Correlation of clinical outcome, radiobiological modeling of tumor control, normal tissue complication probability in lung cancer patients treated with SBRT using Monte Carlo calculation algorithm.

PURPOSE/BACKGROUND: We analyzed the predictive value of non-x-ray voxel Monte Carlo (XVMC)-based modeling of tumor control probability (TCP) and normal tissue complication probability (NTCP) in patients treated with stereotactic body radiotherapy (SBRT) using the XVMC dose calculation algorithm. MATERIALS/METHODS: We conducted an IRB-approved retrospective analysis in patients with lung tumors treated with XVMC-based lung SBRT. For TCP, we utilized tumor size-adjusted biological effective dose (s-BED) TCP modeling validated in non-MC dose calculated SBRT to: (1) verify modeling as a function of s-BED in patients treated with XVMC-based SBRT; and (2) evaluate the predictive potential of different PTV dosimetric parameters (mean dose, minimum dose, max dose, prescription dose, D95, D98, and D99) for incorporation into the TCP model. Correlation between observed local control and TCPs was assessed by Pearson's correlation coefficient. For NTCP, Lyman NTCP Model was utilized to predict grade 2 pneumonitis and rib fracture. RESULTS: Eighty-four patients with 109 lung tumors were treated with XVMC-based SBRT to total doses of 40 to 60 Gy in 3 to 5 fractions. Median follow-up was 17 months. The 2-year local and local-regional control rates were 91% and and 78%, respectievly. All estimated TCPs correlated significantly with 2-year actuarial local control rates (P < 0.05). Significant corelations between TCPs and tumor control rate according to PTV dosimetric parameters were observed. D99 parameterization demonstrated the most robust correlation between observed and predicted tumor control. The incidences of grade 2 pneumonitis and rib fracture vs. predicted were 1% vs. 3% and 10% vs. 13%, respectively. CONCLUSION: Our TCP results using a XVMC-based dose calculation algorithm are encouraging and yield validation to previously described TCP models using non-XVMC dose methods. Furthermore, D99 as potential predictive parameter in the TCP model demonstrated better correlation with clinical outcome.

Undifferentiated Endometrial Carcinomas: Clinicopathologic Characteristics and Treatment Outcomes.

OBJECTIVE: Undifferentiated endometrial carcinoma (UEC) represents a recently recognized and rare diagnosis that is commonly misclassified on histopathologic evaluation. These cancers account for less than 10% of carefully reviewed series of endometrial cancers from academic medical centers. We reviewed a single-institutional experience with the management of UEC focusing on clinicopathologic characteristics and treatment outcomes. METHODS: The medical records of all patients treated for histologically proven endometrial carcinoma between 2007 through 2016 were reviewed. Analysis was limited to 24 consecutive patients with histologically proven endometrial carcinomas that had at least a component of undifferentiated carcinoma on central pathology review. All patients were initially treated by definitive surgical resection. Grade 3 endometrioid carcinomas treated over the same period were used as a control group. The Kaplan-Meier method was used to estimate survival outcomes. RESULTS: The median age at diagnosis was 66 years (range, 37-74 years). Ten patients presented with locally advanced or metastatic disease (42%). Fifteen patients (63%) received adjuvant chemotherapy with carboplatin and paclitaxel, 12 patients (50%) received adjuvant pelvic external beam radiation, and 10 patients (42%) received adjuvant vaginal cuff brachytherapy. With a median follow-up of 14 months (range, 0.5-115 months), 4 patients (21%) had developed disease recurrence and/or progression, 2 patients (11%) had died of disease, and 1 patient died of treatment complications. Twelve patients (63%) were alive with no evidence of disease at last contact. Outcomes were comparable to those with grade 3 endometrioid carcinoma. CONCLUSIONS: Our data are consistent with prior studies demonstrating that UEC represents a rare clinical entity characterized by high rates of locally advanced disease at presentation. However, survival outcomes appear to be comparable to other high-grade endometrial cancers. Further studies investigating optimal adjuvant therapy in these patients are warranted.

Spatial mapping of functional pelvic bone marrow using FLT PET.

