OBSEVANJE BENIGNIH BOLEZNI Strokovno srečanje 7.3.2024 OBSEVANJE BENIGNIH BOLEZNI strokovno srečanje Združenja za radioterapijo in onkologijo Ljubljana, 7.3.2024 ZBORNIK PRISPEVKOV Strokovni in organizacijski odbor: Helena Barbara Zobec Logar, Ivica Ratoša Urednici zbornika: Ivica Ratoša, Helena Barbara Zobec Logar Organizator in izdajatelj: SZD, Združenje za radioterapijo in onkologijo in ONKOLOŠKI INŠTITUT LJUBLJANA Kataložni zapis o publikaciji (CIP) pripravili v Narodni in univerzitetni knjižnici v Ljubljani COBISS.SI-ID 188115459 ISBN 978-961-7029-80-2 (Onkološki inštitut, PDF) Leto izdaje: 2024 Elektronska publikacija je brezplačno dostopna na spletnih straneh Onkološkega inštituta Ljubljana na: https://www.onko-i.si/publikacije-in-posnetki-predavanj-s-strokovnih-dogodkov slovenje Onkološki Inštitut 135 Kirurgija ONKOLOŠKI INSTITUT Obsevanje od 2016 - 2023 14 bolnikov (10 m, 4 ž)- 58 let/53let Vseh 14 bolnikov- stadij N Mb Dupuytren- 17 rok (5 obe,7 ena (4-d, 3-l) Mb Ledderhose - 7 nog : (3 obe, 1 L) Sledenje : 6 mesecev - 7 let (povprečno 44 mesecev). Pri 4 bolnikih > 5 let Pri vseh bolnikih je bil dosežen regres bolezni pri 2 celo popoln regres. Pri vseh bolnikih je po regresu bolezen stabilna, do napredovanja bolezni ni prišlo pri nobenem. TRN PETNICE Spina calcanei Calcaneodinia Nastanek Vnetje plantarne aponevroze Lok stopala se pri obremenitvi med prenosom teže od petnice proti srednjemu delu in prstom preveč spusti. Stalna napetost mišic stopala in goleni Kronična preobremenitev, vnetje pokostnice, delno natrganje fascije Pri tekačih je vzrok čezmerna pronacija (vzvračanje noge navznoter). Na mestu največje obremenitve (sredina pete), nastane najprej hrustančna „ojačitev" pete, ki nato zakosteni (trn petnice). Mb. Haglund Sinonimi: Vnetje ahilove tetive Retrokalkanealni bursitis Posteriorna kalkanealna tuberoza Mulholland deformacija Zdravljenje Skoraj vse vrste zdravljenja so zgolj izkustvene, raziskav je malo Počitek, NSAR Led-zmanjša akutno vnetje Silikonski vložki pod peto- amortizacija Peta- vložek, ki dvigne peto (pri visokem stopalnem loku) Čevelj, ki stabilizira gleženj Fizioterapija, masaža Mišice -vaje za raztezanje Eliminacija problema: Hoja brez obutve Čevelj z mehko peto ali brez pete Mb Haglund Zdravljenje Blokada- lokalna injekcija (analgetik+kortikosteroid) Uz Laser ? Elektroterapija, Magnetoterapija Extracorporeal shock therapy (udarni valovi) Imobilizacija Obsevanje OBSEVANJE Linearni pospeševalnik Elektroni Ortovoltni aparat Obsevanje 3 x /teden Odmerek sevanja: 5 Gy v 10 frakcijah 3 Gy v 6 frakcijah HETEROTOPNA OSIFIKACIJA (HO) Heterotopna osifikacija (HO) je nastanek zrelega lamelarnega kostnega tkiva, ki lahko vsebuje tudi kostni mozeg na nepravem mestu v mehkih tkivih. Opisana je bila že v 19. stoletju in je bila znana pod različnimi nazivi kot so myositis osifikans, neurogeni osteom, osificirajoča fibromiopatija . Poznamo tri vrste HO: travmatsko, nevrogeno in genetsko Najpogostejša je travmatska HO, ki nastane kot pove ime, po zlomih, poškodbah, izpahih, operacijah in zelo obsežnih opeklinah. Nevrogena nastane po poškodbah hrbtenice in glave in cžs. Genetska HO je sestavni del nekaterih redkih genetskih bolezni , kot so fibrodysplasia ossicans progressiva, Albrightova hereditarna osteodistrofija. HO nastane zaradi nepravilne diferenciacije pluripotentne mezenhimalne celice v osteoblastno zarodno (stem) celico. Natančen mehanizem poteka ni znan. HO je klinično asimptomatska in jo opazimo le na rtg posnetkih kosti. Simptomatska postane, ko povzroči bolečine ter zmanjšanje gibljivosti v prizadetem sklepu, kar lahko vodi do popolne zatrjenosti sklepa. Scintigram kosti lahko zazna HO že 3 tedne po poškodbi, na rtg posnetku pa je vidna po 4. do 6.tednih. Približno tretjina je ocenjenih kot klinično pomembnih, kar se kaže kot bolečina v predelu sklepa, zmanjšana gibljivost, ki lahko napreduje do popolne zatrditve sklepa. HETEROTOPNA OSIF1KACIJA (HO) HO nastane zaradi nepravilne diferenciacije pluripotentne mezenhimalne celice v osteoblastno zarodno (stem) celico. Natančen mehanizem poteka ni znan. HO je klinično asimptomatska in jo opazimo le na rtg posnetkih kosti. Simptomatska postane, ko povzroči bolečine ter zmanjšanje gibljivosti v prizadetem sklepu. Scintigram kosti lahko zazna HO že 3 tedne po poškodbi, na rtg posnetku pa je vidna po 4. do 6.tednih. Približno tretjina je ocenjenih kot klinično pomembnih, kar se kaže kot bolečina v predelu sklepa, zmanjšana gibljivost, ki lahko napreduje do popolne zatrditve sklepa. Ko je HO že razvita je edino učinkovito zdravljenje operacija, zato je profilaksa nastanka HO zelo pomembna. Nastanek HO preprečujemo na več načinov : - nesteroidni antirevmatiki - obsevanje Najbolj znana profilaksa je z nesteroidnimi antirevmatiki (NSAR) , od katerih je najbolj pogosto uporabljan in preiskovan Indometacin. NSAR delujejo tako, da inhibirajo diferenciacijo mezenhimske celice v kostno ter indirektno z inhibicijo remodeliranja kosti (preko prostaglandinskih receptorjev oz. inhibicijo sinteze prostaglandinov.) Ko je HO že razvita je edino učinkovito zdravljenje operacija, zato je profilaksa nastanka HO zelo pomembna. Nastanek HO preprečujemo na več načinov : - nesteroidni antirevmatiki - obsevanje Najbolj znana profilaksa je z nesteroidnimi antirevmatiki (NSAR) , od katerih je najbolj pogosto uporabljan in preiskovan Indometacin. NSAR delujejo tako, da inhibirajo diferenciacijo mezenhimske celice v kostno ter indirektno z inhibicijo remodeliranja kosti (preko prostaglandinskih receptorjev oz. inhibicijo sinteze prostaglandinov.) Int. J. Radiation Oncology Biol. Phys., Vol. 60, No. 3, pp. 888-895, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved RADIOTHERAPY VS. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS FOR THE PREVENTION OF HETEROTOPIC OSSIFICATION AFTER MAJOR HIP PROCEDURES: A META-ANALYSIS OF RANDOMIZED TRIALS EMILIOS E. PAKOS, M.D.,* AND JOHN P. A. IOANNIDIS, M.D.*+t * Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; +Biomedical Research Institute, Foundation for Research and Technology-Hellas, Ioannina, Greece; iInstitute for Clinical Research, Department of Medicine, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, MA Purpose: To evaluate the efficacy of radiotherapy (RT) vs. nonsteroidal antiinflammatory drugs (NSAIDs) in the prevention of heterotopic ossification (HO) after major hip procedures. Methods and Materials: We conducted a meta-analysis of 7 randomized studies (n=1143) comparing RT with NSAIDs. Conclusions: Although absolute differences may be small, postoperative RT is on average more effective than NSAIDs in preventing HO after major hip procedures. The risk of developing HO was less than half with RT than as compared with NSAID. Int. J. Radiation Oncology Biol. Phys., Vol. 60, No. 3, pp. 888-895, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved RADIOTHERAPY VS. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS FOR THE PREVENTION OF HETEROTOPIC OSSIFICATION AFTER MAJOR HIP PROCEDURES: A META-ANALYSIS OF RANDOMIZED TRIALS EMILIOS E. PAKOS, M.D.,* AND JOHN P. A. IOANNIDIS, M.D.*+t * Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; +Biomedical Research Institute, Foundation for Research and Technology-Hellas, Ioannina, Greece; iInstitute for Clinical Research, Department of Medicine, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, MA Purpose: To evaluate the efficacy of radiotherapy (RT) vs. nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of heterotopic ossification (HO) after major hip procedures. Methods and Materials: We conducted a meta-analysis of 7 randomized studies (n=1143) comparing RT with NSAIDs. Conclusions: Although absolute differences may be small, postoperative RT is on average more effective than NSAIDs in preventing HO after major hip procedures. The risk of developing HO was less than half with RT than as compared with NSAID. RADIATION PROPHYLAXIS FOR HETEROTOPIC OSSIFICATION ABOUT THE HIP JOINT—A MULTICENTER STUDY MICHAEL HEINRICH SEEGENSCHMIEDT, M.D.,* HANS-BRUNO MAKOSKI, M.D.,+ OLIVER MICKE, M.D.,t AND THE GERMAN COOPERATIVE GROUP ON RADIOTHERAPY FOR BENIGN DISEASES * Department of Radiation Oncology, Therapy and Nuclear Medicine, Alfried-Krupp-Hospital, Essen, Essen, Germany; +Department of Radiation Oncology and Nuclear Medicine, Community Hospital Duisburg, Duisburg, Germany; ^Department of Radiation Oncology, Westfalian Wilhelms-University Munster, Munster, Germany Int. J. Radiation Oncology Biol. Phys., Vol. 51, No. 3, pp. 756-765, 2001 Copyright © 2001 Elsevier Science Inc. Results: 114 institutions reported their clinical experience with prophylactic RT for the prevention of heterotopic ossification about the hip joint: 70 community hospitals, 23 university hospitals, and 21 private RT practices. In 1999, 5677 patients (5989 hips) had received prophylactic RT. Conclusion: This patterns of care study comprises the largest number of cases reported for prophylactic hip RT to date. The results reveal that both preoperative (within 24 h) and postoperative RT (within 72 h) are effective in preventing heterotopic ossification after hip surgery. Single-dose RT concepts, especially, can be recommended as an excellent treatment alternative for patients with contraindications to long-term steroid or nonsteroidal anti-inflammatory agents, and this approach has become standard in most German RT institutions. RADIATION PROPHYLAXIS FOR HETEROTOPIC OSSIFICATION ABOUT THE HIP JOINT—A MULTICENTER STUDY MICHAEL HEINRICH SEEGENSCHMIEDT, M.D.,* HANS-BRUNO MAKOSKI, M.D.,+ OLIVER MICKE, M.D.,t AND THE GERMAN COOPERATIVE GROUP ON RADIOTHERAPY FOR BENIGN DISEASES * Department of Radiation Oncology, Therapy and Nuclear Medicine, Alfried-Krupp-Hospital, Essen, Essen, Germany; +Department of Radiation Oncology and Nuclear Medicine, Community Hospital Duisburg, Duisburg, Germany; ^Department of Radiation Oncology, Westfalian Wilhelms-University Munster, Munster, Germany Int. J. Radiation Oncology Biol. Phys., Vol. 51, No. 3, pp. 756-765, 2001 Copyright © 2001 Elsevier Science Inc. Results: 114 institutions reported their clinical experience with prophylactic RT for the prevention of heterotopic ossification about the hip joint: 70 community hospitals, 23 university hospitals, and 21 private RT practices. In 1999, 5677 patients (5989 hips) had received prophylactic RT. Conclusion: This patterns of care study comprises the largest number of cases reported for prophylactic hip RT to date. The results reveal that both preoperative (within 24 h) and postoperative RT (within 72 h) are effective in preventing heterotopic ossification after hip surgery. Single-dose RT concepts, especially, can be recommended as an excellent treatment alternative for patients with contraindications to long-term steroid or nonsteroidal anti-inflammatory agents, and this approach has become standard in most German RT institutions. Radiotherapy Prevents Heterotopic Ossification in All Body Sites: Long-term Results of a National Multicenter Patterns of Care Study in 462 Cases H. M. Seegenschmiedtl, O. Micke2, N. Willich3 G. C. G. B. D/German Cooperative Group on Radiotherapy for Benign Diseases4 1 Alfried-Krupp Krankenhaus, Essen, Germany, 2 St. Franziskus Hospital, Bielefeld, Germany, 3 Westfalian University Munster, Munster, Germany, 4 DEGRO, Berlin, Germany Purpose/Objective(s): German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) conducted a multi-center cohort study to analyze the use of prophylactic radiotherapy (RT) to prevent heterotopic ossification (HO) in various body sites. This study summarizes the long-term outcome for all non-pelvic sites. Materials/Methods: This PCS was conducted between 2002 and 2006 in all German RT institutions to assess the accrual pattern, the number of treated patients, the specific treatment indications and the applied RT schedules for prophylactic RT in all other body sites besides the hip to prevent HO after various types of injuries or surgical procedures. Results: 114 RT institutions applied prophylactic RT to prevent HO at any body site, mostly about the hip in conjunction with total hip arthroplasty (THA). Of those, 56 (49%) reported specific clinical experiences with prophylactic RT in other body regions besides the hip joint. A total of 462 cases were collected with the following anatomical distribution: 105 shoulders; 242 elbows; 57 knees; 7 mandibular joints; and 52 other sites, including the upper and lower arm, femur, tibia and fibula, abdominal wall and other soft tissue sites with painful or functionally disturbing HO. Most of the patients (92%) reported a traumatic event prior to the occurrence of the local HO. Only 6/56 (11%) institutions applied preoperative RT (1 x 6 - 7 Gy), while 50/56 (89%) used various postoperative RT concepts (mostly 1 x 7 Gy). The following clinical outcome was achieved at a minimum follow-up of 1 year: the overall reported radiological failure rate 53/462 (11.5%) and the functional failure rate was 37/462 (8%); 28 of 53 cases with new HO after partial or complete removal of HO and RT were salvaged with additional surgery plus secondary RT; 379 (82%) cases reached a functional improvement compared to the preoperative status; 46/462 remained in stable functional condition. One prognostic factor contributing to radiological failures was a time delay of .96 hours to initiate RT after completion of surgery. Conclusions: This multicenter study comprises the world-largest number of cases reported so far for the use of prophylactic RT to prevent HO in non-pelvic body sites. It proved that both pre and postoperative RT are very effective in all body sites to prevent HO and achieve a similar radiological and functional success as for the hip joint after THA. Radiotherapy Prevents Heterotopic Ossification in All Body Sites: Long-term Results of a National Multicenter Patterns of Care Study in 462 Cases H. M. Seegenschmiedtl, O. Micke2, N. Willich3 G. C. G. B. D/German Cooperative Group on Radiotherapy for Benign Diseases4 1 Alfried-Krupp Krankenhaus, Essen, Germany, 2 St. Franziskus Hospital, Bielefeld, Germany, 3 Westfalian University Munster, Munster, Germany, 4 DEGRO, Berlin, Germany Purpose/Objective(s): German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) conducted a multi-center cohort study to analyze the use of prophylactic radiotherapy (RT) to prevent heterotopic ossification (HO) in various body sites. This study summarizes the long-term outcome for all non-pelvic sites. Materials/Methods: This PCS was conducted between 2002 and 2006 in all German RT institutions to assess the accrual pattern, the number of treated patients, the specific treatment indications and the applied RT schedules for prophylactic RT in all other body sites besides the hip to prevent HO after various types of injuries or surgical procedures. Results: 114 RT institutions applied prophylactic RT to prevent HO at any body site, mostly about the hip in conjunction with total hip arthroplasty (THA). Of those, 56 (49%) reported specific clinical experiences with prophylactic RT in other body regions besides the hip joint. A total of 462 cases were collected with the following anatomical distribution: 105 shoulders; 242 elbows; 57 knees; 7 mandibular joints; and 52 other sites, including the upper and lower arm, femur, tibia and fibula, abdominal wall and other soft tissue sites with painful or functionally disturbing HO. Most of the patients (92%) reported a traumatic event prior to the occurrence of the local HO. Only 6/56 (11%) institutions applied preoperative RT (1 x 6 - 7 Gy), while 50/56 (89%) used various postoperative RT concepts (mostly 1 x 7 Gy). The following clinical outcome was achieved at a minimum follow-up of 1 year: the overall reported radiological failure rate 53/462 (11.5%) and the functional failure rate was 37/462 (8%); 28 of 53 cases with new HO after partial or complete removal of HO and RT were salvaged with additional surgery plus secondary RT; 379 (82%) cases reached a functional improvement compared to the preoperative status; 46/462 remained in stable functional condition. One prognostic factor contributing to radiological failures was a time delay of .96 hours to initiate RT after completion of surgery. Conclusions: This multicenter study comprises the world-largest number of cases reported so far for the use of prophylactic RT to prevent HO in non-pelvic body sites. It proved that both pre and postoperative RT are very effective in all body sites to prevent HO and achieve a similar radiological and functional success as for the hip joint after THA. Heterotopna osifikacija Profilaktično obsevanje Linearni pospeševalnik 7Gy v eni frakciji Predoperativno Do 12 ur pred operacijo (optimalno 4 ure) Pooperativno Do 72 ur po operaciji Pooperativno obsevanje je zaradi logističnih razlogov težje izvedljivo Heterotopna osifikacija Profilaktično obsevanje Linearni pospeševalnik 7Gy v eni frakciji Predoperativno Do 12 ur pred operacijo (optimalno 4 ure) Pooperativno Do 72 ur po operaciji Pooperativno obsevanje je zaradi logističnih razlogov težje izvedljivo Bolniki 2008-2023 Skupaj 45 M -32 Ž -13 Starost 26 - 91 let Povprečno 56 let Kolk 35 17-D, 12-L ,6 L+D Kolk - oba 3 Komolec 7 1 obsevan pooperativno Gluteus 1 osifikat Koleno 3 Radius 1 MTP-sklep-2. prst 1 E.mail: Kot ste želeli v enem od preteklih elektronskih sporočil Vam pošiljam povratno informacijo glede pacienta D.P. ki je bil dne 22.09.2015 obsevan in operiran zaradi heterotopnih osifikatov desnega kolka. Pacient se dobro počuti, gibljivost v desnem kolku se je močno popravila, na rtg posnetkih pa ni videti ponovnih osifikatov. Prilagam tudi rtg posnetek. Epicondylitis -idis [epikondilitis] ž ^ epikondilitis Vir: Slovenski medicinski slovar - Univerza v Ljubljani, Medicinska fakulteta ~ lateralis humeri teniški ^ komolec; ~ medialis humeri golfski ^ komolec Strahlenther Onkol 2014 -190:293-297 DOI 10.1007/s00066-013-0504-1 © Springer-Verlag Berlin Heidelberg 2014 OJ. Ott • S, Hertel - U.S. Gaipl * B. Frey * M. Schmidt - R. Fietkau The Erlangen Dose Optimization trial for low-dose radiotherapy of benign painful elbow syndrome* Long-term results Patients and methods. Beetwen February 2006 and February 2010, 199 evaluable patients were recruited for this prospective trial. All patients received low-dose orthovoltage radiotherapy. One course consisted of 6 fractions in 3 weeks. In the case of insufficient pain remission after 6 weeks, a second course was administered. Low-dose radiotherapy proved to be a highly effective option for sustained pain control in the treatment of painful elbow syndrome Therefore, for radiation protection purposes we recommend the standard use of single doses of 0.5 Gy and total doses of 3.0 Gy per radiation series in the treatment of benign painful elbow syndrome Strahlenther Onkol 2014 -190:293-297 DOI 10.1007/s00066-013-0504-1 © Springer-Verlag Berlin Heidelberg 2014 OJ. Ott • S, Hertel - U.S. Gaipl * B. Frey * M. Schmidt - R. Fietkau The Erlangen Dose Optimization trial for low-dose radiotherapy of benign painful elbow syndrome* Long-term results Patients and methods. Beetwen February 2006 and February 2010, 199 evaluable patients were recruited for this prospective trial. All patients received low-dose orthovoltage radiotherapy. One course consisted of 6 fractions in 3 weeks. In the case of insufficient pain remission after 6 weeks, a second course was administered. Low-dose radiotherapy proved to be a highly effective option for sustained pain control in the treatment of painful elbow syndrome Therefore, for radiation protection purposes we recommend the standard use of single doses of 0.5 Gy and total doses of 3.0 Gy per radiation series in the treatment of benign painful elbow syndrome Re-irradiation for humeral epicondylitis Retrospective analysis of 99 elbows Matthias G. Hautmann1 @ ■ Lukas P. Beyer2 • Matthias Hipp3 • Ulrich Neumaier4 • Felix Steger1 • Barbara Dietl1 -Katja Evert5 • Oliver Kölbl1 ■ Christoph Süß1 Received: 16 March 2019/Accepted:27 June2019/Publishedonline: 15 July 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019 Material and methods The analysis was performed on patients from three German radiotherapy institutions and included 99 re-irradiated elbows. Pain was documented with the numeric rating scale (NRS). Evaluation of the NRS was done before and directly after each radiation therapy as well as for the follow-up of 24 months Conclusion Re-irradiation of humeral epicondylitis is an effective and safe treatment. All subgroups showed a good response to re-irradiation for at least 24 months Re-irradiation for humeral epicondylitis Retrospective analysis of 99 elbows Matthias G. Hautmann1 © • Lukas P. Beyer2 • Matthias Hipp3 • Ulrich Neumaier4 • Felix Steger1 ■ Barbara Dietl1 ■ Katja Evert5 • Oliver Kölbl1 ■ Christoph Süß1 Received: 16 March 2019 / Accepted: 27 June 2019 / Published online: 15 July 2019 © Springer-Verlag GmbH Germany, pa rt of Springer Natu re 2019 Material and methods The analysis was performed on patients from three German radiotherapy institutions and included 99 re-irradiated elbows. Pain was documented with the numeric rating scale (NRS). Evaluation of the NRS was done before and directly after each radiation therapy as well as for the follow-up of 24 months Conclusion Re-irradiation of humeral epicondylitis is an effective and safe treatment. All subgroups showed a good response to re-irradiation for at least 24 months Zdravljenje Počitek, hlajenje NSAID Fizioterapija Uz Udarni valovi (Extracorporeal shock therapy) Obsevanje Linearni pospeševalnik Odmerek 3,0 Gy v frakcijah po 0,5 Gy Keratoakantom Tumor zraste iz epitela dlačnega folikla. Značilna je hitra rast tumorja, ki v nekaj tednih zraste do kupolastega tumorja premera 1-2 cm. Po nekaj mesecih večina tudi spontano regrediira. Klasifikacija tumorja se je v desetletjih spreminjala od benignega tumorja do dobro diferenciranega ploščatoceličnega karcinoma. Ker je ločevanje benignega od dobro diferenciranega ploščatoceličnega karcinoma klinično in histološko zelo težavno, večina avtorjev meni, da je skrbno spremljanje (wait and see policy) preveč tvegano. Priporočeno zdravljenje je ekscizijska biopsija z 4 mm varnostnim robom. Keratoakantom Starost 94 let 2 leti po obsevanju Keloidi Incidenca: 0,09 (VB) -16 % (Kongo) Nastanek: operacija,poškodba,tetoviranje,prebadanje,ugriz,opeklina Patogeneza ni povsem pojasnjena. Povečana proliferacija fibroblastov in tvorba kolagena, močno povečana sinteza rastnih dejavnikov (TGF-beta,VEGF,CTGF) Možnosti zdravljenja Operacija Kortikosteroidi-obliž, injekcije Silikonski gel Laser Krioterapija Pri vseh zdravljenjih je več kot 50 % ponovitev (60-80%) Kombinirano zdravljenje z operacijo in pooperativnim obsevanjem zmanjša verjetnost ponovne rasti keloida na 10-30 %. Anamneza: V levem uhlju je nekaj let nosil uhan. Po nastanku keloida je bil operiran leta 2003, nato 2004,2009, 2012 in 2017, dobival je tudi injekcije kortikosteroidov v uhelj. Keloid je vedno ponovno zrasel. Operacija in pooperativno obsevanje 2019 Kontrola 3 leta po kombiniranem zdravljenju OBSEVANJE BENIGNIH BOLEZNI 7. marec 2024 Onkološki inštitut Ljubljana, Predavalnica v stavbi C RADIOTHERAPY FOR NON-MALIGNANT DISORDERS: A PRACTICAL OVERVIEW Angel Montero, MD, PhD @Oncoangel CENTRO INTEGRAL ONCOLÓGICO SÍitmÍ hm CIOCC HOSPITAL UNIVERSITARIO KM HOSPITALES hm sanchinarro o Facultad HM de Ciencias de la Salud de la Universidad Camilojosé Cela __ , , . # Universidad KM hm hospitales CamiloJoséCela 5EK EDUCATION GRDUP Disclosure I've been a radiation oncologist for more than 20 years... (...with all the biases and COIs that this implies.) RADIATION THERAPY FOR CANCER TREATMENT: AN ACCEPTED STANDARD. BUT... ...RADIATION THERAPY FOR NON-MALIGNANT (BENIGN) CONDITIONS?! KM hm hospitales ...AS OLD AS THE HILLS. Radiation Treatment of Benign and Inflammatory Conditions i. 2. a. 4. 