CIED malfunction in patients receiving radiation is a rare event that could be detected by remote monitoring.

INTRODUCTION: An increasing number of patients with cardiac devices require radiation therapy for treatment of a variety of cancers. This study aimed to identify the incidence and predictors of cardiac implantable electronic devices (CIED) malfunction in a real-world population that has received radiation therapy. METHODS: This retrospective cohort study included 109 adult patients who received radiation therapy at the University of Rochester Medical Center, Radiation Oncology Department, between 2000 and 2015. Sixty patients had pacemakers and 49 had automatic implantable cardioverter defibrillators. Subjects received either high energy (16 MV) and/or low energy (6 MV) photon beams with or without electron beams (6-16 MeV). We included interrogations done from first day of radiation and up to 3 months' postradiation therapy. Outcomes analyzed were device-related malfunctions and device-related clinical events. Fisher's exact, Wilcoxon, and Kruskall-Wallis tests were used for bivariate analysis. Logistic regression with robust adjustment was used for multivariate analysis. RESULTS: We identified six device-related malfunctions. All events were minor and included partial settings reset leading to loss of historical data, pacing thresholds changes, lead impedance changes, and LV output increase. Two patients had device-related clinical events, including dyspnea and diaphragmatic-stimulation. In bivariate analysis, CIED malfunction was associated with CIED duration in situ. In multivariate analysis, there was no significant statistical association between adverse events and beam energy type, CIED location, or dose of radiation delivered to the target. CONCLUSIONS: CIED malfunctions are uncommon in real-world patients and associated with minor clinical events. In our cohort, remote CIED monitoring would have identified all events.

ACR Appropriateness Criteria® Recurrent Hodgkin Lymphoma.

This topic addresses the management of recurrent Hodgkin lymphoma. While autologous stem cell transplantation may be appropriate for select cases of recurrent disease following comprehensive combined-modality therapy, other options exist for patients treated with lower-dose therapy for early-stage disease. Additionally, innovative targeted therapies provide newer salvage options to consider. The American College of Radiology Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation, or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. By combining the most recent medical literature and expert opinion, this revised guideline can aid clinicians in the complex decision-making associated with the management of recurrent Hodgkin lymphoma.

Second primary head and neck cancer after Hodgkin lymphoma: a population-based study of 44,879 survivors of Hodgkin lymphoma.

BACKGROUND: Survivors of Hodgkin lymphoma (HL) are at an increased risk of developing second malignancies. To the authors' knowledge, the risks of head and neck cancer (HNC) after HL and subsequent survival have not been thoroughly investigated. METHODS: From the US population-based Surveillance, Epidemiology, and End Results (SEER) database for 1973 through 2011, survivors of HL who developed HNC as a second cancer were analyzed. Patients with a first primary HNC were used as a comparison group. Observed-to-expected ratios and summary statistics were performed on patients with HL with squamous cell carcinoma (HL-SCC) and salivary gland cancer (HL-SGC). The impact of HL history on overall survival was assessed using a multivariate Cox proportional hazards model. RESULTS: The observed-to-expected ratio for SCC among patients with HL was 1.73 (95% confidence interval [95% CI], 1.36-2.16; P<.05), whereas it was 8.56 for SGC (95% CI, 5.82-12.15; P<.05). Using Cox proportional hazards modeling, a history of HL was found to be an adverse prognostic factor for overall survival for SCC (hazard ratio, 1.37; 95% CI, 1.08-1.73 [P = .009]) but not SGC (hazard ratio, 1.21; 95% CI, 0.82-1.79 [P = .34]). The inferior survival of the patients in the HL-SCC cohort appears to be attributable to more deaths from HL and other malignancies diagnosed after SCC. CONCLUSIONS: There is a significantly increased risk of salivary and nonsalivary HNC after HL, and worse survival for patients with HL-SCC versus those with a first primary SCC. Clinicians should be aware of the risks of HNC after HL. In the absence of evidence-based criteria, the authors recommend that survivors of HL undergo periodic head and neck examination.

Malignant peripheral nerve sheath tumors (MPNST): a SEER analysis of incidence across the age spectrum and therapeutic interventions in the pediatric population.

