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Radiation-induced myelopathy is a devastating late effect of radiotherapy. Fortunately, this late effect is exceptional. The clinical presentation of radiation myelopathy is aspecific, typically occurring between 6 to 24 months after radiotherapy, and radiation-induced myelopathy remains a diagnosis of exclusion. Magnetic resonance imaging is the most commonly used imaging tool. Radiation oncologists must be extremely cautious to the spinal cord dose, particularly in stereotactic radiotherapy and reirradiation. Conventionally, a maximum dose of 50Gy is tolerated in normofractionated radiotherapy (1.8 to 2Gy per fraction). Repeat radiotherapies lead to consider cumulative doses above this recommendation to offer individualized reirradiation. Several factors increase the risk of radiation-induced myelopathy, such as concomitant or neurotoxic chemotherapy. The development of predictive algorithms to prevent the risk of radiation-induced myelopathy is promising. However, radiotherapy prescription should be cautious, regarding to ALARA principle (as low as reasonably achievable). As the advent of immunotherapy has improved patient survival data and the concept of oligometastatic cancer is increasing in daily practice, stereotactic treatments and reirradiations will be increasingly frequent indications. Predict the risk of radiation-induced myelopathy is therefore a major issue in the following years, and remains a daily challenge for radiation oncologists., (Copyright © 2020 Société française de radiothérapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Ultrasound is now recognized as a key tool in the practice of medicine in isolated situations. This study aims to evaluate the impact of transthoracic echocardiography (TTE) in a military mission when performed by a trained military practitioner (MP)., Materials and Methods: We conducted a 2-month retrospective observational study on the use of TTE in a French medical complex in Mali with a mission that included providing a medical aid to the population. All patients were included. Every ultrasound performed by the MP was listed, and the epidemiologic data, indication for the exam and results were collected for each TTE., Results: A total of 349 patients were included, 16 were war-wounded patients and 333 came for a general medical consultation. In all, 153 ultrasounds were performed, including 48 TTEs. Sixteen TTEs were performed to evaluate injuries in war-wounded patients. During the 333 medical consultations, 32 TTEs were realized. The indications were dyspnoea (10), heart murmur (7), acute chest pain (5) and assessment of heart disease (10). TTE permitted a direct positive diagnosis for 18 patients: 7 with acute heart failure and 11 with morphologic problems. The normality of the exam was a supplementary argument to exclude a cardiac implication for eight patients., Conclusions: TTE can provide important information with a direct impact on the management of patients. Faced with cardiac emergencies, an adapted training can be proposed for the MP. Thereby, the transfer of conventional cardiac views could facilitate the advice of a cardiologist., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To assess the accuracy of volumetric modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) when treating moving targets (such as lung or liver lesions), focusing on the impact of the interplay effect in the event of complex breathing motion and when a gating window is used., Methods: A dedicated programmable motion platform was implemented. This platform can carry large quality assurance (QA) phantoms and achieve complex three-dimensional (3D) motion. Volumetric modulated arc therapy SBRT plans were delivered with TrueBeam linac to this moving setup and the measured dose was compared to the computed one. Several parameters were assessed such as breathing period, dose rate, dose prescription, shape of the breathing pattern, the use of a planning target volume (PTV) margin, and the use of a gating window., Results: Loss of dose coverage (D95%) was acceptable in most situations. The doses received by 95% of the CTV, D95% ( C T V m ) ranged from 94 to 101% (mean 98%) and the doses received by 2% of the CTV D2% ( C T V m ) ranged from 94% to 110% of the prescribed dose. A visible interplay effect was observed when no margin was used or when the number of breathing cycles during the treatment delivery was lower than 20., Conclusions: In our clinical context, treating lung and liver lesions using VMAT SBRT is reasonable. The interplay effect was moderated and acceptable in all simulated situations., (© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.)

