Stereotactic ablative radiotherapy after concomitant chemoradiotherapy in non-small cell lung cancer: A TITE-CRM phase 1 trial.

BACKGROUND AND PURPOSE: Platinum based chemoradiotherapy is the standard of care for inoperable non-small cell lung cancer (NSCLC). With evidence that NSCLC can have a dose dependent response with stereotactic ablative radiotherapy (SABR), we hypothesize that a SABR boost on residual tumor treated with chemoradiotherapy could increase treatment efficacy. The purpose of this study was to determine feasibility of such an approach. MATERIAL AND METHODS: A prospective phase I trial was performed including 26 patients. Time-to-event continual reassessment method (TITE-CRM) was used for dose escalation which ranged from 3 × 7 to 3 × 12 Gy for the stereotactic boost, after 46 Gy (2 Gy per day) of chemoradiotherapy. RESULTS: Median follow-up was of 37.1 months (1.7-60.7), and 3, 4, 3, 3, 9 and 4 patients were included at the dose levels 1, 2, 3, 4, 5 and 6, respectively. During chemoradiotherapy, 9 patients experienced grade 3 toxicity. After stereotactic radiotherapy, 1 patient experienced an esophageal fistula (with local relapse) at the 3 × 11 Gy level, and 1 patient died from hemoptysis at the 3 × 12 Gy level. The 2-year rate of local control, locoregional free survival, metastasis-free survival, and overall survival was 70.3%, 55.5%, 44.5% and 50.8%, respectively. CONCLUSION: In the treatment of NSCLC with chemoradiotherapy followed by a stereotactic boost, the safe recommended dose in our protocol was a boost dose of 3 × 11 Gy.

Radiosensitivity of Colon and Rectal Lung Oligometastasis Treated With Stereotactic Ablative Radiotherapy.

INTRODUCTION: Patients with metastatic colorectal cancer (CRC) may present with oligometastatic lung lesions for which stereotactic ablative radiotherapy (SABR) can be utilized. This study aims to report efficacy and prognostic factors associated with colorectal lung metastases treated with SABR. MATERIAL AND METHODS: This is a retrospective study including patients who presented with lung oligometastasis from CRC treated with SABR from September 2007 to November 2014. RESULTS: We identified 53 oligometastatic patients with 87 lung lesions. The median prescription dose was 60 Gy in 3 fractions (median biological effective dose of 180 Gy). The median follow up was 33 months. The 1- and 2-year local control, metastasis-free survival, and overall survival were 79.8% and 78.2%, 29.2% and 16.2%, and 83.8% and 69.3%, respectively. On multivariate analysis, rectal primary site (P = .001) and > 2 metastases (P = .02) were significantly associated with a lower local control rate. Rectal lesions were associated with higher radiation dose (169.3 Gy vs. 153.3 Gy; P = .01) and higher rate of KRAS mutations (73.3% vs. 40.4%; P = .02). KRAS mutation did not predict for local control, but predicted for a 1-year metastasis-free survival detriment (0% vs. 37.5%; P = .04), when compared with KRAS wild-type. On multivariate analysis, there is an overall survival detriment associated with gross tumor volume ≥ 3266 mm3 (P = .03) and > 2 metastases (P = .04). CONCLUSION: In CRC, oligometastatic lung lesions treated with SABR had a worse outcome in patients presenting with a rectal primary, > 2 metastases, or treated with a larger gross tumor volume. More aggressive treatment may be considered in this subset of patients to improve outcome.

Major efficacy of trabectedin in 2 metastatic osteosarcoma patients with wild-type Asp1104 ERCC5 tumor status.

BACKGROUND: Treatment of osteosarcoma of the extremities consists of surgical resection preceded and followed by chemotherapy, including high-dose methotrexate or adriamycin-based protocols. When distant relapse occurs, therapeutic options are scarce. Trabectedin, a DNA-binding agent, is indicated for the treatment of patients with advanced soft tissue sarcomas after failure of anthracyclines and ifosfamide. In this indication, the 6-month progression-free survival is about 35-40%. Recent reports showed that some specific single nucleotide polymorphisms (SNPs) from DNA repair genes could be associated with sensitivity to trabectedin in soft tissue sarcomas. CASE REPORTS: We report our experience of 2 metastatic, heavily pre-treated osteosarcoma patients who were treated with trabectedin. Pyrosequencing analyses of tumors from both patients for several SNPs of the ERCC1, ERCC5 and BRAC1 genes were performed. Both patients showed major response to trabectedin, which was interestingly related with homozygoty of the common guanine allele of ERCC5 (G/G genotype; Asp/Asp) after pyrosenquencing analysis of tumors from both patients. This polymorphism was previously shown to be associated with better outcome in soft tissue sarcoma patients treated with trabectedin. CONCLUSION: Homozygoty for the wild-type Asp1104 SNP of the ERCC5 gene was found in 2 cases of relapsed osteosarcoma, who responded to trabectedin.

Inhalation study of polymethyl methacrylate following radiologist exposure during percutaneous vertebroplasty.

