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Radiotherapy and Oncology : Journal of... Oct 2022Image-guided radiotherapy using cone beam-CT (CBCT) images is used to evaluate patient anatomy and positioning before radiotherapy. In this study we analyzed and...
BACKGROUND AND PURPOSE
Image-guided radiotherapy using cone beam-CT (CBCT) images is used to evaluate patient anatomy and positioning before radiotherapy. In this study we analyzed and optimized a traffic light protocol (TLP) used in lung cancer patients to identify patients requiring treatment adaptation.
MATERIALS AND METHODS
First, CBCT review requests of 243 lung cancer patients were retrospectively analyzed and divided into 6 pre-defined categories. Frequencies and follow-up actions were scored. Based on these results, the TLP was optimized and evaluated in the same way on 230 patients treated in 2018.
RESULTS
In the retrospective study, a total of 543 CBCT review requests were created during treatment in 193/243 patients due to changed anatomy of lung (24%), change of tumor volume (24%), review of match (18%), shift of the mediastinum (15%), shift of tumor (15%) and other (4%). The majority of requests (474, 87%) did not require further action. In 6% an adjustment of the match criteria sufficed; in 7% treatment plan adaptation was required. Plan adaptation was frequently seen in the categories changed anatomy of lung, change of tumor volume and shift of tumor outside the PTV. Shift of mediastinum outside PRV and shift of GTV outside CTV (but inside PTV) never required plan adaptation and were omitted to optimize the TLP, which reduced the CBCT review requests by 23%.
CONCLUSIONS
The original TLP selected patients that required a treatment adaptation, but with a high false positive rate. The optimized TLP reduced the amount of CBCT review requests, while still correctly identifying patients requiring adaptation.
Topics: Humans; Radiotherapy, Image-Guided; Retrospective Studies; Radiotherapy Planning, Computer-Assisted; Workflow; Lung Neoplasms; Cone-Beam Computed Tomography; Radiotherapy Dosage; Radiotherapy, Intensity-Modulated
PubMed: 36067908
DOI: 10.1016/j.radonc.2022.08.030 -
Journal of Thoracic Disease Jan 2023
PubMed: 36794129
DOI: 10.21037/jtd-22-1420 -
Pneumologie (Stuttgart, Germany) Jun 2020An 80-year old female was referred to our hospital with left internal carotid artery stenosis and a childhood history of hemoptysis.
HISTORY
An 80-year old female was referred to our hospital with left internal carotid artery stenosis and a childhood history of hemoptysis.
INVESTIGATIONS AND DIAGNOSIS
The ECG showed 2nd degree Mobitz atrio-ventricular block. The chest x-ray and computerized tomography identified a shift of the mediastinum and the heart to the left. The left lung was completely destroyed whilst the right lung was enlarged and crossed the midline. Pulmonary function tests revealed a moderate restrictive ventilation disorder. The diagnosis of autopneumonectomy was based on patient history together with radiological findings.
TREATMENT AND COURSE
A pacemaker was implanted with two stimulation electrodes via a left cephalic venous cutdown. A carotid endarterectomy was also performed without any complication.
CONCLUSION
After autopneumonectomy, postpneumonectomy like syndrome may occur in very rare cases, whereupon operative treatment is mandatory. Any respiratory infections should be treated with antibiotics. Pacemaker electrode placement via the subclavian vein is contraindicated due to the risk of a catastrophic pneumothorax.
