Role of high-dose salvage radiotherapy for oligometastases of the localised abdominal/pelvic lymph nodes: a retrospective study.

BACKGROUND: Abdominal/pelvic lymph node (LN) oligometastasis, a pattern of treatment failure, is observed occasionally, and radiotherapy may work as salvage therapy. The optimal prescription dose, however, is yet to be determined. This study assessed the efficacy of high-dose radiotherapy. METHODS: The medical records of 113 patients at 4 institutes were retrospectively analysed who had 1 to 5 abdominal/pelvic LN oligometastases and were treated with definitive radiotherapy between 2008 and 2018. The exclusion criteria included non-epithelial tumours, uncontrolled primary lesions, palliative intent, and re-irradiation. The prescription dose was evaluated by using the equivalent dose in 2 Gy fractions (EQD2). Patients receiving EQD2 ≥ 60 Gy were placed into the high-dose group, and the remaining others the low-dose group. Kaplan-Meier analyses were performed to evaluate overall survival (OS), local control (LC), and progression-free survival (PFS). Univariate log-rank and multivariate Cox proportional hazards model analyses were performed to explore predictive factors. Adverse events were compared between the high-dose and low-dose groups. RESULTS: The primary tumour sites included the colorectum (n = 28), uterine cervix (n = 27), endometrium (n = 15), and ovaries (n = 10). The rate of 2-year OS was 63.1%, that of LC 59.7%, and that of PFS 19.4%. On multivariate analyses, OS were significantly associated with solitary oligometastasis (hazard ratio [HR]: 0.48, p = 0.02), LC with high-dose radiotherapy (HR: 0.93, p < 0.001), and PFS with long disease-free interval (HR: 0.59, p = 0.01). Whereas high-dose radiotherapy did not significantly improve 2-year OS in the entire cohort (74.8% in the high-dose vs. 52.7% in the low-dose; p = 0.08), it did in the subgroup of solitary oligometastasis (88.8% in the high-dose vs. 56.3% in the low-dose; p = 0.009). As for Late grade ≥ 3 adverse event, ileus was observed in 7 patients (6%) and gastrointestinal bleeding in 4 (4%). No significant association between the irradiation dose and adverse event incidence was found. CONCLUSIONS: As salvage therapy, high-dose radiotherapy was recommendable for oligometastasis in the abdominal/pelvic LNs. For solitary oligometastasis, LC and OS were significantly better in the high-dose group.

Predictive factors of prognosis after radiation and steroid pulse therapy in thyroid eye disease.

To identify predictive factors of prognosis after radiotherapy with concurrent steroid pulse therapy for thyroid eye disease, retrospective analyses were performed among 77 patients. Clinical activity score and magnetic resonance imaging were used to evaluate degrees of orbital inflammation. As a pre-treatment work-up, the thyroid-stimulating antibody (TSAb) level was measured. During a median follow-up of 25.0 months, the 2-year cumulative relapse-free rate (CRFR) was 80.9%. In the univariate analysis, a worse 2-year CRFR was significantly associated with the presence of optic neuropathy (P = 0.001), a higher TSAb rate (P = 0.001), and lower standard deviation (SD) of signal intensity at the extraocular muscle in T2-weighted images (P = 0.006). In the multivariate analysis, TSAb rate and SD affected the CRFR independently. When TSAb activity of 2800% was set as a cut-off at 2 years after treatment, the predictive sensitivity and specificity of relapse were 81.2% and 90.6%, respectively. With regard to SD, the respective sensitivity and specificity values were 81.2% and 82.7% when 100 was set as a cut-off. In conclusion, high TSAb and low SD were significant risk factors for cumulative relapse in orbital radiotherapy. Cut-off values of 2800% for TSAb and 100 for SD may be suitable.

Stereotactic Radiotherapy for Cervical Spinal Intramedullary Metastasis and Multiple Brain Metastases: A Case Report.

