ESTRO 37 S444 2mm isotropic PTV margin.All plans were generated using Monaco Research version 5.19.03 by Elekta AB (Stockholm, Sweden) with the MRI-Linac machine model and a 1.5T magnetic field in cranio-caudal patient direction.Organ At Risk (OAR) dose was lowered as much as possible, while maintaining PTV V100% > 95%.Dosimetric outcomes were evaluated using clinical dose criteria (Table 1), based on the UK SABR consortium guidelines for 5 fractions.Dose criteria for 3 and 1 fraction(s) were calculated using α/β=3. ResultsFor 15 of the 17 (88%) plans with a prescribed dose of 5x7Gy all dose criteria were met (Figure 1).Of the other two plans, one violated the sigmoid D0.5cc by 1.4Gy and one violated the rectum D0.5cc by 0.7Gy.With a prescribed dose of 3x12Gy, 13 plans (76%) met all dose criteria.In two plans, the bowel D0.5cc was violated by 8.2Gy for both cases and one of these plans also violated the bowel D10cc by 0.5Gy.The remaining two plans had violations of the sigmoid D0.5cc of 7.9Gy and 6.2Gy.For a single fraction of 24Gy with a 3mm PTV margin 10 plans (59%) met all dose criteria.In three plans the bowel D0.1cc was violated by 0.7, 7.3 and 7.9Gy.Two of these plans also violated the bowel D5cc by 2.9 and 4.8Gy.In three plans the sigmoid D0.1cc was violated by 0.9, 7.0 and 7.6Gy.One of these plans also violated the sigmoid D5cc by 5.3Gy.Reducing the PTV margin to 2mm for a single fraction of 24Gy increased the amount of plans that met all dose criteria by 30% from 10 to 13 (76%).Two plans violated the bowel D0.1cc by 7.2 and 7.8Gy of which one also violated the bowel D5cc by 3.7Gy.In two plans, the sigmoid D0.1cc was violated by 6.7 and 6.9Gy.In one plan the bladder D0.1cc was violated by 1.9Gy.In almost all cases with violations, the PTV overlapped with an OAR.

To report our experience with full-dose 21 Gy IORT in early breast cancer patients after breast-conserving surgery to define most important selection factors.

Purpose/Objective: Existing preclinical and clinical data suggest that the presence of a systemic inflammatory response plays a critical role in the progression of several solid tumors.The derived neutrophil-to-lymphocyte ratio (dNLR) represents an easily determinable marker of systemic inflammation and has been proposed as a potential prognostic marker.The present study was performed to externally validate the prognostic relevance of an elevated pre-treatment dNLR in a large cohort of non-metastatic breast cancer patients.Materials and Methods: Data from 762 consecutive nonmetastatic female breast cancer patients treated from 1999 to 2004 were evaluated.Disease-free survival (DFS), distant metastases-free survival (DMFS), and overall survival (OS) were assessed using the Kaplan-Meier method.To evaluate the prognostic relevance, univariate and multivariate Cox regression models were performed for each endpoint.Results: Applying receiver-operating characteristics (ROC) analysis, the optimal cut-off level for the dNLR was 3. In univariate analysis, a dNLR ≥3 was associated with poor DFS (HR 1.87, 95%CI 1.28-2.73,p=0.001),DMFS (HR 1.90, 95%CI 1.27-2.85,p=0.002), and OS (HR 1.67, 95%CI 1.07-2.63,p=0.025).Multivariate analysis revealed a significant association between the elevated dNLR and poor DFS (hazard ratio (HR) 1.70, 95%CI 1.09-2.65,p=0.018) and DMFS (HR 1.66, 95%CI 1.02-2.68,p=0.041) but did not show a significant association between the dNLR and OS (HR 1.54, 95%CI 0.91-2.59,p=0.106).Conclusions: In the present study, we confirmed the elevated pre-treatment dNLR as an independent prognostic factor that could be useful for future individual risk assessment in breast cancer patients.

