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Journal of Thoracic Disease Nov 2021Airway complications (ACs) after lung transplantation remain an important source of morbidity and mortality despite significant advances in the surgical technics,... (Review)
Review
Airway complications (ACs) after lung transplantation remain an important source of morbidity and mortality despite significant advances in the surgical technics, leading to increased cost, and decrease quality of life. The incidences of ACs after lung transplantation range from 2% to 33%, even though most transplant centers have reported rates in the range of 7% to 8%. However, the reported rate of ACs has been inconsistent as a result of a lack of standardized airway definitions and grading protocols before the recent 2018 International Society for Heart and Lung Transplantation (ISHLT) proposed consensus guidelines on ACs after lung transplantation. The ACs include stenosis, perioperative and postoperative bronchial infections, bronchial necrosis and dehiscence, excess granulation tissue, and tracheobronchomalacia (TBM). Anastomosis infection, necrosis, or dehiscence typically develops within the first month after lung transplantation. The most frequent AC after lung transplantation is bronchial stenosis. Several risk factors have been proposed to the development of ACs after lung transplantation, including surgical anastomosis techniques, hypoperfusion, infections, donor and recipient factors, immunosuppression agents, and organ preservation. ACs might be prevented by early recognition of the airway pathology, using advance medical management, and interventional bronchoscopy procedures. Balloon bronchoplasty, cryotherapy, laser photo resection, electrocautery, high-dose endobronchial brachytherapy, and bronchial stents placement are the most frequent interventional bronchoscopic procedures utilized for the management of ACs.
PubMed: 34992847
DOI: 10.21037/jtd-20-2696 -
European Urology Oct 2021Urethral stricture disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are... (Meta-Analysis)
Meta-Analysis
CONTEXT
Urethral stricture disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are associated with a high recurrence rate, especially in recurrent USD. Adjunctive measures, such as local drug injection, have been used in an attempt to reduce recurrence rates.
OBJECTIVE
To systematically review evidence for the efficacy and safety of adjuncts used alongside minimally invasive treatment of USD.
EVIDENCE ACQUISITION
A systematic review of the literature published between 1990 and 2020 was conducted in accordance with the PRISMA checklist.
EVIDENCE SYNTHESIS
A total of 26 studies were included in the systematic review, from which 13 different adjuncts were identified, including intralesional injection (triamcinolone, n = 135; prednisolone, n = 58; mitomycin C, n = 142; steroid-mitomycin C-hyaluronidase, n = 103, triamcinolone-mitomycin C-N-acetyl cysteine, n = 50; platelet-rich plasma, n = 44), intraluminal instillation (mitomycin C, n = 20; hyaluronic acid and carboxymethylcellulose, n = 70; captopril, n = 37; 192-iridium brachytherapy, n = 10), application via a lubricated catheter (triamcinolone, n = 124), application via a coated balloon (paclitaxel, n = 106), and enteral application (tamoxifen, n = 30; deflazacort, n = 36). Overall, 13 randomised controlled trials were included in the meta-analysis. Use of any adjunct was associated with a lower rate of USD recurrence (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27-0.50; p < 0.001) compared to no adjunct use. Of all the adjuncts, mitomycin C was associated with the lowest rate of USD recurrence (intralesional injection: OR 0.23, 95% CI 0.11-0.48; p < 0.001; intraluminal injection: OR 0.11, 95% CI 0.02-0.61; p = 0.01). Urinary tract infection (2.9-14%), bleeding (8.8%), and extravasation (5.8%) were associated with steroid injection; pruritis of the urethra (61%) occurred after instillation of captopril; mild gynaecomastia (6.7%) and gastrointestinal side effects (6.7%) were associated with oral tamoxifen.
CONCLUSIONS
Adjuncts to minimally invasive treatment of USD appear to lower the recurrence rate and are associated with a low adjunct-specific complication rate. However, the studies included were at high risk of bias. Mitomycin C is the adjunct supported by the highest level of evidence.
PATIENT SUMMARY
We reviewed studies on additional therapies (called adjuncts) to minimally invasive treatments for narrowing of the urethra in men. Adjuncts such as mitomycin C injection result in a lower recurrence rate compared to no adjunct use. The use of adjuncts appeared to be safe and complications are uncommon; however, the studies were small and of low quality.
