Risk of Aneurysm Residual Regrowth, Recurrence, and de Novo Aneurysm Formation After Microsurgical Clip Occlusion Based on Follow-up with Catheter Angiography

Introduction Established guidelines for radiologic surveillance after microsurgical treatment of intracranial aneurysms are lacking in the literature because of small sample sizes, poor definitions, and heterogeneous use of imaging modalities. We aimed to propose clinically meaningful definitions for postoperative aneurysm residual, recurrence, and de novo aneurysm formation and to analyze our long-term follow-up catheter angiography results in patients with microsurgically treated intracranial aneurysms. Methods A retrospective review of all aneurysms treated microsurgically in a consecutive, single-surgeon series from 1997 to present identified patients with long-term follow-up catheter angiography (\u3e1 year after surgery). Clinical and radiologic data were collected for analysis. Results We identified 240 patients harboring 380 aneurysms (mean follow-up time, 6.0 ± 3.3 years per patient; range, 1.0–16.8 years). Postoperative residuals were present in 16 out of 346 clipped aneurysms (4.6%), of which only 3 were left unintentionally. Two out of 16 residual aneurysms (12.5%) demonstrated regrowth, with a regrowth risk of 2.1% per year from 93.6 patient-years of angiographic follow-up. Of 326 aneurysms with no postoperative residual, 5 (1.5%) demonstrated aneurysm recurrence, with a recurrence risk of 0.26% per year from 1931.9 patient-years of angiographic follow-up. Eight de novo aneurysms were identified in 240 patients (3.3%), with a risk of 0.6% per year from 1441.9 patient-years of angiographic follow-up. Conclusions Microsurgically treated aneurysms have a very low risk of postoperative residuals and aneurysm recurrence. Growth of residuals and de novo aneurysm formation justify following up with catheter angiography 3 to 5 years after microsurgical clipping

Saphenous vein loop fistula in the thigh for maintenance hemodialysis

SCOPUS: ar.jinfo:eu-repo/semantics/publishe

The UK Standardisation of Breast Radiotherapy (START) randomised trials of radiotherapy hypofractionation for treatment of early breast cancer; 10-year follow-up results (CRUK/96/001)

Background: 5-year results of the UK Standardisation of Breast Radiotherapy (START) trials suggested that lower total doses of radiotherapy delivered in fewer, larger doses (fractions) are at least as safe and effective as the historical standard regimen (50 Gy in 25 fractions) for women after primary surgery for early breast cancer. In this prespecified analysis, we report the 10-year follow-up of the START trials testing 13 fraction and 15 fraction regimens.Methods: from 1999 to 2002, women with completely excised invasive breast cancer (pT1–3a, pN0–1, M0) were enrolled from 35 UK radiotherapy centres. Patients were randomly assigned to a treatment regimen after primary surgery followed by chemotherapy and endocrine treatment (where prescribed). Randomisation was computer-generated and stratified by centre, type of primary surgery (breast-conservation surgery or mastectomy), and tumour bed boost radiotherapy. In START-A, a regimen of 50 Gy in 25 fractions over 5 weeks was compared with 41·6 Gy or 39 Gy in 13 fractions over 5 weeks. In START-B, a regimen of 50 Gy in 25 fractions over 5 weeks was compared with 40 Gy in 15 fractions over 3 weeks. Eligibility criteria included age older than 18 years and no immediate surgical reconstruction. Primary endpoints were local-regional tumour relapse and late normal tissue effects. Analysis was by intention to treat. Follow-up data are still being collected. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779.Findings: START-A enrolled 2236 women. Median follow-up was 9·3 years (IQR 8·0–10·0), after which 139 local-regional relapses had occurred. 10-year rates of local-regional relapse did not differ significantly between the 41·6 Gy and 50 Gy regimen groups (6·3%, 95% CI 4·7–8·5 vs 7·4%, 5·5–10·0; hazard ratio [HR] 0·91, 95% CI 0·59–1·38; p=0·65) or the 39 Gy (8·8%, 95% CI 6·7–11·4) and 50 Gy regimen groups (HR 1·18, 95% CI 0·79–1·76; p=0·41). In START-A, moderate or marked breast induration, telangiectasia, and breast oedema were significantly less common normal tissue effects in the 39 Gy group than in the 50 Gy group. Normal tissue effects did not differ significantly between 41·6 Gy and 50 Gy groups. START-B enrolled 2215 women. Median follow-up was 9·9 years (IQR 7·5–10·1), after which 95 local-regional relapses had occurred. The proportion of patients with local-regional relapse at 10 years did not differ significantly between the 40 Gy group (4·3%, 95% CI 3·2–5·9) and the 50 Gy group (5·5%, 95% CI 4·2–7·2; HR 0·77, 95% CI 0·51–1·16; p=0·21). In START-B, breast shrinkage, telangiectasia, and breast oedema were significantly less common normal tissue effects in the 40 Gy group than in the 50 Gy group.Interpretation: long-term follow-up confirms that appropriately dosed hypofractionated radiotherapy is safe and effective for patients with early breast cancer. The results support the continued use of 40 Gy in 15 fractions, which has already been adopted by most UK centres as the standard of care for women requiring adjuvant radiotherapy for invasive early breast cance