Trends in radiation dose for low grade gliomas across the United States.

PURPOSE: Adjuvant radiation is often used in patients with low grade gliomas with high-risk characteristics with a recommended dose of 45-54 Gy. We used the National Cancer Database (NCDB) to see which doses were being used, and if any difference was seen in outcome. METHODS: We queried the NCDB for patients with WHO Grade 2 primary brain tumors treated with surgery and adjuvant radiotherapy. We divided the cohort into dose groups: 45-50 Gy, 50.4-54 Gy, and > 54 Gy. Multivariable logistic regression was used to identify predictors of low and high dose radiation. Propensity matching was used to account for indication bias. RESULTS: We identified 1437 patients meeting inclusion criteria. Median age was 45 years and 62% of patients were > 40 years old. Nearly half of patients (48%) had astrocytoma subtype and 70% had subtotal resection. The majority of patients (69%) were treated to doses between 50.4 and 54 Gy. Predictors of high dose radiation (> 54 Gy) were increased income, astrocytoma subtype, chemotherapy receipt, and treatment in later year (2014). The main predictors of survival were age > 40, astrocytoma subtype, and insurance type. Patients treated to a dose of > 54 Gy had a median survival of 73.5 months and was not reached in those treated to a lower dose (p = 0.0041). CONCLUSIONS: This analysis shows that 50.4-54 Gy is the most widely used radiation regimen for the adjuvant treatment of low-grade gliomas. There appeared to be no benefit to higher doses, although unreported factors may impact interpretation of the results.

The prognostic value of KRAS mutation in locally advanced rectal cancer.

BACKGROUND: The prognostic value of the KRAS proto-oncogene mutation in colorectal cancer has been debated. Herein, we analyzed the National Cancer Database (NCDB) to assess the role of KRAS mutation as a prognostic marker in patients with locally advanced rectal cancer (LARC). METHODS: We identified LARC patients treated with neoadjuvant chemoradiation from 2004-2015 excluding those with stage I/IV disease and unknown KRAS status. Multivariable logistic regression identified variables associated with KRAS positivity. Propensity adjusted univariable and multivariable analyses identified predictors of survival. RESULTS: Of the 784 eligible patients, 506 were KRAS-negative (KRAS -) and 278 were KRAS-positive (KRAS +). Median survival was 63.6 months and 76.3 months for KRAS + and KRAS - patients respectively, with propensity adjusted 3 and 5-year survival of 79.9% vs. 83.6% and 56.7% vs. 61.9% respectively (HR 1.56, p 1.074-2.272). Male sex, no insurance, and KRAS + disease were associated with poorer survival on unadjusted and propensity adjusted multivariable analyses. CONCLUSIONS: Our analysis of KRAS + LARC suggest that KRAS + disease is associated with poorer overall survival. Given the inherent limitations of retrospective data, prospective validation is warranted.

Time from stereotactic radiosurgery to immunotherapy in patients with melanoma brain metastases and impact on outcome.

BACKGROUND: The role of immunotherapy for metastatic melanoma has expanded over the past decade triggering questions regarding the combination and timing of immunotherapy and radiation for brain metastases. We used the National Cancer Database (NCDB) to see if the time from radiation to immunotherapy in patients with melanoma brain metastases had an impact on survival. METHODS: We queried the NCDB from 2010 to 2015 for patients with melanoma brain metastases treated with immunotherapy and stereotactic radiosurgery (SRS). Receiver operator characteristic (ROC) curve analysis was done to determine a timepoint associated with outcome. Cox regression was used to identify predictors of survival. Propensity matching was done to account for indication bias. RESULTS: We identified 247 patients meeting the above criteria. The median patient age was 62 years (27-90) and the vast majority were Caucasian (99%). The median SRS dose was 22 Gy (18-24 Gy).The median time to SRS was 39 days (0-344) and the median time to immunotherapy was 56 days (6-454). The ROC analysis revealed 8 days from SRS to immunotherapy as associated with outcome. Fifty-six patients had immunotherapy prior to SRS, 30 patients had immunotherapy within 0-7 days of SRS, and the remaining 161 had immunotherapy greater than 7 days from SRS. Three year survival rates were 21%, 55%, and 35% for those timeframes, respectively (p = 0.0153). Propensity matching of the 0-7 day and > 7 day groups yielded 28 pairs and Kaplan Meier analysis showed 3 year overall survival of 55% and 35%, in favor of immunotherapy within 7 days of SRS (p = 0.0357). Multivariable Cox regression identified lack of extracranial disease, more recent year of treatment, and time from SRS to immunotherapy of 0-7 days as predictors of improved survival. CONCLUSIONS: Immunotherapy within 7 days of SRS shows a possible association with improve outcomes in patients with brain metastases from melanoma.

Utilization of Adjuvant Radiotherapy for Resected Colon Cancer and Its Effect on Outcome.