The purpose of this study was to determine the ability of regions identified with bony landmarks on CT imaging to accurately represent active bone marrow when compared to FLT PET imaging. These surrogate regions could then be used to create a bone marrow sparing radiation therapy plan when FLT PET imaging is not available. Whole body (WB) FLT PET images were obtained of 18 subjects prior to chemoradiation therapy. The FLT image of each subject was registered to a CT image acquired for that subject to obtain anatomic information of the pelvis. Seventeen regions were identified based on features of the pelvic bones, sacrum, and femoral heads. The probability of FLT uptake being located in each of 17 different CT-based regions of the bony pelvis was calculated using Tukey's multiple comparison test. Statistical analysis of FLT uptake in the pelvis indicated four distinct groups within the 17 regions that had similar levels of activity. Regions located in the central part of the pelvis, including the superior part of the sacrum, the inner halves of the iliac crests, and the L5 vertebral body, had greater FLT uptake than those in the peripheral regions (p-value < 0.05). We have developed a method to use CT-defined pelvic bone regions to represent FLT PET-identified functional bone marrow. Individual regions that have a statistically significant probability of containing functional bone marrow can be used as avoidance regions to reduce radiation dose to functional bone marrow in radiation therapy planning. However, because likely active bone marrow regions and pelvic targets typically overlap, patient-specific spatial detail may be advantageous in IMRT planning scenarios and may best be provided using FLT PET imaging.

Incidence and Predictors of Persistent Opioid Use in Survivors of Head and Neck Cancer Treated With Curative Radiation.

PURPOSE: We sought to characterize the incidence of chronic opioid dependence among head and neck cancer survivors treated by radiation, as well as to identify patient and treatment factors associated with persistent use. MATERIALS AND METHODS: The medical records of patients with head and neck cancer who received radiation therapy from January 2012 to July 2016 were reviewed. All patients received 60 to 70 Gy with curative intent. Patients who progressed or died within 1 year were intentionally excluded. Opioid doses were calculated in morphine equivalent daily doses in milligrams (mg). Univariate and multivariate regression models were used to identify associations between demographic, medical, disease, and persistent opioid use. RESULTS: Two hundred and sixty-one patients were included. The median follow-up was 39 months (range: 12 to 83 mo). Two hundred and eleven patients (80%) received opioids for pain control during radiation. The median morphine equivalent daily dose during treatment was 73.8 mg (range: 5 to 561 mg). Rates of persistent opioid use at 6 months, 1 year, and 2 years from completion of radiation were 41.8%, 30.1%, and 26.0%, respectively. On multivariate analysis, only preradiation opioid use correlated with persistent opioid use at all 3 time points (P<0.05). Smoking history and a Charlson comorbidity index ≥2 predicted for persistent opioid use at some time points, but not all. CONCLUSIONS: High rates of persistent opioid use exist in patients with head and neck cancer after radiation therapy. Early interventions to appropriately wean patients should be further investigated.

The impact of skeletal muscle abnormalities on tolerance to adjuvant chemotherapy and radiation and outcome in patients with endometrial cancer.

INTRODUCTION: Skeletal muscle abnormalities, such as low skeletal muscle mass, measured by skeletal muscle index (SMI), and low skeletal muscle quality, measured by skeletal muscle density (SMD), are associated with poor prognosis in cancer. There has been little investigation of their impact on tolerance to radiation therapy and overall outcome in gynaecologic cancers. We examined the effect of low SMI and SMD on treatment tolerance and survival outcomes in patients with endometrial cancer receiving pelvic radiation. METHODS: Stage IB-IVA patients with endometrial cancer treated at one institution between 2007 and 2017 were reviewed. All patients received hysterectomy and pelvic radiation. SMI was based on the cross-sectional area of skeletal muscle at the L3 vertebral body. SMD was expressed as the mean radiation attenuation in Hounsfield units (HUs) at the same vertebral level. RESULTS: Sixty-four patients met criteria for analysis. Forty-four per cent had low SMI (<41 cm2 /m2 ), 80% had low SMD (mean < 33 HU if BMI> 25 and mean < 41 HU if BMI < 25), and 33% had both. Patients with both features were less likely to complete planned chemotherapy (p = 0.01); this was consistent on multivariate analysis. Radiation treatments were well-tolerated regardless of SMI or SMD. On survival analysis, having both low SMI and low SMD was associated with poorer outcomes compared with having either individual factor (p = 0.04). CONCLUSION: Large percentages of patients with endometrial cancer have low skeletal muscle mass and density. Low skeletal muscle measures predict for poor tolerance to chemotherapy in this patient population. Compliance with adjuvant radiation is high, regardless of SMI and SMD.