7. Benign Tumors 1. Angiomas 2. Cystic hygromas Giant-cell tumors oi bone 4. Fibroid uteri Ô. Pituitary adenomas (a) chrontophil (h) chromophobe (t) basophil 0. Xanthomatosis Other Conditions 1. Arthritis (Marie-iStrumpell) Bursitis S- Cystic synovitis 4. Metrorrhagia (non-specific} 5- Keloids The radiation treatment of benign and inflammatory conditions occupies an important place in modern therapeutics. The number oí lesions found to respond well to radiation therapy has gradually increased over a period of years until at present nearly half of the cases seen in the radiotherapy department are treated for benign or inflammatory conditions^ This excludes the use of radiation iq^roiatol-ogy, where its < strated^ad it Th^A oiWj^Ban^n^^Buc- toinong, in fact, to 'Aiaf-H^^ 'n an editorial. If, howeve^l^^xclude the group in which there is only a small percentage of good results, along with those conditions about which there is lack of agreement as to the value of the treatment, we are still left with an impressive number of lesions which respond satisfactorily, and with which we should all be familiar. July 194« X». Ü. 8»k»uw; fw I«il*»c im MaMtnMlm tink tl.KnitTülu M Ctoi«r*. Da Dcric> tenUUcr Bvukl MlttaOai* 4Wf TtM KrvnkWHaAlU TM (MtofefaatwUaa» M M iliirrh Xmwwvfctuf Am P4u(tf«aat*iM«i tim mit (uta m«wM I« o*aa TtSU, *m «tw. IHM« (M t Jüm, vrkk* m UAifa» SdiMnoi ui-i Aawk«raU«Mg • ujU UflHk*--' 1 ria{«r r^yluh Kit, iwxlinailai 4>a Sdiwriw iixk m i«nt« vltUa >'»1U, M rata lilün 14 Jtiumt, w«I«Im M Mttgw Ha, inil min 41» ■ihM— Mflfc te ml« Ai*ii JA ■ |Mk Wl 4mm tJBMf MkirJ»«, lafeUid m h*Mc«> HUi**rw» vJ iWllt«:^«, rrramirrt». Mrk «I ,1-r ¿rUlan wr. ' ■ ¿ff ■ S^mkVvuWI inr .»-• i.*: i' O-, n».| 41« VmAmmii iHiimI im MflBAai| Am t wHifcn V*ck «tot T*fn mMM tUk 4m tWu« Ui im »*Ui««utAltii uix 3 cot D«t l*itU >'nl im Mmukumxt%m mt tis UJIktigm MJkiekm, vdckm «rtun Hat ¡»kr• u tkratkla »n—>IIito nl dhatrUt Mra m Ilankaaakfcait litt, ha MaJ iimm Jib« »riftnami «Uli XnukWl, Ml WMga I* * 11 «»4 ¿aKkvtUnn( im Kalj^alaak« «iWalhaa ca4 mich «tu ttmmm VUM rm «n|«Ab 44' Nwli jüto Xtiaulcv 4a* Ual|Mlnk)« imil—Ii 44 «U» WlaW «Mar wilrlnai 41a Kala pb^pa «m, 41« Uummb »ai aladaitaa tick aa4 aaefc 4a» rSaiWa Xawmimmf dar SlnMn tcaehnii^B 4» guu IhMAJUmmmi (RaiUV Schmid-Monnard, C. (1898). ÜberHeilung des Gelenkrheumatismus durch Röntgenstrahlen bei Kindern. Fortschritte aufdem Gebiet der Röntgenstrahlen, 1, 209. Radiation Treatment of Kon-Malïc.nant Conditions Inflammatory Tuberculous lymphadenitis Acute lymphadenitis Nasopharyngeal lymphoid hypertrophy Parotitis (а) acute postoperative (б) chronic suppurative Enlarged mediastinal lymph nodes following various infections, especially whooping cough Herpes (а) zoster (б) simplex Plantar warts Hugh F. Hare, M.D. Lahey Clinic, Boston Miitwn Ofxotow i Stoat MM» - M 1 % Radiotherapy for Yon-Malignant Disorders (HM^mrr (M|h mi (M Mk mnm»>iinm ■ • m»..» " ™ 1 I.-I.M l ■ □ loi nu ■ ! ». ________I.M.M \H1IMuidrlint-\ fur radiotherapy of non-malignant disorder* Pirt I: pltUtal ptlntlfilrv ndJofclattitkat nctbaltmv a«l nillacrak thk ■mui >«y U*>l< lfc.1 • IMt VUlri < WKMf4 Bnl fcn>4l MU» - Ha« Im* Iimi IU4H ■W l4fM(«fHimi lm(* WvwnU 111). OMOIKAI AKIK'tt DEGRO uuidclino Tur the radiotherap) oí non-malignant iliuinlMt =9 UVIIW AMKlf DEGRO guidclinrt fur ihr radiothrrapi of n<>n-niiili|¡iunt disorders r«t II: l'ai*!»! «tnnill» .k.l.tal il—t J«r. Uka « I t Iff |M IWmc» Dmmi \tA M>» MMl«M UkKÎISAL AKTIrt I DEGRO practical guidelines for the radiotherapy ..«•_.._____i:_______ .1:_____•____ D..~> i\ (U*0tr»»*py «M) Oncology 8) <2007) 175-177 www. tbcfre«n)oumal. com Radiotherapy of non-malignant disorders: Where do we stand? Jan Willem Leer", Paul van Houtteb, Heinrich Seegenschmiedtc The ESTRO Nice conference on radiotherapy for non-malignant diseases was aimed at finding the current clinical evidence of radiotherapy in well-selected non-malignant disorders. In view of possible litigations for colleagues treating benign disorders, it is important that the professional community defines a consensus piocess and lavs down a consensus statement on what is regarded acceptable and what not. (A) There is sufficient evidence: the indication is accepted, those who do not do it may start doing it on a routine basis. (B) The evidence is controversial: the indication can only be accepted in the context of clinical trial designed to confound clinical evidence. (C| There is insufficient evidence: the indication is not accepted on a routine basis, and those who do it should stop doing it. AN INCREASING CORE OF KNOWLEDGE ABOUT ITS UTILITY... Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines 'M H SEEGENSCHMIEDT, MO, PhD, zO MICKE, MO. PhD and J4R MUECKE, MD, PhD; the German Cooperative Group on Radiotherapy for Non-malignant Diseases (GCG-BD) Non-malignant indications for RT comprise about 10-30% of all treated patients in most academic, public and private R'l facilities in Ciermany. Over the past decade, various so called patterns Updated strategies in the treatment of benign diseases—a patterns of care study of the german cooperative group on benign diseases Jan Kriz MD Heinrich M. Seegensch mi edt MD, PhD bf Amelie Bartels MD % Oliver Micke MD, PhD c, Ralph Muecke MD d% Ulrich Schaefer MD, PhD f, Uwe Haverkamp MD, PhD a, Hans T. Eich MD, PhD a general and v, their RT treatnl Overall, there active RT facU these benign o The largest yroi indications for degenerative joi 10-30% of ALL attended patients Available in ALL radiotherapy facilities (>300) Irradiated diseases: 46% degenerative disorders 40% osteoarthritis 7% functional disorders 4% hyperproliferative disorders 2% CNS diseases iving RT in 2014, | those, 16,989 pa-diseases, another 1563 (4%) for w/c) for functional eceived stereotac-irradiated because Oncology (20IS) 3, 240-244 Institution N =46 KM hm hospitales RADIATION THERAPY IN SPAIN FOR BENIGN DISORDERS: RESULTS OF THE 2019 VS. 2022 SURVEY 2019 Equipment N = 46 0 Public # Private • Other . Linac Orthovoltage Other Number of patients with benign diseases treated per year <10 pacientes/aAo 11 -50 pacientes/aAo 51-100 paacntes/aiNo >100pacwntes/arto 56.5% N = 82 40(48,8% PROPOSED MECHANISMS OF RADIATION EFECTS: Antiinflammatory 4, leucocyte-endothelium interaction ■2-6 Gy ■ Osteoarthritis ■Tendynopathy ■Enthesitis ■Alzheimer's disease 4/ vasodilation 4- vascular permeation pain ■ r f !■ ni--n rr.v S Immunomodulatory properties and molecular effects in inflammatory diseases of low-dose X-irradiation M*l/HcOM " Km/jnwi MT' AimnManaa-. Lwtwtg K*J*DU\ M. SMtmttt^aMt'. Udo S Otfd' endCtat AfcM' vv "" |i.in ta» i Immunomodulatory ■10 Gy ■ Graves' ophtalmopathy Circulating lymphocites Antigen stimulation Antiproliferative Retarding mitotic cycle Proliferation inhibition ■-10 Gy • Keloids • Heterotopic ossification •AMD ■ Dupuytren/Ledderhose Ablative Effect on cell compartiment Effect on microenviroment Overpasing traditional'radioresistence' ■>20-25 Gy ■ Cardiac arrythmias ■Trigeminal & other neuralgia •CNS functional disorders Courtesy from Dr. B. Alvarez RADIATION THERAPY FOR BENIGN DISORDERS: A GROWING INTEREST... SKELETAL DISORDERS Osteoarthritis Tendonitis Bursitis Enthesitis Fasciitis Heterotopic ossification SOFT-TISSUE DISORDERS • Fibromatosis • Dupuytren/Lederho se • Peyronee • Keloids • Pterigion CARDIOVASCULAR DISORDERS Vasculopathy Hemangiomas AVM Intratable arrythmia CNS FUNCTIONAL DISORDERS Essential tremor Epilepsy Parkinson's disease Alzheimer disease INFECTIOUS DISORDERS Necrotizing fasciitis Shingles COVID19 pneumonia .IN A BROAD SPECTRUM OF DISORDERS. Osteoarthritis affects millions in Europe and the burden is growing SWEDEN im In 2019, over 57 million people in Western Europe1 had osteoarthritis (OA), and it caused the loss of over 2 million years of healthy life.3 Numbers affected in the region have grown by 54% since 1990. GERMANY Source. IHME. Global Burden of Disease Data 2019 OA does not just affect the elderly: 43% of those affected are under 65 0.08m o left f t <35 35-44 55-64 65-74 Options for pharmacological symptom relief are limited • No treatments can stop or reverse the joint damage associated with OA. • Many people with OA also have other conditions,, such as cardiovascular disease, which limit the pain medications they can take. Existing pain medications are not meant for long-term use. 27-54% of people have pain despite taking prescription pain relief medication^10 .9 Only 30% are very satisfied with their current OA medication11 OA has a significant impact on people's quality of life and daily activities Most people with OA have joint pain, and this impacts their ability to function normally. People who have more severe pain have more limitations to their activities3 and worse mental health" and quality of life.3 91% say OA limits their ability to do normal activities-1 49°/c 0 report that OA affects theirwork3 84% have joint pain or tenderness3 37% report that OA limits their social lives3 Up to 60% have moderate to severe pain6 LOW-DOSE RADIATION THERAPY HAS PROVEN EFFECTIVENESS FOR OA PAIN RELIEF... Strahltntb« Onlcol <2015) 191 1-6 DOl 10 1007 <00046-014-0757-3 REVIEW ARTICLE DEGRO guidelines for the radiotherapy of non-malignant disorders Pari II: Painful degenerative skeletal disorders Oliver J. Ott • Marcus Niewald • Hajo-Dirk \Yeitmann • Ingiid Jacob • Iienaeus A. Adauiietz • I'lrich Schaefer - Ludwig Krilliolz - Rrinliaid Heyd - Ralph Murckr ■ German Cooperative Gioup on Radiotherapy for Benign Diseases (GCG-BD) Shoulder syndrome 58-100% Elbow syndrome Between lÇJÎijmi-therapv for elb 2000 patients \_ 'mi th.» nnl^ ~8o% Gonarthrosts | Coxarthrosis | Response rates (complete and partial response CR and PR) usually reached 58-100% 2-3 months after radiotherapy [14. 17] In 7928 retrospectively- evaluated patients. Heyd et al [6] report with PR 12% less than 6 m< 55% with CR. and 33% it benefit Early-treatment paui seemed to be more effective than with chronic pain Data about a higher success rate for patients with calcifications were inconsistent Low-dose radiotherapy- is an effective therapeutic option for painful Kellgren stage 2-3 arthrosis of the knee joint and can be recommended even if surgical mterventions are not possible or dpsirahle nr if nther conservative treatment ie side effects or cou. S patients treated with Considering the results of the retrospective studies, low-dose radiotherapy may be an effective therapeutic option for painful Kellgren stage 2—4 arthrosis of the hip joint even 58-91% me after low-dose radio->en reported m more than .-e and prospective analy- ses Approximately S2 % of the patients experienced significant pain reduction The CR and PR rates were 45% (ranee 5-94%) and 35'. (range 7-7j»e)[iji] I Trochanteric bursitis | Glatzel et al [3] reported on 34 patients who were treated with total dose methods are ass< tramdicated The low-dose radiotherapy- for painful arthrosis of the knee joint have been published Of these patients 5069 were surveyed within the framework of a German patterns of care study-performed in 2010 [10]. A response to radiation therapy ui terms of a marked and complete reduction of pain was shown in 58-91 % of the irradiated patients [Plantar fasciitis| Retrospective analyses reported on CR rales ui 12-81%. and PR rates in 7-7-1°,» [9. IS. 18] In a randomized tnal. Heyd el al [7] randomly compared two dose regimens 3 0Gy/0.5Gyvs 6 0 Gy 1 0 Gy in 130 patients Radiotherapy led to a both groups, and tive la another r if surgical other conservative excessive side effe< 24-89% or desirable or if ire associated with J The results from 895 patients treated with low-dose radiotherapy for pauiful arthrosis of the hip joint have been published A response to radiation therapy 111 terms of a marked and complete reduction of pain was shown in 24-89% of the irradiated patients [19] [Arthrosis of the hand and finger joints | Considering the results of the retrospective studies, low-dose radiotherapy may be an effective therapeutic option for painful arthrosis of the hand and finger joints, even if other conservative treatment methods are associated with -80% 0/ Tactions of 1.0 Gy After 3 months 38 »-j 73% >„ had a PR Olscbew^ki and Klem [12] reported on another 26 patients They- found an overall response rate of 73%. with 23% CR and 50% PR rates men was equally effec-•waid et al [11] evaluated the efficacy of two other dose concepts in 62 évaluable patients 6.0 Gy/1.0 Gy vs 0 6 Gy/0 1 Gy After one year, compared to the very- low-dose arm the higher-dose arm led to a significant advantage m tenus of pain control excessive side effe< 809 patients treated The results from 'therapy for pauiful 63-75% arthrosis of the liam'i .uiu uuyei juuns nin e been published A response to radiation therapy in terms of a marked and complete reduction ofpaui was shown ui 63-75»» of the irradiated patients [4] ...AND MANY WERE ABLE TO PROVE IT!! CARDIO-VASCULAR DISEASES Non-invasive Cardiac Radiation for Ablation of Ventricular Tachycardia: a New Therapeutic Paradigm in Electrophysiology Eun-Jeong Kim,* Giovanni Davogustto,* William G Stevenson and Roy M John Division of Cardiovascular Medicine. Department of Medicine. Vanderbilt University Medical Center. Nashville. TN. USA •Both authors contributed equally to this work Abstract Non-invasive ablation of cardiac tissue to control ventricular tachycardia (VT) is a novel therapeutic consideration in the management of ventricular arrhythmias associated with structural heart disease. The technique involves the use of stereotactic radiotherapy delivered to VT substrates. Although invasive mapping can be used to identify the target, the use of non-invasive ECG and imaging techniques combined with multi-electrode body-surface ECG recordings offers the potential of a completely non-invasive approach. Early case series have demonstrated a consistent decrease in VT burden and sufficient early safety to allow more detailed multicenter studies. Such studies are currently in progress to further evaluate this promising technology. Keywords Ventricular tachycardia, ablation, non-invasive, stereotactic body radiation therapy Disclosure: William Stevenson is cohdder of a patent for the needle ablation electrode consigned to the Brigham and Women's Hospital. Roy John has receded lecture honoraria from B«sense Webster and Medtronic Received: 13 February 2018 Accepted: 20 February 2018 Citation: Arrhythmia & Electrophysiology Review 2018;7{1):8-10. DOt: 10.15420/aer7.1£01 Correspondence: Roy M John, MBBS. PhD. FRCP. Division of Cardiology. Department of Mediane, Vanderbilt University Medical Center, 2220 Pierce Avenue, 383 Preston Research Building. Nashville. TN 37232-4300. USA. E: royjohnevanderbilt.edu Risen from the dead: Cardiac stereotactic ablative radiotherapy as last rescue in a patient with refractory ventricular fibrillation storm Eberhard P. Scholi, MO, PhD.' " Katharina Seidensaal. MO, Patrick Naumann, MO, Florian André, MO; Hugo A. Katus, MD, PhD/" Jiirgen Debus. MO, PhD M» ^^^ À H 1 ^Km ■ I* v' ■ i iHKB Conclusion Wc pre»en I a case with favorable outcome in a patient suffering from severe postishemic VF storm in which stereotactic radiotherapy was paralleled by a rapid decline of arrhythmia burden. This case further strengthens stereotactic radiotherapy as a bailout strategy in patients with refractory ventricular arrhythmias. However, caution is warranted and patients should therefore be selected carefully, since data on long-term toxicity are scarce. Heart Rhythm Case Reports, Vol 5, No 6, June 2019 Clinical Oncology 35 (2023) 611-620 Contents lists available at ScienceDirect Clinical Oncology journal homepage: www.clinicaloncologyonline.net Original Article A Meta-analysis of the Efficacy and Safety of Stereotactic Arrhythmia Radioablation (STAR) in Patients with Refractory Ventricular Tachycardia G.A. Viani*j, A.G. Gouveiatt, J.F. Pavoni§, A.V. Louie % ). Detsky% D.E. Spratt||, F.Y. Moracs f** Conclusion The current limited body of evidence suggests that STAR is effective and safe for treating patients with refractory ventricular tachycardia. STAR rcduccd the consumption of AAD and the number of ICD shocks. The current metaanalysis supports the ongoing nine trials and other future prospective studies using STAR for patients with refractory ventricular tachycardia. (a) % of VT burden reduction at 6 months ONCOLOGY Studies Cuculich 2017 Neuwirth 2019 Robinson 2019 Giani 2020 Carbucicchio 2021 Lee 2021 Estimate (95%C0 92%(70-100) 90%(71-100) 94%(84-100) 80%(45-100) 93%(85-100) 85%(60-100) Overall (12=0%, p=0.96) 92%(85-100) 60 70 80 90 100 11) Check for updntos (b) % patients using < 2 AAD at 6 months Studies Cuculich 2017 Robinson 2019 Giani 2020 Estimate (95%CI) 75%(50 -100) -88%(73 -100) 80 %(50-100) _ Overall (12=0%, p=0.7) 85% (72-99) 50 60 70 80 go 100 (c) OS at 6 mo Studies Cuculich 2017 Neuwirth 2019 Robinson 2019 Giani 2020 Carbucicchio 2021 Lee 2021 Estimate (95%CI) 75%(50-100) 95%(83-100) 90%(76-100) 91%(70-100) 7S%(4S-100) 71%(38-100) ' Overall (12=0%, p=0.S7) 89% (81-97) 40 50 60 70 80 90 100 (d) OS at 12 mo Studies Cuculich 2017 Neuwirth 2019 Robinson 2019 Giani 2020 Estimate (95%CI) 75% (40-100) 95% (83 -100) 73% (54- 93) 60% (40 - 98) Overall (12=24%, p=0.1) 82% (65-98) 40 60 80 100 ■te m tn» AGE-RELATED MACULAR DEGENERATION •Leading cause of blindness in the Western world after cataracts •>50yo •Female>male •Dry-AMD: better pognosis Cross Section of Macula with Dry AMD Cross Section of Macula with Wet AMD Fovea Retina RPE Bruch's Membran« Choroid Drusen Thinning Retina Abnormal Blood Vessel Breaking Through Bruch's Membrane The progression of wet AMD Normal vision Wet AMD -85% 15% 7TI Wim tm-VJ-f/SS tffîiVffffffi iMfmi Intcrnitiorul jouriul of Radiation Oncology biology »physics www.redjournal.org Critical Review Radiation Therapy for Neovascular Age-related Macular Degeneration Amar U. Kishan, MD,* Bobeck S. Modjtahedi, MD,1 Lawrence S. Morse, MD, PhD,f and Percy Lee, MD* *Harvard Medical School, Boston, Massachusetts; 'Department of Ophthalmology and Vision Sciences, University of California, Davis, Sacramento, California; and 1Department of Radiation Oncology, David Geffen School of Mediane at UCLA, Los Angeles, California Rcceivcd Jun 13, 2012. Acccptcd for publication Jul 15, 2012 In the enormity of the public health burden imposed by age-related macular degeneration (ARMD). much effort has been directed toward identifying effective and efficient treatments. Currently, anti-vascular endothelial growth factor (VEGF) injections have demonstrated considerably efficacy in treating neovascular ARMD. but patients require frequent treatment to fully benefit. Here, we review the rationale and evidence for radiation therapy of ARMD. Hie results of early photon external beam radiation therapy therapy, and brachytherapy. The evidence suggests that these 3 modem modalities can provide a dose-dependent benefit in the treatment of ARMD. Most importantly, preliminary data suggest that all 3 can be used in conjunction with anti-VEGF therapeutics, thereby reducing the frequency of anti-VEGF injections required to maintain visual acuity. © 2013 Elsevier Inc. m 1 MV The Epi-Rad system handpiece. The surgeon s a small strand of Strontium-90 into the tip after insertion into the eye. The brief exposure damages diseased cells preferential^. BT kV Photodynamic therapy sensitive dye - - ) VEGF KM ri hospitales Focal laser for wet AMD Macular degeneration Laser ^^H beam tI^I u Abnormal t Cold laser activates dye only in abnormal blood vessels Vertebral Hemangiomas Benign lesions characterised by aberrant vessels in vertebral bodies. More frequent in women Affect 10-12% of the population 0.9-1.2% symptomatic (pain and neurological symptoms) Treatment: in symptomatic patients only • Surgery: laminectomy, vertebrectomy • Embolization, ethanolisation • Vertebroplasty RT effective in pain relief, dose-related response (Rades IJROBP 2003)20-34 Gy: 39%36-40 Gy: 82% dose-response ROS ft Cell cyle arrest and senecence Progenitor fibroblast Myofibroblast/ fibrocyte hampered recruitment of leukocytes Macrophage CONNECTIVE TISSUE HYPERPROLIFERATIVE DISORDERS Heterotopic Ossification lili. 1 RadiiliMi :>ncc]0gy Biol. fhyt., Vol. «J, No. J, pp. Î88-895, 2001 Copuigbit C 1004 Et1.? vie: Inc. fYuiV'J u] it " USA. Ail ngbb ffieiYtd 0JW-3O16 M t'rciit matter [tal: lO.lOlS/j.Iji obp.2003.11.D15 ELSEVIER CLINICAL INVESTIGATION_Benign Disease RADIOTHERAPY VS. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS FOR THE PREVENTION OF HETEROTOPIC OSSIFICATION AFTER MAJOR HIP PROCEDURES: A META-ANALYSIS OF RANDOMIZED TRIALS Emiliqs E. Pakos, M.D.,* and John P. A. Iqannidis, M.D.