Topics: Aged, 80 and over; Carotid Stenosis; Endarterectomy, Carotid; Female; Hemoptysis; Humans; Lung; Lung Diseases; Pacemaker, Artificial; Pneumonectomy; Respiratory Function Tests; Subclavian Vein; Treatment Outcome; Venous Cutdown
PubMed: 32557508
DOI: 10.1055/a-1148-8770 -
Translational Pediatrics Apr 2024In congenital diaphragmatic hernia (CDH), abdominal organs are displaced into the chest, compress the lungs, and cause mediastinal shift. This contributes to development... (Review)
Review
In congenital diaphragmatic hernia (CDH), abdominal organs are displaced into the chest, compress the lungs, and cause mediastinal shift. This contributes to development of pulmonary hypoplasia and hypertension, which is the primary determinant of morbidity and mortality for affected newborns. The severity is determined using prenatal imaging as early as the first trimester and is related to the laterality of the defect, extent of lung compression, and degree of liver herniation. Comprehensive evaluation of fetal CDH includes imaging-based severity assessment, severity assessment, and evaluation for structural or genetic abnormalities to differentiate isolated from complex cases. Prenatal management involves multispecialty counseling, consideration for fetal therapy with fetoscopic endoluminal tracheal occlusion (FETO) for severe cases, monitoring and intervention for associated polyhydramnios or signs of preterm labor if indicated, administration of antenatal corticosteroids in the appropriate setting, and planned delivery to optimize the fetal condition at birth. Integrated programs that provide a smooth transition from prenatal to postnatal care produce better outcomes. Neonatal care involves gentle ventilation to avoid hyperinflation and must account for transitional physiology to avoid exacerbating cardiac dysfunction and decompensation. Infants who have undergone and responded to FETO have greater pulmonary capacity than expected, but cardiac dysfunction seems unaffected. In about 25-30% of CDH neonates extracorporeal life support is utilized, and this provides a survival benefit for patients with the highest predicted mortality, including those who underwent FETO. Surgical repair after initial medical management for the first 24-48 hours of life is preferred since later repair is associated with delayed oral feeding, increased need for tube feeds, and increased post-repair ventilation requirement and supplemental oxygen at discharge. With overall survival rates >70%, contemporary care involves management of chronic morbidities in the context of a multidisciplinary clinic setting.
PubMed: 38715680
DOI: 10.21037/tp-23-602 -
Life (Basel, Switzerland) Dec 2023Unilateral proximal interruption of the pulmonary artery (UPIPA) is a rare congenital disease, and its optimal management remains undefined in the existing literature.... (Review)
Review
BACKGROUND
Unilateral proximal interruption of the pulmonary artery (UPIPA) is a rare congenital disease, and its optimal management remains undefined in the existing literature. The occasional necessity for pneumonectomy is still supported by limited evidence.
METHODS
A systematic review of the literature was conducted using the PubMed search engine, focusing on UPIPA cases that received pneumonectomy. Thirty-one pertinent articles were selected and included in the analysis. A case reported from our institution was included in the analysis.
RESULTS
We found 25 adults and seven children affected by UPIPA who received an indication for pneumonectomy, plus an additional case that was reported by our institution. Among adult patients, the predominant indication was hemoptysis (57%), followed by suspected or confirmed lung cancer (23%). Approximately 46% of surgical procedures were classified as urgent or emergent. Postoperative complications were observed in 36% of cases, with no recorded mortality. In pediatric cases, pneumonectomy was primarily a life-saving intervention, performed urgently or emergently in 75% of instances. A possible late complication in pediatric patients involves a mediastinal shift leading to respiratory distress, which may be mitigated using an inflatable prosthesis.
CONCLUSIONS
Pneumonectomy achieves complete resolution of UPIPA symptoms. In the adult population, its primary indication is hemoptysis, with procedures conducted in both elective and urgent/emergent settings. Despite a mortality rate of zero, a notable proportion of patients may experience postoperative complications. In pediatric cases, the clinical presentation varies more extensively, and pneumonectomy is typically reserved for life-threatening situations, emphasizing the need for careful patient selection.
PubMed: 38137929
DOI: 10.3390/life13122328 -
Journal of Clinical Medicine Jan 2024Fetal magnetic resonance imaging (MRI) is broadly used as a method for assessing prognosis in congenital diaphragmatic hernia (CDH). In addition to the extent of lung...
