Supraclavicular Research Articles

Supraclavicular versus Infraclavicular Subclavian Vein Catheterization in Coronary Artery Bypass Graft Surgery

Background: Percutaneous central vein catheterization is one of the most invasive procedures commonly performed by anesthesiologists during cardiac surgery. Objectives: The aim of this study was to investigate the complications of supraclavicular (SC) versus infraclavicular (IC) approaches for subclavian vein catheterization during coronary artery bypass graft surgery. Materials and Methods: Between October 2014 and June 2015, this prospective, randomized clinical trial was performed in 280 patients. The patients were randomly cannulated by SC or IC approach. The success and complication rates were compared for the two approaches. The outcome of this study was analyzed using SPSS software and through Chi-square test. Results: In the first attempt of catheterization, the success rate in SC (78.6%) group was lower than IC (94.3%) group (P = 0.0001). The overall success rate in two attempts were 136 (97.1%) in the IC approach and 132 (94.3%) in the SC approach (P = 0.238). In 12 (4.3%) patients, subclavian catheterizations were failed after two attempts in both approaches. In 28 (10%) patients, hematoma at puncture site occurred, 1 (0.7%) in IC approach, and 27 (19.3%) in SC approach (P = 0.0001). The differences in other complications on two approaches were statistically insignificant. Conclusions: Compared with the SC approach, the IC approach resulted in fewer hematomas at puncture sites. The incidence of overall cannulation failure and other complications were similar on both approaches.

Estimation of the Thyroid Secondary Cancer Risk on the Patient of Standard Breast External Beam Radiotherapy.

Background:The purpose of this study was to estimate the secondary cancer risk of thyroid in standard radiotherapy methods which are commonly used for breast cancer patients.Methods:A total of 64 breast cancer patients (their age range was around 50 years old) who referred to Seyed-Al-Shohada hospital (Isfahan, Iran) were included in this study. The radiotherapy of the mentioned patients was performed using 6-MV photon beams. Dose measurements were also done using thermoluminescent dosimeters. Calculation of the risk of developing secondary cancer in thyroid was done using the Biological Effects of Ionizing Radiation Committee VII and recommended quantity of the International Radiation Protection Commission, excess relative risk.Results:The mean radiation dose to thyroid for the tangential beams, tangential field with supraclavicular (SC) field, and also a tangential field with SC field in modified radical mastectomy (MRM) were 0.883 ± 0.472, 1.512 ± 0.365, and 1.587 ± 0.37, respectively. The risk of developing secondary thyroid cancer over a period of 5 years after breast cancer therapy in the tangential, tangential with a SC field, and also tangential beam with SC field in MRM were 9.974 ± 4.318, 17.891 ± 0.365, and 18.783 ± 4.384, respectively. The mean of the measured thyroid doses in patients treated with tangent fields was significantly lower than the patients under the irradiation of the tangent fields with SC field (P < 0.001).Conclusions:Using radiation protection equipment is suggested for breast cancer patients who treated with the studied radiotherapy methods.

Endocavitary versus Linear Array High-Frequency Probe in Ultrasound-Guided Supraclavicular Subclavian Vein Central Access.

Background:Vascular access is a top priority in the critically ill patients. Cannulation – venous and/or arterial – is the first step in any emergency situation. Ultrasound (US)-guided vascular cannulation was found to have a higher success rate and a decreased incidence of mechanical complications as compared with the landmark one.Aim:This study aims to compare subclavian vein (SCV) access through supraclavicular (SC) approach by endocavitary (EC) probe technique versus linear array high-frequency probe technique.Settings and Design:A prospective, randomized controlled study conducted on 60 patients.Patients and Methods:Study was carried out on 60 adult patients presenting for the surgical intensive care unit in Fayoum University Hospital. Patients were classified into two groups: Group (A) (n = 30): Catheter was inserted using the EC probe and Group (B) (n = 30): Catheter was inserted using the linear array high-frequency probe.Statistical Analysis Used:Student's t-test was applied for calculation of normally distributed variables and Mann–Whitney U-test for nonnormally distributed variables. Categorical data between the groups were compared using Chi-squared test. P < 0.05 indicated a statistically significant difference.Results:The frequency of successful cannulation of the SCV at first attempt was significantly higher in Group A compared to Group B (P = 0.044). The number of attempts and the time needed for venous access were significantly lower in Group A compared to Group B (P = 0.038, <0.001 respectively). No significant difference was found regarding the incidence of posterior wall puncture, arterial puncture, or hematoma, (P = 0.671, 0.055, 1 respectively).Conclusion:The use of EC probe technique for Subclavian venous access through the SC approach significantly increased the success rate compared to the linear array high-frequency probe.