Assessing the Financial Toxicity of Radiation Oncology Patients Using the Validated Comprehensive Score for Financial Toxicity as a Patient-Reported Outcome.

PURPOSE: The financial burden of cancer care may significantly affect patient quality of life and clinical outcomes. However, the financial effect of radiation therapy on patients remains difficult to characterize, in part owing to the lack of standardized methods to measure patient distress related to treatment costs. Here, we assessed financial burden in the radiation oncology population by applying the Comprehensive Score for Financial Toxicity (COST), a patient-reported outcome measure, which has been validated in medical oncology patients.   METHODS AND MATERIALS: Consecutive patients from a single academic radiation oncology clinic were recruited. Participants completed the 11-item COST-Functional Assessment of Chronic Illness Therapy questionnaire, with total possible scores ranging from 0 to 44. Scores were collected along with data regarding patient demographics, insurance, diagnosis, and treatment. Univariate and multivariate analyses were performed to identify factors associated with higher financial burden as measured by COST. RESULTS: A total of 167 patients completed the COST questionnaire. Lower COST scores indicated higher financial toxicity. The population's mean COST score was 21.9 (95% confidence interval, 20.5-23.3). Fifteen percent of participants reported grade 2 to 3 COST toxicity, corresponding to a moderate or severe effect on quality of life. Use of concurrent or previous systemic therapy was significantly associated with lower COST scores on univariate analysis (P = .03), but not significant on multivariate analysis. A subset analysis of posttreatment follow-up patients identified rural residence and recent completion of radiation therapy as significant correlates of worse COST scores on univariate analysis, and rural residence remained independently associated on multivariate analysis (P = .017). CONCLUSIONS:  COST effectively identified a significant number of radiation oncology patients experiencing financial toxicity, indicating its prevalence in this population. A correlate of financial toxicity in this population is the use of systemic therapy. Of those who have completed radiation therapy, rural residence was independently associated with worse financial toxicity.

What is the hold up?-Mixed-methods analysis of postoperative radiotherapy delay in head and neck cancer.

BACKGROUND: Delays in postoperative radiotherapy (PORT) for head and neck cancer (HNC) increase the risk for recurrence and mortality. The multifactorial nature of delays calls for an in-depth understanding of potential contributors from the patient's and provider's perspectives. We sought to identify causes of delays in adjuvant radiotherapy initiation for HNC. METHODS: We performed a mixed-methods study including patients with HNC care team members. Forty in-depth interviews were performed (26 patients; 14 care team members). Timing and demographic data were collected from medical records. RESULTS: Median time from surgery to radiotherapy initiation was 45 days; 15 participants began after 42 days. Process delays and failure to communicate the urgency and significance of PORT initiation contributes to delays. Patients with a strong social support system experience less delays. CONCLUSIONS: Achieving reductions in PORT initiation requires efficient care coordination, improved communication between interdisciplinary teams, and strengthening social support systems for patients with HNC.

The Impact of Radiotherapy Facility Volume on the Survival and Guideline Concordance of Patients With Muscle-invasive Bladder Cancer Receiving Bladder-preservation Therapy.

