Predictive factors on outcomes in metaplastic breast cancer.

PURPOSE: Metaplastic breast cancer (MBC) is a rare, aggressive variant of breast cancer, with limited data available regarding treatment and outcomes. This study aims to review patients with MBC treated at our tertiary care institution with an emphasis on the role of treatment modality and histologic classification. METHODS: With IRB-approval, we queried our pathology database for patients with MBC diagnosis. All cases were re-evaluated by dedicated breast pathologists and confirmed as MBC breast cancer. Patient demographics, clinical/pathologic histology, and treatment were analyzed with respect to outcomes including local-regional recurrence (LRR), distant metastasis (DM), and overall survival (OS). Univariate and multivariate Cox proportional hazards models were performed to evaluate the impact on outcomes. Kaplan-Meier methods estimated survival. RESULTS: We evaluated 113 patients with MBC diagnosed between 2002 and 2013. Median age was 61 years and median pathologic tumor size 2.5 cm; 76 (67%) were ER/PR/Her2 negative, 83 (74%) grade 3. Median follow-up was 38 months. 47 (42%) underwent breast conservation therapy (BCT), 66 (58%) had mastectomy, 61 (54%) underwent adjuvant radiation (RT), and 85 (75%) had chemotherapy. At 2 and 5 years, the LRR/DM/OS rates were 12%/15%/90% and 21%/35%/69%, respectively. On Cox regression analysis, only adjuvant RT correlated with reduced LRR [RR 3.1 (1.13-9.88), p = 0.027], while chemotherapy, type of surgery, and T-N stage did not. Only T-stage (p = 0.008) correlated with DM, however chemotherapy, RT, surgery type, and N-stage were not. Univariate analysis demonstrated histologic subtype did not significantly correlate with local (p = 0.54) or distant (p = 0.83) disease control. CONCLUSIONS: This study represents among the largest institutional experiences in the outcomes of MBC. At this time, there does not appear to be a clear histologic subset of MBC which has significantly different clinical outcomes from the other subtypes. Although limited in its sample size, this study shows RT remains important in local-regional control.

Rapid and complete radiological resolution of an intradural cervical cord lung cancer metastasis treated with spinal stereotactic radiosurgery: case report.

Stereotactic radiosurgery (SRS) has emerged as a treatment option for patients with spinal metastatic disease. Although SRS has been shown to be successful in a multitude of extradural metastatic tumors causing cord compression, very few cases of intradural treatment have been reported. The authors present a rare case of an intradural extramedullary metastatic small cell lung cancer lesion to the cervical spine resulting in cord compression in an area that had also been extensively pretreated with conventional external-beam radiation therapy. The patient underwent successful SRS to this metastatic site, with rapid and complete resolution of his lesion.

Trends in Radiation Oncology Residency Applicant Interview Experiences and Post-Interview Communication.

PURPOSE: To report trends in applicant interview experiences and post-interview communication (PIC) between the 2016 and 2018 radiation oncology interview cycles. METHODS AND MATERIALS: An anonymous survey was sent to all 203 residency applicants to a single institution during the 2018 Match, and the results were compared to a similar 2016 survey. RESULTS: Response rates in 2018 and 2016 were 53% and 56%, respectively. Applicants from 2018 were asked less frequently than 2016 applicants about where else they were interviewing (71% vs 84%, P = .024) and how highly they planned to rank a program (11% vs 23%, P = .018). A higher proportion of 2018 programs explicitly discouraged PIC (median, 53% vs 33%, P < .0001), and more 2018 respondents chose not to send any thank-you notes/emails (42% vs 17%, P < .0001). When comparing 2018 results to 2016, no significant differences were observed in the proportion of applicants who notified their top program that they would rank that program highly (54% vs 60%, P = .354). No difference was observed in the rate of reported distress associated with a sense of obligation to send PIC (49% vs 46%, P = .664), and similar rates of respondents said they would feel relieved if PIC was discouraged (94% vs 89%, P = .223). Most respondents again reported that they would prefer a policy to actively discourage applicants from notifying their top programs of their high rank (60% vs 66%, P = .974). CONCLUSIONS: Compared to 2016, respondents in 2018 reported that fewer programs are engaging in potential Match violations, and more are actively discouraging PIC, possibly as a result of increased awareness from recent publications. A similar number of applicants continued to engage in "gamesmanship," but more are choosing not to send thank-you notes/emails. Most respondents continue to prefer a policy discouraging PIC.

