Cyberknife fractionated radiotherapy for adrenal metastases: Preliminary report from a multispecialty Indian cancer care center

Purpose: Metastasis to adrenal gland from lung, breast, and kidney malignancies are quite common. Historically radiotherapy was intended for pain palliation. Recent studies with stereotactic body radiotherapy (SBRT) including Cyberknife robotic radiosurgery aiming at disease control brings about encouraging results. Here we represent the early clinical experience with Cyberknife stereotactic system from an Indian cancer care center. The main purpose of this retrospective review is to serve as a stepping stone for future prospective studies with non- invasive yet effective technique compared to surgery. Methods: We retrospectively reviewed four cases of adrenal metastases (three: lung and one: renal cell carcinoma) treated with Cyberknife SBRT. X sight spine tracking was employed for planning and treatment delivery. Patients were evaluated for local response clinically as well as with PETCT based response criteria.Results: With a median gross tumor volume of 20.5 cc and median dose per fraction of 10 Gy, two patients had complete response (CR) and two had partial response (PR) when assessed 8-12 weeks post treatment as per RECIST. There was no RTOG grade 2 or more acute adverse events and organs at risk dosage were acceptable. Till last follow up all the patients were locally controlled and alive. Conclusion: Cyberknife SBRT with its unique advantages like non- invasive, short duration outpatient treatment technique culminating in similar local control rates in comparison to surgery is an attractive option. World literature of linear accelerator based SBRT and our data with Cyberknife SBRT with small sample size and early follow up are similar in terms of local control in adrenal metastases. Future prospective data would reveal more information on the management of adrenal metastases

Successful Heart-Liver Transplant Using Dual-organ Normothermic Perfusion in a Patient With Fontan Failure

Advances in surgical technique and multidisciplinary management have improved long-term survival for patients born with single ventricle physiology. However, patients who have undergone Fontan completion remain at risk for long-term comorbidities associated with the complex hemodynamic changes following the procedure, including Fontan failure and Fontan-associated liver disease.1 Combined heart-liver transplantation (CHLT) is a rare but lifesaving procedure that has been described in the setting of heart and liver failure secondary to Fontan failure.2 As long-term survival continues to improve for Fontan patients, the incidence of Fontan-associated liver disease will increase. Thus, improving CHLT outcomes and access to both organs is a strong priority. Here, we describe a successful CHLT for a patient with chronic ventricular dysfunction and Fontan-associated liver disease. The key innovation in this case was the use of normothermic machine perfusion (NMP) to preserve both the heart and liver grafts. This approach extended the preservation time for the liver while also mitigating the risk of ischemic injury and reducing the time pressure constraints on the heart transplant team. Notably, this stands in contrast to traditional static cold storage (SCS), where metabolic activity is reduced through hypothermia, but the extended cold ischemic time can lead to increased vulnerability to reperfusion injury

Psychosocial Assessment of Candidates for Transplantation (PACT) Score Identifies High Risk Patients in Pediatric Renal Transplantation

Background: Currently, there is no standardized approach for determining psychosocial readiness in pediatric transplantation. We examined the utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) to identify pediatric kidney transplant recipients at risk for adverse clinical outcomes.Methods: Kidney transplant patients <21-years-old transplanted at Duke University Medical Center between 2005 and 2015 underwent psychosocial assessment by a social worker with either PACT or unstructured interview, which were used to determine transplant candidacy. PACT assessed candidates on a scale of 0 (poor candidate) to 4 (excellent candidate) in areas of social support, psychological health, lifestyle factors, and understanding. Demographics and clinical outcomes were analyzed by presence or absence of PACT and further characterized by high (≥3) and low (≤2) scores.Results: Of 54 pediatric patients, 25 (46.3%) patients underwent pre-transplant evaluation utilizing PACT, while 29 (53.7%) were not evaluated with PACT. Patients assessed with PACT had a significantly lower percentage of acute rejection (16.0 vs. 55.2%, p = 0.007). After adjusting for HLA mismatch, a pre-transplant PACT score was persistently associated with lower odds of acute rejection (Odds Ratio 0.119, 95% Confidence Interval 0.027–0.52, p = 0.005). In PACT subsection analysis, the lack of family availability (OR 0.08, 95% CI 0.01–0.97, p = 0.047) and risk for psychopathology (OR 0.34, 95% CI 0.13–0.87, p = 0.025) were associated with a low PACT score and post-transplant non-adherence.Conclusions: Our study highlights the importance of standardized psychosocial assessments and the potential use of PACT in risk stratifying pre-transplant candidates