Influence of body habitus on dose parameters of nodal levels III to IV irradiation for breast cancer: comparison of 3 techniques

This study aimed to investigate the effect of body habitus on supraclavicular (SC) dose-volume histogram (DVH) parameters among breast cancer patients according to 3 different techniques. Three SC irradiation plans were generated for 24 postoperative breast cancer patients: (1) direct antero-posterior field only (1fieldP), with dose prescribed to a 3-cm depth; (2) 3-cm depth plan (3cmP) using an antero-posterior field plus a posterior boost with the dose prescription defined to 3 cm; and (3) optimized plan (OptP) similar to 3cmP, with dose prescribed depending on the anatomy. The OptP plans had the least variation in DVH parameters with body habitus; 3cmP plans were the most varied. Conformity index among normal weight patients were 0.73, 0.78, and 0.87 (p = 0.02) and 0.61, 0.6, and 0.82 among overweight-obese patients for 1fieldP, 3cmP, and OptP, respectively (p < 0.001). V95% of the planning target volume among normal weight patients were 72.63%, 78.03%, and 87.18% for 1fieldP, 3cmP, and OptP, respectively (p = 0.02). The corresponding values among overweight-obese patients were 60.5%, 59.62%, and 81.62%, respectively (p = 0.001). Fixed depth dose prescriptions caused greater SC under dose than plans optimized according to patient's anatomy.

Glucocorticoids suppress brown adipose tissue function in humans: A double-blind placebo-controlled study.

To investigate the effect of glucocorticoids on brown adipose tissue (BAT) function in humans. In a randomized double-blind cross-over design, 13 healthy adults underwent 1 week of oral prednisolone treatment (15 mg/d) and placebo with an intervening 2-week wash-out period. BAT function was assessed in response to cooling (19°C) and to a standardized meal, by measuring fluoro-deoxyglucose (FDG) uptake using positron emission tomography-computed tomography and skin temperatures overlying the supraclavicular (SCL) BAT depots using infrared thermography. Postprandial energy and substrate metabolism was assessed by indirect calorimetry. During cooling, prednisolone significantly reduced BAT FDG uptake (standardized uptake value, SUVmax, 6.1 ± 2.2 vs 3.7 ± 1.2; P < .05) and SCL temperature (-0.45 ± 0.1 vs -1.0 ± 0.1°C; P < .01) compared to placebo. Postprandially, prednisolone significantly blunted the rise in SCL temperature (+0.2 ± 0.1 vs -0.3 ± 0.1°C; P < .05), enhanced energy production (+221 ± 17 vs +283 ± 27 kcal/d; P < .01) and lipid synthesis (+16.3 ± 3.2 vs +23.6 ± 4.9 mg/min; P < .05). The prednisolone-induced reduction in SCL temperature significantly correlated with the reduction in FDG uptake (r = 0.65, P < .05), while the increase in energy production significantly correlated with the increase in lipogenesis (r = 0.6, P < .05). Prolonged exposure to glucocorticoid suppresses the function of human BAT. The enhancement of energy production and lipogenesis in the face of reduced dissipation of energy as heat suggests that glucocorticoids channel energy towards fat storage after nutrient intake. This is a novel mechanism of glucocorticoid-induced obesity.

Clinical study of Arteriovenous needle used in rescuing patients with hemorrhagic shock

Objective To evaluate the clinical value of subclavian vein puncture with 16 G arteriovenous indwelling needle for emergency treatment of hemorrhagic shock, so as to provide a new approach for the rapid establishment of deep venous passage. Methods 80 patients with acute hemorrhagic shock were randomly divided into patients with arteriovenous indwelling needle group(catheter group) and conventional guide wire deep vein puncture group(routine puncture group), 40 cases in each group.The two groups were treated with supraclavicular subclavian vein puncture.The operation time, success rate of the first puncture, puncture times and rehydration rate, incidence of complications were observed in the two groups. Results The operation time of indwelling needle group was (62±22)s, which was significantly shorter than (672±178)s of the conventional puncture group, there was significant difference between the two groups(t=15.062, P=0.000). The first time success rate of puncture in the indwelling needle group was 70%(28 cases), which in the conventional group was 80%( 32 cases), the difference was not statistically significant(χ2=1.067, P=0.439), all patients were in 3 attempts in successful puncture.The velocity of infusion of 500 mL hydroxyethyl starch in the indwelling needle group was (198±51)s, which was better than (456±86)s in the conventional puncture group, the difference between the two groups was statistically significant(t=9.318, P=0.000). The two groups had no deep vein puncture related complications. Conclusion Arteriovenous indwelling needle by supraclavicular subclavian vein puncture with conventional guide wire supraclavicular subclavian vein puncture catheter can be used for emergency treatment of hemorrhagic shock, but the indwelling needle group in the operation time and velocity is superior to conventional guide wire group, more suitable for the rescue of patients with acute hemorrhagic shock time is pressing, stay with stable circulation can be through the guide wire inserted catheter indwelling subclavian vein catheter. Key words: Injections, intravenous; Injections, intra-arterial; Venepuncture; Subclavian vein; Shock, hemorrhagic