A case of cervical (C) spinal intramedullary metastasis and multiple small brain metastases from papillary thyroid carcinoma was presented. Spinal metastasis caused posterior neck and left shoulder pain, dysesthesia in both legs, and motor weakness in both legs and left arm, though the brain metastases were asymptomatic. Both the spinal and brain metastases were successfully treated by frameless stereotactic radiotherapy (SRT)/stereotactic radiosurgery (SRS). The patient's symptoms were almost entirely relieved within two months. A 76-year-old woman was diagnosed as having a thyroid tumor and lung metastasis by roentgenography and computed tomography. Biopsy of the thyroid tumor extending into the mediastinum revealed papillary thyroid carcinoma. She underwent surgical resection of thyroid with dissection of the mediastinum lymph node area. Internal oral radioisotope therapy was not effective for the multiple small lung metastases. She did well for 15 months, but later developed posterior neck and left shoulder pain and dysesthesia in the right leg and then dysesthesia and motor weakness in both legs. Then she experienced weakness in the left upper extremity. Magnetic resonance imaging (MRI) disclosed a small cervical spinal intramedullary mass lesion at the level of C6 and C7 on the left side as well as nine small brain lesions. The cervical spinal intramedullary metastatic tumor was treated by volumetric modulated arc radiotherapy (VMAT) SRT and the nine small brain metastatic tumors were treated by dynamic conformal arc (DCA) SRS uneventfully. A total dose of 39 Gy (100% dose) was delivered in 13 fractions for the spinal lesion (prescription, D95=95% dose; maximum dose=46.3 Gy). Single fraction SRS of 22 Gy (prescription, D95=100% dose) was performed for each of the nine small brain tumors. The spinal tumor was decreased in size on follow-up MRI two months after SRT. Three of the nine brain lesions had disappeared and six were decreased in size on follow-up MRI two months after SRS. Motor weakness in the left extremities and right leg was fully improved, and she could walk again without a cane within two months after SRT. She had only slight dysesthesia in the right leg, possibly due to lumbar spondylosis at the end of the six-month follow-up after SRT. The spinal tumor continued to decrease in size on follow-up MRI five months after SRT. Eight of the nine brain lesions had disappeared and one was decreased in size on follow-up MRI five months after SRS.

Anaphylaxis caused by ingestion of jellyfish.

Although anaphylaxis caused by foods is well known, an immediate allergic reaction due to jellyfish ingestion has never been reported. We report a 32-year-old Japanese female, who developed anaphylaxis after eating salt-preserved jellyfish. The patient was a surfer and had frequently been stung by jellyfish. Thirty minutes after eating salted jellyfish, she showed wheals and oral stinging sensation and 60 minutes later when she was dancing the hula, she showed an asthma-like attack, hypotension, nausea, vomiting and abdominal pain. Prick-to-prick test for the salted jellyfish produced a positive reaction as strong as that induced by histamine. Immunoblot analysis revealed that IgE antibodies in the patient serum reacted with an approximately 200 kDa protein in extracts from tentacle and umbrella of living jellyfish and in extract from the salted jellyfish, as well as a 25 kDa protein only in extracts from living jellyfish. This patient is considered to be the first reported case of anaphylaxis caused by intake of jellyfish. It is speculated that the patient was first sensitized through the skin by jellyfish stings and then jellyfish intake induced generalized attack of anaphylaxis. The 200 kDa unknown jellyfish protein may be the causative allergen.

Psoriasis vulgaris caused by ceramic inserts used in total hip replacement.

BACKGROUND: Ceramics are inorganic nonmetallic materials and are used as bioinert components in joint replacement surgeries. Ceramics are known to be low allergenic. We experienced a ceramic-induced psoriasis. OBJECTIVE: We report a first case of possible ceramic-induced psoriasis caused by a ceramic insert. METHODS: A 55-year-old female received an implanted ceramic-on-ceramic total hip replacement for osteoarthritis of the right hip joint. Following surgery, she developed psoriatic lesions, which continued for 10 years. We suspected that psoriasis was caused by a ceramic insert and removed it surgically. RESULTS: When the ceramic insert was replaced with a polyethylene-on-metal hip joint, the psoriatic lesions completely disappeared. CONCLUSION: The pathogenesis of psoriasis is still an enigma, although deregulation of nuclear factor κB signaling and resulting abnormal cytokine secretion are speculated to be involved. Ceramics may affect these signaling events and cause the onset of psoriasis.