Accessory Gallbladder Complicating Liver Transplantation

Abstract. Accessory gallbladder in a donor liver allograft is an uncommon anatomical finding that can complicate liver transplantation if unrecognized. This case describes a patient who underwent liver transplantation with a donor graft containing an accessory gallbladder that was obscured during transplantation; as a result, the patient experienced a prolonged postoperative course complicated by multiple readmissions for suspected biloma and intra-abdominal infection. The diagnosis of accessory gallbladder was not made until operative exploration several months after the initial transplant. Removal of the accessory gallbladder has led to resolution of clinical problems

Cyberknife fractionated radiotherapy for adrenal metastases: Preliminary report from a multispecialty Indian cancer care center

Purpose: Metastasis to adrenal gland from lung, breast, and kidney malignancies are quite common. Historically radiotherapy was intended for pain palliation. Recent studies with stereotactic body radiotherapy (SBRT) including Cyberknife robotic radiosurgery aiming at disease control brings about encouraging results. Here we represent the early clinical experience with Cyberknife stereotactic system from an Indian cancer care center. The main purpose of this retrospective review is to serve as a stepping stone for future prospective studies with non- invasive yet effective technique compared to surgery. Methods: We retrospectively reviewed four cases of adrenal metastases (three: lung and one: renal cell carcinoma) treated with Cyberknife SBRT. X sight spine tracking was employed for planning and treatment delivery. Patients were evaluated for local response clinically as well as with PETCT based response criteria.Results: With a median gross tumor volume of 20.5 cc and median dose per fraction of 10 Gy, two patients had complete response (CR) and two had partial response (PR) when assessed 8-12 weeks post treatment as per RECIST. There was no RTOG grade 2 or more acute adverse events and organs at risk dosage were acceptable. Till last follow up all the patients were locally controlled and alive. Conclusion: Cyberknife SBRT with its unique advantages like non- invasive, short duration outpatient treatment technique culminating in similar local control rates in comparison to surgery is an attractive option. World literature of linear accelerator based SBRT and our data with Cyberknife SBRT with small sample size and early follow up are similar in terms of local control in adrenal metastases. Future prospective data would reveal more information on the management of adrenal metastases.</p

Dosimetric comparison between Volumetric Modulated Arc Therapy (VMAT) vs Intensity Modulated Radiation Therapy (IMRT) for radiotherapy of mid esophageal carcinoma