Topics: Captopril; Humans; Injections, Intralesional; Male; Mitomycin; Recurrence; Tamoxifen; Triamcinolone; Urethra; Urethral Stricture
PubMed: 34275660
DOI: 10.1016/j.eururo.2021.06.022 -
Brachytherapy 2022Precision breast intraoperative radiation therapy (PB-IORT) is a novel approach to adjuvant radiation therapy for early-stage breast cancer performed as part of a phase...
A comparative study using time-driven activity-based costing in single-fraction breast high-dose rate brachytherapy: An integrated brachytherapy suite vs. decentralized workflow.
INTRODUCTION
Precision breast intraoperative radiation therapy (PB-IORT) is a novel approach to adjuvant radiation therapy for early-stage breast cancer performed as part of a phase II clinical trial at two institutions. One institution performs the entire procedure in an integrated brachytherapy suite which contains a CT-on-rails imaging unit and full anesthesia capabilities. At the other, breast conserving surgery and radiation therapy take place in two separate locations. Here, we utilize time-driven activity-based costing (TDABC) to compare these two models for the delivery of PB-IORT.
METHODS
Process maps were created to describe each step required to deliver PB-IORT at each institution, including personnel, equipment, and supplies. Time investment was estimated for each step. The capacity cost rate was determined for each resource, and total costs of care were then calculated by multiplying the capacity cost rates by the time estimate for the process step and adding any additional product costs.
RESULTS
PB-IORT costs less to deliver at a distributed facility, as is more commonly available, than an integrated brachytherapy suite ($3,262.22 vs. $3,996.01). The largest source of costs in both settings ($2,400) was consumable supplies, including the brachytherapy balloon applicator. The difference in costs for the two facility types was driven by personnel costs ($1,263.41 vs. $764.89). In the integrated facility, increased time required by radiation oncology nursing and the anesthesia attending translated to the greatest increases in cost. Equipment costs were also slightly higher in the integrated suite setting ($332.60 vs. $97.33).
CONCLUSIONS
The overall cost of care is higher when utilizing an integrated brachytherapy suite to deliver PB-IORT. This was primarily driven by additional personnel costs from nursing and anesthesia, although the greatest cost of delivery in both settings was the disposable brachytherapy applicator. These differences in cost must be balanced against the potential impact on patient experience with these approaches.
Topics: Brachytherapy; Breast Neoplasms; Female; Humans; Mastectomy, Segmental; Workflow
PubMed: 35125328
DOI: 10.1016/j.brachy.2021.12.006 -
Current Oncology (Toronto, Ont.) Oct 2021(1) Background: We aimed to analyze currently available studies with intraoperative radiotherapy (IORT) as a choice of treatment where the Xoft Axxent electronic... (Review)
Review
(1) Background: We aimed to analyze currently available studies with intraoperative radiotherapy (IORT) as a choice of treatment where the Xoft Axxent electronic brachytherapy (eBx) system was used as a single-dose irradiation and an exclusive radiotherapy approach at the time of surgery in patients with early breast cancer (EBC). We also compared the results of the systematic review to the Bulgarian experience. (2) Methods and Materials: We performed a systematic review of the studies published before February 2021, which investigate the application of a single-fraction 20 Gy radiation treatment, delivered at the time of lumpectomy in EBC patients with the Xoft Axxent eBx System. A systematic search in PubMed, Scopus, and ScienceDirect was performed. The results are reported following the PRISMA guidelines. The criteria on patients' selection for IORT (the additional need for EBRT), cosmetic outcomes, and recurrence rate from the eligible studies are compared to the treatment results in Bulgarian patients. (3) Results: We searched through 1032 results to find 17 eligible studies. There are no published outcomes from randomized trials. When reported, the cosmetic outcomes in most of the studies are defined as excellent. The observed recurrence rate is low (1-5.8%). Still, the number of patients additionally referred to postoperative external breast radiotherapy (EBRT) is up to 31%. Amongst the 20 patients treated in Bulgaria, the cosmetic outcomes are also evaluated as excellent, five of which (25%) are referred for EBRT. Within median follow-up of 39 months, there was one local and one distal recurrence. (4) Conclusions: Current evidence demonstrates the Xoft Axxent eBx system as a safe and feasible technique for IORT delivery in EBC patients. There are no randomized controlled trials conducted at this time point to prove its long-term effectiveness. Better patient selection and a reimbursement strategy have to be proposed to extend the application of this technique in Bulgaria.
