Purpose: We evaluated sparing of normal structures using 3-dimensional (3D) treatment planning for proton therapy of ocular melanomas.Methods and Materials: We evaluated 26 consecutive patients with choroidal melanomas on a prospective registry. Ophthalmologic work-up included fundoscopic photographs, fluorescein angiography, ultrasonographic evaluation of tumor dimensions, and magnetic resonance imaging of orbits. Three tantalum clips were placed as fiducial markers to confirm eye position for treatment. Macula, fovea, optic disc, optic nerve, ciliary body, lacrimal gland, lens, and gross tumor volume were contoured on treatment planning compute tomography scans. 3D treatment planning was performed using noncoplanar field arrangements. Patients were typically treated with 3 fields, with at least 95% of planning target volume receiving 50 GyRBE in 5 fractions.Results: Tumor stage was T1a in 10 patients, T2a in 10 patients, T2b in 1 patient, T3a in 2 patients, T3b in 1 patient, and T4a in 2 patients. Acute toxicity was mild. All patients completed treatment as planned. Mean optic nerve dose was 10.1 Gy relative biological effectiveness (RBE). Ciliary body doses were higher for nasal (mean: 11.4 GyRBE) than temporal tumors (5.8 GyRBE). Median follow-up was 31 months (range: 18-40 months). Six patients developed changes which required intraocular bevacizumab or corticosteroid therapy, but only 1 patient developed neovascular glaucoma. Five patients have since died: 1 from metastatic disease and 4 from other causes. Two patients have since required enucleation: 1 due to tumor and 1 due to neovascular glaucoma.Conclusions: 3D treatment planning can be used to obtain appropriate coverage of choroidal melanomas. This technique is feasible with relatively low doses to anterior structures, and appears to have acceptable rates of local control with low risk of enucleation. Further evaluation and follow-up is needed to determine optimal dose-volume relationships for organs at risk to decrease complications rates. (C) 2016 Elsevier Inc. All rights reserved.

Polyethylene wear and subsequent osteolysis are major obstacles to the long-term success of total hip arthroplasty (THA). We conducted a study to determine the incidence of loose acetabular components that did not show frank signs of loosening on either plain radiography or computed tomography (CT), or radiographically silent loosening (RSL). In this retrospective study, we evaluated patients who underwent revision THA and were evaluated with plain radiography and CT between 2000 and 2012. Any patient with imaging that showed signs of component movement was excluded. Of the 104 patients who met the study inclusion criteria, 17 (16.3%) met the criteria for RSL of the acetabular shell. Patients with RSL presented at a similar age (P = .961) and with a similar sex profile (P = .185) compared with patients with stable acetabular components and were more likely to present with pain (P = .0487). Acetabular components may be loose even if there is no evidence of component migration on radiographic studies. Surgeons should be aware of the incidence of RSL and the potential of RSL to affect patient care and potential surgical options.

BACKGROUND: The therapeutic benefit of targeting T2/FLAIR in addition to contrast-enhancing (CE) tumor during re-irradiation for recurrent glioma can be attenuated by augmented toxicity. Given its steep dose fall-off and narrow penumbrae, PT minimizes volume of brain parenchyma outside target volume, potentially permitting a less toxic delivery of large-volume re-irradiation. METHODS: From 2/2011 to 12/2013, 19 consecutive adult patients with recurrent glioma treated with PT re-irradiation at a single institution were retrospectively analyzed. Planning target volume (PTV) included T2/FLAIR and CE abnormalities. Covariates assessed were age, gender, KPS at time of PT, number of salvage treatments, grade at initial diagnosis, interval between prior radiotherapy and PT, PT dose, PT PTV, bevacizumab failure, concurrent use of temozolomide and/or bevacizumab, and post-PT radiation necrosis. OS time from PT start was estimated with Kaplan-Meier analysis; comparisons used log-rank statistic. Multivariate analysis used the Cox proportional hazards model. RESULTS: Median age was 42 and median KPS was 90. Median salvage treatments was 2 (range 1-9). Median interval between prior radiotherapy and PT was 36.1 months (mos) (range 6.9-162.9). 12 patients (63%) were bevacizumab-refractory. Median PT dose was 50.4 CGE and median PTV was 224.2 cc. 5 patients (26%) remain alive. Median OS was 9.4 mos overall, 6.6 mos amongst bevacizumab-refractory patients, and 12.3 mos amongst bevacizumab-naive patients. Prior bevacizumab failure (hazard ratio (HR) 3.79; P = 0.047), shorter interval since prior radiotherapy (HR 1.04; P = 0.02), and Grade 4 disease (HR 4.17; P = 0.03) were prognostic of inferior OS. One patient had grade 3 radiation necrosis in the setting of PT re-irradiation for progressive brainstem glioma. One patient had grade 2 radiation necrosis, and another had grade 2 stroke. No other grade ≥3 toxicities were observed. CONCLUSION: Large-volume PT re-irradiation for recurrent glioma is safe and associated with promising OS outcomes, particularly in the setting of bevacizumab-refractory tumors.