Outcomes and patterns of relapse after definitive radiation therapy for oligometastatic cervical cancer

PurposeSurvival rates for women with metastatic cervical cancer are low, with limited management options. Definitive radiation therapy (RT) for oligometastatic disease has led to prolonged survival in other malignancies, but this approach has yet to be systematically studied for cervical cancer. Methods and materialsWe evaluated 38 patients who received definitive RT to oligometastatic sites of cervical cancer at a single institution from 2002 to 2015. Patients presented with synchronous (n=9) or metachronous (n=15) oligometastatic disease to supraclavicular (SCV) nodes, or with recurrent disease in mediastinum (n=10) or lung (n=7). Three patients were treated for both SCV and mediastinal sites, and six patients were treated for para-aortic or pelvic recurrences along with oligometastatic sites. Most received chemotherapy: induction (n=5), concurrent (n=24), or adjuvant (n=5). Outcomes were evaluated via Kaplan-Meier, and associations were examined via Cox proportional hazards modeling. ResultsMedian follow-up was 35.2months (range 3.1–94.7). Median overall survival (OS) was 50.7months from end of RT, with 2-year and 3-year OS rates of 74% and 65%. Median progression-free survival (PFS) was 21.7months, with 1-year and 2-year PFS rates of 63% and 48%. Of the 38 patients, 21 (55%) experienced progression, at a median time of 24.8months. There was one in-field failure. Other relapses occurred regionally (n=10) and distally (n=12), with two patients experiencing both. The most common site of recurrence following treatment of SCV disease was mediastinum (n=7). The incidence of grade≥3 toxicity from treatment of oligometastatic sites was <3%. ConclusionsDefinitive RT to sites of oligometastatic cervical cancer can result in excellent local control, favorable outcomes, and even achieve long-term survival for carefully selected patients, with minimal RT-associated toxicity.

Clinical value of radiotherapy in 78 patients with pT3N0M0 breast cancer after modified radical mastectomy

Objective To investigate the value of post-mastectomy radiotherapy (PMRT) in patients with T3N0 breast cancer (BC) who were treated with modified radical mastectomy (MRM). Methods A retrospective analysis was performed on the clinical data of BC patients treated with MRM from 1997 to 2014.The inclusion criteria were as follows: (1) female patients; (2) pathological diagnosis of invasive BC; (3) tumor volume greater than 5 cm without axillary lymph node metastasis; (4) the patients who received no neoadjuvant chemotherapy or endocrine therapy and had no distant metastasis or other second primary cancers. A total of 78 patients met the inclusion criteria. Forty patients (51%) received PMRT and sixty-seven patients (86%) received adjuvant chemotherapy. The Kaplan-Meier method was used to calculate overall survival (OS), disease-free survival (DFS)(DFS), and local-regional recurrence (LRR) rates, and survival differences between groups were analyzed by the log-rank test. Results The median follow-up time was 79 months (6-232 months). For all patients, the 5-year OS, DFS, and LRR rates were 89%, 87%, and 2%, respectively. The 5-year DFS, OS and LRR rates for radiotherapy group were 84%, 84% and 0%, respectively, versus 91%(P=0.641), 96%(P=0.126), and 5% for non-radiotherapy group. Only estrogen receptor/progesterone receptor (ER/PR) status and molecular type had significant impacts on DFS (P=0.002 and 0.031, respectively). One patient in non-radiotherapy group had chest wall recurrence. Conclusions MRM is effective in reducing LRR in T3N0M0 BC patients. Only ER/PR status and molecular type significantly influence DFS. Effective systemic therapy may be helpful for some T3N0 patients to avoid chest wall and supraclavicular radiotherapy after MRM, but large-sample studies are needed to further confirm this conclusion. Key words: Breast cancer/radiotherapy; Local regional recurrence