Aim: outcomes of Liver Transplantation (LT) in recipients with portal vein thrombosis (PVT). Methods: we reviewed 392 adult patients transplanted between January 2003 and September 2011; 42 (10.7%, group A) had PVT at the time of LT. There were 18 PVT diagnosed prior to LT and 24 intraoperative findings. Results: median follow-up post-LT was 1019 days (range 0-3025). There were no differences between the 2 groups in terms of sex, age, MELD at LT, transplant indication, follow up, ischaemia time, donor's age, donor's sex, donor's days in ICU and graft steatosis. Reconstruction of the PV in group A was done by direct anastomosis (3 patients, 7.1%), thromboendovenectomy + direct anastomosis (34, 80.9%), thromboendovenectomy + interposition graft (2, 4.8%), jump graft (1, 2.4%), anastomosis on a collateral (1, 2.4%); 1 patient died intraoperatively before the PV anastomosis was completed. All patients in group A received i.v. heparin in the immediate post-operative period. In group A 2 patients required haemodialysis post-LT, 1 haemofiltration and mean time on ventilation was of 5 days; in group B (no PVT), 12 patients required haemodialysis (ns), 10 haemofiltration (ns) and mean time on ventilation was 4 days (ns). Mean ICU stay was 10 days in group A, 6 in group B (ns). One recipient (2.4%) in group A and 2 in group B (0.6%, ns) developed hepatic artery thrombosis (HAT); they were retransplanted. There were 2 (4.8%) primary non function (PNF) in group A and 3 (0.9%, ns) in group B. Three patients (7.1%) were retransplanted in group A and 16 (4.6%) in group B (ns). One-year patient survival was 75% vs. 87% (ns) and graft survival 70% vs. 84% (ns) in groups A and B respectively. The 5-year patient survival was 72% vs. 77% (ns) and graft survival 67% vs. 74% (ns). Four patients in group B (1.14%) and 7 in group A (16.6%) developed PVT post-LT. Of the latter 2 were treated with TIPPS, 2 with thrombolysis and stent placement, 1 with prophylactic endoscopic varices ligation, 1 with LMWH, 1 required no treatment. None were listed for re-LT or required further surgery. Conclusion: our experience confirms that the presence of PVT is not a contraindication for LT and survival outcomes are similar to patients without PVT; cases of re-thrombosis can be successfully treated by interventional radiology. An important role can be played by pre-LT diagnosis and planning of surgery.

An 11-year-old boy with irreversible intestinal failure secondary to chronic intestinal pseudo-obstruction (CIPO) and intestinal failure-associated liver disease (IFALD) underwent a combined en bloc reduced liver and small bowel transplantation. He was discharged home after 9 weeks on full oral intake without requiring intravenous nutritional or fluid supplementation. The first episode of mild acute rejection, which occurred 18 months after transplantation, was successfully treated with steroids. An episode of rotavirus gastroenteritis led to severe exfoliative rejection of the bowel graft, which was resistant to steroid and Infliximab treatment but responded to OKT3. There was associated Epstein-Barr virus viremia with no evidence of posttransplant lymphoproliferative disease. Another episode of moderate to severe acute liver rejection occurred 5 months later. At the same time, multiple biliary strictures were diagnosed and treated. Persistent clinical symptoms of abdominal pain and increased stomal output as well as atrophy of the ileal mucosa on several biopsies, suggested the possibility of chronic rejection (CR). A second combined whole liver and small bowel transplant was performed. The diagnosis of CR was confirmed on histology of the explanted graft. The postoperative course was severely complicated and 71 days after the retransplantation, the boy died because of respiratory failure and multiorgan failure. In summary, intestinal transplantation can be successfully performed in children with CIPO, giving them the opportunity to be free from total parenteral nutrition. As survival following intestinal transplantation continues to improve, the problem of CR has become increasingly important and the only treatment available is retransplantation, which is associated with poor outcomes.

Introduction. Because of concerns for a higher complications rate, reluctance exists about the use of the extended right split liver graft (ERG) for liver transplantation (LTx).

Introduction. During the last decade alternative techniques to the use of full-size cadaveric liver grafts have been employed. In particular grafts from living donor and from splitted livers. Different results have been reported with the use of different types of liver grafts. We retrospectively reviewed and analysed the results of primary isolated liver transplantations in children and adults.

Skepticism remains about the use of the extended right (ER) split graft (segments I, IV-VIII) for adult liver transplantation. We analyzed the results of primary liver transplantation performed with an ER graft in adult and in pediatric recipients. At our Institution, between October 1997 and June 2005, 32 primary liver transplantations with an ER graft were performed in 22 adult and 10 pediatric recipients. All the splitting procedures were performed in situ. Actuarial patient and graft survival among the adult recipients of the ER graft were 100% and 100% at 1 year, and 94% and 94% at 5 years. In the pediatric recipients, patient and graft survival were 90% and 79% both at 1 and 5 years. No hepatic artery thrombosis (HAT) occurred in the adult group, while in the pediatric recipients HAT occurred in two cases. A higher biliary morbidity occurred in the ER graft group when compared with the whole size graft 34% versus 13% (P = 0.03). However, this did not affect patient and graft survival. The results of this study may represent a further argument in favor of extensive splitting of all suitable grafts.