The Residency Match: Interview Experiences, Postinterview Communication, and Associated Distress.

BACKGROUND: Interview experiences and postinterview communication during the residency match process can cause distress for applicants, and deserve further study. OBJECTIVE: We both quantified and qualified the nature of various interview behaviors during the 2015-2016 National Resident Matching Program (NRMP) Match and collected applicant perspectives on postinterview communication and preferences for policy change. METHODS: An anonymous, 31-question survey was sent to residency candidates applying to 8 residency programs at a single academic institution regarding their experiences at all programs where they interviewed. RESULTS: Of 6693 candidates surveyed, 2079 (31%) responded. Regarding interview experiences, applicants reported being asked at least once about other interviews, marital status, and children at the following rates: 72%, 38%, and 17%, respectively, and such questions arose at a reported mean of 25%, 14%, and 5% of programs, respectively. Female applicants were more frequently asked about children than male applicants (22% versus 14%, P < .0001). Overall, 91% of respondents engaged in postinterview communication. A total of 70% of respondents informed their top program that they had ranked it highly; 70% of this subset reported associated distress, and 78% reported doing this to improve match success. A total of 71% would feel relief if postinterview communication was actively discouraged, and 51% would prefer applicants to be prohibited from notifying programs of their rank. CONCLUSIONS: Applicants to several residency programs reported being asked questions that violate the NRMP Code of Conduct. The majority of applicants would prefer postinterview communication to be more regulated and less prevalent.

Neoadjuvant chemoradiation for non-metastatic pancreatic cancer increases margin-negative and node-negative rates at resection.

OBJECTIVE: To compare neoadjuvant to adjuvant chemoradiation in non-metastatic pancreatic cancer patients. METHODS: Single-institution data were obtained for patients with non-metastatic pancreatic cancer treated with concurrent chemoradiation from 2011 to 2014. Univariate analyses were performed to evaluate clinical and pathological outcomes. RESULTS: Fifty-two well-matched patients were enrolled (21 underwent neoadjuvant chemoradiation, 11 with adjuvant chemoradiation and 20 in the definitive group). Median tumor size was 2.6 cm pretreatment and 2.5 cm after neoadjuvant chemoradiation but 3.2 cm on pathology, with a treatment effect in 95.2% of specimens. Clinical node positivity at diagnosis for neoadjuvant and adjuvant chemoradiation groups was similar (28.6% vs 27.3%, P = 0.12). Of the 36 neoadjuvant patients, 21 (58.3%) underwent complete resection. In the neoadjuvant vs adjuvant chemoradiation groups, positive margins were decreased (4.8% vs 63.6%, P < 0.001), as was pathological nodal positivity (23.8% vs 90.9%, P < 0.001). After a median follow-up of 13.3 months, locoregional control for neoadjuvant and adjuvant chemoradiation was 7.7 and 7.2 months, respectively (P = 0.12) and the definitive group was 1.2 months (P = 0.014 compared with the surgical cohort). One-year overall survival was better with neoadjuvant than with adjuvant chemoradiation but this was not significant (94% vs 82%, P = 0.20); 1-year survival for the definitive group was 59% (P = 0.03 compared with the surgical cohort). CONCLUSIONS: Neoadjuvant chemoradiation remains a promising approach for non-metastatic pancreatic cancer for improving resectability and pathological and clinical findings. Computed tomography may not fully demonstrate the effectiveness of neoadjuvant treatment.

Program director and chief resident perspectives on the educational environment of US radiation oncology programs.

PURPOSE: Our goals were toexamine the educational approachesused at radiation oncology residency programs nationwide andto evaluate program director(PD) and chief resident (CR) perceptions of their educational environment. METHODS AND MATERIALS: We distributed a survey regarding curricular structure via email toall identified US radiation oncology residency PDs and CRs. Pearson χ2 test was used toevaluate whether differences existed between answers provided by the 2 study populations. RESULTS: The survey was disseminated to 200 individuals in 85 US residency programs: 49/85PDs(58%)and 74/115 (64%)CRs responded. More than one-half of PDs and CRs report that attending physicians discussed management, reviewed contours, and conducted mock oral board examinations with the residents. At nearly 50% of programs, the majority of teaching conferences use a lecture-based approach, whereas only 20% reported predominant utilization of the Socratic method. However, both PDs (63%) and CRs (49%) reported that Socratic teaching is more effective than didactic lectures (16% and 20%, respectively), with the remainder responding that they are equally effective. Teaching sessions were reported to be resident-led ≥75% of the time by 50% of CRs versus 18% of PDs (P = .002). Significantly more CRs than PDs felt that faculty-led teaching conferences were more effective than resident-led conferences (62% vs 26%, respectively; P < .001). There was a difference in perception regarding the protection of educational time, with 85% of PDs versus 59% of CRs reporting this time as being "never" or "infrequently" compromised by clinical duties (P = .005). CONCLUSIONS: There is considerable variability between PDs and CRs in the perceived structure and effectiveness of resident education in US radiation oncology residency programs. These data suggest opportunity for improvement in radiation oncology residency training, such as encouraging more faculty-led, Socratic-based teaching conferences. Increased communication between PDs and CRs can better align perceptions with educational goals.