Brentuximab for Refactory Hodgkin’s Lymphoma: A Case Report

Hodgkin's lymphoma (HL) continues to be an intriguing, and fascinating lymphoma [1]. HL is expected to cure the majority of patients. Brentuximab vedotin is a CD30 antibody. We survey efficacy of brentuximab in patient with HL who was resistant to treatment. A 43 year old male referred with cough and right supraclavicular lymphadenopathy. His disease was HL, nodular sclerosis type (stage IIB and grade II) with megakaryocytosis in bone marrow aspiration (BMB). He was treated with 6 cycles of induction chemotherapy including adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) and achieved a complete remission by imaging assessment. Then he received ifosfamide, carboplatin, etoposide (ICE) plus brentuximab vedotin (1.8 mg/kg every 3 weeks) regimen for 6 courses. At the end of this time he been eligible for autologous bone marrow transplantation (BMT). Bone marrow was done and after 13 days with good engraftment the patient discharge hospital. Therapists should be try with a specific target when they need a new and potent treatment like BMT for an active disease. Brentuximab vendotin is a new drug in policy of recurrence that it used for a few of cases in Iran.

Outcomes and Patterns of Relapse Following Definitive Radiation Therapy for Treatment of Oligometastatic Cervical Cancer

Survival rates are low for women with metastatic cervical cancer. Definitive radiation therapy to sites of oligometastatic disease has been reported to result in prolonged survival in other malignancies but has not been systematically studied in women with cervical cancer. The goal of this study was to report on clinical outcomes for women with cervical cancer treated with definitive radiation to isolated sites of recurrence. From 2001 to 2015, a total of 41 patients were treated with definitive radiation therapy using IMRT (n = 15), stereotactic (n = 6), or 3D (n = 20) photon therapy for oligometastatic cervical cancer. Patients presented either with synchronous oligometastatic disease to mediastinum (n = 1) or supraclavicular (SCV) lymph nodes (n = 8) with intact pelvic primary, or with recurrent disease to mediastinum (n = 10), SCV (n = 15), lung (n = 6), or bone (n = 1). Patients with recurrent disease were diagnosed at a median 21 months following initial diagnosis of primary disease (range: 2-177 months). Overall survival (OS) and progression-free survival (PFS) were evaluated via Kaplan-Meier method. Median follow-up time was 31.5 months (range: 1-104 months). Thirty-two patients presented with squamous cell carcinoma, 7 with adenocarcinoma, 1 with neuroendocrine, and 1 with papillary serous histology. The median age at diagnosis of patients in the cohort was 45 years (range: 24-77 years). Seven of 41 patients received induction chemotherapy prior to radiation (17.1%). Median overall survival (OS) from end of radiation treatment was 42 months (95% CI: 21-63 months), with an OS rate at 2-years of 72.2%. Median progression-free survival (PFS) was 13 months (95% CI: 4.2-21.8 months). Of the 41 patients treated, a total of 9 experienced disease progression (22%), with a median time-to-progression of 13 months (range: 4-42 months). Relapses occurred in the mediastinum (n = 5), lungs (n = 2), pelvis (n = 1), or brain (n = 1). All mediastinal recurrences occurred following treatment of SCV nodal basins. There were no local or in-field recurrences. There were no statistically significant associations with age (≥50 vs. <50 years), race (white vs. non), histology (SCC vs. non-squamous), induction chemotherapy, oligometastatic presentation (synchronous vs. recurrent), radiation technique (IMRT/stereotactic vs. 3D), radiation dose (≥50 vs. <50 Gy), or metastatic site (distant vs. mediastinal vs. SCV) in regard to either OS or PFS; however, a trend towards increased mortality was noted for patients presenting with pulmonary or osseous metastasis (HR 2.908, P = .062). Treatment with definitive radiation therapy to sites of oligometastatic cervical cancer can result in durable survival and excellent local control. Randomized trials are needed to determine if higher rates of survival can be attributed to treatment effect or patients selection.

