Safety of thoracic radiotherapy in patients with prior immune-related adverse events from immune checkpoint inhibitors.

BACKGROUND: Immune checkpoint inhibitors (ICIs) and thoracic radiotherapy are increasingly used to treat advanced cancers. Despite data indicating exaggerated radiation toxicities in patients with autoimmune disease, the safety of thoracic radiotherapy in patients with prior ICI-associated immune-related adverse events (irAEs) is undefined. PATIENTS AND METHODS: Patients treated from 2014 to 2020 with ICIs were queried for receipt of corticosteroids and radiotherapy. Patients who received thoracic radiation after symptomatic irAEs were assessed for ≥grade 2 radiation pneumonitis (RP). Characteristics predictive of RP were assessed using logistic regression and response relationships were modeled. RESULTS: Among 496 assessed patients, 41 with irAE history subsequently treated with thoracic radiotherapy were analyzed. Most irAEs were grade 2 (n = 21) and 3 (n = 19). Median time from irAE onset to radiotherapy was 8.1 months. Most patients received stereotactic body radiation therapy (n = 20) or hypofractionated radiotherapy (n = 18). In total, 25 patients (61%) developed ≥grade 2 RP at a median of 4 months from radiotherapy and 11 months from onset of irAEs. Three months from RP onset, 16 of 24 (67%) assessable patients had persistent symptoms. Among patients with prior ICI pneumonitis (n = 6), five patients (83%) developed ≥grade 2 RP (grade 2, n = 3; grade ≥3, n = 2). The mean lung radiation dose (MLD) predicted for RP (odds ratio: 1.60, P = 0.00002). The relationship between MLD and RP was strong (area under the receiver-operating characteristic curve: 0.85) and showed an exaggerated dose-response. Among patients with an MLD >5 Gy (n = 26), 21 patients (81%) developed ≥grade 2 RP. CONCLUSION: This is the first study assessing the toxicity of radiotherapy among patients with prior irAEs from ICIs. Patients with prior irAEs were found to be at very high risk for clinically significant and persistent RP from thoracic radiotherapy. Careful consideration should be given to the possibility of an increased risk of RP, and close monitoring is recommended in these patients.

Combined UK/US field hospital management of a major incident arising from a Chinook helicopter crash in Afghanistan, 28 Jan 2002.

On Monday, 28 January 2002, a US Army Chinook helicopter crashed on landing in Afghanistan. Sixteen casualties were airlifted from the scene for treatment at the US Army 274th Forward Surgical Team and the British 34 Field Hospital Troop at Bagram airfield before aeromedical evacuation out of Afghanistan. This was the largest mass casualty incident to be dealt with in a combined fashion by the British and American medical services in Afghanistan during the initial months of Operation ENDURING FREEDOM. It illustrated how multinational surgical teams can successfully manage such incidents by following common and agreed protocols. The lessons learned are relevant to any combined operations in the near future.

12 year review of testicular tumour treatment by the army medical services.

Between 1977 and 1988 144 patients with tumours of testicular origin were referred to the Queen Elizabeth Military Hospital at Woolwich. 140 of these were malignant and all but two were treated and followed. Three of the malignant lesions appeared to be extragonadal. During the 12 year period staging has become increasingly accurate and treatment protocols have improved. These changes are reflected in this series. Ten deaths from tumour occurred (6.9%) but only one of these in the last three years of the study period despite an increasing case load at the time. The clinical presentation, treatment, and results of treatment are presented and the advances of treatment and improvement of prognosis discussed.

The effect of peritoneal lavage with tetracycline solution on postoperative infection. A prospective, randomized, clinical trial.

A prospective randomized trial was performed to determine the value of tetracycline lavage in addition to systemic antibiotic prophylaxis in 159 patients undergoing elective and emergency intestinal operations. Tetracycline lavage was associated with a significant overall reduction in postoperative infection rates in 25 of 74 patients (34 percent) receiving saline lavage compared with 15 of 85 patients (18 percent) having tetracycline lavage (P less than 0.05). Tetracycline lavage was associated with a significant reduction in the counts of aerobic and anaerobic bacteria in the peritoneal fluid at the end of the operation (P less than 0.05 and P less than 0.01, respectively) and with a significant reduction of aerobes 24 hours postoperatively (P less than 0.02). Tetracycline lavage would appear to confer clinical benefit in preventing postoperative infection.

The surgical treatment of gastroduodenal Crohn's disease.

Crohn's disease can affect any part of the gastrointestinal tract. Gastroduodenal involvement is uncommon and was not recognised until 1949 (1). Since then approximately 200 cases have been described in several series in the world literature. This paper describes the clinical presentation and surgical management of ten patients treated in the Birmingham General Hospital between 1970 and 1984.