OBJECTIVES: Higher facility surgical volume predicts for improved outcomes in patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy. We investigated the association between facility radiotherapy (RT) case volume and overall survival (OS) for patients with MIBC who received bladder-preserving RT, and the relationship with adherence to National Comprehensive Cancer Network (NCCN) guidelines for bladder preservation. METHODS: The National Cancer Database was used to identify patients diagnosed with nonmetastatic MIBC from 2004 to 2015 and received RT at the reporting center. Facility case volume was defined as the total MIBC patients treated with RT during the period. Facilities were stratified into high-volume facility (HVF) or low-volume facility at the 80th percentile of RT case volume. OS was assessed using Kaplan-Meier analysis. Rates of compliance with NCCN guidelines regarding the use of transurethral resection of the bladder tumor before RT, planned use of concurrent chemotherapy, and total RT dose were compared. Cox proportional hazard model was used to evaluate predictors of OS. RESULTS: There were 7562 patients included. No differences in age, Charlson-Deyo score, T stage, or node-positive rates were observed between groups. HVFs exhibited greater compliance with NCCN guidelines for bladder preservation (P<0.0001). Treatment at an HVF was associated with the improved OS for all patients (P=0.001) and for the subset of patients receiving NCCN-recommended RT doses (P=0.0081). Volume was an independent predictor of OS (P=0.002). CONCLUSIONS: Treatment at an HVF is associated with improved OS and greater guideline-concordant management among patients with MIBC.

Opportunities for use of radiation therapy in penile cancer based on patterns of care in the United States from 2007 to 2013.

BACKGROUND: Radiation therapy (RT) is an effective modality for the treatment of squamous cell carcinomas of the penis. The National Comprehensive Cancer Network recommends consideration of primary radiation for penile preservation, in surgically unresectable tumors, and as adjuvant therapy for positive margins, bulky groin nodes or pelvic nodes. We performed a population-based analysis to evaluate the usage of RT in penile cancer from 2007 to 2013. METHODS: We used the Surveillance, Epidemiology and End Results (SEER) database to identify men diagnosed with squamous cell carcinoma of the penis from 2007 to 2013. Patients were grouped as early stage (T1-T2N0), locally advanced (T3-T4N0), node-positive (T1xN1-3) and metastatic. We used linear regression model to test for factors associated with adjuvant radiation in node-positive patients. RESULTS: We identified 2200 men diagnosed with penile cancer between 2007 and 2013. Of these, 66.4% had early stage, 10.7% had locally advanced, 15.5% had node-positive, 3.2% had metastatic cancer. Among patient with early stage cancer, RT was used in 14 patients (1.0%) and postoperative radiation in an additional 45 patients (3.1%). Among 340 patients with node-positive cancer, 62.1% received surgery alone, 5.6% radiation alone, 21.8% surgery with adjuvant radiation, and 10.6% neither surgery nor radiation. Of patients who had surgery, 26.0% had adjuvant radiation. On univariate analysis, higher nodal stage (N2-3 versus N1) was associated with adjuvant radiation (p = 0.02), while there was a trend for higher T-stage (T3/T4 versus T1/T2) (p = 0.08) and history of prior malignancy (p = 0.06). On multivariate analysis, only higher nodal stage (N2-3 versus N1) was associated with use of adjuvant radiation [hazard ratio (HR) 1.94, p = 0.03]. CONCLUSIONS: A small percentage of patient who are eligible for primary or adjuvant RT in the United States receive this treatment. Further work should be done to assess barriers to use of radiation in patients with penile cancer.

Visceral adipose ratio as a novel predictor for acute bowel toxicity in patients receiving pelvic radiation: Preliminary dosimetric analysis and clinical validation.

INTRODUCTION: During radiation treatment planning, the small bowel (SB) is often contoured as a 'bowel bag' encompassing the entire peritoneal space that may be occupied by SB. This method incorporates large volumes of visceral adipose, potentially resulting in misleading estimates of radiation dose to the SB. We evaluated the relative volume of adipose within the peritoneal space and applied this as a correction factor to standard bowel bag dosimetric measures, hypothesizing that corrected SB measures would better correlate with acute toxicity. METHODS: Eighteen consecutive patients receiving pelvic radiation for gynaecologic cancers over a 1-year period at an academic medical centre were included. Bowel function was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire. Bowel bags were contoured on simulation computed tomography (CT) scans. Adipose was auto-contoured using previously published Hounsfield Unit criteria and used to create an adipose correction factor (ACF). The ACF was applied to V45 cc and V40% volumes to create adipose corrected measures (AC-V45 cc and AC-V40%). Correlations between EPIC scores and dosimetric measures were assessed using Spearman coefficients. RESULTS: V45 cc and V40% did not correlate with overall EPIC bowel domain score; however, AC-V40% did show a significant correlation (P = 0.02). Correlations of V45 cc and V40% with the bowel bother subdomain of EPIC were both significantly improved by applying the ACF (P = 0.02 for AC-V45 cc; P < 0.01 for AC-V40%). CONCLUSIONS: Adipose corrected bowel bag dosimetric constraints correlate better with acute bowel toxicity than current standard practice. Longer follow-up is needed to determine if similar findings are seen with late toxicity.