Primary multifocal extranodal lymphoma in left humerus, two kidneys and ileum: one case report and literature review

In this paper, we analyzed one case of primary multifocal extranodal non-Hodgkin’s lymphoma and reviewed the related literatures.We investigated the clinical data of this case with primary multifocal extranodal lymphoma and retrospected the related references.The key words, primary extranodal lymphoma and multifocal, were used to search Pubmed and Wanfang Database, and finally only three cases were found.The 68-year-old woman was confirmatively diagnosed as primary multifocal extranodal B cell non-Hodgkin’s lymphoma.The positron emission tomography/computed tomography (PET/CT) scan showed multiple hypermetabolic lesions in the left humerus, both kidneys and ileum.The confirmative diagnosis was based on clinical manifestations and serological tests, imaging features of CT and PET/CT, and especially on the histopathological and immunohistochemical studies.After one cycle chemotherapy (rituximab, Vincristine and prednisone) and another cycle (rituximab, Vincristine, cyclophosphamide and prednisone), a repeat PET/CT scan showed a complete metabolic resolution of the lesions in the kidneys and ileum, and a partial metabolic resolution of the left humerus.After four cycles of chemotherapy, there were new extensive involvements of the right supraclavicular and intrapulmonary lymph nodes, bilateral pleural and pericardium, and the patient gave up chemotherapy.This case demonstrated the imaging findings of an uncommon primary multifocal extranodal lymphoma in left humerus, both kidneys and ileum, and highlighted the usefulness of CT and PET/CT scan in identifying the extent of disease involvement, in guiding a biopsy, and in assessing the treatment response of lymphoma.It is essential to differentiate between primary multifocal extranodal lymphoma and lymphoma extensive metastases. Key words: Lymphoma; Bone; Kidney; Ileum

Dosimetric comparison between three radiotherapy regimens involving supraclavicular and infraclavicular regions in breast cancer patients after breast-conserving surgery

Objective To evaluate the dosimetric difference between fixed-field static intensity-modulated radiotherapy (IMRT), fixed-field dynamic multileaf collimator (DMLC), and volumetric modulated arc therapy (VMAT), all of which involve supraclavicular and infraclavicular regions, in breast cancer patients after breast-conserving surgery. Methods This study included 14 female patients with breast cancer who received radiotherapy after breast-conserving surgery in our hospital from October 2012 to April 2016. The radiation field included the chest wall and supraclavicular and infraclavicular regions. IMRT, DMLC, and VMAT plans were generated for each patient while using identical optimization conditions. The doses to planning target volume (PTV) and organs at risk (OARs) were compared based on dose-volume histogram (DVH); one-way analysis of variance or nonparametric Wilcoxon rank test was used for comparison. Results For the dose distribution of PTV, VMAT achieved the best V95, V98, CI, and HI (P<0.009). Concerning the doses to OARs, VMAT achieved the best V5, V20, and Dmean of the ipsilateral lung and the best V5 and Dmean of the contralateral lung (P<0.022). Dmean of the spinal cord was significantly lower in VMAT than in IMRT and DMLC (P=0.004). Conclusions VMAT is preferred for the patients with breast cancer to be treated with radiotherapy involving supraclavicular and infraclavicular regions after breast-conserving surgery. It can improve the dose distribution of target and reduce the doses to organs at risk and radiotherapy toxicities. Key words: Breast neoplasms/intensity-modulated radiotherapy; Breast neoplasms/volume modulated arc therapy; Dosimetry

Comparative analysis of supraclavicular nerve injury after clavicle fracture surgery using two different incisions

Objective To compare and analyze supraclavicular nerve injury after mid-section clavicle fracture surgery using two different incisions, and provide solutions for protecting supraclavicular nerve in clavicle fracture surgery. Methods Between August 2010 and October 2013, 73 patients with mid-section clavicle fractures were treated with open reduction and internal fixation surgery by using minimally invasive incision (group A) or conventional incision (group B). In group A, there were 20 males and 18 females, with an average age of 36.7 years. The fractures classified by Robinson included 6 type 2A2, 21 type 2B1 and 11 type 2B2. In group B, there were 18 males and 17 females, with an average age of 38.6 years. There were 7 2A2, 16 2B1 and 12 2B2 fractures. The incidence of postoperative numbness around the incision and the area of the numbness were recorded. Patient satisfaction and shoulder joint function were evaluated by Constant-Murley score and the DASH score in two groups. Results All 73 patients were follow-up for (19.30±4.08) months on average. The numbness incidence and area of group B was significantly higher than group A in 2 weeks, 3 months and 1 year postoperatively (P 0.05). Conclusion The iatrogenic injury of supraclavicular nerves in clavicle fracture surgery impact the patients' quality of life. Surgeons should pay more attention to protect supraclavicular nerves. Using minimally invasive incision can protect supraclavicular nerves effectively in clavicle fracture surgery. Key words: Surgical procedures,minimally invasive; Clavicle; Fractures,bone; Supraclavicular nerve