Predictors of distant metastasis in human papillomavirus-associated oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-positive oropharyngeal cancer is associated with favorable outcomes, prompting investigations into treatment deintensification. The purpose of this study was for us to present the predictors of distant metastases in patients with HPV-positive oropharyngeal cancer treated with cisplatin-based chemoradiotherapy (CRT) or cetuximab-based bioradiotherapy (bio-RT). METHODS: In patients with stage III to IVb HPV-positive oropharyngeal cancer, the Kaplan-Meier analysis was used to calculate distant metastases rates. Univariate analysis (UVA) and multivariate analysis (MVA) were used to identify factors associated with distant metastases. RESULTS: Increased distant metastases rates were noted in active smokers versus never/former smokers (22% vs 5%), T4 vs T1 to T3 (15% vs 6%), and cetuximab-based bio-RT versus CRT (23% vs 5%). All remained significant on MVA. CONCLUSION: T4 tumors and active smokers have substantial rates of distant metastases, and trials investigating intensified systemic therapies may be considered. Higher rates of distant metastases observed with concurrent cetuximab are hypothesis generating, but further data are needed. © 2017 Wiley Periodicals, Inc. Head Neck 39: 940-946, 2017.

The impact of decompression with instrumentation on local failure following spine stereotactic radiosurgery.

OBJECTIVE Spine stereotactic radiosurgery (SRS) is a safe and effective treatment for spinal metastases. However, it is unknown whether this highly conformal radiation technique is suitable at instrumented sites given the potential for microscopic disease seeding. The authors hypothesized that spinal decompression with instrumentation is not associated with increased local failure (LF) following SRS. METHODS A 2:1 propensity-matched retrospective cohort study of patients undergoing SRS for spinal metastasis was conducted. Patients with less than 1 month of radiographic follow-up were excluded. Each SRS treatment with spinal decompression and instrumentation was propensity matched to 2 controls without decompression or instrumentation on the basis of demographic, disease-related, dosimetric, and treatment-site characteristics. Standardized differences were used to assess for balance between matched cohorts. The primary outcome was the 12-month cumulative incidence of LF, with death as a competing risk. Lesions demonstrating any in-field progression were considered LFs. Secondary outcomes of interest were post-SRS pain flare, vertebral compression fracture, instrumentation failure, and any Grade ≥ 3 toxicity. Cumulative incidences analysis was used to estimate LF in each cohort, which were compared via Gray's test. Multivariate competing-risks regression was then used to adjust for prespecified covariates. RESULTS Of 650 candidates for the control group, 166 were propensity matched to 83 patients with instrumentation. Baseline characteristics were well balanced. The median prescription dose was 16 Gy in each cohort. The 12-month cumulative incidence of LF was not statistically significantly different between cohorts (22.8% [instrumentation] vs 15.8% [control], p = 0.25). After adjusting for the prespecified covariates in a multivariate competing-risks model, decompression with instrumentation did not contribute to a greater risk of LF (HR 1.21, 95% CI 0.74-1.98, p = 0.45). The incidences of post-SRS pain flare (11% vs 14%, p = 0.55), vertebral compression fracture (12% vs 22%, p = 0.04), and Grade ≥ 3 toxicity (1% vs 1%, p = 1.00) were not increased at instrumented sites. No instrumentation failures were observed. CONCLUSIONS In this propensity-matched analysis, LF and toxicity were similar among cohorts, suggesting that decompression with instrumentation does not significantly impact the efficacy or safety of spine SRS. Accordingly, spinal instrumentation may not be a contraindication to SRS. Future studies comparing SRS to conventional radiotherapy at instrumented sites in matched populations are warranted.

Stereotactic Body Radiotherapy for T3N0 Lung Cancer With Chest Wall Invasion.