Aims: Dosimetric comparison of VMAT with IMRT in middle third esophageal cancer for planning target volume (PTV) and organs at risk (OAR). Materials and Methods: Ten patients in various stages from I‒III were inducted in the neo-adjuvant chemoradiation protocol for this study. The prescribed dose was 4500 cGy in 25 fractions. Both VMAT and IMRT plan were generated in all cases and Dose Volume Histogram (DVH) comparative analysis was performed for PTV and OAR. Paired t-test was used for statistical analysis. Results: The PTV Dmean and D95 in IMRT and VMAT plan were 4566.6 ± 50.6 cGy vs 4462.8 ± 81.8 cGy (P = 0.1) and 4379.8 ± 50.6 cGy Vs 4424.3 ± 109.8 cGy (P = 0.1), respectively. The CI and HI for PTV in IMRT vs VMAT plans were 0.96 ± 0.02 vs 0.97 ± 0.01 (P = 0.4) and 10.58 ± 3.07 vs 9.45 ± 2.42 (P = 0.2), respectively. Lung doses for VMAT vs IMRT were 4.19 vs 2.59% (P = 0.03) for V35-7.63 vs 4.76% (P = 0.01) for V30-13.6 vs 9.98% (P = 0.01) for V25-24.77 vs 18.57% (P = 0.04) for V20-46.5 vs 34.73% (P = 0.002) for V15. The Mean Lung Dose (MLD) was reduced by VMAT technique compared to IMRT; 1524.6 ± 308.37 cGy and 1353 ± 186.32 cGy (P = 0.012). There was no change in Dmax to spinal cord in both the techniques. There was a dose reduction by VMAT compared to IMRT to the heart but it was statistically insignificant; V35-6.75% vs 5.55% (P = 0.223); V30-12.3% vs 10.91% (P = 0.352); V25-21.81% vs 20.16% (P = 0.459); V20-38.11% vs 32.88% (P = 0.070); V15-61.05% vs 54.2% (P = 0.10). Conclusion: VMAT can be a better option in treating mid esophageal carcinoma as compared to IMRT. The VMAT plans resulted in equivalent or superior dose distribution with a reduction in the dose to lung and heart

Outcomes in Kidney Transplant Recipients From Older Living Donors

Background. Previous studies demonstrate that graft survival from older living kidney donors (LD; age >60 years) is worse than younger LD but similar to deceased standard criteria donors (SCD). Limited sample size has precluded more detailed analyses of transplants from older LD. Methods. Using the United Network for Organ Sharing database from 1994 to 2012, recipients were categorized by donor status: SCD, expanded criteria donor (ECD), or LD (by donor age: = 70 years). Adjustedmodels, controlling for donor and recipient risk factors, evaluated graft and recipient survivals. Results. Of 250,827 kidney transplants during the study period, 92,646 were LD kidneys, with 4.5% of these recipients (n = 4,186) transplanted with older LD kidneys. The use of LD donors 60 years or older increased significantly from 3.6% in 1994 to 7.4% in 2011. Transplant recipients with older LD kidneys had significantly lower graft and overall survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with LD 70 years or older, but overall survival was similar. Older LD kidney recipients had better graft and overall survival than ECD recipients. Conclusions. As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar to or better than SCD recipients, better than ECD recipients, but worse than younger LD recipients. With increasing kidney donation from older adults to alleviate profound organ shortages, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys

Preemptive VAE—An Important Tool for Managing Blood Loss in MVT Candidates With PMT

Background. Explantation of native viscera in multivisceral transplant candidates, particularly in those with extensive portomesenteric thrombosis (PMT), carries considerable morbidity due to extensive vascularized adhesions. Preemptive visceral angioembolization has been previously described as a technique to minimize excessive blood loss during mobilization of the native viscera but is not well described specifically in patients with extensive PMT. Methods. In a series of 5 patients who underwent mutivisceral transplant for PMT from June 2015 to November 2018, we performed preoperative superior mesenteric, splenic, and hepatic artery embolization to reduce blood loss during explanation and evaluated the blood loss and blood product utilization, as well as 30-day rates of infectious complications. Results. Following preemptive embolization, median total blood loss was 6000 mL (range 800–7000 mL). The median transfusion requirements were as follows: 16 units packed red blood cells (range 2–47), 14 units fresh frozen plasma (range 0–29), 2 units cryoprecipitate (range 1–14), 4 units platelets (range 2–10), and 500 mL cell saver autotransfusion (range 0–1817). In the first 30 postoperative days, 2 out of 5 patients developed positive blood cultures and 3 out of 5 developed complex intra-abdominal infections. Two patients developed severe graft pancreatitis resulting in mycotic aneurysm of the aortic conduit; bleeding from the aneurysm led to 1 patient mortality. Conclusions. Preoperative embolization is an effective modality to mitigate exsanguinating blood loss during multivisceral transplant in patients with portomesenteric thrombosis; however, it is unclear if the resultant native organ ischemia during explant carries clinically relevant consequences