Prevalence of hypothyroidism among patients with breast cancer treated with radiation to the supraclavicular field: a single-centre survey

PurposeWe investigated the prevalence of hypothyroidism (HT) in patients with breast cancer who received radiation therapy to the supraclavicular (SC) field to evaluate the effect of radiation on thyroid.MethodsBetween April 2007 and May 2016, consecutive patients with invasive breast cancer who received SC radiation were recruited. Thyroid-stimulating hormone (TSH) and free thyroxine (fT4) were measured between April and August 2016. On the basis of the radiation-planning CT images, thyroid volume was calculated and dose–volume parameters were estimated. The endpoints were the prevalence of HT as determined by high levels of TSH and low levels of fT4 in serum, and the prevalence of subclinical HT, determined by high-serum TSH and normal fT4.ResultsAmong the 68 consecutive patients, 26 were excluded from evaluation (10 patients died, 6 had a history of previous thyroid disease and 10 were lost to follow-up). One (2.4%) and six (14.3%) of these patients had HT and subclinical HT, respectively, with a mean TSH level of 8.27 µU/mL. By univariate analysis, a predictive factor of HT and subclinical HT was a thyroid volume <8 cm3 (OR 6.44, 95% CI 1.14 to 36.6; p=0.043). Multivariate analysis also showed an association between thyroid volume <8 cm3 and HT or subclinical HT (OR 18.48, 95% CI 1.48 to 230.86; p=0.024).ConclusionsThe prevalence of HT in patients with breast cancer studied was relatively low. Although thyroid volume appeared to be a predictive marker of HT in this cohort, further prospective evaluation is needed.

Clinical experience of anterior cervical approaches in the treatment of cervical neurogenic tumor of the peripheral nerve

Objective To investigate the clinical effect of using anterior cervical approaches in the treatment of cervical neurogenic tumor of the peripheral nerve from different parts. Methods A retrospective review of 22 cases of cervical neurogenic tumor of peripheral nerves was performed, who were admitted to Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University from January 2009 to January 2015.All 22 patients underwent microsurgical operations with anterior approach of sternocleidomastoid muscle in 10 cases, posterior approach of sternocleidomastoid muscle in 4 cases, anterior cervical retropharyngeal approach in 3 cases, trans-oral approach in 2 cases, and supraclavicular approach in 3 cases. Results The tumors in all 22 cases were totally resected.No surgical complications such as cerebrospinal fluid leakage were observed except 2 cases which developed hoarseness postoperatively that improved that after neurotrophic treatment. All cases were followed up for 12-84 month with a mean 48.3±18.7 month.Recurrence occurred in 1 case which underwent 2nd operation. Conclusion It seems safe and effective to select appropriate approaches corresponding to various tumor locations in the treatment of cervical neurogenic tumors of peripheral nerves. Key words: Head and neck neoplasm; Neurogenic neoplasms; Microsurgery; Treatment outcome

Comparison of the anesthetic effect of ultrasound-guided brachial plexus block by different approaches in distal radius surgery

Objective To compare the anaesthetic effect of ultrasound-guided brachial plexus block by different approaches (interscalene, axillary, supraclavicular) in distal radius surgery. Methods Ninety adult patients undergoing elective surgery for distal radius fracture open reduction and internal fixation, distal radius fracture after implant removal surgery distal radius fracture, were randomly divided into interscalene group(group A), axillary group(group B) and supraclavicular group (group C) for brachial plexus block under ultrasound-guided(n=30). The performance time and complications were recorded. Besides, the onset time and block execution time of median nerve, ulnar nerve, radial nerve, lateral medial cutaneous nerve, forearm medial cutaneous nerve were evaluated. Results There is no significant difference in performance time(P>0.05) and the onset time of pain block in median nerve, radial nerve, lateral medial cutaneous nerve (P>0.05). As for ulnar nerve and medial antebrachial cutaneous nerve, there were no difference in onset time of pain block between group A[(21±6) min] and group C[(20±5) min] (P>0.05), but they were longer than group B[(8±5) min] (P 0.05), but they were longer than group B[(10±6) min] (P<0.05). The complete suceess rate of group B(90%) were higher than other two groups. We found that two patients in group A and one patient in group C were complicated with phrenic nerve block and one patient in group B showed little tolerance of tourniquet. Conclusions Ultrasound-guided axillary brachial plexus block in the distal radius surgery is recommended because of better blockage of ulnar nerve and medial antebrachial cutaneous nerve and fewer complications. Key words: Ultrasound; Brachial plexus block; Distal radius

Abstract P1-10-13: Can the risk of radiation-induced cardiac disease in breast cancer be mitigated with cardiac-sparing techniques?