Introduction: Total knee arthroplasty (TKA) is an effective operation for the management of osteoarthritis of the knee. Conventional technique utilizing manual instrumentation (MI) allows for reproducible and accurate execution of the procedure. The most common techniques make use of intramedullary femoral guides and either extrameduallary or intrameduallary tibial guides. While these methods can achieve excellent results in the majority of patients, those with ipsilateral hardware, post-traumatic deformity or abnormal anatomy may preclude the accurate use of these techniques. Patient-specific instrumentation (PSI) is an alternative innovation for total knee arthroplasty. Utilizing magnetic resonance imaging (MRI) or computed tomography (CT), custom guide blocks are fabricated based on a patient9s unique anatomy. This allows for the benefits of computer assisted navigation (CAN) but without the increased operative times or the high learning curve associated with it. Furthermore it allows the use of familiar cutting blocks and guides to check the accuracy of the PSI guide blocks. In this study we sought to evaluate the accuracy of PSI techniques in patients with previous ipsilateral hardware, which would make the use of MI technically challenging and possibly subject to inaccuracy. Methods: After reviewing our database of 300 PSI total knee arthroplasty patients, 16 patients were identified (10 male, 6 female) using the Zimmer NexGen Patient Specific Instrumentation System. Fourteen patients included in the study had a preexisting total hip arthroplasty on the ipsilateral side, 1 had a preexisting sliding hip screw, and 1 patient had a preexisting cephalomedullary nail. Postoperative mechanical axis alignment measurements were performed using plain long-standing radiographs. The American Knee Society Score was used to evaluate clinical outcomes postoperatively. Results: Sixteen total knee arthroplasties were performed using PSI, all in the setting of previous ipsilateral hardware placement. The average age at the time of surgery was 72, with patients ranging from 56 to 85 years of age. Eleven of the included knees had a preoperative varus alignment and 5 had valgus alignment. The average value of a deformity identified via the preoperative planning software was 7.85°. The average value of a deformity identified via preoperative radiographs was 10.1°. Average postoperative mechanical axis was 3.1° measured from plain radiographs. Average angle between the femoral mechanical axis and femoral component was 90.0°. The average angle between the tibial mechanical axis and tibial component was 90.6°. The average difference between the femoral mechanical and anatomic axes was 5.9°. The average discrepancy between medial and lateral joint space on an anterior-posterior standing radiograph was 0.4 mm. At an average of 4.5 months follow-up, American Knee Society knee scores show an aggregate average score of 82.94. Conclusion: Patient specific instrumentation is an innovative technology in TKA that replaces the use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. This study demonstrates that PSI is capable of producing favorable radiographic and clinical outcomes despite preexisting ipsilateral hardware, which may preclude the use of customary manual instrumentation. We believe PSI is an accurate and effective tool for use in patients with preexisting ipsilateral hardware.

We compared dose to pelvic bone marrow from intensity modulated radiation therapy (IMRT) and two proton beam therapy techniques. IMRT and proton plans were generated for 5 patients with high risk prostate cancer treated at the CDH Proton Center to the full pelvis to 50.4 Gy followed by a cone down to the prostate to a final dose of 79.2 Gy in 1.8 Gy (RBE) fractions. The nodal volumes were contoured according to the RTOG online atlas. All plans were created using the treatment planning software platform. For consistency, IMRT plans were designed to the same PTV and using the same normal tissue constraints as the proton plans. The IMRT plans used a 7 field co-planar approach with all fields treated daily. The 3-D proton plans used multiple matching fields treated daily for the pelvis portion of treatment and alternating right and left lateral beams for the prostate only portion of treatment. The intensity modulated proton therapy (IMPT) plans used right and left lateral beams with both fields treated daily. Both modalities adequately covered the planning target volume with the 98% isodose line covering the PTV. The 2 proton techniques consistently reduced the dose to bone marrow compared with IMRT. The mean bone marrow dose and volume of bone marrow receiving 5, 10, 20 and 40 Gy was reduced with both proton planning techniques compared with IMRT. IMPT was the best technique for reducing dose to the bone marrow. The mean bone marrow dose was 20.1 Gy for IMPT, 24.4 Gy for 3-D protons, and 29.9 Gy for IMRT. The IMPT plans significantly reduced dose to bone marrow compared with IMRT (p<0.001). When comparing IMPT to IMRT, the volume of bone marrow receiving 5 Gy (62 vs. 77%), 10 Gy (58 vs. 73%), 20 Gy (52 vs. 67%) and 40 Gy (17 vs. 38%), were all reduced with IMPT (p<0.05 at each dose level). Both proton techniques also delivered significantly less dose to the bladder and rectum compared with IMRT. When comparing IMPT to IMRT, the mean bladder dose was 30 Gy vs. 45 Gy and V40Gy for bladder was 29% vs. 60% in favor of IMPT. The mean rectal dose was 30 Gy vs. 47 Gy and V40Gy for rectum was 40% vs. 72% in favor of IMPT. Proton therapy reduces dose to bone marrow compared with IMRT. While a simple 3D proton technique reduces dose to bone marrow, bladder and rectum compared with IMRT, the IMPT technique proved even better at shielding the bone marrow. To our knowledge, this is the first report comparing dose to bone marrow across IMRT, 3-D protons, and IMPT in men with high risk prostate cancer receiving pelvic radiation therapy followed by a cone down to the prostate.

Vestibular schwannomas are benign tumors of the Schwann cells of the eighth (VIII) cranial nerve. Precision radiotherapy techniques used to manage these tumors include stereotactic radiotherapy (SRT), which can be delivered with either a conventional or hypofractionated regimen. The radio-biologic rationale and reported clinical outcomes of patients treated with SRT are reviewed.