the radiation protection and the radiation safety point of view, to the existing experimental and supply areas. Taking into account the upgraded energy and intensity of the primary proton beam, a new assessment of the radiation protection and radiation safety of the HIE-ISOLDE facility is necessary. Special attention must be devoted to the shielding assessment of the beam dumps and of the experimental areas. In this work the state-of-the-art Monte Carlo particle transport simulation program FLUKA was used to perform the computation of the ambient dose equivalent rate distribution and of the particle fluxes in the projected HIE-ISOLDE facility (taking into account the upgrade nominal primary proton beam energy and intensity) and the shielding assessment of the facility, with the aim of identifying in the existing facility (ISOLDE) the critical areas and locations where new or reinforced shielding may be necessary. The consequences of the upgraded proton beam parameters on the operational radiation protection of the facility were studied.

[Encapsulated implantable venous access device: two clinical cases]. / Cathéter à chambre implantable inextirpable: à propos de deux cas cliniques.

We report two cases of encapsulated indwelling central venous catheter in adults. The patients involved were treated by chemotherapy and their catheter had been implanted for 15 and 6 years. However, this complication is well-known in children and a similar problem is frequently observed with pacemaker leads removal. The difficulty to remove the device is due to fibrous encapsulation of indwelling catheters in the vein wall. In all cases reported, the catheter was left in place. The potential main complications not yet observed are infection of the catheter and venous thrombosis.

[Using a pleural implantable access system for the management of malignant pleural effusions. Experience of Institut Curie]. / Utilisation du cathéter à chambre implantable pleural dans la gestion des pleurésies malignes. Expérience de l'Institut Curie.

PURPOSE: Malignant pleural effusion has a very poor prognosis, raises problems of medical management and impairs quality of life. The authors report the first experience of a pleural implantable access system for the treatment of recurrent symptomatic malignant pleural effusion. DESCRIPTION: Prospective follow-up of 26 patients between 20/8/2005 and 2/11/2006 in a single center. Thirty pleural implantable access systems were placed in 26 patients (22 patients with breast cancers, 3 bilateral placements and one case of replacement) under sedation following the decision of a multidisciplinary meeting. EVALUATION: Twenty-five patients obtained partial or complete relief of their dyspnea. Four patients underwent spontaneous pleurodesis after a maximum of 2 months. Twelve patients were receiving chemotherapy at the time of placement. The number of aspirations performed varied between 1 and 28 over a period of 11 to 330 days. Eight patients died within 1 month after placement of the system and 6 survived more than 6 months. Seven patients died at Institut Curie or in a palliative care unit without returning home. The other 16 patients presented a total of 198 days of hospitalization for 2,305 days of catheter implantation. No placement failures were observed in this series. Two infectious complications (infectious pleuro-pneumonia and skin infection over the puncture site) and two mechanical complications (expulsion of the port and disconnection between the port and the catheter) were observed and easily treated. One patient developed loculation of the pleural cavity after 16 thoracenteses making further thoracentesis ineffective. CONCLUSIONS: The pleural implantable access system is an interesting alternative in terms of efficacy and safety for the outpatient management of malignant pleural effusion. It shows a number of advantages in terms of comfort and infectious risk compared to tunneled pleural catheters.

Monitoring of Staphylococcus xylosus DSM 20266 added as starter during fermentation and ripening of soppressata molisana, a typical Italian sausage.

AIMS: "Soppressata molisana", a fermented sausage produced in southern Italy, is commonly obtained without starter addition. However, the use of starter cultures is more and more recommended in meat fermentation processes in order to guarantee stable production performance. In this study, the survival of the Staphylococcus xylosus DSM 20266 was evaluated during the ripening of "soppressata molisana" fermented sausage. METHODS AND RESULTS: The fastest method of RAPD-PCR was employed for discrimination of the added strain from those naturally present during the ripening of the "soppressata molisana". The results obtained were confirmed by analysis of the DNA macrorestriction profile by PFGE. The electrophoretic pattern of bacterial total proteins was also studied, but clear differences between the different strains could not be detected. CONCLUSIONS: The RAPD technique was a valid tool for monitoring Staph. xylosus DSM 20266 in "sopressata molisana". SIGNIFICANCE AND IMPACT OF THE STUDY: This study highlights the possibility of monitoring the presence of Staph. xylosus strains during the ripening of fermented sausages by a reliable and repeatable technique such as RAPD.