The abstract does not do justice to the facts of the article. Yes, although the difference in the CI was approximately 8% higher in the lateral position than in the sitting position (statistically significant), BWe found no difference in healthy fetal blood flow indices among positions, suggesting these changes are not clinically significant.[ Statistical significance does not indicate clinical significance. The results of this study confirm to me that the sitting position for spinal or epidural placement in the obese parturient is the position of choice. I would have found it interesting had the investigators randomly assigned patients to either the lateral or sitting position for block placement and then compared the time in the positions to initiate the block and to obtain surgical anesthesia.I note that the supine position with 15-degree left lateral tilt had the lowest CI of the 4 positions, but again with no impairment in FHR, umbilical artery pulsatility, and resistivity indexes. This is a great relief to me. Now I do not have to Beat crow[ from the obstetricians whom I continually berate to maintain the supine position with 15-degree left lateral tilt until the baby is born. Even better, based on the results, I would not have to insist that the mother must be in the full lateral position until the baby is born by cesarean delivery. It would be excruciatingly difficult to convince obstetricians of the need for this! T ransversus abdominis plane (TAP) block is a regional technique used to block T6-L1 nerve branches and is increasingly used for postoperative analgesia after surgery on the lower abdomen. It has the potential to be an alternative to spinal opioid for analgesia after cesarean section. However, few data have been published on its comparative efficacy. This prospective, randomized, double-blinded, placebo-controlled trial compared the efficacy of the TAP block with and without spinal morphine after cesarean section in 80 women.Patients received a standard spinal anesthetic of 11 to 12.5 mg hyperbaric bupivacaine with 10 Hg fentanyl and then were randomized to 1 of 4 groups to a combination of spinal morphine or saline with TAP block containing local anesthetic or saline: S m T s , S m Tla, S s Tla, or S s T s , with 20 patients in each group. Patients also received 100 Hg spinal morphine or an equivalent volume (0.1 mL of saline. The bilateral TAP blockade was performed with bupivacaine 2 mg/kg, based on her weight when the patient first appeared at the hospital. All patients had standard monitoring and received rectal paracetamol and diclofenac immediately after surgery. All had standard postoperative analgesia with oral paracetamol, rectal diclofenac, and morphine via patient-controlled analgesia. The primary outcome was pain on movement; secondary outcomes were pain at rest, morphine consumption, proportion of patients who had adequate analgesia, satisfaction, sedation, nausea, and pruritus. Patients were evaluated at 6, 12, 24, 36, and 48 hours after TAP block.All patients completed the study...
Lung cancer is the leading cause of cancerrelated deaths among Canadian men and women. In Canada, an estimated 17,400 deaths and 20,500 new cases of lung cancer occurred in 1999 (National Cancer Institute of Canada, 1999). Men continue to outnumber women in terms of incidence and death due to cancer (Figure 1), including lung cancer which accounts for approximately 30 percent of all cancer deaths in men and 20 percent in women (Health Canada, 1998; National Cancer Institute of Canada, 1999).For men, the incidence of lung cancer ranks second to prostate cancer (Figure 2). For example, in 1999 there were an estimated 12,000 newly diagnosed cases of lung cancer compared to 16,600 cases of prostate cancer. Although lung cancer remains the leading cause of death among men, both incidence and mortality rates have been declining since the mid-1980s (Health Canada, 1998 National Cancer Institute of Canada, 1999).However, incidence and mortality rates of lung cancer in women continue to rise (Figure I). Interestingly, for 1999 the estimated incidence of lung cancer is less than half the incidence of breast cancer, 8,500 and 18,700, respectively (Figure 3). Yet given previously observed death rates, lung cancer will account for an estimated 6,800 deaths compared to 5,400 deaths from breast cancer (National Cancer Institute of Canada, 1999).The lifetime probability of developing lung cancer for women is 1 in 21 (National Cancer Institute of Canada, 1999). Among men, the probability of developing lung cancer during their lifetime is 1 in 11. Although cancer primarily afflicts Canadians over age 60, lung cancer is the leading cause of cancer deaths among men aged 35-84 and women aged 50 or older (Figure 4). The incidence of lung cancer among women aged 45-74 ranks second to breast cancer, and among men aged 70 or older ranks second to prostate cancer. However; lung cancer is the most common type of cancer in men aged
Background: The aim of this study was to evaluate the outcomes of priming salvage radioimmunotherapy (RIT) with a low dose of external beam radiotherapy (EBRT) in patients with relapsed low grade non-Hodgkin lymphoma (LG-NHL). Methods: Patients who received salvage RIT with or without 2 × 2 Gy EBRT between March 2009 and February 2013 were retrospectively reviewed at a single institution. Planning target volume (PTV) for EBRT was created by adding a 1-2 cm expansion to the gross tumor volume depending on the anatomical location. Kaplan−Meier method via log-rank was employed to analyze the endpoints freedom from progression (FFP) and overall survival (OS). Results: We identified 22 patients who received salvage RIT without chemotherapy with a median follow up of 34 months. Of these, 9 (41%) patients were treated with EBRT immediately prior to RIT, and 13 (59%) received salvage RIT alone. Median FFP was not reached in patients who underwent combination treatment, while it was 9 months for patients treated with RIT alone (p = 0.02). OS for all patients at 36 months was 80.3% with no significant difference between the two groups (p = 0.88). On univariate analysis, the addition of EBRT was associated with improved FFP [hazard ratio (HR) = 4.17; 95% confidence interval (CI), 1.24-19.1; p = 0.02)]. No long term toxicities were reported in both groups. Conclusions: RIT outcomes and effects were improved with addition of low-dose EBRT immediately prior to it, in the treatment of relapsed LG-NHL with no additional toxicity. This study is hypothesis-generating and the findings should be validated in prospective studies.