Impact of Peer Review on Use of Hypofractionated Regimens for Early-Stage Breast Cancer for Patients at a Tertiary Care Academic Medical Center and Its Community-Based Affiliates.

PURPOSE: Data have demonstrated that hypofractionated radiation therapy (HFRT) and conventionally fractionated radiation therapy regimens are equivalent with respect to outcomes. Efforts to increase HFRT use have had mixed success. We implemented a prospective peer review chart rounds integrating all practice sites and reviewed the use of HFRT in an attempt to identify potential predictors of use. MATERIALS AND METHODS: Patients treated with whole-breast radiation therapy within our cancer care network from January 2016 to June 2017 were evaluated. Radiation courses with a dose per fraction of greater than 2 Gy were considered HFRT, whereas those with a dose per fraction of less than or equal to 2 Gy were considered as conventionally fractionated radiation therapy. Patient, provider, and tumor characteristics were categorized by use of HFRT and compared between groups using a χ2 test or two-tailed t test. RESULTS: A total of 349 consecutive patients were identified. All 120 patients treated at the main academic site received HFRT. There was significant variation in use of HFRT among community-based providers (28% to 100%; P < .001). There was increased use of HFRT after implementation of institution-wide prospective peer review (66% v 81% before and after implementation, respectively; P = .001). Age, tumor grade, chemotherapy receipt, surgeon type (academic v community), and treatment after implementation of peer review all correlated with HFRT use. On multivariable analysis, treatment after implementation of peer review ( P < .001) remained a significant predictor of HFRT use, as did age ( P = .005), tumor grade ( P = .013), and surgeon type ( P < .001). CONCLUSION: Significant variation persists in the use of HFRT among providers. Increased awareness and oversight through prospective peer review may be useful in improving compliance to HFRT. Expanding these efforts to include education of referring surgeons may be helpful.

The impact of sarcopenia on tolerance of radiation and outcome in patients with head and neck cancer receiving chemoradiation.

BACKGROUND AND PURPOSE: Sarcopenia is a predictor of poor prognosis in cancer patients. One potential mechanism for worse outcomes in sarcopenic patients is worse tolerance to treatment; this has not been investigated with regard to radiation treatment. We reviewed our institutional experience of head and neck cancer patients receiving concurrent chemoradiation and assessed outcomes with respect to sarcopenia. MATERIALS AND METHODS: Patients treated between 2012 and 2016 were reviewed. Sarcopenia was assessed from radiation planning computed tomography (CT) scans using muscles at the C3 vertebral body using previously published methods. Survival was calculated using the Kaplan-Meier method. Association between patient factors and outcome was calculated in univariate and multivariate analyses. RESULTS: Two hundred and forty-six patients were included. Fifty-eight percent met criteria for sarcopenia. Thirty-seven percent experienced chemotherapy delays of >1 week and 14% had radiation treatment breaks >1 week. On multivariate analysis, concurrent smoking (HR 3.85, p < 0.01) and sarcopenia (HR 2.15, p = 0.01) were associated with chemotherapy toxicity and age >65 years (HR 2.94, p < 0.01) and sarcopenia (HR 2.99, p = 0.04) were associated with prolonged radiation breaks. Sarcopenia was associated with worse overall survival (HR 1.83, p = 0.03) and progression-free survival (HR 1.65, p = 0.03) in the overall cohort. When analyzed separately, sarcopenia was not associated with outcomes in p16-positive oropharynx cancers. CONCLUSION: Sarcopenic patients receiving concurrent chemoradiation are more likely to require radiation treatment breaks and suffer chemotherapy toxicity than their non-sarcopenic counterparts. This may contribute to worse survival outcomes in head and neck cancer, with the exception of p16-positive oropharyngeal cancer.

