To report outcome (freedom from local progression [FFLP], overall survival [OS] and toxicity) after stereotactic, palliative or highly conformal fractionated (>12) radiotherapy (SBRT, Pall-RT, 3DCRT/IMRT) for adrenal metastases in a retrospective multicenter cohort within the framework of the German Society for Radiation Oncology (DEGRO).Adrenal metastases treated with SBRT (≤12 fractions, biologically effective dose [BED10] ≥ 50 Gy), 3DCRT/IMRT (>12 fractions, BED10 ≥ 50 Gy) or Pall-RT (BED10 < 50 Gy) were eligible for this analysis. In addition to unadjusted FFLP (Kaplan-Meier/log-rank), we calculated the competing-risk-adjusted local recurrence rate (CRA-LRR). Three hundred twenty-six patients with 366 metastases were included by 21 centers (median follow-up: 11.7 months). Treatment was SBRT, 3DCRT/IMRT and Pall-RT in 260, 27 and 79 cases, respectively. Most frequent primary tumors were non-small-cell lung cancer (NSCLC; 52.5%), SCLC (16.3%) and melanoma (6.7%).Unadjusted FFLP was higher after SBRT vs Pall-RT (P = .026) while numerical differences in CRA-LRR between groups did not reach statistical significance (1-year CRA-LRR: 13.8%, 17.4% and 27.7%). OS was longer after SBRT vs other groups (P < .05) and increased in patients with locally controlled metastases in a landmark analysis (P < .0001). Toxicity was mostly mild; notably, four cases of adrenal insufficiency occurred, two of which were likely caused by immunotherapy or tumor progression.Radiotherapy for adrenal metastases was associated with a mild toxicity profile in all groups and a favorable 1-year CRA-LRR after SBRT or 3DCRT/IMRT. One-year FFLP was associated with longer OS. Dose-response analyses for the dataset are underway.

BackgroundIn this pooled 2-center series LINAC radiosurgery (SRS) has been applied as a treatment option for a subset of refractory trigeminal neuralgia (TN) patients. This study approached to retrospectively assess the efficacy and safety of LINAC SRS and to provide a brief overview addressed to the technical development from frame-based towards frameless robotic SRS.MethodsFrom 2001 to 2017 n = 55 patients (pts) were treated, n = 28 were female (51%), mean age: 66 years (range 36–93 years); TN etiology: 37 classic TN, 15 multiple sclerosis (MS)-related TN, 2 symptomatic TN, and 1 atypical TN. Previous treatment was present in n = 35 (63.6%) pts. (some multiple or combined) with n = 23 microsurgical vascular decompression and n = 17 percutaneous retrogasserian rhizotomy. A 6 MV LINAC (4–5 mm collimators) was applied in all pts. (n = 26 framebased - n = 29 frameless robotic). The dorsal root entry zone (DREZ) was targeted in n = 35 cases and the retrogasserian target in n = 20 pts. with a homogeneous dose for the entire study cohort (90 Gy). SRS outcome was measured using the Barrow Neurological Institute (BNI) score for pain and hypaesthesia and statistically evaluated by univariate and multivariate analyzes.ResultsMean follow-up (FU) was 30 months (2 lost FU); the total rate of post SRS BNI pain I-IIIa (=painfree w or w/o medication) was 69% (88% for the classic TN pts), 29% (38.8% classic TN) were classified as BNI pain I-II (=painfree w/o medication). A BNI hypaesthesia II-III was present in 9.4% (n = 5) and BNI hypaesthesia IV in n = 2. Between groups analysis demonstrated no correlation of SRS responsiveness with age, gender, MS- or not MS-associated TN, previous surgery, framebased/frameless robotic SRS. DREZ targeting significantly better suppressed TN compared to RG targeting (p = 0.01). Additionally, a statistical trend for a better BNI pain outcome (p = 0.07) along with a significant increase in BNI hypaesthesia (p = 0.01) was found when using a larger partial trigeminal 70 Gy volume.ConclusionOur retrospective analysis support LINAC SRS as an effective and safe treatment option in TN. Frameless robotic SRS of TN is safe when using a dedicated LINAC system. A target definition closer to the brainstem and tendencially a larger target volume were associated with a better outcome for pain.