Topics: Brachytherapy; Breast Neoplasms; Bulgaria; Electronics; Female; Humans; Neoplasm Recurrence, Local
PubMed: 34677253
DOI: 10.3390/curroncol28050335 -
Cancers Dec 2023Previous work has reported the design of a novel thermobrachytherapy (TBT) balloon implant to deliver magnetic nanoparticle (MNP) hyperthermia and high-dose-rate (HDR)...
Previous work has reported the design of a novel thermobrachytherapy (TBT) balloon implant to deliver magnetic nanoparticle (MNP) hyperthermia and high-dose-rate (HDR) brachytherapy after brain tumor resection, thereby their synergistic effect. This paper presents an evaluation of the robustness of the balloon device, compatibility of its heat and radiation delivery components, as well as thermal and radiation dosimetry of the TBT balloon. TBT balloon devices with 1 and 3 cm diameter were evaluated when placed in an external magnetic field with a maximal strength of 8.1 kA/m at 133 kHz. The MNP solution (nanofluid) in the balloon absorbs energy, thereby generating heat, while an HDR source travels to the center of the balloon via a catheter to deliver the radiation dose. A 3D-printed human skull model was filled with brain-tissue-equivalent gel for in-phantom heating and radiation measurements around four 3 cm balloons. For the experiments, a 1 cm diameter balloon was surgically implanted in the brains of three living pigs (40-50 kg). The durability and robustness of TBT balloon implants, as well as the compatibility of their heat and radiation delivery components, were demonstrated in laboratory studies. The presence of the nanofluid, magnetic field, and heating up to 77 °C did not affect the radiation dose significantly. Thermal mapping and 2D infrared images demonstrated spherically symmetric heating in phantom as well as in brain tissue. pig experiments showed the ability to heat well-perfused brain tissue to hyperthermic levels (≥40 °C) at a 5 mm distance from the 60 °C balloon surface.
PubMed: 38067387
DOI: 10.3390/cancers15235683 -
Journal of Contemporary Brachytherapy Dec 2022To compare the rectal and bladder doses using two different vaginal packing techniques among uterine cervical cancer patients receiving high-dose-rate (HDR)...
PURPOSE
To compare the rectal and bladder doses using two different vaginal packing techniques among uterine cervical cancer patients receiving high-dose-rate (HDR) intracavitary brachytherapy (ICBT).
MATERIAL AND METHODS
Forty-five patients with cervical cancer were randomized to receive two sessions of ICBT using tandem and ring applicator (Varian), following completion of pelvic external beam radiotherapy treatment. The procedure was performed with vaginal balloon plus gauze packing or vaginal gauze packing alone, each of which was used in one of two sessions. Sequence of the type of vaginal packing was chosen with computer-generated block randomization. A HDR dose of 8.5 Gy was prescribed to point A in all patients. Volumetric dose parameters, such as D, D, D, and D of the rectum and bladder were compared between the two techniques of vaginal packing.
RESULTS
The mean age of patients was 51 years. Majority (88%) of patients had locally advanced stages of cancer at baseline (stage IIB or more). Rectal doses were significantly less in combined packing technique (D: 7.52 Gy vs. 9.02 Gy, = 0.01; D: 6.46 Gy vs. 7.42 Gy, < 0.01; D: 5.91 Gy vs. 6.7 Gy, < 0.01; D: 5.29 Gy vs. 5.97 Gy, < 0.01). Bladder doses were higher in the combined packing technique (D: 11.20 Gy vs. 10.76 Gy, = 0.18; D: 9.64 Gy vs. 9.32 Gy, = 0.56; D: 8.64 Gy vs. 8.36 Gy, = 0.55; D: 7.56 vs. 7.33 Gy, = 0.55).
CONCLUSIONS
Combined vaginal packing resulted in statistically significant reduction in rectal radiation dose compared with standard vaginal gauze packing in high-dose-rate brachytherapy of cervix cancer using tandem and ring applicators.