BACKGROUND: Malignant peripheral nerve sheath tumors (MPNST) are very rare in the general population and challenging to treat. A paucity of data exists regarding the incidence of MPNST across all age groups and treatment outcomes in the pediatric population. We aimed to characterize both using the Survival, Epidemiology, and End Results (SEER) database. PROCEDURE: The SEER-18 database with information on the United States population from 1973 to 2009 was queried for cases of MPNST. For incidence data, 1,182 cases were found among the general population. Of those, 165 cases were in individuals aged 0-19. After exclusions, 139 cases from the SEER-18 database met study criteria for outcomes analysis. For each patient, variables including gender, age, race, stage (localized, regional, or distant), surgical treatment, and radiotherapy were obtained. RESULTS: The overall incidence of MPNST was 1.46 per million person-years, with increased incidence among the elderly. In the pediatric population, the incidence was 0.56 per million person-years, and was higher among post-pubertal children aged 10-19. Median overall survival in the pediatric population was 30 months, with only localized disease and treatment with surgery being positive prognostic factors on multivariate analysis. CONCLUSIONS: MPNST is a rare disease and, among children, is most frequent seen in adolescents. Surgery is crucial as first-line treatment for MPNST, especially if the tumor is localized at diagnosis. In patients with non-localized MPNST, the disease remains extremely difficult to manage, and both surgery and radiotherapy are interventions that should be considered.

Therapy-Related Cardiac Risk in Childhood Cancer Survivors: An Analysis of the Childhood Cancer Survivor Study.

PURPOSE: The impacts of radiotherapy dose and exposed cardiac volume, select chemotherapeutic agents, and age at exposure on risk for late-onset cardiac disease in survivors of childhood cancer remain unresolved. PATIENTS AND METHODS: We determined the rates of severe to fatal cardiac disease in 24,214 5-year survivors in the Childhood Cancer Survivor Study diagnosed between 1970 and 1999 at a median age of 7.0 years (range, 0 to 20.9 years), with a median attained age of 27.5 years (range, 5.6 to 58.9 years). Using piecewise exponential models, we evaluated the association between cardiac disease rates and demographic and treatment characteristics. RESULTS: The cumulative incidence of cardiac disease 30 years from diagnosis was 4.8% (95% CI, 4.3 to 5.2). Low to moderate radiotherapy doses (5.0 to 19.9 Gy) to large cardiac volumes (≥ 50% of heart) were associated with an increased rate of cardiac disease (relative rate, 1.6; 95% CI, 1.1 to 2.3) compared with survivors without cardiac radiotherapy exposure. Similarly, high doses (≥ 20 Gy) to small cardiac volumes (0.1% to 29.9%) were associated with an elevated rate (relative rate, 2.4; 95% CI, 1.4 to 4.2). A dose-response relationship was observed between anthracycline chemotherapy and heart failure with younger children (age ≤ 13 years) at the greatest risk for heart failure after comparable dosing. CONCLUSION: These observations support advances in radiation field design and delivery technology to reduce cardiac dose/volume and should guide future treatment protocols. They also inform clinical practice guidelines for post-therapy surveillance and risk-reducing strategies.

The Benefit of Adjuvant Radiotherapy in High-grade Nonmetastatic Retroperitoneal Soft Tissue Sarcoma: A SEER Analysis.

OBJECTIVES: Controversy persists on the use of adjuvant radiotherapy (RT) in patients with retroperitoneal sarcoma (RPS). High-grade disease is known to be associated with decreased local control and overall survival (OS). Because RT has proven beneficial for local control and OS in patients with high-grade extremity soft tissue sarcoma, we evaluated the efficacy of adjuvant RT in high-grade RPS. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify patients with pathology-confirmed RPS from 1973 to 2010. Clinical characteristics and outcomes were analyzed. RESULTS: Of 480 total patients, 144 (30.0%) received postoperative radiation. Patients who received adjuvant RT had improved median OS (36 mo) compared with those who did not (27 mo, hazard ratio [HR]=0.79, P=0.023). On multivariate analysis the use of adjuvant RT (HR=0.80; 95% confidence interval [CI], 0.65-0.98; P=0.029), male sex (HR=1.32; 95% CI, 1.10-1.59; P=0.003), age above 65 years (HR=1.38; 95% CI, 1.15-1.67; P=0.001), and increasing the Surveillance, Epidemiology, and End Results historical stage (HR=1.46; 95% CI, 1.21-1.76; P<0.001) were all prognostic factors for OS. CONCLUSIONS: In a large retrospective analysis, postoperative RT improved OS in high-grade RPS patients. As such, adjuvant RT should be strongly considered in all patients with high-grade RPS. The optimal timing of RT relative to surgery requires further study.