*+î Risk ratio for Brooker 3 or 4 HO (RT vs NSAID) Graves' Ophtalmopathy Orbital radiation therapy for Graves' ophthalmopathy: Measuring clinical efficacy and impact Ezra Hahn MD \ Normand Laperriere MD, FRCPC J, Barbara-Ann Millar MBChB, FRCPC \ James Oestreicher MD6, Hugh McGowan MDb, Hatem Krema MDb, Harmeet Gill MD b, Dan DeAngelis MDb, Jeff Hurwitz MD b, Nancy Tucker MD b, Rand Simpson MDb, Caroline Chung MD, FRCPC, CIP*"* 'Department of fhuhaOon Omcohgy. Umimxy of Toronto. Toronto, (totaru*. C'anuia *f>cpartmrnt of Ophthalmology *mJ linan Science*. IMivrrsty of Toronto. Toronto. CMtano. Canada Revoved 14 lamury 2014. mktd 20 February 2014. acwpicd 2* Fcbru*y 2014 AMrart Purpose: Cimo' ophthalmopathy «GO) t» an *u»o«mmur>e cundifcuo pnmartN nunafrd »nth prolonged onawt of fiucooor%codv »bach can be tuixaid with ti|m((aM ade cffcvu Orbcal radutwn dicnf) mmI «ympiofm In chat ttiady. the therapcutc benefit of RT «a» evaluated in rnm of patient't abikty to taper thctr (wtHntcimd icqwicnvntv «kh may better reflect the (ncfhito] mechantwn of RT and (vm«k a elincaUy relevant rofMi« endpoint Method* and material*: Th» n a rttw^relst rox* of conaccutive («baib treated **th orbcal RT for GO bctecen 2000 and 2010 at a »taffe ternary totprtat «itfc a ded*.ated ooihr radutum therapy danc TV primary measure of treatment retpontc «a» defined m f»c ability to taper gtucucofbcoMk Mkmmg RT »idwui any further exacerbation of t«btofa(iy «ymptomt Additoiul endpon* tnchahnf ocular cymptocm «fcptopu. pRftMiv. \t«ual acuity, eitnocubr movement! and ncod for turpcal intervention kic repotted. Rrvuttv: Of V» dipMe pabentv »Kb a mean Mkm-up of 9J month», Xl («MS) paticntt (rounded to RT Of patent* taking ««UtMknwb at bandine. 91% were able to taper off «rtioamwk completely and #»e rem*rung ptfrentt bad ikocaed their dote» by Diplopia, uwul acuity, and extraocular movement» improved in 29%, Xl%, and MS of prtacnu, reipcetnciy The molun reduction in p»opa>us «a» 2.5 mm and 2 mm m the left Conclusions: Orbital RT is a generally wcD-tolcraled treatment that helps minimize the dose and duration of corticosteroid therapy for patient» with GO vwiiilc improving ocular symptoms, including proptosis and diplopia. Prospective research should consider using corticosteroid requirement as a measure of response to orbital RT for GO. cmdvutininom ofg1«ocnict.t»yfti A B m ■ 2 Si IV . Mfc Morbus Dupuytren/Ledderhose •Proliferative connective tissue disorder affecting the plantar fascia (Dupuytren's) or plantar fascia (Ledderhose) •Subcutaneousfibrouscordsand nodules leading to retraction of the toes. •Affects 1-3% of the European population, related to CLD, alcoholism,... •Treatment: corticosteroids, allopurinol, NSAlDs, surgery... •Radiotherapy: 15 Gy /3Gy/fx) x 2 courses 3-6 weeks apart; stabilisation or improvement in 80-90%. Radiotherapy and Oncology 185 (2023) 109718 ELSEVIER Contents lists available at ScienceDirect Radiotherapy and Oncology journal homepage: www.thegreenjournal.com Radiotherapy aOncology Original Article Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial f (8) Anneke de Haan3'*, Johanna G.H. van Nesb, M. Willemijn Kolffc, Peter-Paul van derToornd( A. Helen Westenberg e, Annelies E. van der Vegt f,\ Henk Groeng,Jelle Overbosch h, Hans Paul van der Laan: Paul M.N. Werker1, Johannes A. Langendijka, RoelJ.H.M. Steenbakkers a Arm 1 (sham-radiotherapyj Arm 2 (radiotherapy) Progressive pair) | Stable pain | Partial pain rçspenw Complete pain response Quality of Life $— 6 months 12 months 18 months • Sham-RT ■ RT Dutch population E months 12 months 16 months -1-1-1-1 Baseline FU 6M FU 12M FU 18M Time point In conclusion, compared to sham-radiotherapy, radiotherapy for symptomatic Ledderhose disease is an effective treatment, resulting in a significant pain reduction, improvement of QoL scores and bare feet walking abilities, without increased toxicity. Hidradenitis suppurative Chronic inflammatory-proliferative skin disorder appearing as folliculitis with ulcerated and oozing papules and pustules. Affects 1% of the population; localized in folds (axilla, groin, neck, buttocks,...) Evolves to fibrosis, contracture, distortion of the tissues. Radiation therapy 3-8Gy (0.5-2Gy/fx) effective and safe in reducing incidence and complications. Gynecomastia Benign proliferation of mammary glandular tissue in men due to androgen/estrogen imbalance. Associated with hypogonadism, hepatopathies, Leydig's tumors... Also in patients under ADT: 3-13% with GnRH analogues but 40-70% with bicalutamide 150mg/24h. Radiotherapy: • Prophylaxis: 10 Gy -J, risk 50-60%. Therapeutic: 2 x 6 Gy -J, pain and intensity 35-45%. >; MSAA n Keloids Excessive tissue proliferation in the healing process • Typically after surgery, piercings or aggressions with bladed weapons or firearms. • Treatment: surgery but 80'% relapse Radiotherapy: EBRT or BT reduces the risk of relapse after surgery. Start <24h after surgery (ideally <90 minutes). Also useful as exclusive treatment in inoperable/irresectable patients. CNS FUNCTIONAL DISORDERS Outcomes from stereotactic surgery for essential tremor Robert Francis Dallapiazza,1 Darrin J Lee,1 Philippe De Vloo,' Anton Fomenko,1 Clement Hamani,1 Mojgan Hodaie,' Suneil K Kalia,' Alfonso Fasano,2,3,4 Andres M lozano' Table 1 A comparison of surgical outcomes for ET DBS FUS GKRS RF Experience 1093 patients 1S1 patients 360 patients 278 patients since 1998 since 2013 since 2007 since 1986 Level of Evidence. Lewi 2 Level 1 level 4 Levels 2-4 (OCEM) Tremor control Unilateral: Unilateral: Unilateral: Unilateral: 12-month follow 3S%-7S% 48%-€3% 74%-90% up Bilateral Bilateral: no Bilateral: no Bilateral: no G6%-78% data data data Tremor control Unilateral: Unilateral: Unilateral: Unilateral: long-term foUow- 60%-7S% 56* 3%-63% 74%-»% up Bilateral 7S% Quality of life S7.9%-82% 37%-73% 6S% 47% Improvements Complications (range, transient Unilateral and permanent) bilateral 11*-39%. Dysarthria 22%-7S% 3% 1%-3% 4.6*-29% 9%-17%, Ataxia/gait S6%-«6% 23« 0%-17% S%-27% Pawsthesi* S%, 5 9% 14*-2S% \HrVk 6V-42* Hemiparesis 4.5'A.6.7% 2%-7% VMTk 0%-34% Tremor symptoms Treatment» Unilateral tremor 1. Unilateral DBS 2. Unilateral FUS, GK or RF thalamotomy Bilateral tremor 1. Bilateral DBS (Single or staged surgery) 2. Unilateral DBS for dominant or more affected upper extremity with delayed staging for secondary DBS 3. Unilateral DBS followed by RF or GK thalamotomy Patients unwilling or unable to undergo DBS Treatments. Significant medical comorbidities • GKRS thalamotomy Skull favorable for FUS • FUS thalamotomy Infection of DBS system • RF, GKRS, or FUS thalamotomy EI. essential tremor; D6S. deep brain stimulation: FUS, foaised ultrasound; GKRS. gamma knife radkKurqieal thalamotomy; RF. radiofrequency. •Out-patient treatment •130-160 Gy in a single fraction •Tremor control @12months: 48-53% •QoL improvement in 65% J Neurol Neurosurg Psychiatry 2019;90:474-482. Stereotactic radiosurgery for functional disorders Geuurd M. Kwms. M.I)..IJ Michakl C. Park. M.I).. Ph.D.. Marc A. Goldman. M.I).,1 Ponmtun-4 näiottuvn for mo RaJbnrgrryJorFúmáúoiittrt* K*Bowníriyíortplltpn' Radiosurgery for the Treatment of Psychiatric Disorders: A Review Mare Ltrveque', Romain Canon1-*-'. Jean Regis'-14 leksell 1985 1 SAO ALIC 120 Gy Mlndes 1987 7 SAO ALIC 160 Gy llppltz 1999 9 OCD ALIC MS Del Valle 2006 9 Heteroagresión 6; OCD 2, SAD 1 ALIC; LL NS ROck 2008 9 OCD ALIC 180 200 Gy lop« 2009 S OCD AUC 180 Gy Slav!n2009 4 OCD ALIC 180 Gy Kondzlolka 2011 3 OCD ALIC 140-150 Gy Pobre 45% bueno; 27» pardal; 27» pobre 78% bueno 67» bueno, 33» pardal 40»bueno 40* moderada; 20» nula 75» parcial: 25» nula 100» pardal Woftd NdífOSfg 120131 SO. 3/4S3?tl-S32tS Stereotactic Radiosurgery for Trigeminal Neuralgia: A Retrospective Multi-Institutional Examination of Treatment Outcomes Raj Singh1, Joanne Davis:, Sanjeev Sharma 3 Conclusions SRS is an effective treatment option for TN patients in community settings. Initial pain relief following SRS was achieved in a vast majority of TN patients with associated minor toxicities observed in less than 20% of all patients. Frameless Image-Guided Radiosurgery for Initial Treatment of Typical Trigeminal Neuralgia Joseph C. T. Chen1, Javad Rahimian2, Rombod Rah ¡mi an2, Alonso Arellano2, Michael J. Miller2, Michael R. Girvigian2 2016 Singh et al. Cureus 8(4): ©554. DOI 10.7759/cureus.554 Device/Method OMax/Collmwtor H Follow-up (Months) S Good topons« S BNI PS = I. II Dysesthesia fanseft 2009 (61 CytwKnrfe/IGRS 56-75 GyA mm 33 Huang 200818) Gamma foufe/fcame 79 Gy/4 mm 89 Broman 2000 (1) Gamma Knife/frame 75 Gy/4 mm 82 Kon&iota 1998 (101 Gamma Knife/frame 70-« Gy/4 mm 23 Present study NomMGRS 90 Gy/4 mm 44 23 GO 12 12 15 94 77.5 87 96 91 27 56 NR 74 52 0 0 2* 0 0 DM*. Mown dot*. KîfiS. >>ugtf«M radowgwy WORIO NCUNOBUMOCItY. OO) I O I O I t j mlu JO I O 07 OOI Respiratory Mediane (2012) 106. 1063-1069 Available online at www.scieflcadirect.com SciVerse ScienceDirect journal homepage: www.elsevier.com/locaia/rmed SHORT COMMUNICATION External beam radiation therapy is safe and effective in treating primary pulmonary amyloidosis Shaohua Ren3 *, Gang Ren b * Department of Respiratory Medicine, Lishui Central Hospital, No. 2 Dengta Street, Zhejrang Province 323000, PR China b Molecular Imaging Program at Stanford (MIPS), Department of Radiology, Stanford University, California, CA 94305-5344, USA KEYWORDS Primary pulmonary amyloidosis; Tracheobronchial amyloidosis; External beam radiation therapy Summary The aim of the prospective study was to explore the safety and effectIvensss of external beam radiation therapy (EBRT) in three patients with biopsy proven primary pulmonary amyloidosis, including two tracheobronchial amyloidosis patients and one primary parenchymal amyloidosis patient, All three patients were treated to 24 Gy in 12 fractions utilizing CT simulation and 3-D planning. All three patients had significant Improvement in clinical symptoms, radiological imaging as well as pulmonary function tests. The improvement in the clinical symptoms was evident in 2 days. Toxicities related to EBRT were not observed during the follow-up range from 42 to 54 months. EBRT to 24Gy was safe and effective in the three patients with primary pulmonary amyloidosis, and resulted in rapid relief of pulmonary symptoms. © 2012 Elsevier Ltd. All rights reserved. InicfiMiuio j| juumal of Radiation Oncology bio lu By • physics Clinical Investigation: Thoracic Cancer Long-Term Results of Conformai Radiotherapy for Progressive Airway Amyloidosis Mirth Tain Truong, M.D.,* Lisa A. Kachnic, M.D.,* Gregory A. Grillone, M.D.,f Harry K. Bohrs, B.S.,* Richard Lee, M.D.,* Osamu Sakai, M.D., Ph.D.,* and John L. Berk, M.D.!( Departments of "Radiation Oncology, 'Otolaryngology, !Radiologyr and Medicine, Amyloid Treatment and Research Program, Boston University School of Medicine, Boston Medical Center, Boston, MA Received May 9. 2011. and in Summary Ten patients with symptomatic airway amyloidosis were followed for a median of nearly 7 yeans after 20 Gy external beam radiotherapy. RT appeared effective in controlling progressive airway amyloidosis of the larynx and tracheobronchial nee in S of 10 patients by stabilizing amyloid deposits and improving pulmonary funciion. It did so with no obvious lale morbidity. n Jul 26, 2011. Accepted far publication Jul 28. 2011 Spirometry before/after RT a; MM HI-K1 <2-2* wot ia-!S mtn*i ft*>f Spirometrie changes post RT ilii Neurofibrillary tangles (NFT Neuronal loss Synaptic degeneration 55 yo MMSE: 10-20 Rosen Modified Hachinski Ischemic Score <4 Diagnostic criteria for Alzheimer's disease NINCDS-ADRDA. A: 10Gy/5fx B: 20Gy/10fx Safety and toxicity (CTCAE) Evolution of neurocognitive test and PET at 12 months University of Virginia Commonwealth NCT02769000 Phase II 30 >55 yo Rosen Modified Hachinski Ischemic Score <4 Diagnostic criteria for Alzheimer's disease NINCDS-ADRDA. Florbetapir F 18 confirmatory PET A: 10Gy/5fx B: 20Gy/10fx Safety and toxicity (CTCAE) Evolution neurocognitive test at 12 months University of Geneva NCT03352258 Phase III 20 18-80 yo Prodromal phase AD or mild/moderate symptoms A: no RTE B: 10Gy/5fx Safety Reduction in amyloid deposits by PET at 8-12 weeks Evolution neurocognitive test at 6 months Kyung Hee University NCT04203121 Fase III 10 50-90 yo MMSE: 10-24 Mild/moderate AD symptoms A: 9Gy/5fx B: 5,4Gy/3fx Safety Evolution neurocognitive test, MRI and PET at 6 months Changes in amyloid deposits at 6 months by variations in 18-flutemetamol-PET (SUV variation >5%) 2023: FIRST CLINICAL RESULTS IN HUMANS International Journal of Radiation Oncology*Biology*Physics ELSEVIER Volume 117, Issue 1,1 September 2023, Pages 87-95 CLINICAL INVESTIGATION Low-Dose Whole Brain Radiation Therapy for Alzheimer's Dementia: Results From a Pilot Trial in Humans C. Leland Rogers MD * s, Satah K, Lageman PhD t. lames Fontanesi MP t. George D. Wilson PhD t, Peter A. Boling MD T. Surbhii Bansal MD T. lohn P. Karis MP i. Marwan Sabbagh MD S. Miriesh P, Mehta MD II. Timothy J. Harris MP. PhD t Show more v + Add to Mendeley Share w Cite https://doi.Org/10.1016/j.ijrobp.2023.03.044 71 Get rights and content 71 Purpose We report neurocognitive, imaging, ophthalmologic, and safety outcomes following low-dose whole brain radiation therapy (LD-WBRT) for patients with early Alzheimer dementia (eAD) treated in a pilot trial. Methods and Materials IntJ Radiat Oncol Biol Phys, volume 108, issue 3, supplement, e747, november 01, Trial-enrolled patients were at least 55 years of age, had eAD meeting NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association) Alzheimer's Criteria with confirmatory flliorodeoxv.glucose and florbetapir positron emission tomography findings; had the capacity to complete neurocognitive function, psychological function, and quality-of-life assessments; had a Rosen modified Hachinski score <4; and had estimated survival >12 months. Results Five patients were treated with LD-WBRT (2 Gy*5 over 1 week; 3 female; mean age, 73.2 years [range, 69-77]}. Four of 5 patients had improved (n=3) or stable (n=l) Mini-Mental State Examination (second edition) T-scores at 1 year. The posttreatment scores of all 3 patients who improved increased to the average range. There were additional findings of stability of naming and other cognitive skills as well as stability to possible improvement in imaging findings. No safety issues were encountered. The only side effect was temporary epilation with satisfactory hair regrowth. Conclusions Our results from 5 patients with eAD treated with LD-WBRT (10 Gy in 5 fractions) demonstrate a positive safety profile and provide preliminary, hypothesis-generating data to suggest that this treatment stabilizes or improves cognition. These findings will require further evaluation in larger, definitive, randomized trials. N = 5 WBI 5 x 2Gy At 12 months (MMSE-2): 3 improved 1 stabilizated 1 worsened 2020, https://doi.org/10.1016/j. ijrobp.2020.07.162 BEDSIDE MEDICINE FOR BEDSIDE DOCTORS An Open Forum for brief discussions, of the workaday problems of the bedside doctor. Suggestion» for iubjccts for discussion invited. November, 1931 THE USE OF RADIOTHERAPY IN ACUTE PYOGENIC INFECTIONS John D. Lawson, M. D. (Woodland Clinic, Woodland).—The treatment of acute pyogenic infections through the use of radiotherapy is not new, but recently has received considerable attention with the result that it has come into more general usage. The more common acute infections in which roentgenotherapy has been utilized with success are erysipelas, furunculosis, carbunclës, cellulitis, lymphadenitis, lymphangitis, parotitis, and acute pelvic inflammatory disease. In all of these conditions we find a rather remarkable response to the use of this physical agent, provided the disease has not progressed to suppuration. If necrosis has already occurred and the lesion has become entirely localized, it has not been our experience that any favorable results are obtained. If, however, extension is continuing about a necrotic area the effect of radiotherapy is quite satisfactory as it will inhibit further progression. In the treatment of acute pyogenic infections by means of roentgen rays the point of first importance is the selection of cases. This mode of therapy will certainly come into disrepute if attempts are made to produce results in instances where necrosis and suppuration have already occurred. and included in the irradiated area. If radiation is limited to the lesion itself a high percentage of patients will have further extension, whereas if the application includes the larger area this will not occur. It has not been our practice to reirradiate within forty-eight hours, but if the lesion has progressed and there is still no evidence of necrosis at the end of that time the same dosage is repeated. As stated before, the results obtained in this field are such as would convince the most skeptical, and it has been routine at the Woodland Clinic for several years to refer all acute nonsuppurative pyogenic infections to the radiotherapy department for treatment. * * * Moses Scholtz, M. D. (1930 Wilshire Boulevard, Los Angeles). — The term "radiotherapy" colloquially implies x-rays and radium, and strictly speaking it should also comprise the superficial actinic modality of the ultra-violet ray. Pyogenic infections of the skin naturally divide into two groups, superficial and deep. The superficial infections of the skin are represented by various types of pyodermias, such as pyogenic intertrigos, impetiginous streptococcic dermati-tides, perleche, and common impetigos. ROENTGEN TREATMENT QF ACUTE CERVICAL LYMPHADENITIS * L CHARLES ROSENBERG, M.D. KCWÎÏK, K. J. Acute cervical lymptiadetiitis in children, secondary to infections of the upper respiratory tract, is frequently encountered, particularly ill the locality about Newark Mativ of the macs under observation proceeded to the stage- of suppuration. Some radical deviation, there-tore, from the usual course ot treatment was considered. Attention was tunjed to the iiicre»itig nunibei oi reports >n the current literature in which the trcTiir.tctt of wtient3 who had various acute and chronic inflammatiqn-s with roentgen ray* was dis«l$Kortiug the eases, mid a surgeon would see only a fe»v eases, in tlie most of which the treatment was inefficient itnrl incomplete. As before stated, in only a small percentage of cases, 5 to 10 por cent,, ts it advisable to remove fibrous nodules after radiation. Jf such nodules are removed and examined, little or no lubcreutfHis material would lie found, the fibrous stroma of the glands remaining. In the trentmcnt of tuberculous adenitis tlic first and most important consideration is thnt it is a local manifestation of o constitutional disease. Most of the laryngologists arc referring' tuberculous adenitis for radiation ns n routine procedure, and many will not remove diseased tonsils if tlie cervical glands nre enlarged until tlie elands have been given a thorough course of treatment, «¡ti er by roentgen rnys or radium. Radiation of the enlarged cervicnl glitntls is im]X>rtmit before removing tlie tonsils of children under fifteen years of age, «ml particularly so if tinder tlic age of five or six, ns tlie lymphatic vessels urc wide o|*;ii, unci in the removal of the tonsils before mdiation there is danger of producing a general infection if tuberculosis ia present. In the past the treatment of tuberculous gin mis depended I firstly upon the physician first consulted, Tlie treatment given lias been the hygienic, medical, roentgen ray and radium find light therapy, vnceine unrl surgical. Tuberculin has given nnsatisfnetory results, and sine«- radiation protluees a systemic cfl'cct similar to successful ■ Itfiul belors Ih* lV««tnwrolo»d County Medcal Society, Oiccnaliure. I'«.. Noirnllr 9, 1970. Twelve-Year Review of X-Ray Therapy of Gas Gangrene1 JAMES F. KELLY, M.D., F.A.C.R., and D. ARNOLD DOWELL, M.D. Omaha, Nebraska The first report on the x-rav treatment of gas gangrene was made in Deeember 1931, before the Radiological Society of North America at Hie Seventeenth Annual Meeting in St. Louis (1). The mortality rate for gas gangrene up to that time had been 50 per cent or higher and that figure was attained only by the sacrifice of many arms and legs. The mortality rate in the group of 8 cases then reported was 25 per cent, and no additional tissue was removed in anv ease after x-ray therapy was begun. a disease as gas gangrene with its form« high mortality and morbidity. The x-ra' O v / < however, has definitely removed gas gai grene from that group of diseases in whic experimental therapy is any longer ju tifiablc. Chemotherapy has failed in our vicinil and also in other places, as was to be e: peeted, since in a well developed case ■ gas gangrene there is definite interferes in the circulation to the infected area ar consequently in the most serious cases tl chemical fails to reach the diseased tissue Radiology, Oct 1941 MORTALITY RATE PRIOR TO X-RAY THERAPY MORTALITY RATE SINCE X-RAY THERAPY ir From Hippocrates (0 Welch Surg. Gen. X-rays / "Si Report Millar's First S Etiology M.C. U.S. A. Report Used Hippocrates Determined World War S.G. & 0. in 460-370 B.C. to 1900 a.d. Vol. XII 1932 192S First1 Second2 Third1 Fourth1 Statistics Report Report Report Report to May 1933 1936 1936 193S 1940 As the etiology was unknown prior io 1900 no definite mortality rate can be established No effective treatment was known > ) 00% I I S6% I I SURGERY 50% 1----------- M 45% I The above reports are representa- 0 I R 40% I tive of the results obtained T I A 34% | with surgery. . . . L I 1 30% I Between 1930 and 1941 the mor-T | Y 25% I tality rate with the use of sur-I R 20% | gery and serum shows some A I T 15% ( variations E I 10% I 5% I 0% ! 364 cases one or more x-ray treatments 11.5 , mort. 288 cases three or mure x-ray treatments 5 .9% inort. 42 cases three or more x-ray treatments. No serum. No amputations 4.7% mort. Fíe. 1. End oí «¡u íaiutrene as a Seriem» infection (if x rav Uicranv Ubcd). Radiology, Oct 1941 InternationalDo5E:REsroNSESocjety o s 60 50 40 a 30 73 ai. DosiKapmue. 