PubMed: 36819474
DOI: 10.5114/jcb.2022.123975 -
BMC Research Notes Feb 2023In this study, it was aimed to evaluate the functionality to deliver different prescription dose except 20 Gy for the Xoft Axxent Ebt (electronic Brachytherapy) system...
PURPOSE
In this study, it was aimed to evaluate the functionality to deliver different prescription dose except 20 Gy for the Xoft Axxent Ebt (electronic Brachytherapy) system and analyzing the system in terms of radiation dosimetry in water and 0.9% isotonic Sodium Chloride (NaCl) solution.
MATERIALS AND METHODS
In the Xoft Axxent eBT, different prescription dose in single fraction were calculated for different balloon applicator volumes based on source position and irradiation times. EBT-XD Gafchromic film was calibrated at 6MV photon energy. A balloon applicator filled with 0.9% isotonic NaCl solution was used to deliver a radiation dose of 20 Gy, 16 Gy, 10 Gy on the applicator surface. Then the balloon applicator was filled with water and the same measurements were repeated. Finally, the balloon applicator was irradiated by positioning it at different distances in the water phantom to simulate the isodose contour.
RESULTS
At the time the balloon applicator was filled with water and 0,9% NaCl solution, the difference between the planned dose and the absorbed dose was ~ 2% vs. 15% for 30 cc, ~ 5% vs. 14% for 35 cc and ~ 3,5% vs. 10% for 40 cc respectively. Finally, the absorbed dose at a distance of 1 cm from the applicator surface was measured as 9.63 Gy.
CONCLUSION
In this study, it was showed that different prescription dose could be possible to deliver in the Xoft Axxent eBT system based on the standard plan. In addition, the absorbed dose was higher than the planned dose depending on the effective atomic number of NaCl solution comparing to water due to photoelectric effect in low energy photons. By measuring the dose distributions at different distances from the balloon applicator surface, the absorbed dose in tissue equivalent medium was determined and the isodose contours characteristics was simulated.
Topics: X-Rays; Sodium Chloride; Radiography; Saline Solution; Water; Radiation Dosage
PubMed: 36855193
DOI: 10.1186/s13104-023-06287-1 -
Diagnostics (Basel, Switzerland) Sep 2022Peripheral arterial disease (PAD) is an increasingly pathological condition that commonly affects the femoropopliteal arteries. The current fashionable treatment is... (Review)
Review
Peripheral arterial disease (PAD) is an increasingly pathological condition that commonly affects the femoropopliteal arteries. The current fashionable treatment is percutaneous transluminal angioplasty (PTA), often with stenting. However, the in-stent restenosis (ISR) rate after the stenting of the femoropopliteal (FP) district remains high. Many techniques have been proposed for the treatment of femoropopliteal ISR, such as intravascular brachytherapy, laser atherectomy, second stenting and drug-coated balloons angioplasty (DCB). DCB showed a significantly lower rate of restenosis and target lesions revascularization (TLR) compared to conventional PTA. However, further studies and multi-center RCTs with dedicated long-term follow-up are needed to verify the true efficiency of this approach. Nowadays, the correlation between PAD and inflammation biomarkers is well known. Multiple studies have shown that proinflammatory markers (such as C-reactive proteins) and the high plasma levels of microRNA could predict the outcomes after stent placement. In particular, circulating microRNA-320a, microRNA-3937, microRNA-642a-3p and microRNA-572 appear to hold promise in diagnosing ISR in patients with PAD, but also as predictors of stent patency. This narrative review intends to summarize the current knowledge on the value of circulating biomarkers as predictors of ISR and to foster the scientific debate on the advantages of using DCB in the treatment of ISR in the FP district.
PubMed: 36140608
DOI: 10.3390/diagnostics12092207 -
International Journal of Hyperthermia :... 2020Hyperthermia (HT) has been shown to improve clinical response to radiation therapy (RT) for cancer. Synergism is dramatically enhanced if HT and RT are combined...
AIM
Hyperthermia (HT) has been shown to improve clinical response to radiation therapy (RT) for cancer. Synergism is dramatically enhanced if HT and RT are combined simultaneously, but appropriate technology to apply treatments together does not exist. This study investigates the feasibility of delivering HT with RT to a 5-10mm annular rim of at-risk tissue around a tumor resection cavity using a temporary thermobrachytherapy (TBT) balloon implant.