Aim: To investigate the incidence and the morphology of third root for the mandibular permanent first molars from indigenous Iraqi population and their significance in the successful of endodontic treatment. Materials and Methods: A clinical, radiographical prospective evaluation of first mandibular permanent molar teeth (n= 788) and laboratory analysis of 695 extracted first mandibular permanent molars collected from University Mosul, College of Dentistry, Department of Conservative Dentistry and private dental clinic were collected and examined. All the clinical cases treated as third root present, unless otherwise both 90º, 20° mesial radiographical shift and trapezoidal access opening excluded the presence of this macrostructure. The third root was classified in three groups on the basis of the curve of the root/root canal according to Ribeiro and Consolaro (1997). Chi-square was used to determine the significance between both genders, whereas descriptive statistics was used to describe the result of observations. Results: Upon clinical and laboratory observation of total 1483 first mandibular permanent molars, 121 (8.1%) exhibited radix entomolaris (RE), 17 (14%) were classified as type I (straight root/root canal), 33 (27.2%) as type II (an initially curved entrance and the continuation as a straight root/root canals) and 71(58.6%) as type III (an initial curve in the coronal third of the root canal and a second buccally orientated curve starting from the middle to apical third). Statistical analysis with Chi-square indicated no significant differences between both genders regarding the occurrence of RE. In all cases, RE occurred bilaterally. Out of 71 teeth attended for clinic, 87.3% teeth required retreatment, while the apparent reason of extraction for 86% of 50 collected extracted teeth with RE seemed failure of endodontic treatment and the cleaning and obturation confined to the mesial and distal canals only. In all cases, the orifice of the RE was located distolingual from the main canal in the distal root. Conclusion: Clinicians should be aware of this unusual root morphology in mandibular first molars. Radiographs exposed at two different horizontal angles are needed to identify this additional root. The access cavity must be modified in a distolingual direction in order to visualize and treat the RE; this results in a trapezoidal access cavity.

Optimal doses for the treatment of adrenal metastases with stereotactic radiotherapy (SBRT) are unknown. We aimed to identify dose-volume cut-points associated with decreased local recurrence rates (LRR). A multicenter database of patients with adrenal metastases of any histology treated with SBRT (biologically effective dose, BED10 ≥50 Gy, ≤12 fractions) was analyzed. Details on dose-volume parameters were required (planning target volume: PTV-D98%, PTV-D50%, PTV-D2%; gross tumor volume: GTV-D50%, GTV-mean). Cut-points for LRR were optimized using the R maxstat package. One hundred and ninety-six patients with 218 lesions were included, the largest histopathological subgroup was adenocarcinoma (n = 101). Cut-point optimization resulted in significant cut-points for PTV-D50% (BED10: 73.2 Gy; P = .003), GTV-D50% (BED10: 74.2 Gy; P = .006), GTV-mean (BED10: 73.0 Gy; P = .007), and PTV-D2% (BED10: 78.0 Gy; P = .02) but not for the PTV-D98% (P = .06). Differences in LRR were clinically relevant (LRR ≥ doubled for cut-points that were not achieved). Further dose-escalation was not associated with further improved LRR. PTV-D50%, GTV-D50%, and GTV-mean cut-points were also associated with significantly improved LRR in the adenocarcinoma subgroup. Separate dose optimizations indicated a lower cutpoint for the PTV-D50% (BED10: 69.1 Gy) in adenocarcinoma lesions, other values were similar (<2% difference). Associations of cut-points with overall survival (OS) and progression-free survival were not significant but durable freedom from local recurrence was associated with OS in a landmark model (P < .001). To achieve a significant

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