1Q:62&«43, 2012 Formerly NonUntarify in liiology, Toxicology, and Medicirtf Copyright © 2012 University of Massachusetts ISSN: 1559-3258 DOI: 10.2203/do5tre3poirce 124) 16.Calabrcst> THE ROLE OF X-RAYS IN THE TREATMENT OF GAS GANGRENE: A HISTORICAL ASSESSMENT Edward J. Calabrese, Gaurav Dhawan □ Department of Public Health, Environmental Health Sciences, University of Massachusetts 20 - 10 Standard techniques from 1942: 1) 1-3 treatments per day: 2) distance, 40 cm. 3) kV must be adequate to thoroughly penetrate the tissues involved: 4) 60-120 cGy with 1-3 mm A1 filter for prophylaxis and 150 cGy with Cu filter for therapy; and 5) after 500 cGy (a dose which can cause skin erythema), a maximum of 25 cGy/d 1928 1933 1936a 1936b 1938 1940 1940* 1940* Statistical Reports (year reported)) LOW-DOSE RADIOTHERAPY FOR PNEUMONIA: OLDIE BUT GOLDIE?? YALE JOURNAL OF BIOLOGY AND MEDICINE 86 (2013), pp.555-570. Copyright ©2013. REVIEW How Radiotherapy Was Historically Used To Treat Pneumonia: Could It Be Useful Today? Edward J. Calabrese, PhD*, and Gaurav Dhawan, MPH Fig. 7 (case 4).—A, the limes on the second clay of pneumonia, with l''g 8 (.«is« 4).—icm|ierature curve for the second to eighth days, consolidation chicfly in the vipht lower lobe. The sputum contained uneumococci not type, I, II, ill. B, the ninth day, the lungs are almost clear. 836 cases of pneumonia treated with low-dose radiotherapy between 1905-1946 •Treatment of acute infection and prevention of post-herpetic neuralgia (n=108) •624 cGy; 6 fractions; 104 cGy/fx •Radiotherapy before 8th day decreases risk of post-herpetic neuralgia LI Radiation Oncology • RioJogv • Physics Volume 63, Number 2, Supplement. 200 5 2333 Radiotherapy for Herpes Zoster iHZ) In the Acute Time: A Re I respective Study with Long Follow-Up M.l. SujcjjDflQ,1 5. Eiieri.3 C. Luthi" 'Radio-Oncology, Hospital of Son, Sion, Valuis, Switzerland -Heattfi Observatory, Sian, Vaiais, Switzerland Purpose/Ohji-elhe: A retrospective study has been undertaken to study the efiieienev_jjnd_5alc^ ircaimenUifjl^^iMt^^ well as to identify predictor factors for the occurrence of post hcjpelic neuralgia fPHN) and the risk of malignant tumour. Materials/Methods: One hundred and eight patients were treated between January 1975 and November 2003 in the acute phase (1-30 days from the onset of rashes), 54 (SO'S) patients were in the group A (I -7 days), and 54 150%) patients were in the group tl (E —30 days). The median age was 66.5 years frange 17-S9) for group A, and 67.5 years grange 30-SE) for group B. The patients were asked to rank any discomfort connected to the dermatome concerned as none, noticeable, mild, moderate, or severe. The corresponding numerical values were also defined for the patients: no pain= 0, noticcablc= I. mild pain= 2 moderate pain= 3 and severe pain= 4. The follow-up was conducted by the radiation oncologist or by general practitioners. Results: Assessment of acute pain. Proportions of patients with pain at the end of RT were 77.1% for group A and E2.4'jL for group B. Assessment of Postherpetic Neuralgia. At three months, sis months and at least one year after the end of RT, the PHN were 25%, 20.8%, and 12 %■ for group R, 10.3%. 10.3% and 6.7^ for group A. No patients show severe pain at > 6 months. Results of the multivariate analyses showed that, when controlling for age and gender, the risk of having pain three months after treatment was 2.67 higher in patients of group B compared to patients from group A. Further, this risk decreased to around 2 after 6 months and one year or more. Kadiothcrapy had an important effect on pain in both, patients older than 60 years and younger patients, with 100% pain free. Conclusions: This is the first retrospective cohort study in unselected patients which were treated with radlotherapyiRT). To our knowledge, this study has the longest follow-up to date. 'nfisstud^showsjhat^Tj^ least as_much_antlvira^^ RT Is safe and no malignant tumor related RT was observed. In the Tuture our results should be controlled in a randomised trial with or without antiviral therapy in high risk patients. The combination treatment with the well known antiproliferative and the anti-inflammatory cfTcels of radiation might improve the PHN. LET'S TALK ABOUT... © 2023 Greater Poland Cancer Centre. Published by Via Medica. All rights reserved, e-ISSN 2083-4640 ISSN 1507-1367 REVIEW ARTICLE Reports of Practical Oncology and Radiotherapy 2023, Volume 28, Number 1, pages: 74-78 DOI: 10.5603/RPOR,a2023.0001 Submitted: 06,09.2022 Accepted: 15.12.2022 KM hm hospitales The 5Rs dilemma of radiotherapy for non-malignant diseases: 5Rs to darken OR 5Rs to shine Angel Montero1'2, Beatriz Alvarez1,2 'Department of Radiation Oncology, HM Hospitales, Madrid, Spain faculty of Health Sciences, Universidad Camilo José Cela, Madrid, Spain Resistance to change f Reluctance N_ J Reimbursement Risk of induced neoplasms ZERO TOXICITY DOES NOT EXIST... REVIEW ARTICLE Radiotherapy for benign disease; assessing the risk of radiation-induced cancer following exposure to intermediate dose radiation IWMAMt » NCXtOWH M. MOL *»AIA aumtLC. *K1 MO. JO «MtmnCH. MO. MO *«icmmo I Hunn mo mc> rt focit I tatlo*. net not Types Absolute L ifetime Risk Sarcoma <0 0001% for lGy and a 100-cm2 field Skin (basal cell carcinoma) 01% for 100-cm1 field Braintumor 0 2% after 20 Gy for endocrine orbitopathy Thyroid carcinoma 1% per Gy for children <10 years Breast carcinoma (WBRT) <5% for one breast. 1 Gy. age <35: <3% for age 35-45): 0% >45 Lung carcinoma 1% within 25 years after a mean lung dose of 1 Gy McXeownSReUH BrJRedat 20!5 88(1056) 20150405. Strahlentherapie und Onkologie Current Diuussion Estimation of Cancer Risks from Radiotherapy of Benign Diseases Kiamltüdigef Trott', Fiwdrkh * Jiripud' Bv contrast, in radiotherapy of epicondylopalhia humeri. heel spur and other disorders in the extremities, no critical organ except skin is in Ihe primary treatment beam. Direct risk estimates for the approximately 100-cm2 skin area treated to a mean dose of 3 Gy would result in a lifetime local basalioma risk of 0.006%. The different indications for radiotherapy of benign diseases are associated with widely differing radiation risks. The main factor determining risk is Ihe site of treatment. For all peripheral indications such as Dupuvtren's contracture, tennis elbow or heel spur, radiation risks are very small, indeed, and comparable to those from common diagnostic X-ray examinations. Radiation carcinogenesis Estimation of the carcinogenic risk of radiotherapy of benign diseases from shoulder to heel Jan Th. M. Jansen"-*, Jehan J. Broersea b, Johannes Zoetelief", Claudia Klein£, M. Heinrich Seegenschmiedtc T 35 to E30 g 25 I 20 ales - • 1 Average females ... " Average "mâles" Males 0 20 40 60 80 100 Age at time of exposure (year) Attributable lifetime risk for induction of a fetal tumour, at high doses and dose rates, from a single dose at various ages of exposure end both genders, according to the Internetionel Commission on Radiological Protection [2/ KVKIMTKU Is Anesthesia Dangerous? Asicciatiofi between ane»the»ia-related death* and «9« or patient»' ASA status (adapted from (I]) Mortality m 000 >5\ confidence A» 0-7 years 06 017-37 &-1SyMra 1 _ ¡0^3?_ 16-39 years [052 074-093 4075 yotre 52 2741 275 yean 21 83-34 TOXICITY DEPENDS ON THE CHARACTERISTICS OF THE RADIATION THERAPY, NOT THE RADIATION ITSELF. ©2023 Greater Poland Cancer Centre, Reports of Practical Oncology and Radiotherapy Published by Via Medica. 2023, Volume 28, Number 1, pages: 74-78 All rights reserved. DOI: 10.5603/RPOR.a2023.0001 e-ISSN 2083-4640 Submitted: 06.09.2022 ISSN 1507-1367 REVIEW ARTICLE Accepted: 15.12.2022 The 5Rs dilemma of radiotherapy for non-malignant diseases: 5Rs to darken OR 5Rs to shine Angel Montero1,2, Beatriz Alvarez1,2 'Department of Radiation Oncology, HM Hospitales, Madrid, Spain 2Faculty of Health Sciences, Universidad Camilo losé Cela, Madrid, Spain B f Robustness V_ /-\ Realibility ^_> KM hm hospitales Responsiveness f RADIATION \ I THERAPY J Reduced cost Reproducibility HOW DO WE WANT TO LOOK AT RADIATION THERAPY FOR BENIGN DISEASES? EFFECTIVENESS TOXICITY CENTRO INTEGRAL ONCOLOGICO SÍitales hm CIOCC K M hm hospitales www.radioterapiahm.com angel.monteroluis@gmail.com OBSEVANJE BENIGNIH BOLEZNI 7. marec 2024 Onkološki inštitut Ljubljana, Predavalnica v stavbi C Facultad HM de Ciencias de la Salud de la Universidad Camilo José Cela , . • Universidad KM hm hospitales Camilo José Cela K Hfl radioterapiahm.com A. Montero Luís Hospital Universitario HM Sanchinarro HOW DO WE m DO IT KM hm hospitales Department of Radiation Oncology 4 LINACS (+1 ongoing MR-LINAC) 2 DEDICATED CT HDR BRACHYTHERAPY 11 ATTENDING PHYSICIANS 8 MEDICAL PHYSICS 4 RO RESIDENTS -2000 NEW PAX/YEAR KM HOSPITAL UNIVERSITARIO hm puerta del sur OSTEOARTHRITIS: A HIGHLY PREVALENT DISEASE IN EUROPE... ..AS WELL AS IN SPAIN Osteoarthritis (OA) affects 7 million people in Spain Responsible for 30% of temporary disability #18% 19,6% I; of females II of males /^I^SociedadEspanolad» O ÄTReumatoiogia 0 Semergen ArtRoCad Q Arthritis & Rheumatism (Arthritis Care & Research) Vol. 61. No. 2. February 15. 2009. pp 158-165 DOI 10.1002/art.24214 © 2009, American College of Rheumatology ORIGINAL ARTICLE Economic Burden of Knee and Hip Osteoarthritis in Spain ESTIBALIZ LOZA,1 JUAN MIGUEL LOPEZ-GOMEZ,2 LYDIA ABASOLO,1 JESUS MAESE.' LORETO CARMONA,1 ENRIQUE BATLLE-GUALDA,2 and hie ARTROCAD STUDY GROUP . IMilina LOCATION Cervical Spine OA Lumbar Spine OA Coxarthrosis Gonarthrosis Hand OA EPISER 2016 10,10(10 al95% 9,07-11,24) 15,52 (IC al 95V 14,30-16.83) 5,13 (IC al 95% 4.40-599) 13,83 (IC al 95% U66-15.ll) 7,73 (IC al 95% 6,89 8,67) 707» 60% 50% 40% 30% 20% 10% 0% 65% 35% Satisfied Dissatisfied SATISFACTION WITH THE ACHIEVED DEGREE OF PAIN AND DISABILITY RELIEF REVIEW ARTICLE DEGRO guidelines for the radiotherapy of non-malignant disorders Part II: Painful degenerative skeletal disorders Oliver J. Ott • Marcus Niewald • Hajo-Dirk Weltmann • Ingrid Jacob • Irenaeus A. Adainietz • I ii ich Schaefer - Ludwig Keilholz - Reinhard Heyd • Ralph Muecke -German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) Shoulder syndrome less than 6 m< 58-100% Elbow svndrome Between 1923 therapy for elb inH ">ni 1 th* r>iitr/i -80% 2000 patients \ Trochanteric bursitis 73% Gonarthrose Response rates (complete and partial response CR and PR) usually reached 58-100% 2-3 months after radiotherapy (14. 17] in 7928 retrospectively evaluated patients Hevd et al [6] repori with PR 12% 55% with CR. and .'3% < benefit Early treatment pain seemed to be more effective than with chronic pain Data about a higher success rate for patients with calcifications were inconsistent Low-dose radiotherapy' is an effective therapeutic option for painful Kellgren stage 2-3 arthrosis of the knee joint and can be recommended even if surgical interventions are not possible or dfsimhle nr if nther methods are ass< traindicated The. 58-91% onservative treatment ie side effects or con-5 patients treated with | Coxarthrosis | Considering the results of the retrospective studies, low-dose radiotherapy may be an effective therapeutic option for painful Kellgren stage 2—4 arthrosis of the hip joint even if surgical intervention-, ire nnt mssihlf or desirable or if 24-89% me after low-dose radio-■en reported in more than .•e and prospective analyses, Approximately 82 % of the patients experienced significant pain reduction The CR and PR rates were 45 % (range 5-94%) and 35% (range 7-73«.) [13] Glatzel et al [3] reported on 34 patients who were treated irsctions of 1 0 Gv After low-dose radiotherapy for painful arthrosis of the knee joint have been published Of these patients. 5069 were surveyed withm the framework of a German patterns of care study performed in 2010 [10] A response to radiation therapy in terms of a marked and complete reduction of pain was shown in 58-91 % of the irradiated patients | Plantar fasciitis | Retrospective analyses reported on C'R rates ui 12-81%. and PR rates in 7-74% [9. 15. 18] In a randomized tn-sl Heyd et al [7] randomly compared two dose regimens 3 0 Gy/0 5 Gy vs 6 0 Gy 1 0 Gv in 130 patients Radiotherapy led to a both groups, and tive In another 1 "80% had a PR Olschewski with total dovi 3 months. 38 *> and Kleui (12] reported on another 26 patients They found an overall response rate of 73%. with 23% CR and 50% PR rates on of pain symptoms 111 men was equally effec->\vald et al [11] es-alu-ated the efficacy of two other dose concepts in 62 evahiable patients 6 0 Gy/1.0 Gy \s 0 6 Gy/0 1 Gy After one year, compared to the very low-dose arm the higher-dose arm led to a significant ads-antage in terms of pain control other conservative excessive side effe< ire associated with i The results from 895 patients treated with low-dose radiotherapy for painful arthrosis of the hip joint have been published A response to radiation therapy 111 terms of a marked and complete reduction of paui was shown in 24-S9% of the irradiated patients [19] [Arthrosis of the hand and finger joints | Considering the results of the retrospective studies, low-dose radiotherapy may be an effective therapeutic option for painful arthrosis of the hand and finger joints, even if other conservative treatment methods are associated with excessive side effe< 809 patients treated 6375% arthrosis of the liam'i .uiu iiiiyei juiins iiAve been published The results from itberapy for painful A response to radiation therapy in terms of a marked and complete reduction of pam was shown m 63-75% of the irradiated patients [4] LOW-DOSE RADIATION THERAPY HAS PROVEN EFFECTIVENESS FOR OA PAIN RELIEF... THE FIRST (?) ATLAS FOR RADIATION PTV DEFINITION... Received: I Revised: 03 July 2020 26 May 2021 Accepted: 08 June 2021 © 2021 The Authors. Published by the British Institute of Radiology https://doi.org/10.1259/bir.20200809 Cite this article as: Alvarez B, Montera A, Hernando O, Ciervide R, Garcia J, Lopez M, et al. Radiotherapy CT-based contouring atlas for non-malignant skeletal and soft tissue disorders: a practical proposal from Spanish experience. Br J Radiol 2021; 94: 20200809. GUIDELINES & RECOMMENDATIONS Radiotherapy CT-based contouring atlas for non-malignant skeletal and soft tissue disorders: a practical proposal from Spanish experience 1BEATRIZ ALVAREZ, MD, 1ANGEL MONTERO, PhD, ^VIDIO HERNANDO, MD, PhD,1 RAQUEL CIERVIDE, MD, PhD, 2JUAN GARCIA, MD, PhD, MERCEDES LOPEZ, MD, 'MARIOLA GARCIA-ARANDA, MD, nXIN CHEN, MD, 2INES FLORES, MD, 1EMILIO SANCHEZ, MD, JEANNETTE VALERO, MD, PhD, 2ALEJANDRO PRADO, MD, 'ROSA ALONSO, MD, 1LEYRE ALONSO, MD, 2PEDRO FERNANDEZ-LETON, MD and 'CARMEN RUBIO, MD, PhD 'Department of Radiation Oncology, HM Hospitales, Madrid, Spain department of Medical Physics, HM Hospitales, Madrid, Spain Address correspondence to: Dr Angel Montero E-mail: angel, mon tero I uisí&gma il.com Beatriz Alvarez and Angel Montero have contributed equally to this study and should be considered as co-first authors. KM hm hospitales Radiotherapy öOncology THERE ARE ATLAS FOR (ALMOST) EVERY RADIOTHERAPY LOCATION, ELSEVIER Radiotherapy and Oncology iwraal h«m«pi(* www theg'aeniournel com Guidelines for delineation of lymphatic clinical target volumes for high conformai radiotherapy: head and neck region M»» wmi«'J'm: onm » •«■' Onginal jttKlr Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving dosed cavity surgery VrilfeUv Strnad A\ Jean-Michel Hannoun-lcviJose-luis Cumot . Krishna Lossl". Daniela Kauer-Dorner Alexandra Resch'. Gyorgy KovicsTib« Major \ Erik Van Limber gen h. On behalf of Working Croup Breast Cancer of CEC-ESTKO on« tu» •» omn m-i v Oral Oncology tournai N>mep»ge: www •!»♦».• i com. i fain «^oncology [Target volume selection and delineation (T and N) for primary radiation •catment of oral cavity, orophary ngeal, hypopharyngeal and laryngeal iquamous ceil carcinoma Vincent Grépiirc' , Cai Grau . Michel Lapryrv'. Philippe Mjin^on Z CLINICAL INVESTIGATION Journal Prc-proofs ESTRO ACROP ptidcbur ft* tarfct volunte delineation of %kwll ba»< tumor? Slepfimu* E. Couibv Briflm O Bmiiimi, Martin Beixk/uv Ata»*idio Bo//ao Michael Biada Ljtua Famelii. Alba Fiesem mo. L"le Gnnuuidt. Aiwa L Grow. 1 milk L Lasel •«.laid, NUvuwliau Niyui. Tufve Nyliolia Lui Psddick. Dnuco Chatte» Weher, Ctaw Bella. Gimeppe Miniuti DOI Reference SOI67.8140l 20)31179-8 doi orp 10 |0)6j »done 2020 11 014 RADIOS »62? VARI \TIOMMIIK CROSS IIMORVOI.I Ml »NIH1I.IMCALTARGETVOLtMKFOR l'ki l(lllll.K»n (ii l'KIM\Kt I. IR(;K lllcai-<;R\IH Som ISSl K SARCOMA OF Till. KXTRKMITY AMONG k i ck: SARCOMA RADIATION ONCOMMaSTS Dian WaM. • Waltb David (, Kiux n.; Ra*an Al. Lun.' Ivv\m ti NaqaJ David Rí««gf. Simm E. Finksuiun.'Ivy Pttuse^ Michael Haooock.1 Yo«-LmG.Qen." NaoyukiG. Saito." Yiw. I. Hm-HOK-K." Xah,m II Wntvft " Thomas F. MAMÏ tVl|_R Radiotherapy and Oncology lurnal homepage: i «thegieeniournal.c ELSEVIER Radiotherapy and Oncology tournai homepage www tltagraanjou'nal.co' Review Attic le Tricks and tips for target volume definition and delineation in breast cancer: Lessons learned from ESTRO breast courses Orit Kaidar-PersonJJ' \ Birgittc V. Offcrscn . Ucsbcth Bocrsma . Icro Mcattini'. David Dodwcll Lynda WyldMarianne Ainat \ Tibor Major'. Thorstcn KuehnVratislav St mad \ Miika Palniu1 Sandra Holr, Fliilip Poortmans" Radiotherapy and Oncology tournai homepage www inagreeniournal.c ESTRO consensus guideline on target volume delineation for el< radiation therapy of early stage breast cancer Igiiul jitule rTRO ACROP guidelines for target volume definition in the treatment locally advanced non-small cell lung Journal Pre-proofs ESTRO ACROP guidelines fot Taajet Vohnie Definition m the thoracic n»di-■hf iMWnii uf Saalt trfi !■» f irer Radiotherapy and Oncology |«u'n«l homepage wwwtti«gra«n|ouraal.com Original article Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving dosed cavity surgery Vratislav Strnad Jean-Michd Hannoun-Levi '.Jose-Luis Guinot'.Kristina L0»l'!. Daniela Kaucr-Dorner'. Alexandra Resch ', Gyorgy Kovacs1. Tibor Major*. Erik Van Umbci-gcn''. On behalf of Working Group Breast Cancer of CEC-ESTRO ELSEVIER Radiotherapy and Oncology tournai homepage www lleg>een)ou'n Original Articic Recommendations from gynaecological (GYN) GEC-ESTRO working ifc group - ACROP: Target concept for image guided adaptive brachytherapy in primary vaginal cancer Maximilian P. Sctamtd1"*. Lars Folalal "". Heiuike Westerveld . Cyrus Chargan". Lisbeth Rohl". Philippe Mofice'. Nicole NcsvacilRenaud Mazcron"Christine Haie-MederRichard Potter Remi A. Nomfth. on behalf of the GEC-ESTRO GYN Working Group_ Radiotherapy and Oncology E5TR0 ACROP guide-line ESTRO ACROP consensus guiddine on CT- and MRI-based target volume delineation for primary radiation therapy of localized prostate cancer ^ Carl Salcmbiet *. Gcen ViUeirs . Berardino De Bart . P«er Hoskm'1. Bradley R. Pieiei^', \!arco Van VulpenVincent Khoo». Ann HenryAlberto Bossi'. Gert De Meerker, Valerie Fomeyne *-' Camann Mi avulaMa at S<» c>m ELSEVIER Radiotherapy and Oncology |«u Birgittc V. Offcrscn'-'. Liesbeth J, BoersnM^C^iK Kirkoye'.^Sandra^fol 'i. j • rcracuk Radiotherapy and Oncology • ttiagraaniouroalC' Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery Vratislav Strnad Jcan-Michd Hannoun-lrviJose-Luis Cuinot'. Kristina LOssL . Daniela Kaucr-Dotnerr. Alexandra Reschr. Gydrjjy Kovacs!. Tibor MajorErik Van Limberjsrn '*. On behalf of Working Group Breast Cancer of CEC ESTRO The Royal Colege of Radiologists Radiotherapy target volume definition and peer review RCR guidance_ Original aiticle Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery Vratislav Strnad Jean-Michel Hannoun-Levi Jose-Luis Cuinot'. Krishna LOssI1'. Daniela Kauer-Dorner'. Alexandra Reschr. Gyorgy Kovacs'. Tibor Majorr. Enk Van Umber^rnOn behalf of Working Group Breast Cancer of CEC ESTRO ELSEVIER Radiotherapy and Oncology journal homepage www tKeg>eenjou«nal.com OhriiuI Article ESTRO consensus guideline for target volume delineation in the setting IT) of postmastectomy radiation therapy after implant-based immediate I|3m| reconstruction for early stage breast cancer Ont Ka»dar-PcT5on*•••,. Birgittc Vrou Offersen^', Sandra Hoi'. Mentxell Arenasd. Cynthia Aristctr. Celine Bourgier '. Mana Joao CardosoBoon ChuaCharlotte E. Cotes'. Tine Engberg Damsgaard '. Domtj CabiyvL. Resltma lagsi ', Racliel Jimenez*", Anna M Kirt>y ". Canne Kirkove", YouiU Kitova1'. Vassilis KoulouliasTanja Marinko'. Icro Meattim . Ingvil Mjaaland'. Gustavo Nader Marta"*, Petra Witt Nys^cm". Elzbieta SenkusTanja Skyttà '. Tcrve F. Tvedskov'. Karoiten Verhocven'". Philip Poortnuns''' KM hm hospitales ..AND EVEN ON-LINE TOOLS FOR TARGET DELINEATION. FIELDRT BJR htIpk//do..wu/10)?b0A* 707I03S6 • hltov6t'Wti*«*Mt tnaduaon (POl NfWlMllnxMMnfll l—«................ POM UMXrlomnRtrtMinr IPIUWT) : 1« HI——1 PoM'MasMctomir DiMdk (PMRO iirmmmii RtglcnlNoiMmMicn iwi Who» l> ■ m im»»»»«»!......i https://econtour.org/ fa eft? »^strahl M v A LOT OF INFORMATION EXISTS REGARDING LDRT WITH ORTHOVOLTAGE AND DIRECT TECHNIQUES... vi'/ C . o ...BUT LESS WITH OTHER RADIATION TREATMENT TECHNIQUES Most of published experiences relies on direct/2D techniques J Riduooo Oncology Bio! Pby» . Vol 52. No 2. pp 496-513.2002 Copyright C 2002 Emvim Scimcf Inc Printed u the USA AU nghtt r««v«i 0360-3016 02 V-«« front mitt« ELSEVIER PII S0360-3016(01 >01814-4 CLINICAL INVESTIGATION Benign Disease CONSENSUS GUIDELINES FOR RADIATION THERAPY OF BENIGN DISEASES: A MULTIC'ENTER APPROACH IN GERMANY Oliver Micke. M D .