A population-based study of prognosis and survival in patients with second primary thyroid cancer after Hodgkin lymphoma.

Hodgkin lymphoma (HL) survivors are at increased risk of thyroid cancer (TC). We sought to determine whether increased risks of high-risk pathology or mortality are seen with thyroid cancer after HL (HL-TC) compared with first primary thyroid cancer (TC-1). From the Surveillance, Epidemiology and End Results (SEER) registry, we compared patient and tumor characteristics as well as survival outcomes between HL-TC and TC-1 and fit a multivariable Cox model to assess for a possible association between HL history and overall survival after TC. Among 139,297 TC-1 and 174 HL-TC patients, history of HL was not associated with anaplastic or sarcoma TC. Multivariable analyzes showed that history of HL was not associated with a difference in risk of death after TC (hazard ratio: 0.96, 95% confidence interval: (0.81, 1.13), p = .61). Despite a significantly increased risk of TC among HL survivors, prior HL is not associated with more aggressive pathologic subtypes or worse prognosis.

Benefit from the inclusion of radiation therapy in the treatment of patients with stage III classical Hodgkin lymphoma: A propensity matched analysis of the Surveillance, Epidemiology, and End Results database.

BACKGROUND: While stage III and IV classical Hodgkin lymphoma (HL) patients are often combined and defined as "advanced stage," there are significant differences in disease distribution and burden between the two stages. This may obscure advantages of radiotherapy (RT) in a combined modality therapy strategy in stage III disease due to the relative lack of benefit in stage IV patients. METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) database, restricting our search to patients with stage III classical HL diagnosed from 2004 to 2012, to examine the difference in overall and cause-specific survival (OS and CSS) between patients who did or did not receive RT. RESULTS: Patients treated with RT had improved OS and CSS relative to those treated without RT (5-year OS 91.6% with RT compared to 71.4% without RT, HR=0.34, p<0.001) and CSS (5-year OS 95.4% with RT compared to 84.7% without RT, HR=0.32, p<0.001). A benefit in OS and/or CSS was seen in all patient subgroups except for older adults (>64years). CONCLUSION: These data support at least a cautionary approach to omitting RT from treatment strategies for patients with advanced stage HL.

Late Relapses After High-dose Chemotherapy and Autologous Stem Cell Transplantation in Patients With Diffuse Large B-cell Lymphoma in the Rituximab Era.

BACKGROUND: The standard of care for diffuse large B-cell lymphoma (DLBCL) relapsing after front-line therapy is high-dose chemotherapy and autologous stem cell transplantation (ASCT). Evidence has suggested that early relapses (ie, within 1 year) after this approach portends exceptionally poor outcomes. However, data examining relapses > 1 year after ASCT for patients with refractory or relapsed DLBCL are limited, in particular, in the rituximab era. We sought to examine the effect of early (≤ 1 year) and late (> 1 year) relapse after ASCT in a single-institution cohort of patients with relapsed and refractory DLBCL treated with chemoimmunotherapy. MATERIALS AND METHODS: A retrospective analysis was performed on the data from 85 consecutive patients who had undergone ASCT for biopsy-confirmed relapsed or refractory DLBCL from 2001 to 2010 at the University of Rochester Medical Center. All patients had received rituximab as a part of treatment. Of the 85 patients, 35 developed relapse after ASCT. These 35 patients were divided into 2 groups according to the timing of the relapse (≤ 1 year and > 1 year after ASCT). RESULTS: The median follow-up period was 6.4 years. For all patients, the overall survival (OS) from post-ASCT relapse was 5.2 years. For the 27 patients developing relapse at ≤ 1 year after ASCT, the median OS was 0.6 year and progression-free survival was 0.4 year. For the 8 patients developing relapse at > 1 year after ASCT, the median OS was 5.9 years and progression-free survival was 2.9 years. CONCLUSION: Patients with relapsed or refractory DLBCL experiencing relapse > 1 year after ASCT had good outcomes. Despite the relative rarity in incidence, a significant risk of relapse of DLBCL after ASCT remains, suggesting the need for continued monitoring because of the possibility of later progression.