OBJECTIVE
Fetal magnetic resonance imaging (MRI) is broadly used as a method for assessing prognosis in congenital diaphragmatic hernia (CDH). In addition to the extent of lung hypoplasia, determined by measuring the lung volume, cardiac impairment due to pulmonary hypertension and left cardiac hypoplasia is decisive for the prognosis. The percentage area of left ventricle (pALV) describes the percentage of the inner area of the left ventricle in relation to the total area, whereas the mediastinal shift angle (MSA) quantifies the extent of cardiac displacement. The prognostic value of pALV and MSA should be evaluated in terms of survival, the need for extracorporeal membrane oxygenation (ECMO) therapy, and the development of chronic lung disease (CLD).
METHODS
In a total of 122 fetal MRIs, the MSA and pALV were measured retrospectively and complete outcome parameters were determined regarding survival for all 122 subjects, regarding ECMO therapy in 109 cases and about the development of CLD in 78 cases. The prognostic value regarding the endpoints was evaluated using logistic regression and ROC analysis.
RESULTS
The MSA was significantly higher in children who received ECMO therapy ( = 0.0054), as well as in children who developed CLD ( = 0.0018). ROC analysis showed an AUC of 0.68 for ECMO requirement and 0.77 with respect to CLD development. The pALV showed a tendency towards higher levels in children who received ECMO therapy ( = 0.0824). The MSA and the pALV had no significant effect on survival (MSA: = 0.4293, AUC = 0.56; pALV: = 0.1134, AUC = 0.57).
CONCLUSIONS
The MSA determined in fetal MRI is a suitable prognostic parameter for ECMO requirement and CLD development in CDH patients and can possibly be used as a supplement to the established parameters.
PubMed: 38202274
DOI: 10.3390/jcm13010268 -
European Journal of Pediatrics Sep 2022In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus.... (Review)
Review
UNLABELLED
In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus. Thanks to its technical advantages, better anatomical definition, and superiority in fetal lung volume estimation, fetal MRI has been demonstrated to be superior to 2D and 3D ultrasound alone in CDH diagnosis and outcome prediction. This is of crucial importance for prenatal counseling, risk stratification, and decision-making approach. Furthermore, several quantitative and qualitative parameters can be evaluated simultaneously, which have been associated with survival, postnatal course severity, and long-term morbidity.
CONCLUSION
Fetal MRI will further strengthen its role in the near future, but it is necessary to reach a consensus on indications, methodology, and data interpretation. In addition, it is required data integration from different imaging modalities and clinical courses, especially for predicting postnatal pulmonary hypertension. This would lead to a comprehensive prognostic assessment.
WHAT IS KNOWN
• MRI plays a key role in evaluating the fetal lung in patients with CDH. • Prognostic assessment of CDH is challenging, and advanced imaging is crucial for a complete prenatal assessment and counseling.
WHAT IS NEW
• Fetal MRI has strengthened its role over ultrasound due to its technical advantages, better anatomical definition, superior fetal lung volume estimation, and outcome prediction. • Imaging and clinical data integration is the most desirable strategy and may provide new MRI applications and future research opportunities.
Topics: Female; Fetus; Hernias, Diaphragmatic, Congenital; Humans; Lung; Lung Volume Measurements; Magnetic Resonance Imaging; Pregnancy; Prognosis; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 35794403
DOI: 10.1007/s00431-022-04540-6 -
JTCVS Techniques Dec 2023Branch-first total aortic arch repair is a paradigm shift in the technical approach for uninterrupted neuroprotection during open aortic surgery. This technique is...
BACKGROUND
Branch-first total aortic arch repair is a paradigm shift in the technical approach for uninterrupted neuroprotection during open aortic surgery. This technique is further modified to instigate hazardous sternal reentry in patients with hostile mediastinal anatomy at risk of aortic injury.
METHODS
Intraoperative preparation and the illustrated operative technique of the cervical branch-first technique are described. The accompanying case series narrates the experiences and outcomes of 4 patients who underwent successful complex reoperative aortic surgery utilizing this technique.