During exclusive curative radiotherapy for head and neck tumors, the patient's organs at risk (OAR) and target volumes frequently change size and shape, leading to a risk of higher toxicity and lower control than expected on planned dosimetry. Adaptive radiotherapy is often necessary but 1) tools are needed to define the optimal time for replanning, and 2) the subsequent workflow is time-consuming. We designed a prospective study to evaluate 1) the validity of automatically deformed contours on the daily MVCT, in order to safely use the "dose-of the day" tool to check daily if replanning is necessary; 2) the automatically deformed contours on the replanning CT and the time gained in the replanning workflow. Forty-eight patients with T3-T4 and/or involved node >2 cm head and neck squamous cell carcinomas, planned for curative radiotherapy without surgery, will be enrolled. They will undergo treatment with helical IMRT including daily repositioning MVCTs. The contours proposed will be compared weekly on intermediate planning CTs (iCTs) on weeks 3, 4, 5 and 6. On these iCTs both manual recontouring and automated deformable registration of the initial contours will be compared with the contours automatically defined on the MVCT. The primary objective is to evaluate the Dice similarity coefficient (DSC) of the volumes of each parotid gland. The secondary objectives will evaluate, for target volumes and all OARs: the DSC, the mean distance to agreement, and the average surface-to-surface distance. Time between the automatic and the manual recontouring workflows will be compared.

Purpose: To determine the incidence and the risks factors of peripherally inserted central catheter (PICC)-related infectious complications., Materials and Methods: Medical charts of every in-patient that underwent a PICC insertion in our hospital between January 2010 and October 2013 were reviewed. All PICC-related infections were recorded and categorized as catheter-related bloodstream infections (CR-BSI), exit-site infections, and septic thrombophlebitis., Results: Nine hundred and twenty-three PICCs were placed in 644 unique patients, mostly male (68.3%) with a median age of 58 years. 31 (3.4%) PICC-related infections occurred during the study period corresponding to an infection rate of 1.64 per 1000 catheter-days. We observed 27 (87.1%) CR-BSI, corresponding to a rate of 1.43 per 1000 catheter-days, 3 (9.7%) septic thrombophlebitis, and 1 (3.2%) exit-site infection. Multivariate logistic regression analysis showed a higher PICC-related infection rate with chemotherapy (odds ratio (OR) 7.2-confidence interval (CI) 95% [1.77-29.5]), auto/allograft (OR 5.9-CI 95% [1.2-29.2]), and anti-coagulant therapy (OR 2.2-95% [1.4-12])., Conclusion: Chemotherapy, auto/allograft, and anti-coagulant therapy are associated with an increased risk of developing PICC-related infections., Clinical Advance: Chemotherapy, auto/allograft, and anti-coagulant therapy are important predictors of PICC-associated infections. A careful assessment of these risk factors may be important for future success in preventing PICC-related infections.

Objective: To assess the safety of peripherally inserted central venous catheter (PICC) placement in patients with altered and uncorrected coagulation parameters or receiving antiplatelet therapy., Materials and Methods: Medical charts of all patients with major primary and secondary hemostasis disorders, combined hemostasis disorders or on antiplatelet therapy and who had undergone non-tunneled PICC placement from December 2009 to December 2013, were retrospectively reviewed. A hemostatic disorder was defined as a platelet count (PC)≤50×10(9)/L, an international normalized ratio (INR) ≥ 2, or an activated partial thromboplastin time (aPTT)≥66s, alone or in combination. Underlying hemostasis disorders were not corrected and antiplatelet therapy was not interrupted before PICC placement in any patient. 