Survival after subsequent non-Hodgkin's lymphoma and non-small cell lung cancer in patients with malignant thymoma.

BACKGROUND: Survivors of malignant thymoma (MT) are at an increased risk of developing subsequent neoplasms. We compare overall survival (OS) between MT survivors who developed non-Hodgkin's lymphoma (NHL) or non-small cell lung cancer (NSCLC), and patients with first primary NHL (NHL-1) or NSCLC (NSCLC-1), respectively. METHODS: Using the population-based Surveillance, Epidemiology, and End Results (SEER) database for 1973 through 2013, 273,313 patients who had NHL-1, 21 patients with MT-NHL, 566,819 patients with NSCLC-1, and 38 patients with MT-NSCLC were identified. Univariate and multivariate models were used to assess the impact of various factors on OS. RESULTS: The observed-to-expected ratio among MT patients was 2.63 [95% confidence interval (95% CI), 1.40-4.49; P<0.05] for NHL and 1.90 (95% CI, 1.33-3.63; P<0.05) for lung cancer. On univariate analysis, MT history did not worsen OS for NHL [hazard ratio (HR), 1.46; 95% CI, 0.87-2.47; P=0.16] or NSCLC (HR, 0.89; 95% CI, 0.61-1.29; P=0.53). On multivariate analysis, MT history was found to be an adverse prognostic indicator on OS for NHL (HR, 2.03; 95% CI, 1.20-3.42; P=0.008), but not NSCLC (HR, 0.87; 95% CI, 0.60-1.25; P=0.45). CONCLUSIONS: Patients who develop NHL after MT have inferior survival than those with first primary NHL. A history of MT does not have an adverse prognostic impact on subsequent NSCLC. Clinicians must be aware of the intrinsic risk for subsequent malignancies after MT and the potential adverse impact of MT history on NHL prognosis but not NSCLC.

Repeat courses of SRS in patients initially treated with SRS alone for brain-metastatic melanoma.

AIM: Stereotactic radiosurgery (SRS) is often used in the treatment of brain metastatic melanoma. Little data exist regarding outcomes of repeat course of SRS in this population. We aimed to identify treatment outcomes and toxicities in melanoma patients treated with repeat SRS after upfront SRS. PATIENTS & METHODS: We reviewed ten consecutive patients treated with repeat SRS following upfront SRS alone for brain metastatic melanoma. RESULTS: The median overall survival from initial treatment was 17.5 months. The median overall survival from repeat SRS was 6.7 months with a 6-month local control rate of 80%. The majority of patients progressed systemically before death. Four patients reported six adverse events, all grade 1. CONCLUSION: Prospective study regarding the safety and efficacy of repeat courses of SRS in patients with brain-metastatic melanoma, especially in combination with novel immunotherapies, is warranted.

Patterns and Timing of Failure for Diffuse Large B-Cell Lymphoma After Initial Therapy in a Cohort Who Underwent Autologous Bone Marrow Transplantation for Relapse.

PURPOSE: To evaluate the location and timing of initial recurrence in patients with diffuse large B-cell lymphoma (DLBCL) who subsequently underwent high-dose chemotherapy with autologous stem cell transplant (HDC/ASCT), to direct approaches for disease surveillance, elucidate the patterns of failure of contemporary treatment strategies, and guide adjuvant treatment decisions. METHODS AND MATERIALS: We analyzed consecutive patients with DLBCL who underwent HDC/ASCT between May 1992 and March 2014 at our institution. Of the 187 evaluable patients, 8 had incomplete data, and 79 underwent HDC/ASCT as a component of initial treatment for de novo or refractory DLBCL and were excluded from further analysis. RESULTS: The median age was 50.8 years; the median time to relapse was 1.3 years. Patients were segregated according to the initial stage at diagnosis, with early stage (ES) defined as stage I/II and advanced stage (AS) defined as stage III/IV. In total, 40.4% of the ES and 75.5% of the AS patients relapsed in sites of initial disease; 68.4% of those with ES disease and 75.0% of those with AS disease relapsed in sites of initial disease only. Extranodal relapses were common (44.7% in ES and 35.9% in AS) and occurred in a variety of organs, although gastrointestinal tract/liver (n=12) was most frequent. CONCLUSIONS: Most patients with DLBCL who relapse and subsequently undergo HDC/ASCT initially recur in the previously involved disease site(s). Time to recurrence is brief, suggesting that frequency of screening is most justifiably greatest in the early posttherapy years. © 2016 Elsevier Inc.