Abstract Introduction: Data suggest that long-term survivors of breast cancer treated with radiation therapy (RT) have an increased risk of cardiac events despite an overall survival benefit, particularly women with left-sided breast cancers. We hypothesized that with cardiac-sparing radiation techniques there would be no difference in long-term cardiac risks between women with right- and left-sided breast cancers. Materials and Methods: The outcomes of 775 consecutive women treated between 1984 and 1999 with breast-conserving therapy (BCT) (n=424) and post-mastectomy radiation therapy (PMRT) (n=351) for stage 0-3 breast cancer were assessed retrospectively through a review of medical records and contact with living patients. The choice of BCT vs PMRT was based on tumor board disposition and patient preference; mastectomy was recommended for multicentric or T3 breast cancers. Ninety-six percent of all node-positive patients received treatment to all nodal regions, including the internal mammary (IM), axillary (AX), and supraclavicular (SC) nodes. BCT patients had computed tomography-planned tangential breast radiation with photons with IM nodes treated within the tangent fields or with a separate en face electron field to minimize cardiac exposure. PMRT patients were treated with en face electron fields for the chest wall and IM for sparing of the lung and heart. The AX and SC nodes were treated with a matched anterior photon field with a posterior-anterior boost field (PAB) when necessary to achieve adequate dose in the AX with both BCT and PMRT. Overall, 411 patients were node-negative and 353 were node-positive. All patients have a minimum potential follow-up of 16.4 years; median actual follow-up for the BCT group was 15 years (range, 0.1-31.2) and for the PMRT group it was 9.5 years (range, 0.1-30.5). Results: Overall survival (OS), cause-specific survival (CSS), and freedom from local-regional recurrence (FFLR) rates for the cohort at 15 years were 58.2%, 72.0%, and 90.8%, respectively. Rates of freedom from cardiac events (FFCE), pulmonary events, and second malignancy were 87.6%, 93.6%, and 86.3%, respectively. On multivariate analysis, OS was correlated with stage (p=.045), number of positive nodes (p=.002), age (p&amp;lt;.0001), diabetes (p =.0021), and modality (p=.0017). Not surprisingly, 15-year survival for patients treated with BCT was better than for patients treated with PMRT (70.9% vs 59.7%; p&amp;lt;.0001). CSS was associated with stage (p=.0207), number of positive nodes (p=.0409), and modality (p=.0003). FFLR was associated with number of positive nodes (p=.0484). FFCE was associated with pretreatment cardiac disease (p&amp;lt;.0001), stage (p=.0461), and age (p=.0056), but not with either breast cancer laterality (p=.1906) or modality (BCT vs PMRT; p=.7487). Discussion: Long-term disease control and survival outcomes were better in BCT than PMRT patients, likely due to selection criteria. Cardiac events were associated with pretreatment heart disease, older age, and stage, suggesting that this population may benefit from advanced radiation techniques that can further limit cardiac dose. Neither breast cancer laterality nor treatment modality was associated with cardiac events. Citation Format: Smith TL, Mokhtech M, Bradley JA, Lightsey JL, Morris CG, Mendenhall NP. Can the risk of radiation-induced cardiac disease in breast cancer be mitigated with cardiac-sparing techniques? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-13.

Patterns of recurrence in patients with stage Ⅲ thoracic esophageal squamous cell carcinoma after radical resection

Objective: To evaluate the patterns of recurrence and their value on target delineation for postoperative radiotherapy (RT) in patients with stage Ⅲ thoracic esophageal squamous cell carcinoma (ESCC) after esophagectomy. Methods: 395 patients (302 male and 93 female) of stage Ⅲ thoracic ESCC after radical resection were enrolled in this study. Among them, 375 patients were treated with two-field and other 20 with three-field esopahgectomy. 97 patients were treated with surgery alone, 212 with adjuvant postoperative chemotherapy (CT), 56 with radiotherapy (RT) and 30 with CT plus RT. Diagnosis of recurrence was primarily based on CT images, some of which were biopsy confirmed. The location and patterns of tumor recurrence were analyzed. Results: The overall failure rates was 75.7% (299/395). Locoregional recurrence (LR) was found in 48.4% of the patients, distant metastasis (DM) in 16.2%, and LR plus DM in 4.3%. There were 208 patients occurred with LR, 26.9% (56) recurred in supraclavicular/neck (51 in supraclavicular), 69.7% (145) in mediastinum (88.7% in upper-mediastinum), and 19.7% (41) in upper abdomen (38 in para-aortic lymph node). Chi-square test and logistic multivariate regression analysis showed that TNM stage and adjuvant therapy were significantly associated with LR (P<0.05). Postoperative RT reduced LR (mainly LR in mediastinum), but postoperative CT did not decrease LR. Conclusions: The recurrence rate is very high in stage Ⅲ thoracic ESCC patients, LR is the main pattern of failure. TNM stage is one of the most important factors for LR. Postoperative radiotherapy can reduce LR but postoperative chemotherapy does not decrease LR. Upper-mediastinum is the most common site of recurrence, followed by supraclavicular and para-aortic regions; these areas should be considered as the key target of postoperative radiotherapy.