The effect of breast volume on toxicity using hypofractionated regimens for early stage breast cancer for patients.

PURPOSE: Hypofractionated radiation therapy (HFRT) remains underused, despite multiple randomized trials showing the equivalence of HFRT to conventional fractionated radiation therapy (CFRT). We sought to retrospectively review the relationship between breast volume and toxicity for HFRT versus CFRT. METHODS AND MATERIALS: Data from 114 patients who received a diagnosis of early stage breast cancer and were treated with lumpectomy and whole breast radiation alone were reviewed. Breast cancer laterality, stage, grade, estrogen/progesterone receptor and human epidermal growth factor receptor 2 status, and systemic therapy use were recorded. Length of follow-up was calculated using the last day of radiation treatment and the date of the most recent follow-up. RESULTS: The median follow-up was 42 months. A total of 83 patients were treated with HFRT and 31 with CFRT. Rates of grade ≥2 skin toxicity were significantly higher in patients undergoing CFRT compared with HFRT (76% vs 28%; P < .0001). In a subset of patients with breast volume ≥1000 cm3, grade ≥2 skin toxicity trended higher for CFRT patients (73% vs 38%; P = .057). For posterior separation >25 cm, the percentage of patients with grade 2 skin toxicity was 43% for HFRT versus 57% for CFRT (P = .67). The volume of breast tissue receiving >105% of the total prescription dose, including boost, was not significantly different for HFRT versus CFRT (P = .70). CONCLUSIONS: Use of HFRT resulted in lower acute skin toxicity rates compared with CFRT. Large breast size (volume ≥1000 cm3) was associated with lower acute grade 2 toxicity with the use of HFRT despite achieving similar dosimetry compared with CFRT.

Weekly cisplatin chemotherapy dosing versus triweekly chemotherapy with concurrent radiation for head and neck squamous cell carcinoma.

BACKGROUND: Triweekly high-dose cisplatin (100 mg/m2 ) with concurrent radiation therapy is the current standard of care in the definitive or appropriate postoperative setting in head and neck squamous cell carcinoma (HNSCC). We compared triweekly 100 mg/m2 with alternative weekly 40 mg/m2 and weekly <40 mg/m2 cisplatin regimens. METHODS: From 2011 to 2016, 163 patients received concurrent cisplatin and intensity-modulated radiotherapy for locally advanced HNSCC. Primary endpoints were overall survival (OS) and progression-free survival. RESULTS: Cisplatin weekly <40 mg/m2 showed inferior OS outcomes when compared to weekly 40 mg/m2 (P = 0.084) and triweekly 100 mg/m2 (P = 0.04) regimens. CONCLUSION: Our study displayed inferior outcomes with weekly cisplatin doses under 40 mg/m2 , suggesting the inferiority of low-dose weekly chemotherapy and the need for ongoing randomized trials to further explore 40 vs 100 mg/m2 chemotherapy regimens.

First-in-Human Phase I Clinical Trial of Pharmacologic Ascorbate Combined with Radiation and Temozolomide for Newly Diagnosed Glioblastoma.