* M. Heinrich Seegenschmiedt. MD.. Ph.D./ and the German Working Group on Radiotherapy of Benign Diseases There were no available atlas for the delineation of volumes in radiotherapy of benign musculoskeletal diseases. We have devised pragmatic guides, intended for daily practice. Using current immobilization, delimitation and planning techniques available in any Radiation Oncology department. But above all, an understandable, reproducible, simple and easy to use guide for all those interested in OA LDRT. These are recommendations, never intended to be mandatory! There are other equally valid techniques and procedures for LDRT in benign musculoskeletal diseases The key and fundamental thing is to adapt your actions to your availability ...but remember Osteoarthritis and Cartilage Open 1 (2020) 1DDD16 Contaits lists available at ScienceDirect Osteoarthritis and Cartilage Open journal hDmepagB: www.Glsevier.com/journals/osteoarthritis-and-cartilage-open/2665-9131 Experimental Protocol Radiotherapy for ostheoarticular degenerative disorders: When nothing else works* Beatriz Alvarez a,2,\ Angel Montero a'1,2, Francisco Aramburuc, Enrique Calvocí Miguel Ángel de la Casa b( Jeannette Valero % Ovidio Hernando a, Mercedes López a, Raquel CiérvideMariola García-Aranda a, Silvia Rodríguez Emilio Sánchez51, Xin Chena, Rosa Alonso a, Paloma García de la Perm r, Carmen Rubio3 FI SFVIFR A Check Tor updates Clinical âhd Tra relational Oncology httpiiffdoi.oig^l 0.1007ft 1Í094-021 -02710-w RESEARCH ARTICLE <8> Check fot update a Low-dose radiation therapy for hand osteoarthritis: shaking hands again? B. Alvarez1 A. Montero1 ■ R.Alon&o'-J. Valero1-M. López'■ ft. Cíérvíde1 - E. Sánchez' ■ O. Hernando1 ■ M. García-Aranda1 Jl. Martí2 A. Prado2-X.Chen-Zhao1 ■ C. Rubio1 Reumatología Clínica (English Edition) Vol ume 17, Issue 10, December 2021, Pages 624-625 LU Letter to the Editor Radiotherapy treatment in benign osteoarticular disease Tratamiento con radioterapia en enfermedad osteoarticular benigna -fr Francisco Aramburua A a, Angel Monterob, José Luís Cabrera Alarcónc, Paloma García de la Peña-Lefevre d Is it time to redefine the role of low-dose radiotherapy for benign disease? Angel Montero,1 Sebastia Sabater,2 Franz Rodel,3 Udo S Gaipl,4 Oliver J Ott,4 Michael Heinrich Seegenschmiedt,5 Meritxell Arenas6 Ann Rheum Dis 2018;0:1-2. doi: 10.1136/annrheumdis-2018-214873 REPORTS OF PRACTICAL ONCOLOGY AND RADIOTHEDAPY 18 ( 2 O I 3 ) SI4-SI5 i:i.si:vii.r Available online at www.sciencedirect.com SciVerse ScienceDirect journal homepage: http://www.elsevier.com/locate/rpor Refresher course: Arthropathy and other benign conditions Radiotherapy for non-malignant diseases Angel Montero Luis KM hm hospitales Osteoarthritis and Cartilage Open 1 (2020) 100016 Contents lists available at SaenceDirect Osteoarthritis and Cartilage Open I 1 .SI \ I [ ' K journal homepage: www.elsevier.œm/journals/osteoarthntis-and-cartîlage-open/266S-9'l31 Experimental Protocol Radiotherapy for ostheoarticular degenerative disorders: When nothing else works* Beatriz Alvareza"2'\ Angel Monteroa,,,2> Francisco Aramburu', Enrique Calvoc, Miguel Ángel de la Casah, Jeannette ValeroOvidio Hernando ', Mercedes López'1, Raquel Ciérvide", Mariola García-ArandaSilvia Rodríguez', Emilio Sánchez ', Xin Chen'1, Rosa Alonso Paloma García de la Peñac, Carmen Rubio a * RodaMrn Oncology, Hospital UnhKTáurío HM SOKhtmmv. Madrid. Span '' Radksfétyúa. HatpMl Universitario HM Satchttamj. Uadnd. ' RhrumaMrlogy. Hospital Unrvcrámno HM Smchinarro. Madrid. Spam íspondiioart rosis cervical omartrosis inCCXTOiLiriVIPlTROCUITIS ASTROS»IMTUfALANGKA «UA«r«OS» Período: Abril 2015-Enero 2018 N = 184 tratamientos (108 pacientes) completados en Enero-2018 85X mujeres Largo seguimiento N=8g Edad: mediana 64 años (42 89 años) EVA PRE-tratamiento SERIE COMPLETA(N=I84) LARGO SEGUIMIENTO(N=89) EVALUACION SUBJETIVA 76* 1* MUAI. MLKM» ANALGESICAS 1* lili EVALUACION SUBJETIVA no* IGUAL Mí JO» NECESIDADES ANALGESICAS ■ Ib MINO« NULA NC EVA POST-tratamiento HMClU 05'JJl IMMOBILIZATION • Thermoplastic masks • Vacuum cushions • AccuForm cushions • Foam cushions, support cushions & wedges c SIMULATION CT Dedicated CT for Radiation Oncology 2-5 mm thickness slices, depending upon target location TARGET DELINEATION • Target volumes should include the entire joint and articular cartilage, the specific joint capsule, the neighbouring bone and/or muscular insertion zone, and the peritendinous bursae and surrounding soft tissue structures RayStation RaySearchrr Laboratories > If 8 ANATOMIC CORRELATION vvw Cutssic ( Hmm MfNti IMn lutton (Map Ttotaurvi Quotation EagHtkUug* RalwinM > Anatomy of lha Human Body The Bartleby.com edition of Gray's Anatomy of the Human Body, 20th Ed. Philadelphia: Lea&Febiger, 1918; New York: Bartleby.com, 2000 Anatomy — branch of bubo tocKfmnl "t Entire shoulder joint and adjacent structures: acromion, glenohumeral joint, and the coracoid process; acromioclavicular ligament, coraco-acromial ligament, coraco-humeral ligament, transverse ligament and the superior-middle-inferior glenohumeral ligaments Synovial bursae around the shoulder: subacromial-subdeltoid (between the joint capsule and the deltoid muscle), subacromial (between the capsule and the acromion), subcoracoid (between the capsule and the coracoid process of the scapula), coracobrachial(between the subscapularis muscle and the tendon of the coracobrachial is muscle), subscapular (between the capsule and the tendon of the subscapularis muscle), and the supra acromial bursa. Tendons that attach to the muscles: teres minor, infraspinous, subscapular and supraspinous and to the origin of the deltoid, the long head of the biceps brachii muscle, trapezius insertion, pectoralis minor insertion and short head of the biceps brachii muscle Radial epicondylitis (tennis elbow syndrome): include 1-2 cm above the lateral humeral epicondyle, including its trochlea and condyle, the radius head, neck and tuberosity plus 1 cm distally. Ulnar epicondylitis (golf elbow syndrome): include 1-2 cm above the medial epicondyle, the ulna olecranon process, ulna coronoid process and its tuberosity, plus 1 cm distally. Synovial bursaes: around the olecranon (superficial, subtendinous and intratendinous bursae) or the cubital fossa (bicipitoradial and interosseous bursae) Ligaments and tendon Insertions: articular capsule, and the lateral, collateral, radial collateral, annular, accessory collateral and ulnar collateral ligaments Finger joint OA: ximal and distal phalanges in the involved joint within 1 cm around the soft tissues in the second to fifth fingers. Thumb OA: half of the metacarpal bone, the joint with the trapezoid bone and continue around 1 cm through the radial bone. To avoid damaging the fingernails, the distal segment of the fingers should be excluded. g \ f e ' -i (â]\ , • o íoY V y \ - V „ / PELVIS&HIP OSTEOARTHRITIS Greater trochanteric pain syndrome (trocahanteric bursitis): trochanteric bursa (superficial and posterior to the greater trochanter of the femur and subjacent to the iliotibial band), the gluteus medius bursa (between the gluteus medius muscle and the greater trochanter) and the gluteus minimus bursa (located beneath the gluteus minimus tendón at the anterosuperior edge of the greater trochanter) and the musculature surrounding the trochanter. Sacroiliitis: include the whole joint between the sacral and iliac bones with a margin ¿1 cm on each side, including the sacroiliac ligaments. Coxarthrosis: whole joint between the iliac bone (acetabulum) and the femoral head, and 1 cm distally through the femoral head. KNEE OSTEOARTHRITIS Gonarthrltls: whole knee joint (lateral and medial supracondylar ridges, capitulum, medial and lateral epicondyles, popliteal fossa, femoral trochlea, lateral and medial tibial condyles, tibial tuberosity, fibula head and the patella bone), the entire synovial capsuleand surrounding soft tissues and musculature, including the main knee bursae (prepatellar, infrapatellar [deep and superficial], suprapatellar, Pes Anserine, semimembranosus (popliteal), and the iliotibial and medial collateral ligament bursae). Q Q Q I ANKLE&FOOT Plantar fasciitis: the entire calcaneus, and the region of the plantar aponeurosis, including insertion of the plantar fascia and the Achilles tendón. Tendonitis (Achilles tendinopathy and other tendinopathies: tibialis posterior, flexor hallux longus, flexor digitorum brevis, peroneus longus and brevis, tibialis anterior, extensor hallux longus, extensor digitorum brevis): include the tendons and synovial sheaths appropriate to each anatomic location fa &% <% I > f r j* a SUMMARY: TARGET VOLUMES LIMITS — — — UtlUML - — '5a iii ill rnm^tmm m Uli aouinxx ljL.il js* -rr- 1.1 IMriMr «II i». <» - * • Lr.r '" I <»»»r i etil •A-Jfc; in KM hm hospitales TRIGEMINAL NEURALGIA Episodes of excruciating stabbing of electrical shock-like pains that / last for some seconds/ J maximum rcachcd within one second \\ \ t/\ Up to 100 times per day Cfg 1 10 20 30 40 50 60 Years 8 5th /10,000/year incidence cranial nerve 95% 3% due to vascular compression bilateral PATHOPHYSIOLOGY OF TRIGEMINAL NEURALGIA: A MOLECULAR REVIEW J Neurosurg 139:1471-1479, 2023 X carbamazepine or oxcarba/.epine laniotrigine gabapentin or pregabalin baclofen botulinum toxin type A Idiopathic I Internal neurolysis Gamma knife surgery Glycerol rhizolysis Radio frequency thermocoagulation B al loon comp re ss i on Trigeminal MVD* Medication Trigeminal Neuralgia I Trigeminal MVD _1 baclofen botulinum toxin type A other drugs** I Gamma knife surgery' Glycerol rhizolysis Radiofrequency thermocoagulation Balloon compression Internal neurolysis*** 1 carbamazepine or oxcarbazepine laniotrigine gabapentin or pregabalin baclofen botulinum toxin type A 1 Gamma knife surgery Glycerol rhizolysis Radiofrequency thermocoagulation Balloon compression Trigeminal MVD**** Stereotactic Radio-Surgery STEREOTAXIC RADIOSURGERY IN TRIGEMINAL NEURALGIA Lars Leksell From the Department of Neurosurgery, Karolinška Institute!, Stockholm, Sweden Acta Chir Scand 137:311-314, 1971 GAMMKNIFE RESULTS » ■ i . .. . . j . Mean or median f pi low-up n . .. I(rt,, _ .. .. Study (year) Number of patients . , Pain relief (%| Complications Young, etal.( 1990^ 110 19£ 95 5 2.7 Maesawa, etal (2001 )B 220 22 76.6 10.2 Pollock, 6131(2002)® 117 26 75 37 Petit, etal.{2003F 112 30 77 7.3 Sheehanetal.(20D5P 136 19 70 19 UrgDsik, et al. (2005^ 107 60 96 20 Longhi.etall {2007P 170 37.4 90 8.75 Fountasretal.(2007)J|! 106 34 3 39. B 16 Kondziolka. etal. {2010J5 503 24 39 10.5 Hayashi, etal. (20111® 130 36 98 24 Marshall, etal.(2|12P 446 20.9 W 44 Young, etal. 120131" 315 66.9 85. & 32.9 Lucas, et al, 12014)'° 446 21.2 34.5 42 R^gis, etal. (2016)6 497 43.6 91.75 21.1 Taichretal.(2D16r 263 24 79 NA Martinet Moreno, et at (2016]" 117 66 91 32.5 Zhao, et all:[Z018f 247 49.7 37.9 31.9 Gagliardi, er al.|2018|" 166 64.7 78 24 Lee, et al. (2018F 103 17 80 55 Recurrence |%) 3 3 13.6 16 29 24 25 18 321 42.9 18.0 40 14.3 451 34.4 39.8 19 3.B 31.2 22 <10 H) I C.D- JB £ MDnlhs Fig. 2. Predicted pain relief maintenance period after Gamma Knife radiosurgery. Solid line represents predicted pain relief maintenance period and dotted line represents 95% confidence interval. Park SH, et al. Yonsei Med J. 2020 doi: 10.3349/ymj.2020.61.2.111. hospitales hm CIOCC KM hm hospitales IMMOBILIZATION: • A fixed frame and facial masks from Brainlab DEFINITION OF VOLUMES: • Fusion of CT and MRI with T1 sequences with or without gadolinium and T2 CISS or FIESTA sequences • A circular cone 4 mm diameter is used to deliver dose to isocenter Prescription point of the dose: in the so-called retro-Gasserian area or anterior cistern. Optionally, on the REZ or Observe-Redlich zone, at the point where the trigeminal nerve leaves the brainstem. For pain relief, anterior cisternal or REZ achieves similar pain control rates although the anterior location is associated with lower rates of secondary hypesthesia ^ i I ^MTCTlrfl T2WJ ^ ^ rv- Mr- A V '7 I rrHTRQ INTEGRAL OMCOLiWO KM hospitales hm CIOCC KM hm hospitales Prescription: 9000 cGy /1 fx fo [Corrected] AX 3d FSPGR+C A Configuration » Axial w\ e. The sputum contained uneumococci not type, I, II, ill. B, the ninth day, the lungs arc almost clear. 836 cases of pneumonia treated with low-dose radiotherapy between 1905-1946 20-MARCH-2020 WHY NOT RADIOTHERAPY? 1104-tl Im pin Dnu ' — r*-— om i«i ao4 (■ah IMU'Mtt Uad» JUt Dr v»|4mM Hál MD r ■■ i «ii irm Ltete nm Di of lin» te II— hmm UraSfOf UD »tW »«rDr Mi M G< (tm X >» n a | iimil mM* la(OMPi) *«m f ayr wi le Mnáf a cfenl X-m bHM< (4 Aori M rad nr 0 5 Cn lar* A» ItXi te« ■R a «ArDw mbiA te a napr el dkmütn aad éiwhi, imi t\y>e\ of pmM 1 llfafnM X-m njHnan, m* |A*t«d &m m te arf- IMOi iln iwAn Wc«» «««tekle ate Mf eAoptetf m te patinad wftal 4 MM ta* ratei a» art vr» nvkMr te COMD- !• m pin» naeln iteÉmp I a a «lá Val jaeva «ntaia te Aww> te feodar« kap inflana a Oar nfow h «ifnKl te ate aa aft aflaoauM> pfcwhyt te eeril Wfa te nhiw te nafN» aitea a lr« kna« A wwaj tea mmí>W |a» a»i r vteh i*m< «atea wffri ám ef te anteni T abé» t a a hitaa al m m a aa atena el fMaoaa arte tateteaap* >>»ai anae ste ooyi>l Dr )ani ViUalt paryilat«ilipaa laate|l»pampaaic»«>ntpa* IktetaMIrtaM ya aa Uaaaa a iflon ate to ateHr éni afta te »tat c< aataaR If tea aéwáaaaate«M|aiattetWB>l»aw»ma»th teteitpw tate to aatel awAte Appeoptatr titea áwaw aae ateaét «variate a aaM k^MK tenate Dr J^h 54 Catet Oh Cay* Ot Jan\ «tek VCD l C tlrtii n EJ Otea a O KipwK KtateVJ ttete^ aaaaeflaa ateaan tetmtenatea epcaaaltea fteli^faiva' HII HIIIWM X Ctltei ii El. Dteaa O Moa laáaetei i api t nt krtainli au4 M M panaaaa tel ■ to awM atea" rte Jšmt timé 1 Cate» IM Affktte of loa tea* el aatmp atete* a aeteal terapan Aa* «•aparca» .-19-ind ucedi «icute ftspirjiMy distre« iyrtdftw* i;a«ds) * — ¡ji*îv t%jwjn fcKhu bpaar'.Rj|ivDhrMn . (U^nùff injfc'. UurM Mam)|jmtiCK«1j1» '1, Ct|RM«ilgniu SdoncoOnsct EIMI1 4■■ MIIIAA ptirei FuM|c,on&uhe nn.HHvUlUHi fj.wii* Irradiation pulmonaire à faible dose iwor l'orage de cytokines du in covilm9 : poorqiMH pas ? Ltnv (Mar fimx rmfrodurwy for COVID- IS-rriatoi cyiotinr norm jjwlrorttr: IVftr Mf? LUrttTOHlttWTM Low-dose radiotherapy for SAftS-CoV-2 pneumonia N*i/Ntoini HI> MMMUMOMI i r&TOtiii. Low-dose radiation therapy: could It bea game-changer for COVID-I-J? fcUMMNft M Anntih N Apm' Radiotherapy and Oncology 147 (2020) 221 ELSEVIER Contents lists available at ScienceDirect Radiotherapy and Oncology journal homepage: www.thegreenjournal.com COVID-19 Rapid Letter Is low dose radiation therapy a potential treatment for COVID-19 pneumonia?* Charles Kirkbya-b-c, Marc Mackenzie0 ' Department of Medical Physics. Jack Ady Cancer Onrre. Lethbridge; b Department of Oncology; ' Department of Physics and Astronomy. University of Calgary: and a Department of Oncology. University of Alberta. Edmonton. Canada Fatal cases of COVID-19 are characterised by acute respiratory distress syndrome (ARDS), sepsis, pneumonia and respiratory failure 11 ]. The high transmission rate of the virus and the corresponding rapid escalation in the number of infections has resulted in unprecedented strains on healthcare systems worldwide, particularly as healthcare workers struggle to treat COVID-19 pneumonia. We would like to draw the radiotherapy community's attention to the potential for low doses (<100 cGy) of low LET radiation to treat viral pneumonia as a possible therapy for COVID-19 patients. It was not uncommon in the early twentieth century to treat pneumonia with X-rays. A review showed low doses from kilovoltage X-rays reduced pneumonia mortality from roughly 30 percent to 10 percent on average |2|. Doses reported were generally in the 20 - few hundred Roentgen range, which given the attenuation through chest wall would likely have resulted in mean lung doses in the tens to <100 cGy range. Some reports noted rapid symptom relief on the order of hours [3.41 Animal models suggested LDRT could reduce the acute phase of pneumonia by half |5|. In light of the current mortality rates associated with COVID-19 pneumonia. it is therefore reasonable to re-examine this old treatment. Pneumonia arises as an inflammatory immune response to infection when the alveoli become inflamed and secrete fluid compromising their gas exchange function. In a viral infection, viruses trigger immune cells to synthesize pro-inflammatory cytokines and chemokines |6|, inciting the immune response. Historical evidence points to the induction of an anti-inflammatory phenotype induced by low doses of radiation as a potential explanation for the observed effects |2|. While doses >200 cGy tends to exert pro-inflammatory effects, triggering common toxicities observed in radiation therapy, more recent work shows low doses (<100 cGy) incite anti-inflammatory properties |7,8| such as decreasing levels of pro-inflammatory cytokines like IL-ip |9), or * The Editors of the journal, the Publisher and the European Society tor Radiotherapy and Oncology (ESTKO) cannot take responsibility for the statements or opinions expressed by the authors of these articles. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. For more information see the editorial "Radiotherapy & Oncology during the COVID-19 pandemic". Vol. 146. 2020. [-mail address: charles.kirkbytfahs.ca (C Kirkby) inhibiting leukocyte recruitment 110]. Therefore, it stands to reason that an LDRT treatment of 30-100 cGy to the lungs of a patient with COVID-19 pneumonia could reduce the inflammation and relieve the life-threatening symptoms. A single fraction 30-100 cGy treatment could easily be delivered on a conventional megavoltage radiation therapy unit. Routinely, much higher, single fraction doses are delivered in a palliative context with fast-tracked patients going through the full workflow process of education, scanning, planning and treatment delivery in a matter of hours. Proof of principle simulations suggest that a POP treatment with a megavoltage beam could easily ensure 99% of the whole lung volume received between 90% and 120% of a 70 cGy prescribed dose. And because of the low doses, common radiotherapy toxicities would be avoided. While a large scale up of such LDRT treatments would not be without obstacles (e.g. existing strain on radiotherapy resources, separatingCOVID-19 patients and cancer patients, etc.). we believe clinical trials to further investigate the efficacy of whole lung LDRT would present a very low risk to COVID-19 pneumonia patients, and have the potential to reduce mortality and alleviate COVID-19 related strains on healthcare systems. References |1| 3iou F. Yu T. Du R. et aL Ctnkal course and risk factorc for mortality of adult inpatients with covid-19 in Wuhan, china: a retrospective cohort study. Lancet 2020. |2| Calabrese EJ. Dhawan C. How radiotherapy was historically used to treat pneumonia: could it be useful today?. Yale J Biol Med 2013:86:555-70. 13) Powell EV. Radiation therapy of lobular pneumonia. Texas State J Med 1936:32:237-40. |4| Oppcnheuncr A. Roentgen therapy of interstitial pneumonia. J Pcdiatr 1943:41:404-14. |5| Dubin IN, Baylin GJ. Cobble Jr WG. The effect of roentgen therapy on experimental virus pneumonia: on pneumonia produced in white mice by swine influenza vims. Am J Roentgenol Radium Ther 1946:55:478-81. |6| Moldoveanu B. Otmishi I'. Jam P.et al. Inflammatory mechanisms in the lung J Inflamm Res 2009:2:1-11. |7| Rodel F. Keilholz L Herrmann M. et al. Radiobiological mechanisms in inflammatory diseases of low-dose radiation therapy, lit J Radial Biol 2007:83:3S7-66. |8| Torres L. Royo. Antelo C. Redondo. Arque2 M. Pianetta. et al. Low-dose radiation therapy for benign pathologies. Rep Pract Oncol Radiother 2020:25:250-4. |9| Schaue D. Jahns j. Hildebrandr C. et aL Radiation treatment of acute inflammation in mice. Int J Radial Biol 2005:81:657-67. 