In this study we analyzed the features of 12 patients who underwent liver transplantation for progressive familial intrahepatic cholestasis (Byler's disease [BD]) in view of the technical features of the OLTx, incidence and type of complications, need for retransplantation, as well as patient and graft survivals. BD was the indication in 12 patients of median age 1.32 years and median weight 10 kg. Median follow-up was 670 days. Major surgical complications requiring reintervention occurred in three patients. No thrombosis of the hepatic artery was observed. Infections with positive blood cultures were diagnosed in four patients. One patient had a biliary anastomotic stenosis successfully treated by percutaneous techniques. Four patients had episodes of acute rejection treated with steroids. Two patients were retransplanted, both of whom died in the early postoperative period due to hepatic vein thrombosis and venoenteric fistula. The actuarial patient and graft survival was 83% at 1 year and 83% at 5 years. Split-liver grafts represent an excellent organ supply for these patients, achieving good results with no mortality on the waiting list.

We reviewed the clinical data of 30 children-hospitalized for acute liver failure in the last 6 years. Ten patients were not listed for liver transplantation OLTX. Their clinical conditions gradually improved and they are all alive without deficit. Among 20 patients listed, 15 underwent urgent OLTX. Two children died on the waiting list and three were suspended from waiting list after few days because of improvement. Survival according to age class was analyzed dividing the patients into two groups: A, age 1 year or less versus B, age between 1 and 16 years. The patient survival was 86% at 6 months and 61% both at 1 and 2 years. Survival at 6 months and 1 and 2 years was 88%, 67%, and 45% for the patients in group A and 83%, 83%, and 83% for the patients in group B (P = NS). Observing graft-to-recipient weight ratio and donor-to-recipient weight ratio most patients received an optimal sized graft. The split-liver technique is considered the preferred method of liver transplantation even in the pediatric patients with acute liver failure; especially in the setting of a cooperative system in which all livers that are suitable for split-liver transplantation are shared between centers. In order to have the best chance for survival, children with acute liver failure should be referred as soon as possible to an highly specialized pediatric liver transplantation center that can offer all the treatment modalities that are currently available.

Alagille syndrome (AS) is a dominantly inherited, multisystem disorder involving the liver, heart, eyes, face, and skeleton. From October 1997 through July 2004, 260 pediatric orthotopic liver transplantations (OLTx) were performed in 231 patients. This report describes 21 patients of median age 1.95 years (range, 0.7-16.7) who had alagille syndrome. We present the technical features of the OLTx, incidence and type of complications, medical conditions related to the syndrome, need for retransplantation, as well as patient and graft survival rates. A split liver technique was used in 16 patients (76%) who received a left lateral segment (LLS) graft whereas 7 patients (33%) received a whole liver. Only cadaveric donors were used. The major surgical complications requiring reintervention in 11 patients (52%) included biliary problems (19%) and vascular complications (17%). One case of hepatic artery thrombosis required retransplantation. Three recipients (14%) died. All other patients are alive with an actuarial survival rate of 90% at 1 year and 80% at 5 years. The actuarial graft survival rate is 85% at 1 year and 75% at 5 years. Patients with AS, despite the associated cardiovascular anomalies, can be treated successfully by a combined approach between cardiologist, radiologist, cardiothoracic, and liver transplant surgeons. With careful planning and operative management, the results are comparable with those obtained with other more common cholestatic diseases.

Biliary atresia (BA) represents the most frequent indication for liver transplantation (OLTX) in the pediatric population. The aim of this paper was to present a series collected over the last 7 years from October 1997 through July 2004, including 260 pediatric OLTX in 231 patients. BA was the indication in 137 patients. There were 69 boys and 68 girls of mean weight 10.68 kg and median age 0.9 years. As a primary transplant, 99 patients received a LLS graft; 27 a whole graft; four a I+IV-VIII segment, and two a I-IV segment. Mean follow up was 1047 days (range, 1-2496 day). Infections were diagnosed in 45 patients, vascular complications in 27 patients. Surgical complications that required reintervention occurred in 25 patients. In 41 cases biliary complications occurred, 11 requiring reintervention. 16 patients were retransplanted. In two cases another re-OLTx was performed. Currently 126 patients are alive, showing an actuarial 1 year survival of 92% and 5 year 91%, with actuarial graft survivals of 85% at 1 year and 82% at 3 and 5 years. Our results confirm the effectiveness of OLTx for the treatment of children with BA and a failed Kasai procedure. Split liver grafts represent an excellent organ supply for these patients, achieving optimal results with no mortality on the waiting list.