4, and 5-Fr single and dual lumen PICCs were used., Results: A total of 378 PICCs were placed in 271 patients (180 men and 91 women; mean age=62±13.4years; range, 18-93 years)) with coagulation disorders. Eighty-nine (23%) PICCs were placed in patients who were receiving antiplatelet therapy (aspirin, clopidogrel, rivaroxaban). Thrombocytopenia was noted in 269PICC placements (71%). Among these patients, 23 had disseminated intravascular coagulation. Prolonged INR and aPTT were observed in 42 procedures (11.1%). PICC placement was achieved in all patients, with a mean number of 1.14 attempts. Peripheral venous access was obtained through the basilic and the brachial vein respectively in 295 (79.1%) and 83 (20.9%) of patients. The placements were performed by residents and fellows in 108 (28.5%) and 270 (71.5%) procedures, respectively. No early or late complications were reported after any procedure. No accidental puncture of the brachial artery occurred., Conclusion: In patients with severe primary and secondary hemostasis disorders, combined hemostasis disorders or on antiplatelet therapy, PICC placement is a feasible and safe procedure and does not require correction of coagulation parameters or discontinuation of antiplatelet therapy., (Copyright © 2015 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: The purpose of this study is to evaluate the complications of peripherally inserted central catheters (PICCs) in orthopedic patients with chronic bone orthopedic infection., Materials and Methods: The institutional review board approved this retrospective study and informed consent was waived. Records of 180 consecutives PICCs placed in patients hospitalized in the orthopedic surgery department were reviewed. All patients had bones infections necessitating a long-term intravenous antibiotics therapy. All PICC complications were recorded during the patient hospitalization: infection [catheter-related bloodstream infection (CRBSI), central line associated bloodstream infection (CLABSI), exit-site infection, septic phlebitis], thrombosis, occlusion, mechanical complication (accidental withdrawal, malposition, median nerve irritation)., Results: One hundred and eighty PICCs were placed in 136 patients. Mean duration of catheterization was 21 days (total 3911 PICC-days). Thirty-six PICCs (20%) were removed due to complications (9.2 complications per 1000 PICC-days): 14 (8%) infections (one CRBSI (Pseudomonas aeruginosa), one septic phlebitis (P. aeruginosa), two exit-site infections and 10 CLABSIs), 11 (6%) occlusions, and 12 (7%) mechanical complications (10 accidental withdrawals, one malposition, one median nerve irritation). One patient had two complications simultaneously. After multivariate analysis, two risk factors were significantly associated with the overall occurrence of complications: age more than 70 years [OR = 2.89 (1.06-7.89], p = 0.04] and number of lumen at least two [OR = 2.64 (1.03-6.75), p = 0.04]., Conclusions: Even in orthopedic patients with chronic orthopedic bone infection, PICCs have a low rate of complication. The increasing lumen number of the PICC is a potential risk factor in our series.

Metastases of prostate cancer originating from the parotid gland are rare. However, this presentation raises the question of the management of visceral metastasis in castration-resistant prostate cancer. We report the case of an 87-year-old man who presented with a right painless parotid mass in the context of castration-resistant prostate cancer, indicating progression of the disease. He received medical treatment based on docetaxel. Here, we discuss the impact of new hormonotherapies such as enzalutamide and abiraterone acetate, which may be used for the management of these patients.

Purpose: To prospectively evaluate the incidence of pulmonary cement embolism (PCE) after vertebroplasty in procedures performed under real-time computed tomographic (CT) fluoroscopy guidance., Materials and Methods: A total of 85 vertebroplasties were performed in 51 consecutive patients (31 women, 20 men; mean age, 71.9 y; range, 48-92 y) in 51 sessions. The needle was inserted with guidance from intermittent single-shot CT scans, and intermittent CT fluoroscopy was used during cement injection only. To reduce the risk of extravertebral or extraosseous leakage, several procedures (cement injection stopping/slowing, needle position changes) were employed. The chest and treated bone were scanned immediately after vertebroplasty. These CT images included the entire thorax as well as the treated vertebrae., Results: No cement emboli were observed on CT after vertebroplasty. After 85 vertebroplasty procedures, 44 extravertebral leaks were detected. Epidural leaks were observed on CT in six treated vertebrae (7%), in 12 cases in the anterior external venous plexus (14.1%), in five in the azygos vein (5.8%), in 19 in the disc space (22%), and in two in the foraminal space (2.3%). On a per-patient basis, the odds of leaks increased with the number of vertebroplasties (P = .05) and the volume of cement used (P = .0412). There was also a higher probability of leak (P < .05) for osteoporotic vertebral compression fractures (67.9%; 95% confidence interval, 47.7%-84.1%) than osteolytic spinal metastases (34.8%; 16.4%-57.3%)., Conclusions: PCE did not occur after vertebroplasty under CT fluoroscopy guidance. Further larger prospective vertebroplasty studies are needed to compare the rates of PCE for CT versus conventional fluoroscopic guidance., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: No studies have specifically evaluated the safety of peripherally inserted central catheter (PICC) placement in patients with profound thrombocytopaenia. We prospectively determined the frequency of haemorrhagic complications of PICC placement in cancer patients with uncorrected profound thrombocytopaenia., Methods: Profound thrombocytopaenia was defined as a platelet count <50 × 10(9)/l. No patients received transfusions before or after the procedure. Three types of adverse effects were analysed: minor oozing, mild haematoma and major haemorrhage., Results: One hundred and forty-three PICC implantations in 101 cancer patients were prospectively included in the study: seven patients (7 %) had a solid tumour and 94 (93 %) a haematological malignancy. Among these 143 procedures in thrombocytopaenic patients, 93 (65 %) were performed with a platelet count 20-50 × 10(9)/l and 50 (35 %) had lower than 20 × 10(9)/l. No major haemorrhage was observed. Minor oozing was observed in six implantations (4 %) and mild haematoma in two (1.5 %), for a total of eight minor haemorrhagic adverse events (5.5 %). In patients with a platelet count <20 × 10(9)/l, 1/50 (2 %) had minor oozing and none had minor haematoma., Conclusions: In cancer patients with uncorrected profound thrombocytopaenia, the incidence of adverse events after PICC implantation was low, and was limited to minor haemorrhagic adverse events., Key Points: • PICC placement has high technical success in profound thrombocytopaenic cancer patients. • Few adverse events are encountered after PICC placement, limited to minor haemorrhage. • PICC placement does not routinely require platelet transfusion in patients with thrombocytopaenia. • Such PICC placement still seems safe when the platelet count is <20 × 10 (9) /l.

Introduction: (125)I-labeled monoclonal antibodies ((125)I-mAbs) can efficiently treat small solid tumors. Here, we investigated the role of apoptosis, autophagy and mitotic catastrophe in (125)I-mAb toxicity in p53(-/-) and p53(+/+) cancer cells., Methods: We exposed p53(-/-) and p53(+/+) HCT116 cells to increasing activities of internalizing (cytoplasmic location) anti-HER1 (125)I-mAbs, or non-internalizing (cell surface location) anti-CEA (125)I-mAbs. For each targeting model we established the relationship between survival and mean nucleus absorbed dose using the MIRD formalism., Results: In both p53(-/-) and p53(+/+) HCT116 cells, anti-CEA (125)I-mAbs were more cytotoxic per Gy than anti-HER1 (125)I-mAbs. Sensitivity to anti-CEA (125)I-mAbs was p53-independent, while sensitivity to anti-HER1 (125)I-mAbs was higher in p53(-/-) HCT 116 cells, suggesting that they act through different signaling pathways. Apoptosis was only induced in p53(+/+) HCT116 cells and could not explain cell membrane radiation sensitivity. Inhibition of autophagy did not modify the cell response to (125)I-mAbs. By contrast, mitotic death was similarly induced in both p53(-/-) and p53(+/+) HCT116 cells by the two types of (125)I-mAbs. We also showed using medium transfer experiments that γ-H2AX foci were produced in bystander cells., Conclusion: Cell membrane sensitivity to (125)I-mAbs is not mediated by apoptosis and is p53-independent. Bystander effects-mediated mitotic death could be involved in the efficacy of (125)I-mAbs binding cell surface receptors., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Progressive multifocal leukoencephalopathy (PML) generally occurs in patients with impaired cellular immunity. Monoclonal antibodies also predispose the patient to PML as they depress the immune system. PML was classically characterized by a lack of inflammation and absence of gadolinium enhancement. However, gadolinium enhancement of PML lesions was first described in HIV-positive patients under therapy. We present a case of gadolinium enhanced PML lesions occuring after natalizumab monotherapy of a relapsing multiple sclerosis. Radiologists must be aware of this particular feature, as confirmation of the diagnostic of PML becomes more challenging. Namely, distinction between starting PML and multiple sclerosis enhanced additional active lesion is difficult and diagnosis must be established by combined analysis of full clinical evolution, brain MRI scans, and polymerase chain reaction of cerebrospinal fluid., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)