RESULTS
The indications for resternotomy included a sixth reoperation for recurrent mycotic aortic pseudoaneurysm, a third reoperation for extensive infective endocarditis, a reoperation for complete Bentall graft dehiscence with contained aortic rupture, and a third reoperation for residual type A dissection. All patients survived their proposed surgery. Two patients were operated on in an emergency setting. Two patients separated from cardiopulmonary bypass with extracorporeal support. None experienced permanent neurological sequelae, gut ischemia, peripheral arterial complications, or in-hospital mortality. One mortality due to decompensated heart failure was reported at 6 months postoperatively.
CONCLUSIONS
The cervical branch-first technique offers unparalleled advantage in neuroprotection from an early stage of complex reoperative aortic surgery. It provides an independent circuit for complete antegrade cerebral perfusion, irrespective of suspension to circulatory flows to the rest of the body during complex reentry into hostile chests. Our experience to date has demonstrated promising outcomes and further refinements will guide patient selection best suited for this technique.
PubMed: 38152225
DOI: 10.1016/j.xjtc.2023.08.030 -
Journal of Radiology Case Reports Aug 2021Tension gastrothorax is a rare, life-threatening clinical condition caused by intrathoracic herniation of the stomach through a diaphragmatic defect which becomes... (Review)
Review
Tension gastrothorax is a rare, life-threatening clinical condition caused by intrathoracic herniation of the stomach through a diaphragmatic defect which becomes increasingly distended over time. If not recognized promptly, this can rapidly progress to respiratory distress, mediastinal shift, and hemodynamic compromise. Initial clinical presentation and imaging findings closely mirror those of tension pneumothorax, confounding diagnosis and potentially leading to unnecessary interventions with increased risk of morbidity and mortality. Here, we present a case of an elderly female who presented with a non-traumatic tension gastrothorax and a review of key imaging features and strategies to aid in recognition and accurate diagnosis of this emergent clinical entity.
Topics: Aged; Dyspnea; Female; Hernias, Diaphragmatic, Congenital; Humans; Pneumothorax; Stomach
PubMed: 35586797
DOI: 10.3941/jrcr.v15i8.4144 -
The Indian Journal of Radiology &... 2020Accurate imaging assessment of cardiovascular invasion by mediastinal masses is essential for determining surgical feasibility. This can sometimes be difficult on CT...
BACKGROUND
Accurate imaging assessment of cardiovascular invasion by mediastinal masses is essential for determining surgical feasibility. This can sometimes be difficult on CT owing to limited space available in the mediastinum, resulting in mediastinal masses abutting and indenting adjacent cardiovascular structures. Cine MRI may aid in such situations by demonstrating differential mobility.
AIMS AND OBJECTIVES
To evaluate the role of cine MRI in assessing cardiovascular invasion by mediastinal masses, by evaluating sliding motion and the presence of chemical shift artifact between the mediastinal mass and apposing structures.
MATERIAL AND METHODS
Retrospective study of 44 patients with mediastinal masses, with equivocal involvement of 162 cardiovascular structures on CT scan, in whom cine MRI was done. Involvement on CT was considered equivocal when there was a loss of intervening fat plane and broad surface (>3 cm) or angle (>90°) of contact between the mediastinal mass and cardiovascular structure. The presence of either sliding movement or type 2 chemical shift artifact or both between mass and the cardiovascular structure was considered as no adherence or invasion. The absence of both the parameters was considered as the presence of invasion or adhesion. Imaging findings were correlated with intraoperative findings.
RESULTS
After excluding 25 cardiovascular structures in 7 patients, 137 cardiovascular structures whose involvement was suspected on CT were evaluated in 37 patients with mediastinal masses. In all, 31 cardiovascular structures showed invasion on MRI out of which 28 structures were invaded or adhered intraoperatively and 106 cardiovascular structures showed no invasion on MRI out of which 97 structures were intraoperatively not invaded/adhered. The sensitivity, specificity and accuracy of our study are 75.7%, 97% and 91.2%, respectively.
CONCLUSION
Cine MRI can be used as an effective tool in patients with equivocal cardiovascular invasion by mediastinal masses on CT scans.
PubMed: 33273761
DOI: 10.4103/ijri.IJRI_69_20