INTRODUCTION: The role of stereotactic body radiotherapy (SBRT) for tumors involving the chest wall (CW) remains ill-defined. The Radiation Therapy Oncology Group 0236 trial allowed inclusion of T3N0 non-small-cell lung cancer (NSCLC) < 5 cm, although ultimately none were enrolled. No published data set investigating this population is available. MATERIALS AND METHODS: We queried an institutional review board-approved prospective SBRT registry to identify patients with tumors involving the CW, defined as radiographic evidence of frank soft tissue invasion or bony destruction. All patients underwent SBRT to a median dose of 50 Gy in 5 fractions and were followed up for tumor control, pain response, and toxicity. RESULTS: Of 820 NSCLC patients reviewed, 13 with CW involvement were identified. Of these 13 patients, 10 had primary T3N0 NSCLC and 3 had recurrent NSCLC. Their median age was 78 years, the Karnofsky performance status was 80, the Charlson score was 3, and the tumor diameter was 4.0 cm. The 1-year local, locoregional, and distant control rates were 89%, 62%, 80%, respectively. Of 9 patients with pretreatment tumor-related CW pain, 7 (78%) reported improvement after treatment. Regarding toxicity, 2 of 13 (15%) experienced new or worsening CW pain (both grade ≤ 2); 3 cases (23%) of grade 1-2 radiation pneumonitis developed. No patient exhibited late skin changes or fibrosis. CONCLUSION: SBRT for NSCLC involving the CW was well tolerated, with promising early rates of tumor control and no grade ≥ 3 toxicity. Tumor-related CW pain was relieved in most patients, and the treatment-related toxicity rates appeared acceptable. Further investigation in this subset of patients with NSCLC is warranted.

Applicant Interview Experiences and Postinterview Communication of the 2016 Radiation Oncology Match Cycle.

PURPOSE: To characterize applicant interview experiences at radiation oncology residency programs during the 2016 match cycle and to assess applicant opinions regarding postinterview communication (PIC) after recent attention to gamesmanship noted in prior match cycles. METHODS AND MATERIALS: An anonymous, institutional review board-approved, 29-question survey was deployed following the rank order list deadline to all 2016 radiation oncology residency applicants applying to a single institution. RESULTS: Complete surveys were returned by 118 of 210 applicants, for a 56% response rate. Regarding possible match violation questions, 84% of respondents were asked at least once about where else they were interviewing (occurred at a median of 20% of program interviews); 51% were asked about marital status (6% of interviews); and 22% were asked about plans to have children (1% of interviews). Eighty-three percent of applicants wrote thank-you notes, with 55% reporting fear of being viewed unfavorably if such notes were not communicated. Sixty percent of applicants informed a program that they had ranked a program highly; 53% felt this PIC strategy would improve their standing on the rank order list, yet 46% reported feeling distressed by this obligation. A majority of applicants stated that they would feel relieved if programs explicitly discouraged PIC (89%) and that it would be preferable if programs prohibited applicants from notifying the program of their rank position (66%). CONCLUSIONS: Potential match violations occur at a high rate but are experienced at a minority of interviews. Postinterview communication occurs frequently, with applicants reporting resultant distress. Respondents stated that active discouragement of both thank-you notes/e-mails and applicants' notification to programs of their ranking would be preferred.

Report of whole-brain radiation therapy in a patient with an implanted deep brain stimulator: important neurosurgical considerations and radiotherapy practice principles.

Patients with implanted neuromodulation devices present potential challenges for radiation therapy treatment planning and delivery. Although guidelines exist regarding the irradiation of cardiac pacemakers and defibrillators, fewer data and less clinical experience exist regarding the effects of radiation therapy on less frequently used devices, such as deep brain stimulators. A 79-year-old woman with a history of coarse tremors effectively managed with deep brain stimulation presented with multiple intracranial metastases from a newly diagnosed lung cancer and was referred for whole-brain radiation therapy. She was treated with a German helmet technique to a total dose of 30 Gy in 10 fractions using 6 MV photons via opposed lateral fields with the neurostimulator turned off prior to delivery of each fraction. The patient tolerated the treatment well with no acute complications and no apparent change in the functionality of her neurostimulator device or effect on her underlying neuromuscular disorder. This represents the first reported case of the safe delivery of whole-brain radiation therapy in a patient with an implanted neurostimulator device. In cases such as this, neurosurgeons and radiation oncologists should have discussions with patients about the risks of brain injury, device malfunction or failure of the device, and plans for rigorous testing of the device before and after radiation therapy.