OBJECTIVE: To assess the atmospheric concentrations of methyl methacrylate (MMA) vapors during percutaneous vertebroplasty for the interventional radiologist and the other operating room staff. MATERIALS AND METHODS: During percutaneous vertebroplasty, a polymethyl methacrylate (PMMA) mixture (about 20 mL) was prepared with a mixing system in a normally ventilated room. Atmospheric concentrations of MMA vapors were measured by a gas absorbent badge for individual exposure (GABIE) passive sampler attached to the surgical gowns of the interventional radiologist and the other operating room staff over a period of 460 min. Active sampling was performed over 15 min with an individual pump placed near the breathing zone of the radiologist. MMA vapor concentrations were then measured using gas chromatography and activated charcoal tubes. RESULTS: Mean MMA vapor concentrations measured by the GABIEs over the period of 460 min were 0.51 parts per million (ppm) for the radiologist and 0.22 ppm for the other operating room staff. The emission peaks measured by using charcoal tubes over 15 min were 3.7 ppm. CONCLUSION: MMA vapor concentrations during percutaneous vertebroplasty were well below the recommended maximum exposure of 100 ppm over the course of an 8-h workday.

Percutaneous discectomy on lumbar radiculopathy related to disk herniation: why under CT guidance? An open study of 100 consecutive patients.

The primary objective of this study conducted on 100 patients is to demonstrate that performing CT-guided percutaneous discectomy for herniated disks results in a significant improvement in pain symptoms at several times (D1, D2, D7, 1 month, 3 months, 6 months). This objective assesses the effectiveness and feasibility of this technique under CT guidance in patients presenting documented lower back pain related to disk herniation that has not improved with appropriate medical treatment. The impact of various factors on the effectiveness of discectomy will also be evaluated. At 1 week, we notes a decrease in average VAS respectively of 71% and 67% in patients treated for posterolateral and foraminal herniated disks; the result for posteromedian herniated disks is only 45% in average decrease. At 6 months post op, 79% of lateralized herniated disks have a satisfactory result (≥ 70% decrease in pain as compared to initial pain), whereas post median herniated disks had a satisfactory result in only 50% of cases. Percutaneous fine needle discectomy probe under combined CT and fluoroscopic guidance is a minimally invasive spine surgery which should be considered as an alternative to surgery. This technique presents several advantages: the small diameter of the probe used (maximum 16 G or 1.5mm) allows a cutaneous incision of only a few millimeters, and a trans-canal approach can be possible; it also decreases the risk of ligamentary lesion and does not cause an osseous lesion of the posterior arc or of the adjacent muscular structures.

[Erdheim-Chester disease: radiological findings]. / Maladie d'Erdheim-Chester: apport de l'imagerie.

CONTEXT: Erdheim-Chester disease is a rare non-Langerhans form of histiocytosis. For the past years, the disease has been reported with an increasing frequency, linked to a better knowledge of it's radiological pattern. Indead, it shows specific imaging appearances, that should be recognized. METHODS: We report four cases illustrating those typical imaging findings. RESULTS: Common X-rays films show bilateral and symmetric heterogeneous osteosclerosis of the metaphysis and the diaphysis in the lower limbs long bones, with paget's disease-like pattern. Magnetic resonance imaging depicts a replacement of the normal fatty bone marrow by a heterogeneous high intensity signal infiltrate on T1 fat-suppressed weighted imaging with intravenous injection of gadolinium and T2 fat-suppressed weighted sequences, sparing the subchondral bone. Bone scintigraphy reveals a pathognomonic bilateral and symmetric increased uptake affecting both diaphysis and metaphysis of the femur and the tibiae. Tomodensitometry enable to disclose visceral and vascular involvement, showing typical "hairy kidney" appearance and perivascular infiltration. CONCLUSION: Erdheim-Chester disease may be a life-threatening disease. A good knowledge of it specific imaging features seems to be crucial for early management and improved prognosis.

Dual guidance (CT and fluoroscopy) vertebroplasty: radiation dose to radiologists. How much and where?

OBJECTIVE: The goal of this study was to evaluate the radiation received by the practitioner when performing percutaneous vertebroplasty guided by CT and fluoroscopy for specific anatomical sites: orbits, hands, ankles, and thorax (under lead-lined apron). MATERIALS AND METHODS: Twenty-four vertebroplasties were performed on 18 patients. RESULTS: The anatomical site that was most exposed to radiation was the right hand (0.37 mSv on average). This study demonstrates a significant correlation between the irradiation dose and fluoroscopy duration, reflecting both the quantity of primary-beam radiation and backscattered radiation. The right hand (P = 0.03), left hand (P = 0.02), and the left orbit (P < 0.0001) are the anatomical zones that are the most affected by the combination of these two types of radiation, with cumulative irradiation doses of 0.45, 0.2, and 0.14 mSv, respectively. There was a significant correlation between the patient weight and radiation of the left hand (P = 0.03), the left orbit (P = 0.03), and the thorax (P = 0.02), confirming the major influence of backscattered radiation. CONCLUSIONS: The most irradiated anatomical sites limiting the number of interventions are the left orbit and the right hand.