110] Arenas M. Cil F. Gironella M. et aL Time course of anti-inflammatory effect of low-dose radiotherapy: Correlation with tgf-beta(l) expression. Radiother Oncol 2008:86:399-406. CLINICAL TRIALS OF LOW-DOSE RADIOTHERAPY FOR COVID-19 PNEUMONIA Row J Saved 1 Status 1 Study Title Conditions Interventions NCT Number Locations 1 □ Recruitinq COVID-19 Pneumonitis Low Dose Lung Radiotherapy * COVID-19 * Radiation: Single NCT04377477 • Radiation (COLOR-19) fraction whole lung Oncology radiotherapy Department, ASST SpedaliCivili Brescia Brescia, Italy 1 □ Not yet Low Dose Whole Lunq Radiotherapy for Older Patients - COVID-19 • Radiation: Low NCT04493294 recruiting With COVID-19 Pneumonitis Pneumonitis dose whole lung radiotherapy for older patients with COVID-19 pneumonitis 3 □ Recruiting Low Dose Radiotherapy for COVID-19 Pneumonitis • Covid19 • Radiation NCT04420390 • Servicio de Radiotherapy Oncologia Radioteripica. Hospital Clinico San Carlos Madrid, Spain 4 □ Recruiting Low Dose Whole Lunq Radiation Therapy for Patients - COVID 19 • Radiation NCT04427566 • Arthur G. James With COVID-19 and Respiratory Compromise Radiation therapy Cancer Hospital and Solove Research Institut at Ohio State University Medici Center Columbus, Ohio. United States 6 □ Active, Low Dose Radiotherapy in COVID-19 Pneumonia * COVID • Radiation: Low NCT04390412 * Imam Hossein not • SARS (Severe Dose Radiotherapy Hospital recruiting Acute Tehran, Iran, Respiratory Islamic Republic Syndrome) of S □ Recruitinq Anii-inflammatory Effect of Low-Dose Whole-Lung • COVID-19 • Radiation: Low NCTÛ4534790 • Social Secure IfiaiYI Radiation for COVID.19 Pneumonia Pneumonia Dose Radiotherapy Mexican Institute Leon, Guanajuat Mexico 7 u Not yet Low-Dose Radiotherapy For Patients With SARS-COV-2 • C avid-19 • Radiation: Low NCTÜ44&6683 recruiting (CQVID-19) Pneumonia 8 O Recruiting Lung Irradiation tot CQVID-19 Pneumonia * Sars-CoV2 • Pneumonia • SARS-CoV2 dose radiation 36 cGy Radiation High dose radiation 100 cGy Radiation Phase t NCT04393948 Radiation: Phase 2 Brigham and Women's Hospital Boston. Massachusetts United States O Not yel Low Dose Pulmonary Irradiation in Patients With recruiting COVID-19 Infection of Bad Prognosis Recruiting Radiation Eliminates Storming Cytokines and Unchecked Edema as a 1-Day Treatment for COVID-19 11 D Recruiting Low Dose Anti-inflammatory Radiotherapy for the Treatment of Pneumonia by COVID-19 CQV1D Pneumonia, Viral • Pneumonia • Coronavirus Infection in 2019 (COVID-19) • Severe Acute Respiratory Syndrome (SARS} Pneumonia • Pneumonia, Viral □ Active, Low Dose Radiation Therapy for Covld-19 Pneumonia not recruiting COVID-19 Pneumonia 13 estudios, 7 países 1 finalizado 8 en reclutamiento Radiation: Lung NCT04414293 • Hospital Provincïa Low Dose de Castellon Radiation Castelôn De La Plana, Castellon, Spain • Radiation: Low NCT04366791 « Emory University Dose Radiation Hospital Therapy Midtown/Winship Cancer Institut« Atlanta, Georgia. United States Radiation: Low- NCT04380&18 dose radiotherapy Drug: Hydroxychloroquine Sulfate Drug: Ritonavir/lopinavir (and 5 more..) U Recruiting Ultra Low Doses of Therapy With Radiation Applicated to • Pneumonia, CQVID-19 Viral * Cytokine Storm Radiation: Ultra- Low-dose radiotherapy Device: ventilatory support with oxygen therapy Drug: Lopihavir/ritonavir (and 6 more ) Radiation Low dose radiation therapy NCT043941&2 Hospital Sant Joan deReus Reus, Tarragona. Spain Hospital Del Mar Barcelona Spain Hospital Universitarfo Madrid Sanchinairo Madrid. Spain Hospital La Milagrosa. GenesisCare Madrid. Spain Hospital Vithas Valencia Consuelo Valencia, Spain All India Institute of Medical Sciences, New Delhi New Delhi. Delhi. India U.S. National Library of Medicine Clin ical Trials.gov 60Ûn ■ «um b D X S Li.. ~N û a « -*- LD-RT Control Stratilemlier On toi CSED} 199tM7-BG nttps JAinijargyi aiwr/sooMfi-023-02067-9 ORIGINAL ARTICLE fi Treatment of COVID-19 pneumonia with low-dose radiotherapy plus standard of care versus standard of care alone in frail patients The SEOft-GICOR IPAtOVID comparative cohort trial M. Arenas1* ■ E. Piqué1 ■ L Tones-Royo1'* ■ J. CL Acosta1* ■ E. Rod ^'guez-Tomái1'J',■ G. De Febrer1 ■ ClV^sco^ ■ R Araguas1" ■ I. A. Gomez1''' ■ E. Malawi ■ M. Arqu ez1'* - M. Algara*^ ■ A. Montero» - M. Montero* - J. M. Simó11 ■ X. Gabaldó11 - D. ParaJa3 - F. Riu1 ■ S. Sabater13 ■ JL Camps3* ■ J. Joven3'' tiItpv.Vil(»Of9"0100í/i0O0«-0M-0174J-4 ORIGINAL ARTICLE i CENTRO INTEGÏAI QNCOLOCKO KM HOSPITALES hm CIOCC K 31 hm hospitales COVID-19 pneumonia treated with ultra-low doses of radiotherapy (ULTRA-COVID study): a single institution report of two cases Original Article Low-dose Radiation Therapy in the Management of COVID-19 Pneumonia (LOWRAD-Covl9). Final results of a prospective phase I—IX —^ trial Noelia Sanmamed Pino Alcantara1'--', Sara Gómez ^ Ara Bustos J. Elena Cerezo'. Miren Gazlañaga*". Anxela Doval ".Juan Corona Cabriel RodríguezNoemi CabeJIo', Mercedes. Duflbrt', francisco Omito1', Javier de Castro", Amanda López". Manuel Fuentes1, Alvaro San?Manuel Vazquez"1" aSftoitoCrttOwpfciriWwitc'eii-Hurt¿Vrtíáwd ¿í^ "** ""* StrilHenttwfOnkol (2021) 197:1010-1020 httptV/dolonj/IO 1007/100066-021-0180M ORIGINAL ARTICLE Could pulmonary low-dose radiation therapy be an alternative treatment for patients with COVID-19 pneumonia? Preliminary results of a multicenter SEOR-GICOR nonrandomized prospective trial (IPACOVID trial) M. Arenas" • - M. Algara*"G - G. De Febrer" - C. Rubio" • X. Sanz*»' - M. A. de la Casa' et al. C Vasco" • J. Marin*'0 - P. Fernàndez-Letôn" - J. Villar"1 • I. Torres-Royo'" • P. Villares" • I. Membrive" • i. Acofta"-1 ■ M. Ldpez-Cano" ■ P. Araguas'" • J. Quera"* • F. Rodriguez-Tombs'u ■ A. Montero* □ ID K M * M M Ctays TAKE-HOME MESSAGE i v >r --u Vhenisn diseases may «...the so called ben* not be so benign as * ized by in truth, ^y may^ are those malignant con ^ L e. loss of organ1 f radiothetapy ■ ■ - life, which justny H. Seegenschmiedt a Not so Benign Diseases Thoughts about Benign and ^^001 UČINKOVITO OBVLADOVANJE TUMORJA JE KLJUČNO ZAČNITE Z ZDRAVILOM XTANDI XTANDI je prvo in edino peroralno zdravilo z dokazano učinkovitostjo v prvem redu zdravljenja, ki je indicirano za zdravljenje rHORP, nrKORP z velikim tveganjem in rKORP brez simptomov ali z blagimi simptomi.1,2 rHORP = razsejani hormonsko občutljiv rak prostate; nrKORP = nerazsejani proti kastraciji odporen rak prostate; rKORP = razsejani proti kastraciji odporen rak prostate SAMO ZA STROKOVNO JAVNOST Pred predpisovanjem, prosimo, preberite celoten povzetek glavnih značilnosti zdravila. Predpisovanje in izdaja zdravila je le na recept zdravnika specialista ustreznega področja medicine ali od njega pooblaščenega zdravnika. Lokalni kontaktni naslov za prijavo neželenih učinkov: farmakovigilanca.si@astellas.com Za vse dodatne informacije o zdravilih podjetja Astellas se obrnite na: medinfo.AB@astellas.com Datum priprave: februar 2024, MAT-AB-XTD-2024-00015 Reference: 1. Povzetek glavnih značilnosti zdravila XTANDI (enzalutamid). 2. Mottet N et al. European Association of Urology 2021. > astellas Astellas Pharma d.o.o., Smartlnska 53, 1000 Ljubljana > Xtandi ' enzalutamid Obsevanje mišičnoskeletnega sistema - pogled fiziatra mag. Urška Kidrič Sivec, dr. med., spec. FRM URI Soča, Oddelek za rehabilitacijo pacientov z okvaro hrbtenjače 1 Fiziatrična obravnava mišičnoskeletne patologije • Radioterapija • V fiziatrični literaturi je možnost uporabe radioterapije navedena le pri heterotopnih osifikacijah (HO) • Radioterapevtske indikacije na področju mišičnoskeletnega sistema so širše 4. 03. 2024 Obsevanje mišičnoskeletnega sistema - pogled fiziatra 2 Heterotopne osifikacije • Definicija: tvorba zrele lamelarne kostnine v nekostnih tkivih, kjer se kostno tkivo praviloma ne pojavlja • Sopomenki • Myositis ossificans (v prečno-progastih mišicah) • Ektopična osifikacija • Značilnosti: • Metabolno aktivna • Nima periosta • Ne atrofira • Vnetje in proliferacija 4. 03. 2024 Obsevanje mišičnoskeletnega sistema - pogled fiziatra 3 HO • Vzroki • Genetski (fibrodisplazija ossifikans progresiva...) • Negenetski • Neposredna poškodba tkiva (operacija, travma) 40% (2-7%) • Poškodba CŽS 10-53% (od teh je 10-20% simptomatskih) • Opekline (večja površina opekline, večja pojavnost HO) • Lokalizacija • Kolk (medenica, poškodba hrbtenjače) • Koleno (operacije, poškodba hrbtenjače) • Komolec (operacije, opekline, nezgodna možganska poškodba) • Rama (operacije, nezgodna možganska poškodba) 4. 03. 2024 Obsevanje mišičnoskeletnega sistema - pogled fiziatra 4 HO • Epidemiologija • Moški pogosteje (m:ž=3:2, m=2.5xž) • Med 20 in 30 letom • Klinična slika • 2-12 tednov po poškodbi ali operaciji • Omejena gibljivost sklepa • Oteklina • Rdečina • Bolečina • Povišana telesna temperatura • Laboratorijsko povišani vnetni parametri, povišana AF 4. 03. 2024 Obsevanje mišičnoskeletnega sistema - pogled fiziatra 5 HO • Klasifikacija • Kolk - razdelitev po Brookerju (I-IV glede na razdaljo med HO in sklepom) • komolec - Hastings in Graham (I-III) • Zdravljenje • Vzdrževanje gibljivosti • Operativna odstranitev po maturaciji (nevarnost ponovitve) • Preprečevanje • NSAID - indometacin • Radioterapija 4. 03. 2024 Obsevanje mišičnoskeletnega sistema - pogled fiziatra 6 Radioterapija (RT) pri HO • Priporočila britanskega združenja (Royal College of Radiologists), marec 2023 • RT in NSAID sta učinkovita v preprečevanju HO, NSAID so cenejši (stopnja priporočila A) • Razmislek o RT pri pacientih, pri katerih je jemanje NSAID kontraindicirano ali obstaja povečano tveganje za nastanek obsežnejše HO, izogib uporabe pri mlajših pacientih (<50 let) • Aplikacija 4 ure pred op. ali znotraj 96 ur po op. (stopnja priporočila A) • Učinkovito 1x obsevanje s 7 Gy (stopnja priporočila A-C), zmanjšano tveganje za RIC (stopnja priporočila D) • Velja kot preventiva nastanka HO v kolku 4. 03. 2024 Obsevanje mišičnoskeletnega sistema - pogled fiziatra 7 Obsevanje pri osteoartikularni bolečini (osteoartroza, periartritis) doc. dr. Ivica Ratoša, dr. med. specialistka onkologije z radioterapijo o Onkološki Inštitut institute of Oncology Ljubljana OSTEOARTROZA (OA) 1-2 % OA je najpogostejša sklepna in revmatska bolezen s prevalenco 17.3 %3 (50 % vseh radiološko odkritih OA je asimptomatskih) EKONOMSKO BREME OA: 1,0-2,5% bruto domačega proizvoda v zahodnem svetu; v Sloveniji ~ 0,4 %.1'2 Slovenija (2016-2020): neposredni in posredni stroški bolezni mišičnoskeletnega sistema in vezivnega tkiva v povprečju znašajo okoli 195 milijonov EUR oz. 5,1% vseh izdatkov za zdravstvo.2 Stroški zdravil za zdravljenje šestih izbranih diagnoz: 17,5 milijonov EUR, kar predstavlja 23,9 % vseh izračunanih neposrednih stroškov v proučevanem obdobju.2 GLAVNE DIAGNOZE (osnovni vzroki) MKB-10 M16 Artroza kolka fkoksartroza) M17 Artroza kolera (gonartroza) M 25 Druge motnje sklepa, ki niso uvrščene drugje M 54 Bolečina v hrbtu (dorzalgijaj M 75 Okvare (lezije) rame M 79 Druge motnje mehkega tkiva, ki niso uvrščene drjgje ZDRAVILA -25 % vseh stroškov Vir: MKB 10, 2QÜ5 1) Hiligsmann M et al (2013) Health economics in the field of osteoarthritis: an expert's consensus paper from the European society for clinical and economic aspects of osteoporosis and osteoarthritis (ESCEO). Semin Arthritis Rheum 43(3):303-313 2) Ekonomske posledice bolezni mišično-skeletnega sistema in vezivnega tkiva v Sloveniji v obdobju 2016-2020 https://nijz.si/wp-content/uploads/2023/01/Porocilo BMSVT 2020.pdf 3) https://www.ortopedija-mb.si/veliki_sklepi%202010.pdf OA: mehanizmi nastanka in življenjsko tveganje Pravi mehanizmi nastanka OA še niso znani. Primarni OA velikih sklepov je navadno posledica nesorazmerja med mehanskimi obremenitvami in sposobnostjo hrustanca, da se na te obremenitve primerno odzove. • Glavne značilnosti: prezgodnje popadanje sklepnega hrustanca (primarno mesto dogajanja), kasneje se pojavi vnetje, kateremu lahko sledijo sekundarne spremembe, ki se pojavljajo na sklepnih in obsklepnih strukturah, kot so sinovialna membrana, fibrozna ovojnica, subhondralna kost (s tvorbo skleroze, subhondralnih cist in osteofitov), kite in mišice. PATOGENEZA (3 prekrivajoči stadiji): 1. Razgradnja hrustančnega matriksa. 2. Odgovor hondrocitov s povečano tvorbo komponent matriksa. 3. Progresivna izguba hrustančnega tkiva zaradi nezmožnosti hondrocitov pri popravi sprememb na hrustancu. Življenjsko tveganje za OA: M proti Ž Hand: 25% Hip 19% Knee: 40% Hand: 47% Hip 29% Knee: 47% DEJAVNIKI TVEGANJA: STAROST: 90 % bolnikov > 45 let SPOL • HORMONSKI VPLIV (Ž menopavza*) • ANATOMIJA SKLEPA: M^ proti Ž* GENETIKA HIPERTENZIJA, HIPERHOLESTEROLEMIJA https://www.ortopedija-mb.si/veliki_sklepi%202010.pdf Dove APH, et al. The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review. Int J Radiat Oncol Biol Phys. 2022; 114(2):203-220. doi: 10.1016/j.ijrobp.2022.04.029 OA: Obvladovanje težav: farmakološki in nefarmakološki ukrepi 50 % OA: asimptomatskih 50 % OA: bolečina, omejena gibljivost in ¿QoL « > O) to 10 Gy) DOZA? In vitro: maksimalni proti-vnetni učinek z dnevno dozo 0,3-0,7 Gy.1,2 TRAJANJE UČINKA? In vitro: učinek do 48 ur, nato izgine po 72 urah.2 Vpliv na deleče celice (mitoza), ^proliferacija celic.3 Regulacija limfocitov, supresija lokalnega avtoimunega dogajanja.3 1 ) Rödel F, et al. Radiobiological mechanisms in inflammatory diseases of low-dose radiation therapy. Int J Radiat Biol. 2007 Jun;83(6):357-66. 2) Arenas M, et al. Anti-inflammatory effects of low-dose radiotherapy. Indications, dose, and radiobiological mechanisms involved. Strahlenther Onkol. 2012 Nov;188(11):975-81. 3) Torres Royo L, et al. Low-Dose radiation therapy for benign pathologies. Rep Pract Oncol Radiother. 2020 Mar-Apr;25(2):250-254. RADIOBIOLOŠKI mehanizmi nizko-doznega obsevanja Dnevna doza 0,3 do 0,7Gy (TD2,5 do 7,5 Gy) proti-vnetni učinek Differences between the effects of irradiation at low and high doses. /• -N /* • Low irradiation doses Gy) Anti-inflamatory properties IL-10, TGF-ß1, IL-4, NF-kB, HÛ-1. HSP70 L-Selectin, E-Se lectin. AP-1, ROS, iNOS VApoptosis J High irradiation doses {>2 Gy) Pro-mflamatory cytokines production IL-1, TNF-«, IL-6, IL-8. IL-12 ROS.iNOS V__ AP-1: Activator Protein-1; HO-1: Heme oxygenase-1:1ISP70: Inductible Heat Shock protein 70; IL: Interleukine; NF-kB; Nuclear lactor-KB: ROS: Reactive Oxygen Species; TGF-pl: Transforming Growth Factor-ß1: TNF- a: Tumor Necrosis Factor- a; iNOS: Inductible Nitric Oxide Synthase. Modulacija vnetnih mehanizmov & poti, ki vključujejo endotelijske celice, levkocite in makrofage (=centralna vloga). Decreased expression of pro-inflammatory cytokines such as IL-1B and TNF-a Polarizacija makrofagov proti oti-vnetnemu fenotipu M2. Decreased expression ^ of adhesion molecules such as P-selectin, V L-selectin, E-selectin, N . ICAM-1, VCAM-1 © Povišana ekspresija proti-vnetnih citokinov. Increased expression of anti-inflammatory cytokines including IL-10, TGF-B1 Zmanjšano nastajanje ROS. Polarization of machrophages toward anti-inflammatory M2 phenotype t © Reduced production of reactive oxygen species (ROS) Increased apoptosis of pro-inflammatory cells Nitric Oxide Pro-inflammatory 1 Phagocytosis 1 Iron recycling T Foam cell formation Immunregulatory t Phagocytosis t Efferocytosis X Foam cell formation t PPAR -y signalling © Inhibition of inducible nitric oxide synthase ■ (iNOS) leading to reduced nitric oxide I I Zmanjšano nastajanje pro-vnetnih citokinov in povečana apoptoza pro-vnetnih celic. Inflamed tissue Inhibicija iNOS: zmanjšan vnetni odgovor. Dove APH, et al. The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review. Int J Radiat Oncol Biol Phys. 2022; 114(2):203-220. doi: 10.1016/j.ijrobp.2022.04.029 Torres Royo L, et al. Low-Dose radiation therapy for benign pathologies. Rep Pract Oncol Radiother. 2020 Mar-Apr;25(2):250-254. doi: 10.1016/j.rpor.2020.02.004. Povzetek učinkovitosti zdravljenja OA in periartritrisa z obsevanjem (odgovor na bolečino: delni in kompletni odgovor skupaj, - 3 mesece po RT) 9 retrospektivnih raziskav (n=4178) 6 prospektivnih (n=1209) 3 randomizirane kontrolirane raziskave (n=340) ARTROZA KOLKA: 24-89 % TROHANTERIČNI BURZITIS: 46-73 % (3 mesece po RT) OA STOPALA in GLEŽNJA: 75 % (6 mesecev po RT) izboljšanje gibljivosti sklepov: 56 % 24-100 % > RAMENSKI SKLEP: 58-100% Utesnitveni sindrom rame (2 do 3 mesece po RT) ■» MALI SKLEPI ROK: 63-94 % ■» ARTROZA KOLENA: 29-91 % Ott OJ, et al.; German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD). DEGRO guidelines for the radiotherapy of non-malignant disorders. Part II: Painful degenerative skeletal disorders. Strahlenther Onkol. 2015 Jan;191(1):1-6. Micke O, et al. Radiotherapy for calcaneodynia, achillodynia, painful gonarthrosis, bursitis trochanterica, and painful shoulder syndrome - Early and late results of a prospective clinical quality assessment. Radiat Oncol. 2018 Apr 19;13(1):71. Alvarez B, et al. Radiotherapy for ostheoarticular degenerative disorders: When nothing else works. Osteoarthr Cartil Open. 2019 Dove APH, Cmelak A, Darrow K, McComas KN, Chowdhary M, Beckta J, Kirschner AN. The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review. Int J Radiat Oncol Biol Phys. 2022 Oct 1;114(2):203-220. RT in degenerativne bolezni sklepov ter obsklepnih tkiv II. N = 703 (461 Ž in 242 M); povprečna starost 63.3 leta (28-96) Srednji čas sledenje 33 mesecev (3-60) Frakcionacija 12 x 0.5 Gy ali 6 x 1.0 Gy Srednje vrednosti VAS pred in takoj po RT: Table 3 Good Response {%) immediately on completion of RT and during follow Diagnosis Good Reponse on completion of RT Calcaneodynia Achillodynia Gonarthrosis Bursitis trochanterica Shoulder Syndrome All patients 46.0% (131/286 patients) 39.1% (18/46 patients) 30.9% (43/139 patients) 27.1% (19/70 patients) 32.7% (53/162 patients) 37.6% (264/703 patients) Izboljšan odgovor na RT po > 3 m t Good Reponse - Follow up 80.7% (113/140 patients) 88.9% (24/27 patients) 29.2% (33/113 patients) 463% (31/67 patients) 60% (54/90 patients) 58.4% (255/437 patients) Dober odgovor na bolečino po obsevanju za celotno skupino: Takoj po zaključenem obsevanju: 264/703 (37,6 %) Statistično značilno izboljšanje v daljšem sledenju, vsaj 3 mesece: 255/437 (58,4 %) (p < 0.001). Brez razlik v dalješ sledenju in samo 30-odstotna učinkovitost: osteoartroza kolenskega sklepa. P-Value <0.001 =0.001 =0.612 =0.012 <0.001 <0.001 Micke O, et al. Radiotherapy for calcaneodynia, achillodynia, painful gonarthrosis, bursitis trochanterica, and painful shoulder syndrome - Early and late results of a prospective clinical quality assessment. Radiat Oncol. 2018 Apr 19;13(1):71. doi: 10.1186/s13014-018-1025-y. 9 retrospektivnih raziskav (n=4178) 6 prospektivnih (n=1209) 3 randomizirane kontrolirane raziskave (n=340) LDRTin podatki iz RCT O o o OA malih sklepov rok, N = 56 >50 let VAS >5, konzervativni ukrepi neuspešni R: 1:1 6 x 1 Gy vs 6 x 0 Gy OA kolenskih sklepov, N = 55 >50 let VAS >5, konzervativni ukrepi neuspešni R: 1:1 6 x 1 Gy vs 6 x 0 Gy OA malih sklepov rok in kolenskih sklepov, N = 236 obsevanj >18 let (srednja starost 68 let); simptomi vsaj 3 m, R: 1:1 6 x 0,5 Gy (3 Gy) vs 6 x 0,05 Gy (0,3 Gy) 3-m-FU: 28 % vs 31 % (NS) 6-m-FU: 41% vs 35% 12-m-FU: 52 % vs 44 % (NS) 3-m-FU: odgovor: 59 % (obe skupini) (NS); Slab nabor bolnikov raziskava predčasno zaključena. • LDRT: učinkovit samo na določeni stopnji razvoja OA? • • Majhen vzorec: nezadosten, za zaznavo 40-odstotne razlike med skupinama • 40 do 50 % bolnikov potrebuje ponovno obsevanje za odgovor na zdravljenje (v raziskavah ni bilo ponovnega obsevanja) • V raziskavah 1 in 2: shema zdravljenja 1 Gy/ dan — nova dognanja — proti-vnetni učinek izrazitejši pri 0,5 Gy/ dan. NS = statistično neznačilno 1) Minten MJMet al. Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial. Osteoarthritis Cartilage. 2018 0ct;26(10):1283-1290. 2) van den Ende CHM, et al. Long-term efficacy of low-dose radiation therapy on symptoms in patients with knee and hand osteoarthritis: follow-up results of two parallel randomised, sham-controlled trials. Lancet Rheumatol. 2020 Jan;2(1):e42-e49. 3) Niewald M, et al; working group "Benign diseases" of the DEGRO (German Society for Radiation Oncology). ArthroRad trial: multicentric prospective and randomized single-blinded trial on the effect of low-dose radiotherapy for painful osteoarthritis depending on the dose-results after 3 months' follow-up. Strahlenther Onkol. 2022 Apr;198(4):370-377. DEGRO: Priporočila PREDPIS DOZE OSTALA PRIPOROČILA Table 1 DEGRO guideline recommendations for the radiotherapy of painful degenerative skeletaUlisoKle^ r^otal doses/ Single doses/ cpri Skeletal disorder Shoulder syndrome Elbow syndrome Trochanteric bursitis Plantar fasciitis Gonarthrosis Coxarthrosis Hand and finger j oint arthrosis series [Gy] fraction [Gy] FrequencV LoE GR of fractions 3.0-6.0 3.0-6.0 3.0-6.0 3.0-6.0 3.0-6.0 3.0-6.0 0-6.0 0.5-1.0 0.5-1.0 0.5-1.0 0.5-1.0 0.5-1.0 0.5-1.0 0.5-1.0 2-3/week 2-3/week 2-3/week 2-3/week 2-3/week 2-3/week 2c B 4 C lb A 2c B 2-3/week 4 C C Gr Gray, LoE Oxford Level of Evidence, GR Grade of Recommendation Zaradi splošne zaščite pred ionizirajočim sevanjem, je RT priporočena, v kolikor so ostale možnosti zdravljenja OA izčrpane. Bolniki < 40 let - obsevanje izjemoma, po skrbni presoji koristi obsevanja in neželenimi učinki. Obsevalni snop: kV ali MV. Perzistirajoča bolečina ali slabši odgovor na RT: obsevanje se lahko ponovi čez 6 do 12 tednov. Pozor - velikost obsevalnega polja, pacemaker, zarodne mutacije in vpliv obsevanja Ott OJ, et al.; German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD). DEGRO guidelines for the radiotherapy of non-malignant disorders. Part II: Painful degenerative skeletal disorders. Strahlenther Onkol. 2015 Jan;191(1):1-6. Torres Royo L, Antelo Redondo G, Arquez Pianetta M, Arenas Prat M. Low-Dose radiation therapy for benign pathologies. Rep Pract Oncol Radiother. 2020 Mar-Apr;25(2):250-254 DEGRO: Priporočila KAJ še paziti pri načrtovanju obsevanja? RAMA: zaščita pljuč & dojke MALI SKLEPI ROK: zaščita nohtov Tarčni volumni/CTV: ❖ Entezopatije: narastišče mišice in priležna kostnina. ❖Artroza: sklepni hrustanec, priležna kostnina, sinovijska ovojnica v celoti, priležne mišice oz narastišča mišic, periartikularno vezivno tkivo. \ Odgovornost in skrbnost pri izvedbi zdravljenja je enaka kot pri zdravljenju malignih bolezni. Priporoča se skrbno sledenje po zaključenem zdravljenju. Ott OJ, et al.; German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD). DEGRO guidelines for the radiotherapy of non-malignant disorders. Part II: Painful degenerative skeletal disorders. Strahlenther Onkol. 2015 Jan;191(1):1-6. RAZISKAVE v TEKU Radiotherapy 3 vs 6 Gy in Gonarthrosis and Coxarthrosis (RAGOCO) ClinicalTrials.gov ID O NCT04424628 Sponsor O Fundación GenesisCare Information provided by O Fundación GenesisCare {Responsible Party) Last Update Posted O 2020-06-22 Lokacija: Španija Randomizacija, predvideno število vključitev: 338 Low dose radiotherapy A: 6x0,5 Gy Low dose radiotherapy B: 6 x 1,0 Gy Primarni cilj: kontrola bolečine (8-12 tednov) in kakovost življenja îecruitINg o Clinical Trial of Low-dose Radiation Therapy in Patients With Knee Osteoarthritis (LoRD-KNeA Trial) ¡LoRD-KNeA) ilinicalTrials.gov ID O NCT05562271 Sponsor O Seoul National University Hospital Information provided by O Byoung Hyuck Kim, Seoul National University Hospital (Responsible Party) Last Update Posted O 2023-11-22 Lokacija: Južna Koreja Randomizacija, predvideno število vključitev: 114 Low dose radiotherapy A: 6xO,5Gy Low dose radiotherapy B: 6x0,05Gy Sham radiotherapy: 6 x 0 Gy Primarni cilj: kontrola bolečine (4-8-12 tednov) in MRI radiološke spremembe REVMATOIDNI ARTRITIS Revmatoidni artritis: kronična avtoimuna bolezen, prizadane 0.4-1.3% svetovne odrasle populacije1 LDRT (nizko-dozna RT): • nižji nivo protiteles anti- kolagen tip II IgG Nižji nivo vnetnih citokinov -IL-1P, IL-6 and TNF-a (vsi trije nivoji LDRT) o o C d) T3 100 80 60 5 40 o C 20 Predklinicna raziskava: Preventive and therapeutic effects of low-dose whole-body irradiation on collagen-induced rheumatoid arthritis in mice â JÎ Young Kim ffi. Yeong Ro Lee, Young Ae Lee, Chin-Hee Song, So Hyuri Han, Seong Jun Cho, Seon Young Nam Journal of Radiation Research, rradlOl, https://doi.org/10.1093/jrr/rradl01 Published: 28 December 2023 Article history t models preventivno O—O Ç....O 50 Gy Doze pri obsevanju benignih bolezni Zelo nizke TD < 2 Gy Doze pri obsevanju benignih bolezni Zelo nizke TD < 2 Gy multiple d/fr, redko 1 fr NizkeTD 2 -10 Gy Benigne bolezni Srednje TD 10 - 40 Gy Pogosta TD pri benignih boleznih Visoke TD >50 Gy Benigni tumorji (Schwannom, gangliom, adenom, trigeminalna nevralgija) Posledice zdravljenja z obsevanjem zgodnje pozne Nižja kot je doza, manjše je tveganja za posledice zdravljenja z obsevanjem. Posledice zdravljenja z obsevanjem A / * i pozne Tveganje za nastanek poznih posledic je majhno. Večina bolnikov ne bo imela nobenih poznih posledic. Pozne posledice zdravljenja z obsevanjem žile - kapilare parenhimski organi očesna leča Posledice zdravljenja z obsevanjem A J * i pozne Nastanek sekundarnega raka je najpomembnejša pozna posledica po obsevanju benignih bolezni. 