head) to 1.11 (rectum) for the composite plan and from 1.00 to 1.27 for individual treatment beams. For the thorax, estimates of the tumor RBE ranged from 1.05 to 1.06; composite plan RBE estimates for OARs (heart, lungs, spinal cord, esophagus, breast, brachial plexus) ranged from 1.02 (breast) to 1.2 (spinal cord). Biological hot spots (RBE up to 1.27) were noted to arise near the distal edge of the Bragg peak. Conclusion: Patient-and tumor-specific RBE estimates from a model that accounts for spatial variations in LET are within +5% of a constant clinical RBE of 1.1. Estimates of the RBE among patients can differ from 1.1 by as much at 15% (RBE w 1.0 to 1.3) for some OAR. The OAR RBE values for individual beams can differ substantially from the RBE for the composite plan, which suggests that beam by beam optimization of (variable RBE x dose) might be exploited to reduce treatment complications (reduce the OAR RBE from w 1.3 to 1.0). This could potentially allow room to increase the therapeutic ratio by 10% to 20% of the total treatment dose.
Background: Clinical validation studies in over 2,200 patients across 8 different disease sites, including breast cancer, have shown the radiosensitivity index (RSI), a gene expression signature, predicts outcomes in patients treated with radiation. We hypothesize that an approach to personalize radiation dose could be developed by integrating RSI into the linear quadratic model of dose and fractionation. Methods: Utilizing the linear quadratic model and RSI, we derived an expression for the genomically adjusted dose (GAD) to model radiation dose effect for individual patients. A higher GAD implies a higher predicted radiation therapy effect. GAD was evaluated as a predictor of clinical outcome in two independent datasets of breast cancer patients treated with surgery and radiation. The association between GAD and distant-metastasis free survival (DMFS) and relapse-free survival (RFS) using univariate (UVA) and multivariate (MVA) Cox proportional hazard models was assessed. Clinical and array-based gene expression were obtained from two independent, previously described cohorts from the Karolinska Institutet and Erasmus University Medical Center. Results: Full radiation treatment details were available for 263 patients in the Erasmus dataset, median follow-up 60 months. GAD-low patients (<75% GAD distribution) were found to have decreased DMFS when compared to GAD-high patients (≥25% GAD distribution) (Hazard Ratio (HR) = 2.31 (95% CI 1.25, 4.25), p=0.006). On MVA, GAD was an independent predictor of DMFS for the whole cohort (HR= 2.11 (1.13, 3.94), p=0.02). When the analysis was restricted to the ER positive cohort, GAD was an independent predictor of outcome both as a continuous (HR=0.977, (0.955, 1.0), p = 0.049) and as a dichotomous variable (HR = 3.42, (1.53, 7.67), p=0.003). These results were independently confirmed in the second Karolinska dataset. The 5 year RFS was 95% for GAD-high patients and 76% in GAD-low patients (p=0.027) and GAD was a significant predictor on MVA for RFS (HR =7.42, (1.41, 137.6), p=0.014). In the Karolinska cohort, we estimate a significant proportion of GAD-low patients (59%) would achieve GAD-high with dose escalation up to 70 Gy. Conclusions: In this study, we develop and validate GAD, a novel and patient-specific measure of radiation dose effect. Importantly, GAD is a clinically actionable metric by adjusting radiation dose. We propose that GAD based radiation dosing is a feasible approach to precision medicine in breast radiation oncology. Citation Format: Ahmed KA, Scott JG, Diaz RJ, Fulp WJ, Torres-Roca JF. The genomically adjusted radiation dose (GAD) and its association with distant metastases in breast cancer: A feasible approach to precision medicine in radiation oncology. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-04.
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