ACR Appropriateness Criteria® Hodgkin Lymphoma-Unfavorable Clinical Stage I and II.

These guidelines review the historical evolution of treatment for early-stage Hodgkin lymphoma (HL) with current standards that rely on prognostic factors to risk stratify and direct current treatment schemes that includes differentiation of favorable and unfavorable presentations. The major clinical trials for unfavorable early-stage HL are reviewed. Patients in this heterogenous subgroup of classic HL are best managed with sequential chemotherapy and radiotherapy. The role of imaging response assessment as a means to modify therapy is a strategy under investigation. Tailoring the radiation treatment volume and radiation dose prescription along with selective use of modern conformal techniques is expected to help reduce long-term toxicities. Many patients are well served receiving involved-site radiotherapy to 30 Gy after appropriate systemic therapy intensity; but, there are nuances for which some variations in the chemotherapy and radiotherapy specifics are appropriately individualized. Following a discussion of the current evidence-based treatment algorithms, several different example cases are reviewed to help physicians make appropriate treatment decisions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® Hodgkin Lymphoma-Favorable Prognosis Stage I and II.

This topic addresses the treatment of newly diagnosed patients with favorable prognosis stage I and II Hodgkin lymphoma. In most cases, combined modality therapy (chemotherapy followed by involved site radiation therapy) constitutes the current standard of care. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. By combining the most recent medical literature and expert opinion, this revised guideline can aid clinicians in the appropriate use of combined modality therapy for favorable prognosis stage I and II Hodgkin lymphoma. Increasing information about the late effects of treatment has led to attempts to decrease toxicity by using less chemotherapy (decreased duration and/or intensity or different agents) and less radiation therapy (reduced volume and/or dose) while maintaining excellent efficacy.

ACR Appropriateness Criteria® Diffuse Large B-Cell Lymphoma.

The management of diffuse large B-cell lymphoma depends on the initial diagnosis including molecular and immunophenotypic characteristics, Ann Arbor staging, and International Prognostic Index (IPI score). Treatment approaches with different chemotherapy regimens used is discussed in detail. The role of radiation as a consolidation is discussed including: (1) the prerituximab randomized trials that challenged the role of radiation, (2) recent prospective studies (UNFOLDER/RICOVER-60), and (3) retrospective studies; the last 2 showed a potential benefit of radiation both for early and advanced stage. The document also discusses the role of positron emission tomography/computed tomography for predicting outcome and potentially guiding therapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Radiation therapy in the management of patients with limited brain metastases.

Brain metastases are the most common form of intracranial tumor in adults and an increasingly important cause of morbidity and mortality. Rising incidence is attributed to advanced radiographic imaging and prolonged survival due to improvements in cancer therapy (including systemic therapies) that are not as effective in treating intracranial disease. Standard treatment options for brain metastases include resection, whole-brain radiation therapy (WBRT), stereotactic radiosurgery, or a combination of these modalities. Most patients with brain metastases receive some form of radiation therapy during the course of their illness, and for the majority of them, the prognosis is poor and WBRT remains the standard. However, within this very diverse patient population, subgroups exist in which prolonged survival is possible. In recent years, several randomized controlled trials have clearly demonstrated the efficacy of stereotactic radiosurgery in well-selected patients. This, along with an increased recognition of the late neurocognitive effects of WBRT, has led many to question the role of upfront WBRT in patients with limited intracranial metastases. In this review, we summarize the evolving role of radiotherapy in the management of brain metastases and then discuss the issues related to neurotoxicity from radiation and future areas of investigation.

The integration of cancer survivorship training in the curriculum of hematology/oncology fellows and radiation oncology residents.