1 % 0,5 % 3% Sekundarni raki Redek zaplet obsevanja benignih bolezni Pomembno! • starost • mesto obsevanja • velikost polja • komorbidnost Sekundarni raki 0 raziskav za benigne tumorje je malo, 0 za nastanek sekundarnih rakov je potreben daljši čas spremljanja, 0 tehnološki napredek pri izvedbi obsevanja. • ankilozantni spondilitis ~ tveganje za levkemijo • peptični ulkus ~ tveganje za rak pljuč, želodca in levkemijo • tinea capitis ~ tveganje za nemelanomski rak kože Recommendations for using radiotherapy for benign disease in the UK 2023 Sekundarni raki Redek zaplet obsevanja benignih bolezni Recommendations for using radiotherapy for benign disease in the UK 2023 Sekundarni raki povzročeni z obsevanjem etiologija in patogeneza Targeted Cancer Cells Radiotherapy Ionizing Radiation Bystander Normal Cells (Not targeted by Radiotherapy) Continued formation of reactive oxygen & nitrogen species Oxidative damage from free radical formation Cancer Cells Death DNA Breaks & Cell Damage Propagation of oxidative stress effects to progkny of Bystander & Targeted Cells Hereditary & Germline Predispositions MYC proto-oncogene: Angiosarcoma Rb gene: Soft tissue sarcomas TP53 gene: Breast cancer, brain tumors, sarcomas & Leukemias Li-Fraumeni Syndrome: Increased risk of RT-induced malignancies Life Style & Environmental Factors Smoking: Angiosarcoma Early Menopause: Breast cancer Other Environmental Factors A New 'Second' Cancer Radiotherapy-Induced Malignancies Khanna L, Second Malignancies after Radiation Therapy: Update on Pathogenesis and Cross-sectional Imaging Findings 2021 Zaključek • Sekundarni raki so redek zaplet obsevanja benignih bolezni Pomembno! • starost > 40 let • mesto obsevanja • velikost polja Spodbujanje zdravega načina življenja - opustitev kajenja! O; Onkološki Inštitut J Institute of Oncology Ljubljana Obsevanje benignih bolezni v CŽS Ljubljana 7.3.2024 Benigni tumorji CŽS • Indolentni • Dolg potek • Redko so življenje ogrožujoči • RADIOTERAPIJA • Samo ena od možnih opcij • Pretehtati kakšno je tveganje zdravljenja • Starost • Rast • Možne posledice spremljanje operacija radioterapija sistemska terapija o Radioterapija tehnični aspekt • Na kakšen način • Fotonska radioterapija • Radiokirurgija • Lokalna RT visoke natančnosti • Konvencionalna RT • Protoni in težji delci • Prednosti • Hiter padec odmerka za tarčo • Ogljikovi ioni velik RBE • Slabosti • Dostopnost • Dozimetrične nejasnosti • Mora biti adaptivna/diagnostika Radioterapija tehnični aspekti • Frakcionirana vs hipofrakcionirana vs radiokirurgija um mu um um um um mm wtm Kari ■ i— t— 45 - 60 Gy v 25 - 33 odmerkih 20 - 30 Gy v 3 - 10 odmerkih I Toksičnost je različna • Odvisno od mesta, odmerka Vprašanje namena • Hitrost povnitve funkcije (če še) Krajša terapija bolj ugodna za bolnika 10 - 25 Gy v enem odmerku = radiokirurgija O Tumor cerebelo-pontinega kota SINONIMI: AKUSTIČNI NEVRINOM, ŠVANOM • Eden redkih tumorjev, kjer je diagnoza večinoma radiološka • Ni sistemske terapije, opcije so spremljanje, RT ali operacija o Tumor cerebelo-pontinega kota Tumorji APC rastejo počasi oziroma pogosto ne rastejo Herdwadker et al 2005 Manchester Bolniki z tumorji APC 1977- 2005 Do 2 cm 1989 bolnikov 729 na opazovanju 552 vsaj 2 MR 230 intrameatalni, 322 ekstra Ekstrameatalni 226 (70%) nespremenjenih, 3 (1%) manjši, 93 (29%) zrastlo Stangerup et al 2006, Copenhagen Pri sporadičnih tumorjih APC je preferirano spremljanje o Tumor cerebelo-pontinega kota RADIOTERAPIJA Način je odvisen od velikosti do 1,5 cm v najdaljšem premeru 13 Gy v enem odmerku večji 45 do 54 Gy v 25 do 30 odmerkih ali 20 do 30 Gy v 6 do 10 odmerkih Powell et al 210, IJROBP Royal Marsden Hospital Standardna frakcionacija Kapoor et al 2010, IJROBP Johns Hopkins Hipofrakcionacija Tumor cerebelo-pontinega kota Novejši rezultati zdravljenja tumorjev APC s hipofrakcionacijo Hearing preservation assessment Gardner-Robertson Ability to use Telephone Serviceable Non-serviceable III III-V Yes No Table 3 Related symptoms before and after hypofractionated stereotactic radiation therapy Before radiation therapy After radiation therapy Hearing Serviceable 95 86 ability Non-serviceable 33 42 Tinnitus 67 42 Vestibular 62 30 dysfunction Reference No. patients Total dose No. fractions Median tumour volume cm3 {minimum- maximum) Median follow-up (months) Local control Song 31 25 5 1.1 (0.1-8.74) 100.00% Williams 131 25 5 15(0.05-8.8) 23 100.00% Anderson 37 20 5 0.89 43.1 90.5X/5 years Wong 31 25 5 3.12 40.6 97.00% Kapoor 376 25 (n = 340) 5 0.89 56 97.00% Karam 37 25 (n = 35) 5 1.03(0.14-7.60) 51 91%/3 years 21 (n m 2) 3 Poen 29 25 5 1.47 (0.56-4.13) 48 96.30% Present study 128 22 5 129 (0.11-6.8) 52 95% 5 years Gawish et al, Clinical Oncology 2023 Tumor cerebelo-pontinega kota Radiokirurgija in lokalna RT visoke natančnosti sta ravno tako učinkoviti metodi pri tumorjih APC Author, vcar RT No. of F rt-s FU median Dose dose Volume PFS <*» hearing Facial Trigeminal (months I per fr I median | median Murphy. 2010 SRS 103 43.2 13 t .95 91.5-5 y NA 99 95 Chopra. 2007 SRS 216 68 13 U 98.3-10 y 44 94.9 100 Fnedman. 2006 SRS 295 40 i t 12.5 NA 99.3 99.3 Myrscth. 2005 SRS 103 36 12.2 NA 93 32 NA 94.8 Combs. 2005 FSRT 106 48.5 57.61.8 3.9 LC 96.6 94 966 97.7 Koh. 2007 FSRT 60 31.9 5Ü'2 4.9 LC 100 77.3 100 100 Stereotactic radiosurgery can he offered using cither a Cobalt unit (Gamma Knife) or a Linear Accelerator (X-knife) with comparable results. Kalogeridi et al, Neurosurgical Review 2020 O Tumor cerebelo-pontinega kota Tumorji se lahko prehodno povečajo, pri večjih lahko nastane hidrocefalus Brada, 2013, ESTRO course on Brain Tumours Powell et al 210, IJROBP Royal Marsden Hospital Standardna frakcionacija No OI zdravimo tumorje APC od 2007, v tem času še nismo imeli primera s hidrocefalusom Tumor cerebelo-pontinega kota Adenom hipofize Od 10 -25% vseh intrakranialnih neoplazem (NIH) so neoplazme hipofize Največ je adenomov (okoli 17 % intrakranialnih neoplazem) Večina je asimptomatskih Lahko hormonsko aktivni, lahko motnje vidnega polja, redkejo drugo (temporalna epilepsija, poškodbe možganskih živcev, hidrocefalus, CSF rinoreja) Hormonsko akivni različne prezentacije glede na vrsto prolaktinomi - amenorjea, galaktoreja... ACTH adenomi - miopatija, redistribucija maščobe... somatotropni - akromegalija, spremembe glasu... tirotropni - palpitacije, tremor, hujšanje... Adenom hipofize Zdravljenje kirurgija medikamentozna terapija radioterapija kombinacija zgornjih radiokirurgija Radioterapija - neinvazivna, lahko dodatek k drugim terapijam, je pa klinični in biokemični odgovor počasen o Adenom hipofize Ni kvalitetnih randomiziran raziskav Podatki iz retrospektivnih serij po operaciji in/ali medikamentozni terapiji primerjava glede preživetja in kontrole tumorja Ni podatkov o tem kdaj RT iz randomiziranih preiskav Gittoes et al 1998 Dekkers et al 2008 Adenom hipofize Indikacije za radioterapijo nesekretomi tumor, ki raste po operaciji predvidevamo, da bo ogrozil funkcioniranje sekretorni povišana vrednost hormonov po operaciji za ukinitev medikamentozne terapije Poleg klasične RT lahko tudi s SRT (lokalna RT visoke natančnosti(45 - 50 Gy # 25 - 30 frakcij)) ali SRS (10 - 25 Gy # 1 frakcija) Adenom hipofize Primerjava klasične in RT visoke natančnosti Tumour control Stereotactic RT (117) Conventional RT (532) Systematic review of published literature Pat'ents (*10) Nonfunctioning pit. adenoma Weighted mean Number of patients 393 5 year PFS 92% Brada 2013 5 10 15 20 25 time since RT (years) SRT in klasična RT podobno učinkoviti, SRS je slabša Brada M, Jankowska P 2008 Gamma knife radiosurgery in nonfunctioning p.a. Adenom hipofize Pri hormonsko aktivnih adenomih, je pomembna tudi biokemična kontrola Barrande et al 2000 Iwai et al 2010 Stereotaktična RT je podobno učinkovita konvencionalni RT Radiokirurgija nima boljših učinkov kot frakcionirana RT Adenom hipofize Pri zdravljenju adenomov hipofize je pomembna tudi toksičnost, ki nevrološka vid - poškodba redka1 poškodba temporalnega režnja - novejše tehnike znižajo odmerek na temporalni reženj2 kognitivne motnje - raziskave niso dale jasne povezave med kognitivnimi motnjami in RT3 endokrina insuficienca - 30 - 60 % bolnikov po 10 letih4 sekundarni tumorji5 cerebrovaskularni dogodki6 o 1.Brada et al 1993 2. Becker et al 2002 3. Brummelman et al 2011 4. Minitti et al 2009 5. Tsang et al 1992 6. Erfurth 2002 Adenom hipofize Sekundarni tumorji večinoma meningeomi, pa tudi gliomi Incidenca narašča s časom od RT Mlajši bolniki bolj ogroženi RR = 3,34 (95% CI 1,06 - 10,6) gliomi, RR = 4,06 (95% CI 1,51 — 10,9) meningeomi Radiation induced second malignancy 0 10 20 30 time since radiotherapy (years) Brada et al 1992 Min niti et al 2005 Adenom hipofize Bolniki z adenomi hipofize so že v osnovi bolj ogroženi zaradi cerebro-vaskularnih incidentov Retrospektivna raziskava - 31/342 bolnikov, ki so bili obsevani zaradi adenoma hipofize je umrlo zaradi cerebrovaskularnega dogodka (srednje opazovano obdobje 21 let)1 vsi dogodki v obsevanem področju prisotnost bolezni hipofize in hormonske terapije sicer otežuje analizo, saj tudi ti faktorji povečujejo tveganje Stereotaktična RT ima potencial zmanjšati tveganje za ICV, sekunarne tumorje, morda za kognitivne motnje Radiokirurgija je pri večjih tumorjih bolj toksična 1. Erfurth et al 2002 Kraniofaringeom Nevroepitelijski tumorji, iz ostankov primitivnega kraniofaringealnega voda ali Rathkejevega žepa Histološko benigni, povzročajo invalidnost in so lahko fatalni Radikalna kirurgija - zlati standard - mutilantna optični aparat hipotalamično - hipofizna os diabetes insipidus Ni vloge sistemskega zdravljenja Radioterapija že dolgo uporabljana metoda o Kraniofaringeom De Vile et al 1996 - RT zmanjša verjetnost progresa (p=0,004) KRANIOPHARINGEOM 2000, 88% manj progresov po RT (p=0,00l) Reference Patient age Surgery - deferred radiotherapy/ Progression-free suivival (years) surgery — postoperative radiotherapy/ Median primary radiotherapy alone/ (range) radiotherapy at recurrence (number of patients treated, extent of surgery) Reference Patient age Surgery + deferred radiotherapy/ Progression-free si (years) surgery - postoperative radiotherapy/ Median primary radiotherapy alone/ (range) radiotherapy ai recurrence (number _of patients treated, extent of surgery)_ Overall survival Reference Patient age (years) Median (range) Surgery - deferred radiotherapy / Progression-free survival surgery - postoperative radiotherapy/ primary radiotherapy alone/ radiotherapy at recurrence (number of patients treated, extent ol surgery] Overall suivival Median 14.0 Radiotherapy at recurrence No subsets 79% at 5 years (3—57) of patienrs with surgery t- deferred 724 at 10 years radiotherapy/surgery - postoperative 72% at 20 years radiotherapy/primary radiotherapy alone: NA data Median 19.0 Surgery • postoperative (3-68) radiotherapy (173 patients. 3$ GTR, 14% STR 51% PR. 9% biopsy. 22% cyst aspiration) No subsets of patients with Surgery - deferred radiotherapy and radiotherapy at recurrence: NAdata Median 7,5 Surgery - deferred radiotherapy (15 (0.8—21) patients, 53% CTR. 47% STR) Surgery - postoperative radiotherapy (37 patients. 5% GTR. 27% STR 68% biopsy/VP shunt/cyst aspiration) Primary radiotherapy alone (9 patients) 83% at 10 years 79% at 20 years 77% at 77% at 20 years 77% at Median 7.4 No subsets of patients with (2—15) surgery - deferred radiotherapy Surgery - postoperative primary radiotherapy alone (19 patients, 58% STR. 42% no surgery) Radiotherapy at recurrence (18 patients) 31% at 10 years Surgery - deferred radiotherapy versus 86% at 10 years primary radiotherapy alone (P = 0.01) 100% at 10 years Surgery - deferred radiotherapy versus surgery and postoperative radiotherapy (P=. 0X101) NA data NS Median 65 (1-11) 32 children (< 16 years) 89 adults (>16 years) Surgery and deterred radiotherapy (66 patients. GTR) Surgery and deferred radiotherapy (30 patients. STR] Surgery and postoperative radiotherapy (22 patients, STR) No subsets of patients with radiotherapy at recurrence Surgery and postoperative radiotherapy (24 patients, 5% GTR. 86% STR, 9% biopsy) No subsets of patient with surgery and deferred radiotherapy and radiotherapy at recurrence: NA data 83% at 5 years 81% at 10 years 47$ at 5 years 41% at 10 years 90% at 5 years 90% at 10 years NAdata 95% at 5 years 89% at 10 years 54% at 20 years 82% at 92%at 70% at Median 8.6 Surgery and deferred radiotherapy (1-15) (15 patients. 53% GTR. 47% STR) Surgery and postoperative radiotherapy (15 patients, 33% SIR, 67% biopsy/cyst aspiration) No subsets of patients with radiotherapy at recurrence Median 85 Surgery and deferred radiotherapy (1-5—24.8) {57 patients. 77% GTR. 16% STR, 7% unknown) Surgery and postoperative radiotherapy [18 patients. 100% STR) Radiotherapy at (24 patients) Median 26.0 Surgery and deferred radiotherapy (25-83) {16 patients. GTR) 40% at 5 years Surgery and deferred radiotherapy (51 patients. PR) No subsets of patients with radiotherapy at recurrence 28 Children No subsets ol patients with (< 16 years) surgery and 59 adults deferred radiotherapy (>16 years) Surgery and postoperative radiotherapy (44 patienrs. surgery extension unknown) Radiotherapy at recurrence Median 29.0 No subsets of patients with (2-64) surgery and deferred radiotherapy Surgery and postoperative radiotherapy (25 patients. 20V CTR: S2% STR: 28% PR. biopsy, cyst aspiration ) Radiotherapy ar recurrence (25 patients) 100% at 5 years P< 0.0001 100% at 10 years 100% at 20 years 47% at 5 years. 38% at 10 years. 32% at 20 years 82% at 5 years. 77% at 10 years. 77% at 20 years NA data NAdata NS 79% at 10 years 73% at 20 years 77% at 10 years 60% at 20 years NA data NS 91% at 10 years 91% at 10 years 73% at 5 years 93% at 5 years NAdata Median 9.0 (2-14} 42% at 10 years Surgery and deferred radiotherapy 84% at 10 years versus surgery and postoperative radiotherapy: 84% at 10 years P 0.004 Surgery and postoperative radiotherapy 86% at Surgery and 10 years deferred radiotherapy 83% at versus surgery 10 years and postoperative radiotherapy: NS MR Median 30 (11-S2) <3 years (n=8) 3 < age <18 years (n = 39) i-sr Surgery and deferred radiotherapy (20 patients. 70% GTR. 30% STR) Surgery and postoperative radiotherapy (11 patients, 100% STR/biopsy-Radiotherapy at n {12 patients) Surgery and deferred radiotherapy {30 patients. GTR) Surgery and deferred radiotherapy (37 patients, STR) Surgery and postoperative radiotherapy {46 pts, 5TR) No subsets of patients with radiotherapy at recurrence 32% at 10 years Surgery and deferred 100% at 10 years radiotherapy versus surgery and postoperative 78% at 10 years radiotherapy P< 0.001 Surgery and postoperative radiotherapy versus radiotherapy at recurrence; NS 752% at 2 years GTR versus STR * radiotherapy (NS) 36.2% at 2 years STR versus STR - radiotherapy 73.3% at 2 years (P <0.001) GTR versus STR NAdata (P< 0.001) 962% at CTR venus SIR - 10 years radiotherapy (NS) 80.8% at STR versus STR - 10 years radiotherapy 95 .Si at (P < 0.050) 10 years GTR versus SIR (NS) CTR. gross total resection; STR. subtotal resection: PR. partial resection. 89Ï at 10 years 76% at 20 years SCR at 85% at 10 years lanalfi et al 2013 90% at (conilnlied on n Kraniofaringeom Optimalna doza, in doza/frakcijo? Radiotherapy dose and fractionation regimens in relation to progression-free and overall survival Reference Median ¡range) Radiotherapy technology planning and/or Progression-free survival or local control radiotherapy dose, Cy delivery equipment rates at last fbLlow-up 50(18-50) Two-dimensional radiotherapy Van der Graaf 79% at 5 years generator 2 MV (4 patients) LINAC 6 MV 72% at 10 years (21 patients) 72% at 20 years 56 (6—70) Two-dimensional radiotherapy Van der Graaf 74% at 10 years generator 2 MV (55 patients) 72% at 20 years 50(50-66) Two-dimensional radiotherapy LINAC 6 MV 88% at 10 years (118 patients) 82% at 20 years NS Children mean dose 55.8 Cobalt 56% with dose <54 Gy (52.5—65.2) 84% with dose >55 Gy Adult mean dose 62.4 Median follow-up 17 years (8-28) (43.2-70) 54.6 (50.4-65.9) Two-dimensional radiotherapy UNAC 6-18 MV 100% at 10 years (radiotherapy alone) 86% at 10 years (surgery - radiotherapy) 50 (40-56) Two-dimensional radiotherapy UNAC 62% at 10 years 50 (45-56) Cobalt 60 machine (16 patients) 78% at 5 years. 76% at 5 years. 65% at Two dimensional radiotherapy 10 years UNAC > 17 MV (15 patients). 56% at 10 years with dose >55 Gy Two-dimensional radiotherapy 79% at 5 years. 45% at 10 years with UNAC 4 MV (6 patients) dose <55 Gy (P < 0.05) Mean 54.4 (45-63) NR 92% at 5 years and at 10 years 59.7 (36-70) with various Cobalt 60 machine (1 patient) Two-dimensional 95% at 5 years fractionation NTD 55.3 radiotherapy UNAC 6-18 MV (23 patients) 89% at 10 years (28-83) 54% at 20 years 54 (44-55,8) Two-dimensional radiotherapy UNAC (26 patients) 84% at 10 years Two-dimensional radiotherapy UNAC/T5KT boost (1 patient) Three-dimensional CRT[ 11 patients! FSRT (2 patients) NR (2 patients) 50 (35-54) NR Gross total resection - radiotherapy: 100%: partial resection - radiotherapy: 82% at 5 years Gross total resection - radiotherapy: 100%: partial resection - radiotherapy: 77% at 10 years Partial resection - radiotherapy: 77% at 20 years 42.5 (34.7-52.5) with Planning technology details NR UNAC 4 MV 78% at 10 years various fractionation 66% at 20 years MID: 54.5 (range NR) 54 (45-58) Two-dimensional radiotherapy UNAC 6—10 MV 96% at 5 years 91% at 10 years NR (54-55.8) Three-dimensional CRT (4 patients) FSRT 100% at 5 years (7 patients) UNAC 6-10 MV 83% at 10 years and at IS years 50.4(45- 54) FSRT UNAC 6 MV Circular collimator 75% at 3 years (5 patients) MLC ( 11 patients) 54 (54-55.8) Three-dimensional CRT 90% at 3 years 52.2 (50,4-56) FSRT UNAC 6-15 MV MLC 100% at 5 years 100% at 10 years 50 Cy (50-55) FSRT UNAC 6 MV Customised block (32 patients) 97% at 3 years MLC (7 patients) 92% at 5 years lanalfi et al 2013 NR. not reported: NTD. normalised total dose {biologically equivalent dose given in 2 Gy/fraction; LINAC. linear accelerator system: GIT. conformal radiotherapy: F5RT. fractionated stereotactic radiotherapy: multileaf collimator. Kraniofaringeom Vprašanje se postavlja glede tarčnih volumnov in robov Radiotherapy target volume definitions in three-dimensional conformai radiotherapy (CRT)ifractionated stereotactic radiotherapy (FSRTJ series Reference Radiotherapy technology planning Target Volumes FSRT CC (5 patients) MLC (11 patients) Computed tomography planning + MRI fusion Three-dimensional CRT Computed tomography planning + MRI fusion FSRT Computed tomography planning + MRI fusion FSRT Computed tomography planning + MRI fusion GTV: post-surgeiy residual lesion including both solid and cystic component CTV = CIV CC: PTV: CTV + 0 mm (minimum margin) PTV: CTV + 5-12 mm (maximum margin) MLC: PTV: GTV + 4-8 mm CTV: tumour bed. residual tumour, or both (including the solid and cystic components) CTV = CTV + 1 cm PTV = CTV +35 mm CTV: post-surgery residual lesion including both solid and cystic component CTV = CTV PTV = CTV + 2 mm CTV: post-surgical tumour bed and any residual solid and cystic component CTV = CTV + 2 mm PTV = CTV + 3 mm CTV = CTV + 2 mm PTV = CTV + 3 mm CC. circular collimator: MLC. multileaf collimator: MRI. magnetic resonance imaging; CTV. gross tumour volume. CTV. clinical target volume: PTV, planning target volume. cistična in solidna komponenta robovi se s slikovnim vodenjem ožajo lanalfi et al 2013 Kraniofaringeom Stranski učinki zdravljenja okvara vida po radikalni operaciji do 54% 2D RT do 24% od 3DCRT do 2,5% omejitev odmerka na 54 Gy v fr po 1,8 - 2 Gy okvara se povečuje posebej nad 60 Gy endokrina okvara lahko izražena že pred zdravljenjem poveča se po operaciji po RT hujša pri otrocih, odvisna od odmerka o hipotalamična disfunkcija glavni vzrok za morbiditeto in mortaliteto lanalfi et al 2013 Kraniofaringeom Nevrološka okvara je pogosto prisotna že prej Malo podatkov o kognitivnem funkcioniranju kognitivni upad sovpada s starostjo in delom možgan, ki so prejeli > 45 Gy z novejšimi tehnikami ga opisujejo na okrog 2,5 - 5 % (opisan, brez formalnega testiranja) Kardiovaskularna toksičnost je redko opisovana premalo poročana? Sekundarni tumorji poročano je bilo le o 5 sekundarnih tumorjih (verjetno jih je več) o Ianalfi et al 2013 Meningeom Najpogostejši primarni tumor CŽS Večina je benignih EANO smernice o Meningeom SRS alternativa operaciji, majhnih dobro omejenih tumorjev, pri starejših oziroma operacije nesposobnih bolnikih 13 Gy v 1 frakciji Kombinirano zdravljenje s subtotalno resekcijo in SRS ohranjanje možganskih živcev Hipofrakcionirana radiokirurgija (18 - 25 Gy v 2 - 5 frakcijah) Frakionirana RT 54 Gy v 30 frakcijah standardni način RT o Meningeom SRS alternativa operaciji, majhnih dobro omejenih tumorjev, pri starejših oziroma operacije nesposobnih bolnikih 13 Gy v 1 frakciji Kombinirano zdravljenje s subtotalno resekcijo in SRS ohranjanje možganskih živcev Hipofrakcionirana radiokirurgija (18 - 25 Gy v 2 - 5 frakcijah) Frakionirana RT 54 Gy v 30 frakcijah standardni način RT o Meningeom Vsi zgoraj opisani pristopi omogočajo lokalno kontrolo okoli 90 % po 10 letih. Glede na kraj vznika se pri bolnikih z meningeomi lahko pokaže katerikoli od že prej opisanih stranskih učinkov. Incidenca stranskih učinkov je običajno nekoliko nižja kot pri kraniofaringeomih in adenomih hipofize o Hvala za pozornost o Obsevanje žilnih malformacij izven CŽS Blaž Grošelj Onkološki inštitut Ljubljana Obsevanje benignih bolezni, OIL 7.2.2024 Žilne malformacije • Arterio-venske malformacije • Malformacije limfatičnega žilja • Veno-limfatične malformacije • Venske malformacije Prisotne od rojstva (fetalni razvoj) Dedne? Sindromi Embolizacija, kirurška odstranitev Nizko pretočne: Visoko pretočne: https://www.hopkinsmedicine.org/health/conditions-and-diseases/vascular-malformations Arteriovenous malformation | Source: American Stroke Association Arterio-venske malformacije https://www.hopkinsmedicine.org/health/conditions-and-diseases/vascular-malformations Arteriovenous malformation | Source: American Stroke Association RT 45 Gy + Talidomid (jutranja slabost, pomiritev ...) 