PURPOSE: Standard treatment for glioblastoma (GBM) includes surgery, radiation therapy (RT), and temozolomide (TMZ), yielding a median overall survival (OS) of approximately 14 months. Preclinical models suggest that pharmacologic ascorbate (P-AscH-) enhances RT/TMZ antitumor effect in GBM. We evaluated the safety of adding P-AscH- to standard RT/TMZ therapy. PATIENTS AND METHODS: This first-in-human trial was divided into an RT phase (concurrent RT/TMZ/P-AscH-) and an adjuvant (ADJ) phase (post RT/TMZ/P-AscH- phase). Eight P-AscH- dose cohorts were evaluated in the RT phase until targeted plasma ascorbate levels were achieved (≥20 mmol/L). In the ADJ phase, P-AscH- doses were escalated in each subject at each cycle until plasma concentrations were ≥20 mmol/L. P-AscH- was infused 3 times weekly during the RT phase and 2 times weekly during the ADJ phase continuing for six cycles or until disease progression. Adverse events were quantified by CTCAE (v4.03). RESULTS: Eleven subjects were evaluable. No dose-limiting toxicities occurred. Observed toxicities were consistent with historical controls. Adverse events related to study drug were dry mouth and chills. Targeted ascorbate plasma levels of 20 mmol/L were achieved in the 87.5 g cohort; diminishing returns were realized in higher dose cohorts. Median progression-free survival (PFS) was 9.4 months and median OS was 18 months. In subjects with undetectable MGMT promoter methylation (n = 8), median PFS was 10 months and median OS was 23 months. CONCLUSIONS: P-AscH-/RT/TMZ is safe with promising clinical outcomes warranting further investigation.

The Efficacy of Conventionally Fractionated Radiation in the Management of Osseous Metastases from Metastatic Renal Cell Carcinoma.

BACKGROUND: There is little data regarding the effectiveness of palliative radiation with conventional fractionation for metastatic renal cell carcinoma (RCC), which has been described as radioresistant. We conducted a retrospective analysis of patients with metastatic bony disease from RCC treated with radiation therapy at our institution. METHODS: Forty patients with histologically confirmed RCC with a total of 53 treatment courses were included. Pain response after radiotherapy was recorded and freedom from progression was generated using posttreatment radiographs. Patient data was analyzed to assess influence on local control. RESULTS: Patients had a median age of 63. Median follow-up was 9.3 months. The most common radiation dose was 30 Gy in 10 fractions. Pain control after radiotherapy was achieved in 73.6% of patients. Increasing age was associated with nonresponse at the initial pain assessment post-RT (p = 0.02). In lesions with initial pain response, nonclear cell histology was associated with increased pain recurrence (p = 0.01) and a shorter duration to pain recurrence (p = 0.01). Radiographic control at 1 year was 62%. CONCLUSIONS: Pain response and control rates for osseous metastatic disease in RCC are comparable to other histologies when treated with conventional fractionation. These appear to be inferior to reported control rates from stereotactic treatments.

FDG-PET metabolic tumor parameters for the reirradiation of recurrent head and neck cancer.

OBJECTIVE: The utility of fluorodeoxyglucose positron emission tomography (FDG-PET) imaging to predict outcome has been well-established for patients undergoing definitive radiation in the initial management of head and neck cancer. However, the usefulness of this modality in the recurrent setting remains uncertain. We sought to evaluate the prognostic value of metabolic tumor parameters measured on FDG-PET in patients treated by reirradiation for recurrent head and neck cancer. METHODS: Thirty-four tumors occurring in 29 patients were reirradiated and were evaluable. The most common disease sites were the oropharynx (n = 9), oral cavity (N = 8), and nasopharynx (n = 6). Potential correlations of FDG-PET maximum standardized uptake value (SUV) and metabolic tumor volume (MTV) with survival endpoints were explored. Multivariate analysis was performed using Cox proportional hazard. RESULTS: The median MTV, SUV, and gross tumor volume, as delineated using the 50% SUVmax threshold, were 366 cc (range, 0-3,567 cc), 8.1 (range, 0-25), and 48.5 cc (range, 1-190 cc), respectively. On univariate analysis, both MTVs (as measured as a continuous variable and using the median value of 266 cc as cutoff) were predictive of decreased overall survival (P < 0.05 for both). A strong trend toward decreased progression-free survival (P = 0.05), in-field control (P = 0.06), and locoregional control (P = 0.07) was also observed with increasing MTV when analyzed as a continuous variable. Multi-variate analysis confirmed MTV as an independent predictor of mortality. CONCLUSION: The PET-derived parameter MTV may serve as a potentially valuable factor for risk stratification and for guiding treatment in future reirradiation trials. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2345-2350, 2018.

Quantitative clinical outcomes of therapy for head and neck lymphedema.

