Analysis of modern anesthetic approaches in endoscopic phthisiosurgery

Objective — to analyze modern anesthetic approaches and their use in endoscopic phthisiosurgery. Materials and methods. During 2008—2021, we performed 133 VATS lung resections in patients with tuberculosis. The following VATS operations were performed: atypical segmentectomy — 29 (21.6 %), typical segmentectomy — 49 (36.9 %), lobectomy — 49 (36.9 %) cases, bilobectomy — 2 (1.5 %), pulmonectomy — 4 (3.1 %) observations.The number of patients diagnosed with newly diagnosed tuberculosis was 62 (46.3 %), with multidrug­resistant tuberculosis 45 (34.4 %) and extensively drug-resistant tuberculosis 26 (19 3 %). One-pulmonary ventilation, which was carried out by endobronchial intubation of the main bronchus of the contralateral lung using a double-lumen tube (DLT) in 115 (86.4 %) patients, in 15 (11.3 %) cases, endobronchial intubation was performed with a single-lumen tube (SLT) and in 3 (3.1 %) tracheal intubation. Results and discussion. The use of a DLT for intubation made it possible to reduce the duration of surgery by 20—25 % compared with the use of a SLT or tracheal intubation. When using a DLT, a more stable, faster and better collapse of the lungs was achieved, which in turn gave a decrease in trauma to its parenchyma due to the fact that additional instrumental actions were not required on the part of surgeons to achieve it.Intraoperative blood loss with DLT was (75.4 ± 38.7) and (112.6 ± 51.8) ml with SLT in experiments with intubation of the main bronchus of the contralateral lung and (184.3 ± 89.8) ml in tracheal intubation, largely due to visualization and comfort working conditions of the surgical team.In the recovery of costs, we adhere to restrictive infusion approaches, which allows avoiding overloading the pulmonary circulation, and therefore reducing the number of pulmonary complications. The qualitative composition of the intraoperative infusion program included crystalloid and colloidal solutions. The quantitative ratio during the intubation of DLT was 3 : 0.5, with SLT 3 : 1. The need for transfusion of blood components was only during tracheal intubation. Conclusions. The most important task of modern anesthesiology in endoscopic phthisiosurgery is to improve patient safety during surgery. The defining technologies of anesthetic protection in this case should be the following categories: means and methods of general anesthesia, methods of respiratory provision and technical means of their application; full intraoperative monitoring of vital functions.

A dosimetric and radiobiological evaluation of VMAT following mastectomy for patients with left-sided breast cancer

Background To compare the dosimetric, normal tissue complication probability (NTCP), secondary cancer complication probabilities (SCCP), and excess absolute risk (EAR) differences of volumetric modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT) for left-sided breast cancer after mastectomy. Methods and materials Thirty patients with left-sided breast cancer treated with post-mastectomy radiation therapy (PMRT) were randomly enrolled in this study. Both IMRT and VMAT treatment plans were created for each patient. Planning target volume (PTV) doses for the chest wall and internal mammary nodes, PTV1, and PTV of the supraclavicular nodes, PTV2, of 50 Gy were prescribed in 25 fractions. The plans were evaluated based on PTV1 and PTV2 coverage, homogeneity index (HI), conformity index, conformity number (CN), dose to organs at risk, NTCP, SCCP, EAR, number of monitors units, and beam delivery time. Results VMAT resulted in more homogeneous chest wall coverage than did IMRT. The percent volume of PTV1 that received the prescribed dose of VMRT and IMRT was 95.9 ± 1.2% and 94.5 ± 1.6%, respectively (p < 0.001). The HI was 0.11 ± 0.01 for VMAT and 0.12 ± 0.02 for IMRT, respectively (p = 0.001). The VMAT plan had better conformity (CN: 0.84 ± 0.02 vs. 0.78 ± 0.04, p < 0.001) in PTV compared with IMRT. As opposed to IMRT plans, VMAT delivered a lower mean dose to the ipsilateral lung (11.5 Gy vs 12.6 Gy) and heart (5.2 Gy vs 6.0 Gy) and significantly reduced the V5, V10, V20, V30, and V40 of the ipsilateral lung and heart; only the differences in V5 of the ipsilateral lung did not reach statistical significance (p = 0.409). Although the volume of the ipsilateral lung and heart encompassed by the 2.5 Gy isodose line (V2.5) was increased by 6.7% and 7.7% (p < 0.001, p = 0.002), the NTCP was decreased by 0.8% and 0.6%, and SCCP and EAR were decreased by 1.9% and 0.1% for the ipsilateral lung. No significant differences were observed in the contralateral lung/breast V2.5, V5, V10, V20, mean dose, SCCP, and EAR. Finally, VMAT reduced the number of monitor units by 31.5% and the treatment time by 71.4%, as compared with IMRT. Conclusions Compared with IMRT, VMAT is the optimal technique for PMRT patients with left-sided breast cancer due to better target coverage, a lower dose delivered, NTCP, SCCP, and EAR to the ipsilateral lung and heart, similar doses delivered to the contralateral lung and breast, fewer monitor units and a shorter delivery time.