Dosimetric Comparison between Conventional 2D and 3D Conformal Radiotherapy in the Treatment of Intact Breast Cancer

Background: Radiotherapy (RT) techniques after Conservative Breast Surgery (CBS) vary. Three Dimension (3D) planning allows for better plan optimization compared to 2 Dimension (2D) plans and also allowing for creating Dose Volume Histograms (DVHs) for both Planning Target Volume (PTV) and Organs at Risk (OAR). Patients and Methods: Twenty consecutive patients with CBS planned for whole breast and supraclavicular (SCV) RT at the National Cancer Institute (NCI), Egypt between January and June 2016 were included in this study. All patients were planned clinically in 2D fashion with no more than 2 cm of ipsilateral lung allowed in the tangential fields “Limited 2D” (Limit-2D) then Target and OAR volumes were drawn according to the Radiation Therapy Oncology Group (RTOG) guidelines and 3D plans and a central slice PTV-based 2D plan, “Modified 2D” (Mod-2D), were performed in the same Computerized Tomography (CT) slices for each patient. Mono-Iso-Centeric technique (MIT) was used in 3D plans. DVH parameters were used to compare the three plans. Results: In 3D plans, compared to Limit-2D, coverage improved for the intact breast (V95% = 95% versus (Vs) 69%, p = 0.036) and SCVPTV (V90% = 90% Vs 65%, p = 0.01). The breast and SCV V 107%, V112% and Dmax were better with 3D plan however not statistical significant (NS). Junctional hot spots were 120% and 107% in the Limit-2D and 3D plans respectively (p = 0.04). The dose to the heart, mean (333 Vs 491 cGy), V10 (5% Vs 10%) and V20 (3% Vs 7%), Ipsilateral lung V20 (19% Vs 26%), and contra lateral breast D-max (205 Vs 462 cGy) were higher in 3D plans however NS, and the dose to the cord was the same. Comparison between 3D and Mod-2D showed better OAR sparing with 3D with mean heart dose (491 cGy Vs 782 cGy, p = 0.025) and Ipsilateral lung V20 (26% Vs 32%, p = 0.07% with statistically comparable target coverage. Conclusion: This study demonstrated that application of 3D plan using MIT improves coverage of breast and SCVPTVs with minimizing hot spot at the junctional area if compared with Limit-2D plans with comparable dose to OAR. When compared with Mod-2D plans, 3D plans not only had better target coverage but also better sparing of OAR, the latter was statistically significant.

Multimodal Imaging for the Detection of Brown Adipose Tissue Activation in Women: A Pilot Study Using NIRS and Infrared Thermography.

Purpose A clear link between obesity and brown adipose tissue (BAT) dysfunction has been recently demonstrated. The purpose of this pilot study is to determine if near-infrared spectroscopy (NIRS) 2D imaging together with infrared thermography (IRT) is capable of identifying thermal and vascular response in the supraclavicular (SCV) areas after the ingestion of an oral glucose load as a thermogenic stimulation. Method We studied two groups of women (obese versus lean) for discerning their different responses. NIRS and IRT images were acquired on the neck in the left SCV region during a 3 h oral glucose tolerance test (OGTT) and immediately after a cold stimulation. Results We detected a significant thermal response of BAT in SCV fossa in both groups. Both during OGTT and after cold stimulation, skin temperature was persistently higher in lean versus obese. This response was not coupled with changes in oxygen saturation of subcutaneous tissue in that area. Discussion and Conclusion The results show that NIRS/IRT may be a novel, noninvasive, radiation-free, easy to use, and low-cost method for monitoring, during the standard clinical practice, the diet and pharmacological intervention which aims to stimulate BAT as a potential therapeutic target against obesity and diabetes.