1957-1961 Zaviralec IL produkcije Blinc A, et al. Thromb Haemost 2008; 99: 235-237 Predstavitev primera 74-letni moški Zdravljen zaradi AV malformacije v medenici + thalidomid -► Nesteroidni zaviralec androgenega receptorja Sočasno visokorizični karcinom prostate AV malformacija v progresu V predavanju bo predstavljen klinični primer, kontrolne slike in potek zdravljenja. O; Onkološki Inštitut ) Institute of Oncology Ljubljana Stereotaktična radioterapija telesa za zdravljenje refraktarne prekatne tahikardij e Jasna But Hadžič STAR - STereotactic Arrhythmia Radioablation SBRT = stereotactic body radiation therapy SABR = stereotactic ablative body radiation therapy VT = ventrikularna tahikardija • Nizko število frakcij (1-8) • Visoka doza na frakcijo (6-34 Gy) • Ozki robovi • BED > 100 Gy • Visoko konformna izodozna porazdelitev doze Nenormalni električni signali iz prekatov Frekvenca > 200 utripov/min Brazgotine po AMI Antiaritmiki Kateterska ablacija ICD Amiodarone Hydrochloride Tablets_ STAR - STereotactic Arrhythmia Radioablation SBRT = stereotactic body radiation therapy SABR = stereotactic ablative body radiation therapy VT = ventrikularna tahikardija SBRT - alternativni pristop k aritmogenemu tkivu • ablativna doza • visoko natančna • vi frakciji • neinvazivna Prednost pred RFA • transmuralne lezije • Homogeno uničenje tarče • Nizko tveganje lx 25Gy na tarčo SBRT srca - literatura A Caso Roport Stereotactic KmlliiMii'Kvry for a t in «llar Sarcoma: A Cuse Uipoi t Cardiac Iti Tncliycard idiosurgory in or Miiligi unit \ fcntriculnr UIUtlM.I.I.IU.tWMM Slrrroludlc Alilall»»- Kailiulliiriili) fur tli« Tnali»«»! . \-H~t las US BnlMi r 1*111. IU> A*Vn l*f«n. Ml I V«v« Ry U*Y \m v.« KV Ii «II ! W <.. >. - hl) II...... I.YM» «*> mnl Hijwt Uli IW>. Am AI «kul Uli. M tty Uli III) Soltys SG, Technol Cancer Res Treat 2008 CvekJ, Cure us 2014 Loo BW, ClrcAE 2015 O Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia Ptdh? S CuwfcH M O. U.nkr. » MMD.^mtiikivnO. l»u U«K. n, O. Utm laxf. U 0. 0««M< CM*«. M 0. U«MI>Mt MO fkt) U^fCW.(UII -It.'-. ua.lt w VmK. U 0 0 (VI. (Vr -.t Halalun. U 0. >«» Hi 0 .-1 (l«o.J C >o-v U D CifUltllK>H ORIGINAL RtSURCH AHIICU Phase l/ll Trial of Electrophysiology-Guided Noninvasive Cardiac Radioablation for Ventricular Tachycardia Pretrtatment Post-treatment ♦ M • IH^HBHI • m >J00 IM 100 M 0 M 100 IM >K0 Number of VT Episodes Robinson CG, Circulation 2019 ENCORE-5 The NEW ENGLAND JOURNAL o/MEDICINE ORIGINAL ARTICLE Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia Phillip S. Cuculich, M.D., Matthew R. Schill, M.D., Rojano Kashani, Ph.D., Sasa Mutic, Ph.D., Adam Lang, M.D., Daniel Cooper, M.D., Mitchell Faddis, M.D., Ph.D., Marye Gleva, M.D., Amit Noheria, M.B., B.S., Timothy W. Smith, M.D., D.Phil., Dennis Hallahan, M.D., Yoram Rudy, Ph.D., and Clifford G. Robinson, M.D. 5 bolnikov-SBRT 2015 • Tarča-anatomske slike in EP mapa • 1 x 25 Gy • RT 14min (11-18 min) O Visualize Anatomical Scar Perform EP Mapping ECGI map Identify Arrhythmogenic Scar Substrate Create a contoured target volume Isochrones r Position Develop Plan Treat J V ENCORE-5 The NEW ENGLAND JOURNAL o/MEDICINE ORIGINAL ARTICLE Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia Phillip S. Cuculich, M.D., Matthew R. Schill, M.D., Rojano Kashani, Ph.D., Sasa Mutic, Ph.D., Adam Lang, M.D., Daniel Cooper, M.D., Mitchell Faddis, M.D., Ph.D., Marye Gleva, M.D., Amit Noheria, M.B., B.S., Timothy W. Smith, M.D., D.Phil., Dennis Hallahan, M.D., Yoram Rudy, Ph.D., and Clifford G. Robinson, M.D. A Serial Evaluation of Left Ventricular Ejection Fraction ON C O tj 45-, 40-35-30-25-20-15-10-5- Baseline 1 Mo 6 Mo 12 Mo A Monthly Assessment of All VT Episodes per Patient 60- 200 150 100 50 0 50 100 150 19 bolnikov • Primarni cilj - varnost in učinkovitost • 94% bolnikov manj aritmij 1778 VT pred RT vs 149 VT po • Brez zgodnje tox • Ni okvar ICD • Utrujenost, slabost • 6 perikardialnih izlivov (1 drenaža) >200 Robinson 2019, Circulation ENCORE-VT (faza Ml) Phase II - Efficacy over time 6 mo pre a> (O Û. 150 24 mo post 78% of patients continued et pri * to me primary e ndpoint i. 6 mo pre L 0-6 mo post h 6-12 mo post 12-18 mo post h 18-24 mo post * Deceased 100 50 2019 AMERICAN SOCIETY FO 0 VT episodes 50 100 (ASTRO) ANNUAL MEETING 150 Wiener 2022 HeartRhytm Večinoma "single center", Cue ulic h 2017 5 Linear accelerator 62 Robinson 2019 19 Linear accelerator 66 Neuwlrth 2019* 10 Cyber Knife 66 Gianni 2020 5 Cyber Knife 67 lloyd 20208 10 Linear accelerator 61 Hoetal2021 6 Linear accelerator 72.S Chin ot al 2021 8 Linear accelerator 74 Carbucicchio 2021 7 Linear accelerator 72 Lee 2021 7 Linear accelerator 70 Pekhl 2021* abstract 33 Cyber Knife 66 Ll-Ting Ho 2021 7 Linear accelerator 56 Yugo2021 3 linear accelerator 68 Qian 2022 6 Linear accelerator 72 Ninni 2022 17 Cyber Knife 68 Wight 2022» 14 Linear accelerator 59.5 Molon 2022 6 linear accelerator 79.5 Aras2022 8 linear accelerator 61.5 Van dcr Reo 2023 6 Linear accelerator 73 KJ majhno število bolnikov Median EF H ICM Follow up time Outcome 2/5 11/19 8 4/5 4/10 2/6 4/8 3/7 5/7 19/33 0/7 0/3 6/6 10/17 5/14 4/6 4/8 6/6 12 months 12 months 28 months 12 months 6 months 6.0 i 4.9 months 7.8 months 8 months 6 months 29 t 23 months 14.5 months 13.5 7.7 months 12.5 months 7.2 months 12 months 8 months 12 months 1 death. Rcduccd burdon of VT 5 death. Reduccd burden of VT 3 death. Rcduced burdon of VT 2 death. Initial reduced burden of VT 3 Tx, 2 hospice. Reduced burden of VT 2 death. Reduccd burden of VT 3 death. Rcduccd burden of VT (not Immediate) 3 death. Reduccd burden of VT 3 death. Reduccd burden of VT 17 death. Gradual decrease in VT 1 death. Rcduccd VT burden 1 death. Rcduccd VT burden 3 death. Reduccd burden of VT 3 death. Rcduccd VT burden 2 death. Modest decrease In VT 1 death. Rcduccd VT burden 4 death. Rcduccd VT burden 2 death. Rcduccd VT burden Drsnica Amin Al Ahmada, HRS 2023, New Orleans Učinkovitost in varnost STAR (a) % of VT burden reduction at 6 months Meta-Analysis > Clin Oncol (R Coll Radiol). 2023 Sep;35(9):611-620. doi: 10.1016/j.clon.2023.04.004. Epub 2023 Apr 24. A Meta-analysis of the Efficacy and Safety of Stereotactic Arrhythmia Radioablation (STAR) in Patients with Refractory Ventricular Tachycardia G A Viani 1, A G Gouveia 2 , J F Pavoni 3 , A V Louie 4 , J Detsky 4 , D E Spratt 5 , F Y Moraes 6 Studies Cuculich 2017 Neuwirth 2019 Robinson 2019 Ciani 2020 Carbucicchio 2021 Lee 2021 Estimate (?S%CI) 92%(70-100) 90%(71-100) 94%(84-100) 80%(45-100) 93%(85-100) 85%(60-100) Overall (12=0%, p=0.96) 92%(8S-100) èQ m Sfi 9fi @6m VT obremenitev ^ 92% 100 (b) % patients using < 2 AAD at 6 months Studies Cuculich 2017 Robinson 2019 Ciani 2020 Estimate (9S%CI) 75%(50 -100) -88%(73 -100) 80 %(50-100) . Overall (12=0%, p=0.7) 85% (72-99) 50 6Q m 80 @6m nI/ proženj ICD za 86% 9Q 100 @6m <2 antiaritmika 85% 150 Viani GA 2023 ClinOncol Problem STAR o Omejitve na kritične organe Organs ul risk. Dom* recommendations/dose limitations Aorta I .oil coronary arteries Superior vena cava Left atrium Whole hear! minus PTV ILsophagus Trachca Bronchial Ircc Spinal canal Skin Whole lungs ^25 Gy ^20 Gy ICD (major electronics) lX>se limilations: l)„£ 20.0 Gy Minor protocol deviation: 20 Gy < /), Major protocol violation: > 25 Gy Dose limitations: M.OGy Minor protocol deviation: 14 Gy < l)m Major protocol violation: D^y > 20 Gy IX»e recommendations: l)Wi <0.6 Gy Dose recommendations: /->„,,54.4 Gy IX*e recommendations: 5 5 Gy IX»vo limitations: l)rM £ 14.5 Gy and <, I ccm Minor protocol deviation: l)^ < 19 Gy, Dlnm<, 14.5 Gy and V90) <4 ccm Major protocol violation: > 19 Gy II I)14.5 Gy II V'9(i) > 4 ccm Dove limilations: D^Z 15 Gy and t^oo,£ I ccm Minor protocol deviation: i)^, < 20 Gy. /), >vl>< 15 Gy and V,0 20 Gy II l)t 15 Gy I V90y > 4 ccm Do*e limitations: />nw£ 15 Gy and VIUi) £ I ccm Minor protocol deviation: l)M <, 20 Gy. /■>, 15 Gy and l'IOO) ¿4 ccm Major protocol violation: > 20 Gy II />| l5Gy I V',<;) > 4 ccm Dose limitations: D^ü7 Gy and VMi) «J0.I ccm Minor protocol deviation: /i^, £ 8 Gy. V6<() £ I ccm Major protocol violation: l)mtX > 8 Gy I l'M>) > I ccm Domt limitations: l)M £ 14.4 Gy and Vw 16Gy II l'Ni(i) > 10 ccm Dose limitations: l'w,. - I'xj, £ 1500 ccm (V7(l) remaining volumc> 1500 ccm) aikl l)yt 5 20 Gy and I)i 3.5 Gy Minor protocol deviation: ume > I (MM) ccm). „ <, 20 Gy and Dw S 5 Gy Major protocol violation: V,,,,., - V-, ~ < 1000 cent (V7 C) remaining volume < 1000 ccm). I)b 5, > 20 Gy and l)un > 5 Gy Dose limilations: />m„ <<> 5 Gy and Mocked from primary beam irradiation Minor protocol deviation: 0.5 Gy < />„,„ i 1.0 Gy Major protocol violation: l)m,x> 1.0 Gy I'*»*«- y*}» ž 1000ccm (V,remaining vol- RAVENTA EP CASE REPORT Oesophagopericardial fistula as a late complication of stereotactic radiotherapy for recurrent ventricular tachycardia Jana Haskova 1*, Kristina Jedlickova2, Jakub Cvek ») 3, Lukas Knybel ») 3, Radek Neuwirth 0 4, and Josef Kautzner1 'Department of Cardiology. Institute for Clinical and Experimental Medicine (IKEM), Videftski 1958/9, Prague 4 140 21. Czech Republic department of Pathology. Institute for Clinical and Experimental Medicine (IKEM), Prague. Czech Republic; 3Department of Oncology. Ostrava University Hospital. Ostrava. Czech Republic; and 4Masaryk University Medical School Bmo. Czech Republic * Corresponding author. Tel; 00420739686615. E-mail address: hasj@ikem.cz Stereotactic body radiotherapy (SBRT) has been suggested as a promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs).1 Early results triggered a wave of enthusiasm, while severe adverse effects have been reported only in an abstract form (Robinson CG, et at. Int J Radiat Oncol 2019;105:682). A 67-year-old patient with a history of inferior myocardial infarction and coronary artery bypass grafting using the gastroepiploic artery was implanted with an Implantable Cardioverter-Defibrilator (ICD) for recurrences of VT 16 years later. He underwent catheter ablation in an expert centre, targeting three different morphologies of VT from the inferior wall. Despite non-inducibility at the end, the patient had recurrences of two faster VTs 2 years later. Stereotactic body radiotherapy was performed (CyberKnife, Accuray), based on electroanatomical maps and positron emission tomography/computed tomography (CT) identification of the scar (25 Gy on 76% isodose, target volume 70 cm3, CTV covered Target Volume (CTV-PTV) margin was isotropic 3 mm) (Figure 1). The maximum dose to oesophagus constraints for oesophagus [D5 ml_ = 9.23 Gy, Dnear max (0.035 ccm) = 13.9 Gy, Dmax = 14.46 Gy]. \ instead of arcs. The patient presented with dysphagia and eariy oesophagitis was confirmed by endosi Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please e Figure I Post-mortem macroscopic picture of the myocardial substrate in the inferior wall (black arrows) and adjacent oesophagopericardial fistula opening through the parietal pericardium (open arrows). Inset. CT angiogram depicting radiosurgical treatment plan with isodose lines. Haskova J, Europace 2022 LBA4_ Longer Term Results from a Phase I/II Study of EP-guided Noninvasive Cardiac Radioablation for Treatment of Ventricular Tachycardia (ENC0RE-VT) 1I) C.G. Robinson. P. Samson, K.M.S. Moore, G.D. Hugo, N. Knutson, S. Mutic, S.M. Godrfu H H rboner M Eaddis A Nnhrrh T.W. Smith,2 P.K. W and P. Cuculich2; ;VV of Radiation Oncolo Medicine. Departme Louis. MO, Washim Radiology; St. Louis. of Radiation Oncolo Medicine, Department of Biomedical Engineering, St. Louis, MO 11% resne pozne toksičnosti • G3 perikardialni izliv (2,2let) • G4 gastroperikardialna fistula (2,4 let) ELSEVIER Heart Rhythm Volume 20, Issue 8, August 2023, Pages 1206-1207 Research Letter Effects of stereotactic arrhythmia radioablation on left ventricular ejection fraction and valve function over time Martijn H. van der Ree MP * f Adrian Luca PhD *, Claudia Herrera Siklody MP *, Variable Worsening No worsening P' Prevalence Mean dose (Gy) Prevalence Mean dose (Gy) Aortic valve 4(20)| 16.8(12.7-19.8) 16(80) 7.2 (1.5-7.2) .03 Menosis 2(W) Regurgitation 2 (SO) Mitral valve 1(4) 5.6 (n.a.) 19 (95) 7.5 (3.8-10.3) M Stenosis 0(0) Regurgitation 1 (100) Tricuspid valve M*) 1.9 (n.a.) 19 (95) 6.7 (2.2-12.6) AO Stenosis 0(0) Regurgitation 1 (100) Van der Ree M, Heart Rhythm 2023 16 Studies, 157 Patients undergoing Cardiac SBRT for Refractory VAs Survival after Cardiac SBRT Cause of Death & 0.7» ] g oso £ s •fe 0.1» ¿5 Û. IS 8 I -Year Mortality 32% * « » Timo after SBRT (Months) HF-related Mortality > Non-Cardiac Death I Death related to rcfractory VAs I Death from HF (1) 2% (2) 4.5% (1) 2% (2) 4% (1) 2% (1) 2% 0) 7% Heart Failure VA Cancer Post-transplantation complication Oesophagoperlcardial Fistula Unspecified non-cardiac cause (24) 52% ■ Sepsis Organ Failure ■ Accidental ■ Amiodarone toxicity ■ Massive Stroke Î Months i Months 12 Months Benali K,Martins R Under review SN0ST0RM 2023 Naše izkušnje Starost PS STAR 1. 83 Ishemična dilatativna kardiomiopatija, CABG, KAF, recidivni perikarditisi, CRT, 7x ablacija! 4 9/20 2. 79 Neishemična dilatativna kardiomiopatija, 2x ablacija, iatrogeni AV blok 2-3 5/21 3. 90 Infiltrativna kardiomiopatija, samo antiaritmik 3 12/22 4. 67 Ishemična kardiomiopatija, lx poskus ablacije, obsežen substrat, nedostopen RFA 3 že 4m hopitalen 5/23 5. 78 Ishemična dilatativna kardiomiopatija, po antiaritmiku kardiogeni šok, električni vihar lx ablacija 4 10/23 $ Priprava CT simulator - vakuumska blazina - respiratorni 4D CT - iv kontrast! Določanje tarče tarča Določitev tarče 1. Apikalna anevrizma L prekata CT, MRI, EKG, EP mapa; Telekonferenca CNCR pred RT 2. Medprekatni septum CT, MRI, EKG, EP mapa; Telekonferenca CNCR po RT jg Washington University in Stlpuis School of Medicine Center for Noninvasive Cardiac Radioablation (CNCR) Departments of Medicine and Radiation Oncology APRIL 2021 SLOVENIA 002 ELECTRICAL MAPPING (l VT) **ECG VTi IBS axis (-V3/-V4) Segment 15 **Prior ablation of VTs Segments 2,8 (2020 procedure) & Segments 2,3,8,9,14 (2021 procedure) SCAR MAPPING **MRI (gadolinium, pre ICD) Segments 2,3,8,9,14 (incomplete data, not all the way to apex or base) Center for Noninvasive Cardiac Radiotherapy Washington university St. Luis Age: 79 Gender: Male LVEF: unknown Cardiomyopathy: NICM NYHA Class: 3-4 Prior Ablations: 2 (2020, 2021) Other Features: On amio + mex CRT after CHB from prior septal ablation 8 VTs in 2020. 6 VTs in 2021. 1 dominant clinical VT now Proposed target FINAL TARGET **Segments 9,> 3 > 2,8 ♦♦Confidence Score = High -^Favorable: Only one clinical VT. Beautiful MRI and catheter maps (correlate). ->Unfavorable: Many circuits in this large septal scar. ->Noteworthy: Previous VTs appearto be exiting 1, 7,10,14,15 -> all along the scar Določanje tarče tarča Določitev tarče 3. LV CT, MRI, EKG, segmentni model Clinical Investigation Method and Atlas to Enable Targeting for Cardiac Radioablation Employing the American Heart Association Segmented Model Jeremy Brownstein, MD,* Muhammad Afzal, MD, FACC, Toshimasa Okabe, MD, Thura T. Harfi, MD, MPH, Matthew S. Tong, DO, Evan Thomas, MD, PhD/ Geoffrey Hugo, PhD,§ Phillip Cuculich, MD,§'n Cliff Robinson, MD,§'M and Terence M. Williams, MD, PhD* Coronal View E Coronal View Sagittal View Septal I / 8 A V 9 V RV 12\ I Lateral 11/ Inferior Določanje tarče tarča Določitev tarče 3. LV CT, MRI, EKG, segmentni model 4,5 (^/M Ml ^tnLolf^^A VfcAr STANKO i 9P Klinični inštitut za, Te/: 0? 05,11.19 STERNA ignoza: F ašanje: preiskav "Evo, sem orientacijsko očrta I tarčni volumen. Je očrtan na t. i. short axis spodnja leva slika. Na zgornji levi sliki je to del povsem bazalno (ob mitral ni zaklopki) inferiorno." dr. Antolič wno tehni ocene br - gluh, zat m2 Določanje tarče tarča Določitev tarče 4. LV + septum Vse + Segmentni model 5. septum Vse +Segmentni model + InHEART tarča i. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. ft3b 14. 15. 16. 17. Batal anterior Batal anteroveptal BimI inferoteptal Ba\al Inferior Baial inferolateral BimI anterolateral Mid anterior Mid anteroteptal Mid inferoieptal Mid Inferior Mid Inferolateral Mid anterolateral Apical anterior Apical teptal Apical Inferior Apical lateral Apex ©tO 279 19 comments Pregled kontur v Arii septum Vse +Segmentni model + InHEART tarča Določanje tarče tarča LV + septum Ivica Ratosa • 1st MD, PhD, Radiation Oncologist 9mo • ® 4th case for us using stereotactic arrhythmia radioablation (#STAR)! Genuine inter-disciplinary cooperation between the teams of UKC Ljubljana and the Institute of Oncology Ljubljana^' .Our first two (\/)(v' cases would not have been successful without the assistance of Cliff Robinson, Geoff Hugo and Phillip Cuculich (https://lnkd.in/ d3CTZuYK) Določitev tarče Vse + Segmentni model Vrisovanje CTV v Arii dr. Bor Antolič, dr. Boštjan Berlot Pošiljanje, QA 2. Pregled tarče in OAR Planiranje Pregled palana + 2. Pregled plana Obsevanje Vrisovanje I TV in OAR Pregled fizika Naše izkušnje leta STAR Učinek 1. 83 9/20 PS 4 ^ PS 2-3 Brez VT Umrl 12/23 11 2. 79 5/21 amjodaron ^ VT umrl 4/22 3. 90 12/22 doma brez VT, umrl 9/23, srč pop 4. 67 5/23 Večkrat hospitalizacije Brez VT, hudo srč pop 5. 78 10/23 septum Izboljšanje, kratke neobstojne VT brez proženja ICD STAR Učinkovitost: • n|/ breme epizod VT • n|/ proženje ICD • nI/ potrebo po antiaritmikih o • Varnost: • Pozna toksičnost G3-5 10% • 1 letna umrljivost cca 30% - kardialni vzrok OBSEVANJE IN AMILOIDOZA Obsevanje benignih bolezni Ljubljana, 7.3.2024 Janka Čarm AMILOIDOZA SKUPINA BOLEZNI, ZA KATERO JE ZNAČILNO ZUNAJCELICNO ODLAGANJE AMILOIDA AL amiloidoza: povzroča odlaganje delcev protiteles - lahkih verig PRIMARNA - vzrok ni poznan SEKUNDARNA - reaktivna, nastane kot posledica kronične okužbe, vnetja (RA, KVBČ), maligne bolezni LOKALIZIRANA -omejena na en organ SISTEMSKA - prizadane številne organe PRIMARNA LOKALIZIRANA AMILOIDOZA SEČNEGA MEHURJA • Redka bolezen • NI jasnega dogovora o priporočeni obravnavi • Značilnosti: - neboleča hematurija - simptomi spodnjih sečil - posnemanje raka sečnega mehurja Boorjan S, Choi BB, Loo MH, et al. A rare case of painless gross hematuria: primary localized AA type amyloidosis of the urinary bladder. Urology 2002; 59: 137. Merrimen JL, Alkhudair WK, Gupta R. Localized amyloidosis of the urinary tract: case series of nine patients. Urology 2006; 67: 904-909 Difuzna oziroma lokalno obsežna zajetosti sečnega mehurja: možnost ohranitvenega zdravljenja? Dimetil sulfid intravezikalno: poskus raztapljanja netopnih amiloidnih skupkov za zdravljenje in preprečevanje ponovitve slabi uspehi: 1/3 ni učinka, pri večini ponovitev Malek RS, Wahner-Roedler DL, Gertz MA, et al. Primary localized amyloidosis of the bladder: experience with dimethylsulfoxide therapy. J Urol 2002; 168: 1018-1020. Nishiyama T, Gejyo F, Katayama Y, et al. Primary localized amyloidosis of the bladder: a case of AL (A.) amyloid protein and combination therapy using dimethyl sulfoxide and cepharanthin. Urol Int 1992; 48: 228-231 Zaman W, Singh V, Kumar B, et al. Localized primary amyloidosis of the genitourinary tract: does conservatism help? Urol Int 2004; 73: 280-282 BENIGNA, toda... Kljub različnim zdravljenjem - ponovitev v 54% Možni recidivi po dolgih intervalih (npr. 14 let po diagnozi) Tirzaman O, Wahner-Roedler DL, Malek RS, et al. Primary localized amyloidosis of the urinary bladder: a case series of 31 patients. Mayo Clin Proc 2000; 75: 1264-1268. Ruffion A, Valignat C, Champetier D, et al. Long-term recurrence of primary amyloidosis of the bladder. Urology 2002; 59: 444. Zdravljenje amiloidoze z obsevanjem? Lokalizirana amiloidoza AL: glava & vrat, grlo, traheobronhialno, lahko ... sečila, orbita, koža ... Zdravljenje z obsevanjem: - za bolnike, kjer kirurško zdravljenje NI primerno - recidivne & obsežne spremembe Hall, Jacob & Rubinstein, Samuel & Lilly, Amy & Blumberg, Jeffrey & Chera, Bhishamjit. (2022). Treatment of Localized Amyloid Light Chain Amyloidosis With External Beam Radiation Therapy. Practical Radiation Oncology. 12. 10.1016/j.prro.2022.03.011. Zdravljenje amiloidoze z obsevanjem? When to recommend local therapy Systemic disease has been excluded by a hematologist; bothersome, symptomatic disease When to recommend surgery Young patients; obstructive lesions; severely symptomatic When to recommend radiation Unacceptable surgical deficit (eg, dysphonia); recurrent disease after surgery; poor surgical/general anesthesia candidacy Dose & fractionation 20-45 Gy at 1.8-2.0 Gy/fraction; 20 Gy in 10 fractions preferred Technique Head & neck (excluding larynx): IMRT; laryngeal: 3D-CRT, lateral fields; tracheobronchial: IMRT or 3D-CRT (IMRT preferred); skin: electrons GTV Radiographic and physical examination (including endoscopically) identified disease CTV Head and neck: involved site (eg, entire nasopharynx); other sites: GTV + 5-10 mm PTV CTV + 3 mm (institution dependent) Abbreviations: CTV = clinical target volume; GTV = gross tumor volume; IMRT = intensity-modulated radiation therapy; 3D-CRT = three dimensional conformai radiation therapy; PTV = planning target volume. Različni odmerki, )d 20 do 45 Gy. Hall, Jacob & Rubinstein, Samuel & Lilly, Amy & Blumberg, Jeffrey & Chera, Bhishamjit. (2022). Treatment of Localized Amyloid Light Chain Amyloidosis With External Beam Radiation Therapy. Practical Radiation Oncology. 12. 10.1016/j.prro.2022.03.011. Kaj pa zdravljenje amiloidoze sečnega mehurja z obsevanjem? EBRT: 12 x 2 Gy = 24 Gy, (cel sečni mehur, po mikciji) IZID po 4 m: - cistoskopsko popolna remisija, - odsotnost hematurije - zmanjšanje simptomov spodnjih sečil - brez akutnih / poznih posledic. - bolnik umrl 7 mesecev po RT (zaradi pridružene nevrodegenerativne bolezni) Cooper CT, Greene BD, Fegan JE, et al. External beam radiation therapy for amyloidosis of the urinary bladder. Pract Radiat Oncol 2018; 8: 25-27. Primarna amiloidoza sečnega mehurja, brez remisije/progres po TURm (spr lateralna stena desno premera cca 5cm): EBRT EBRT alternativa obstoječemu zdravljenju amiloidoze sečnika? zlasti kadar ni odgovora na TURm in se odloča o cistektomiji PRED obsevanjem Vir: arhiv OIL PRED obsevanjem Vir: arhiv OIL Vir: arhiv OIL MRI: 4 mesece PO OBSEVANJU: stena sečnega mehurjaje še vedno difuzno zadebeljena (zadebelitve ni le v kratkem segmentu desno anterosuperiorno), vendar manj kot predhodno (najizraziteje je stena zadebeljena desno lateralno nad ostijem, ki meri v debelino do 18 mm (predhodno vtem delu do 37 mm). Vir: arhiv OIL MRI: 7 mesecev po RT ob različni kapaciteti sečnega mehurja verjetno še dodaten regres patoloških zadebelitev Vir: arhiv OIL ZAKLJUČEK: amiloidoza & obsevanje Obsevanje primarne lokalizirane amiloidoze: - glava&vrat, grlo, traheobronhialno... - bolniki niso kandidati za kirurško zdr. - kirurško zdravljenje mutilantno (obsežne spremembe, anatomsko nedostopne) - recidivne spremembe - odmerek: 20 - 45 Gy - malo/nič akutnih & poznih sopojavov Obsevanje primarne amiloidoze sečnega mehurja: ??? -1 opisan primer