Dosimetric Comparison of IMRT, Hybrid IMRT and Hybrid VMAT For Early Stage Right-Sided Breast Cancer

Purpose This study aimed to evaluate the clinical impact of hybrid intensity-modulated radiotherapy (IMRT) and hybrid volumetric-modulated arc therapy (VMAT) for early-stage breast cancer, including plan quality and second cancer risk (SCR). Methods Three different plans were designed in full IMRT, hybrid IMRT, and hybrid VMAT for each of eight patients with early-stage breast cancer. Target quality, organs at risk (OARs) sparing, and SCR were compared among the three plans. Results Compared with the hybrid IMRT, full IMRT showed deterioration in terms of D2% of simultaneous integrated boost (SIB), V10 of ipsilateral lung, and excess absolute risk (EAR) to contralateral lung and esophagus. The homogeneity index (HI) of SIB, V5 of ipsilateral lung and combined lung, the Dmax and Dmean of the esophagus, the EAR to contralateral breast and lung, and the EAR to the esophagus with hybrid VMAT dramatically increased by 12.5%, 19.49%, 18.87%, 90.59%, 167.69%, 50.14%, 264.68%, and 160.95%, respectively (p = 0.022; 0.040; 0.044; 0.041; 0.003; 0.020; 0.000; 0.003). The EAR to contralateral breast and contralateral lung by full IMRT was significantly decreased compared with the hybrid VMAT (26.97%, p = 0.033; 50.01%, p = 0.026). Conclusion The results confirmed that hybrid IMRT could achieve better target quality and OARs sparing than full IMRT and hybrid VMAT for early-stage right breast cancer. Hybrid IMRT was the best treatment option, while hybrid VMAT performed the worst among the three plans in terms of SCR to peripheral OARs.

The use of a novel method for SPECT/CT quantification of 99m-Tc-PYP uptake in the evaluation of ATTR cardiac amyloidosis

Funding Acknowledgements Type of funding sources: None. Background/Introduction: Bone scintigraphy with 99m-Technecium-Pyrophosphate (99m-Tc-PYP) with planar and SPECT imaging is now commonplace for the non-invasive diagnosis of ATTR cardiac amyloidosis. However, the quantification of 99m-Tc-PYP uptake is based on a semi-quantitative visual score and a heart to contralateral lung ratio which suffer from poor reproducibility. A more robust method of quantifying uptake and reporting results would be beneficial and may be possible using volumetric assessment with fused SPECT/CT acquisition. Purpose The aim of this study was to evaluate the performance of a novel semi-automated quantitative software to diagnose ATTR cardiac amyloidosis in patients with a clinical suspicion of cardiac amyloidosis who underwent 99m-Tc-PYP SPECT/CT imaging. Methods This was a retrospective, single-center study of consecutive patients who underwent 99m-Tc-PYP SPECT/CT imaging from September to December 2020. Quantification software was used to obtain standardized uptake values (SUVs) of 99m-Tc-PYP activity in the whole heart using SPECT/CT data. The total SUVs, mean SUVs, and percentage of injected tracer dose in the heart, as well as two other sets of these measurements adjusted for residual blood pool activity were obtained. Activity in the lung and bone was used to calculate heart to bone and heart to right lung ratios. The results from the software quantification were compared to the results from planar imaging as well as to the final clinical diagnosis of amyloidosis. Results A total of 59 patients were imaged during this time with an average age of 74.1 ± 11.8, and 32 (54.2%) were male. After excluding 8 patients for technical issues, 12 patients were found to be positive for amyloid, 39 were negative, and the average imaging delay time was 75.0 ± 15.2 minutes. 13 methods of assessment were evaluated with the metric of the percentage of injected tracer dose found in the heart that was adjusted for the mean residual blood pool activity having the best discrimination between abnormal and normal studies. The mean percentage of injected dose in positive patients was 2.87% vs 0.98% in the patients without amyloidosis (p &lt; 0.0001). Using a cutoff of 2% to ensure that no patients with amyloid would be missed by screening, there was 100% sensitivity, 94.9% specificity, and 96.1% accuracy. There was a significant difference in the percentage injected dose based on gradations of planar heart to contralateral lung ratio and planar visual score. Conclusion Volumetric software quantification may be a superior method of evaluating 99m-Tc-PYP cardiac amyloidosis studies. This methodology may allow for a quantitative definition of a normal or abnormal 99m-Tc-PYP cardiac amyloid study and provide for the potential of following response to therapy.

Migration of a nodule localization marker to the contralateral lung

Video-assisted thoracoscopic surgery (VATS) has been increasingly used to resect lung nodules avoiding thoracotomy thus reducing morbidity and hospitalization time. One of the main challenges is to localise the target, because very often they are not palpable and small. Various nodule localization techniques have been used to assist VATS resection including metallic marker implantation adjacent to the lesion of interest. These markers have been known to migrate, more often in the pleural space. We report an unusual case of metallic marker migration in the contralateral lung.

Tongue: the unusual site in malignant pleural mesothelioma

Malignant mesotheliomas (MMs) are malignancies of the mesothelium, with primary deposits originating in the pleura, peritoneum, pericardium and the tunica vaginalis (ie, testicular). Metastatic spread is commonly reported to affect the liver, adrenal glands, kidney and contralateral lung (in cases of malignant pleural mesothelioma). Metastases to distant sites are uncommon. Spread to the oral cavity in particular is very rare. A total of 23 cases of metastatic spread to the oral cavity have been reported in the literature to date; of those, 9 cases have been to the tongue. Given the rarity of the site of metastasis, the management remains challenging. This case highlights a rare site of metastasis in MM, discusses treatment options available and briefly talks about technical limitations in treating a mobile structure such as the tongue. Good palliative and supportive care is crucial in managing cases where no curative treatment is possible.