BACKGROUND: Cancer specialists require an understanding of survivors' needs to insure optimal delivery of care. Training programs currently focus on treatment, while survivorship care focuses on time after treatment. Cancer survivorship training represents an education paradigm shift. METHODS: The Cancer Survivorship Workshop was held at the James P. Wilmot Cancer Center of the University of Rochester in academic year 2011-2012, with six sessions held. Objectives included the following: learning about survivorship from patient, primary care physician, and oncologist perspectives using a curriculum based on survivorship literature; designing treatment summaries (TSs) and survivorship care plans (SCPs) for five malignancies (lung, breast, prostate, colon, and lymphoma); and establishing collaboration between hematology/oncology (HO) and radiation oncology (RO) trainees by working together in teams. Course impact was assessed pre- and post-training using a 13-question survey. Questions were answered using a 10-point scale, with predefined rating for each question. RESULTS: Statistically significant differences in responses to several survey questions were observed comparing pre- and post-course experience. Improvement was noted in comfort discussing survivorship issues with patients (p = 0.001), reported knowledge of survivorship care for five types of cancer (p = 0.002), confidence in ability to explain a SCP (p = 0.001), and comfort discussing late effects of cancer treatment (p = 0.001). Five unique sets of TS and SCPs were completed. CONCLUSIONS: This study demonstrates the feasibility of implementing cancer survivorship education into the curriculum of HO and RO training. IMPLICATIONS FOR CANCER SURVIVORS: The project was designed with intension to optimize survivor care through enhanced provider training.

Pleural effusions in patients with Hodgkin lymphoma: clinical predictors and associations with outcome.

Pleural effusions are common in Hodgkin lymphoma (HL). However, little is known about their prognostic significance. One hundred and ten patients with HL who presented to the University of Rochester from 1 January 2003 to 12 December 2010 were reviewed. Pleural effusions were evaluated on review of diagnostic-quality computed tomography (CT) scans. Pleural effusions were present in 26/110 patients: 1/7 (14%) stage I, 11/61 (18%) stage II, 3/18 (17%) stage III and 11/24 (46%) stage IV, and 25/91 (27%) patients had mediastinal involvement, 16/38 (42%) patients had extranodal involvement (any) and 5/14 (35%) patients had E lesions (direct extension to extranodal tissue). Unilateral and bilateral pleural effusions were equally prevalent. Survival analysis demonstrated decreased overall survival for patients with pleural effusions of borderline significance for stage I-IV (p = 0.055) but failed to show significance for patients with stage I-III (p = 0.115). Increasing stage, any extranodal involvement and bulky mediastinal disease were each predictive of pleural effusions. The presence of pleural effusion at presentation may be predictive of inferior survival for patients with Hodgkin lymphoma.

ACR appropriateness criteria follow-up of Hodgkin lymphoma.

The main objectives of follow-up studies after completion of treatment for Hodgkin lymphoma are detection of recurrence for salvage therapy and monitoring for sequelae of treatment. The focus of the follow-up shifts, with time after treatment, from detection of recurrence to long-term sequelae. A majority of recurrence is detected by history and physical examination. The yield for routine imaging studies and blood tests is low. Although routine surveillance CT scan can detect recurrence not detected by history and physical examination, its benefit in ultimate survival and cost-effectiveness is not well defined. Although PET scan is a useful tool in assessing response to treatment, its routine use for follow-up is not recommended. Long-term sequelae of treatment include secondary malignancy, cardiovascular disease, pneumonitis, reproductive dysfunction, and hypothyroidism. Follow-up strategies for these sequelae need to be individualized, as their risks in general depend on the dose and volume of radiation to these organs, chemotherapy, age at treatment, and predisposing factors for each sequela. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is either lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Esophageal metastasis to the iris effectively palliated using stereotactic body radiation therapy and adjuvant intravitreal chemotherapy: case report and literature review.

We report a case of isolated iris metastasis from esophageal adenocarcinoma that was successfully managed with local application of stereotactic body radiation therapy (SBRT) and adjunctive intravitreal therapy. A 53-year-old man with locally advanced esophageal adenocarcinoma achieved a complete clinical and radiographic response after surgery and chemotherapy. Four months later, he developed headache and decreased vision and was diagnosed with metastasis to the iris by slit-lamp examination. The decrease in vision was secondary to cystoid macular edema. The metastatic tumor and the patient's symptoms resolved after treatment with SBRT and intravitreal injections of bevacizumab and triamcinolone. We conclude that SBRT combined with intravitreal chemotherapy is an effective and well-tolerated palliative treatment for metastasis of esophageal adenocarcinoma to the iris.