PURPOSE: Head and neck surgery and radiation cause tissue fibrosis that leads to functional limitations and lymphedema. The objective of this study was to determine whether lymphedema therapy after surgery and radiation for head and neck cancer decreases neck circumference, increases cervical range of motion, and improves pain scores. METHODS AND MATERIALS: A retrospective review of all patients with squamous cell carcinoma of the oral cavity, oropharynx, or larynx who were treated with high-dose radiation therapy at a single center between 2011 and 2012 was performed. Patients received definitive or postoperative radiation for squamous cell carcinoma of the oral cavity, oropharynx, or larynx. Patients were referred to a single, certified, lymphedema therapist with specialty training in head and neck cancer after completion of radiation treatment and healing of acute toxicity (typically 1-3 months). Patients underwent at least 3 months of manual lymphatic decongestion and skilled fibrotic techniques. Circumferential neck measurements and cervical range of motion were measured clinically at 1, 3, 6, 9, and 12 months after completion of radiation therapy. Pain scores were also recorded. RESULTS: Thirty-four consecutive patients were eligible and underwent a median of 6 months of lymphedema therapy (Range, 3-12 months). Clinically measured total neck circumference decreased in all patients with 1 month of treatment. Cervical rotation increased by 30.2% on the left and 27.9% on the right at 1 month and continued to improve up to 44.6% and 55.3%, respectively, at 12 months. Patients undergoing therapy had improved pain scores from 4.3 at baseline to 2.0 after 1 month. CONCLUSIONS: Lymphedema therapy is associated with objective improvements in range of motion, neck circumference, and pain scores in the majority of patients.

Patterns of Care for Elderly Patients With Locally Advanced Head and Neck Cancer.

PURPOSE: To compare patterns of care for elderly patients aged ≥70 years with locally advanced head and neck cancer versus those of younger patients treated for the same disease. METHODS AND MATERIALS: The medical records of 421 consecutive patients over the age of 50 years treated at a single institution between April 2011 and June 2016 for stage III/IV squamous cell carcinoma of the head and neck were reviewed. The primary treatment approach was compared using a t test statistic among 3 age cohorts: 50 to 59 years (118 patients); 60 to 69 years (152 patients); and 70 years and older (151 patients). Logistical regression was used to determine variables that influenced the likelihood of receiving surgery versus nonsurgical treatment, as well as radiation alone versus chemoradiation. RESULTS: There was no difference in sex, T stage, N stage, Karnofsky performance status, or the number of chronic comorbid conditions among the 3 age cohorts (P>.05 for all). A greater proportion of elderly patients aged ≥70 years were treated by radiation alone compared with those aged 50 to 59 and 60 to 69 years (44% vs 16% and 24%, P=.01). Increasing age was associated with a greater likelihood of receiving primary nonsurgical versus surgical treatment (odds ratio 1.023, 95% confidence interval 1.004-1.042) and radiation alone compared with chemoradiation (odds ratio 1.054; 95% confidence interval 1.034-1.075). Ten chemotherapy regimens were used concurrently with radiation for patients aged ≥70 years, including carboplatin/paclitaxel (19%), carboplatin/cetuximab (19%), cisplatin (17%), and cetuximab (17%). CONCLUSIONS: Despite similar performance status and comorbidity burden compared with their younger counterparts, patients aged ≥70 years were more commonly treated with less-aggressive strategies, including radiation alone. The variability of concurrent chemotherapy regimens used further suggests that the standard of care remains to be defined for this population.

CASTLE Thyroid Tumor: A Case Report and Literature Review.

Carcinoma showing thymus-like differentiation is a rare tumor of the thyroid gland, which is structurally similar to thymic tissue. Overall, it has a favorable prognosis. Radiotherapy has been shown to be an effective local treatment, but there have been reports of distant recurrence. It has been suggested that adding chemotherapy may decrease the risk of recurrence. Here, we present a case report of a patient with a large tumor and extrathyroidal extension. The patient was treated with surgery, radiotherapy, and cisplatin with acceptable toxicity. The patient is free of locally recurrent or distant disease at 3 years.