METHODS
A balloon catheter was designed to deliver radiation from High Dose Rate (HDR) brachytherapy concurrent with HT delivered by filling the balloon with magnetic nanoparticles (MNP) and immersing it in a radiofrequency magnetic field. Temperature distributions in brain around the TBT balloon were simulated with temperature dependent brain blood perfusion using numerical modeling. A magnetic induction system was constructed and used to produce rapid heating (>0.2°C/s) of MNP-filled balloons in brain tissue-equivalent phantoms by absorbing 0.5 W/ml from a 5.7 kA/m field at 133 kHz.
RESULTS
Simulated treatment plans demonstrate the ability to heat at-risk tissue around a brain tumor resection cavity between 40-48°C for 2-5cm diameter balloons. Experimental thermal dosimetry verifies the expected rapid and spherically symmetric heating of brain phantom around the MNP-filled balloon at a magnetic field strength that has proven safe in previous clinical studies.
CONCLUSIONS
These preclinical results demonstrate the feasibility of using a TBT balloon to deliver heat simultaneously with HDR brachytherapy to tumor bed around a brain tumor resection cavity, with significantly improved uniformity of heating over previous multi-catheter interstitial approaches. Considered along with results of previous clinical thermobrachytherapy trials, this new capability is expected to improve both survival and quality of life in patients with glioblastoma multiforme.
Topics: Brachytherapy; Brain Neoplasms; Feasibility Studies; Heating; Humans; Hyperthermia, Induced; Magnetite Nanoparticles; Quality of Life
PubMed: 33047639
DOI: 10.1080/02656736.2020.1829103 -
Brachytherapy 2020Intraoperative radiation therapy is an emerging option for adjuvant therapy for early stage breast cancer, although it is not currently considered standard of care in... (Comparative Study)
Comparative Study
Time-driven activity-based costing of a novel form of CT-guided high-dose-rate brachytherapy intraoperative radiation therapy compared with conventional breast intraoperative radiation therapy for early stage breast cancer.
INTRODUCTION
Intraoperative radiation therapy is an emerging option for adjuvant therapy for early stage breast cancer, although it is not currently considered standard of care in the United States. We applied time-driven activity-based costing to compare two alternative methods of breast intraoperative radiation therapy, including treatment similar to the techniques employed in the TARGIT-A clinical trial and a novel version with CT-guidance and high-dose-rate (HRD) brachytherapy.
METHODS AND MATERIALS
Process maps were created to describe the steps required to deliver intraoperative radiation therapy for early stage breast cancer at each institution. The components of intraoperative radiation therapy included personnel, equipment, and consumable supplies. The capacity cost rate was determined for each resource. Based on this, the delivery costs were calculated for each regimen. For comparison across centers, we did not account for indirect facilities costs and interinstitutional differences in personnel salaries.
RESULTS
The CT-guided, HRD form of intraoperative radiation therapy costs more to deliver ($4,126.21) than the conventional method studied in the TARGIT-A trial ($1,070.45). The cost of the brachytherapy balloon applicator ($2,750) was the primary driver of the estimated differences in costs. Consumable supplies were the largest contributor to the brachytherapy-based approach, whereas personnel costs were the largest contributor to costs of the standard form of intraoperative radiation therapy.
CONCLUSIONS
When compared with the more established method of intraoperative radiation therapy using a portable superficial photon unit, the delivery of treatment with CT guidance and HDR brachytherapy is associated with substantially higher costs. The excess costs are driven primarily by the cost of the disposable brachytherapy balloon applicator and, to a lesser extent, additional personnel costs. Future work should include evaluation of a less expensive brachytherapy applicator to increase the anticipated value of brachytherapy-based intraoperative radiation therapy.
Topics: Brachytherapy; Breast Neoplasms; Costs and Cost Analysis; Disposable Equipment; Female; Health Care Costs; Health Personnel; Humans; Intraoperative Period; Middle Aged; Neoplasm Staging; Radiology, Interventional; Radiotherapy, Adjuvant; Time Factors; Tomography, X-Ray Computed
PubMed: 32229072
DOI: 10.1016/j.brachy.2020.02.005