BACKGROUND: Adjuvant radiation is generally not recommended for colon cancer but may be considered in certain clinical scenarios [advanced local disease (pT4) and/or positive margins]. Guidelines in this area are lacking; thus we analyzed the National Cancer Database (NCDB) for patterns of care in this regard and any predictors for outcome. METHODS: We queried the NCDB from 2004 to 2016 for patients with resected adenocarcinoma of the colon having pT4 and/or had positive margins on final pathology and who received adjuvant multiagent chemotherapy. Multivariable logistic regression was used to identify predictors of adjuvant radiation. A propensity score was used to perform matched Kaplan-Meier analysis. Propensity-adjusted Cox regression was used to identify predictors of overall survival. RESULTS: We identified 23,325 patients meeting criteria, of whom 1711 (7%) received adjuvant radiation. Median follow-up was 36 months. The majority of patients were pT4 alone (65%). Predictors of adjuvant radiation were lower comorbidity score, younger age, more remote year of treatment, and both pT4 and positive margins. Kaplan-Meier analysis revealed improved overall survival (OS) in patients with both pT4 and positive margins treated with radiation (median OS: 66 versus 47 months, p = 0.02). Receipt of adjuvant radiation was associated with improved OS [hazard ratio (HR): 0.86 (0.80-0.93) p = 0.0002] on Cox regression analysis. Increased age, higher comorbidity score, lower income, government insurance, and combined pT4/positive margins were indicative of worse survival. CONCLUSIONS: Expectedly, adjuvant radiation use was relatively low but was associated with improved OS in patients with both pT4 and positive margins.

Melanoma brain metastases: is it time to eliminate radiotherapy?

PURPOSE: Immunotherapy has demonstrated efficacy in treatment of intracranial metastasis from melanoma, calling into question the role of intracranial radiotherapy (RT). Herein, we assessed the utilization patterns of intracranial RT in patients with melanoma brain metastasis and compared outcomes in patients treated with immunotherapy alone versus immunotherapy in addition to intracranial RT. METHODS: We queried the National Cancer Database (NCDB) for patients with melanoma brain metastases treated with immunotherapy and intracranial RT or immunotherapy alone. Multivariable logistic regression identified variables associated with increased likelihood of receiving immunotherapy alone. Multivariable Cox regression was used to identify co-variates predictive of overall survival (OS). Propensity matching was used to account for indication bias. RESULTS: We identified 528 and 142 patients that were treated with combination therapy and immunotherapy alone, respectively. Patients with lower comorbidity score were more likely to receive immunotherapy alone. Extracranial disease and treatment at a non-academic center were associated with worse OS. Median OS for all patients was 11.0 months. Treatment with stereotactic radiosurgery (SRS) in addition to immunotherapy was superior to immunotherapy alone, median OS of 19.0 versus 11.5 months (p = 0.006). Whole brain radiation therapy (WBRT) in combination with immunotherapy performed worse than immunotherapy alone, median OS of 7.7 versus 11.5 months (p = 0.0255). CONCLUSIONS: For melanoma patients requiring WBRT, immunotherapy alone may be reasonable in asymptomatic patients. For those eligible for SRS, combination therapy may provide better outcomes. Results of ongoing prospective studies will help provide guidance regarding the use of radioimmunotherapy in this population.

Liver transplant mortality and morbidity following preoperative radiotherapy for hepatocellular carcinoma.

BACKGROUND: Radiotherapy (RT) can be used for tumor downstaging and as a bridge to transplantation in hepatocellular carcinoma (HCC), but its effect on surgical complications is unknown. Therefore, we investigated post-transplant mortality and acute readmission rates in HCC with and without preoperative RT using the National Cancer Database (NCDB). METHODS: After exclusion, 11,091 transplant patients were analyzed, 165 of whom received RT prior to transplant. Multivariable binomial logistic regression analysis identified characteristics associated with use of RT, and factors associated with increased 30/90-day mortality and 30-day readmission, following propensity matching. RESULTS: Although RT (median 40 Gy in 5 fractions) was more often delivered to larger tumors and advanced stages, it resulted in 59% downstaging rate, 39% pathologic complete response rate, and a median of 4 additional months to transplantation. Crude 30/90-day mortality rates were both 1.2% with preoperative RT, compared to 2.7% and 4.4% without. The 30-day readmission rate was 5.5% with RT and 10.7% without it. Propensity matched analysis demonstrated no statistical differences in 30/90-day mortality and a lower 30-day readmission rate with preoperative RT. Age >58, stage III disease, lack of transarterial chemoembolization, and shorter time to transplant independently predicted higher 90-day mortality. CONCLUSION: Preoperative RT for HCC did not increase postoperative mortality or length of stay following liver transplant.

Patterns of care and outcomes in small cell carcinoma of the prostate: A national cancer database analysis.

BACKGROUND: Small cell carcinoma (SCC) of the prostate is a rare, aggressive disease. Evidence is limited; however, the current standard of care is chemotherapy. The benefit of local treatment modalities is unknown. METHODS: We queried the National Cancer Database identifying all SCC/neuroendocrine cases of the prostate, excluding those with unknown nodal or metastatic status, unknown treatment, or those not receiving chemotherapy. Overall survival (OS) was calculated using Kaplan-Meier curves. Multivariable Cox proportional hazards model was used to identify factors associated with survival. A further subgroup analysis was performed on the utility of local therapy on survival in the nonmetastatic setting. RESULTS: Our final cohort included 657 patients with a median age of 68. Most patients had positive lymph nodes (60.1%) and metastatic disease (70.0%). Median survival was 12 months (95% confidence interval [95% CI], 11.1-13.3 months) with a median follow-up of 11.8 months. Metastatic disease, age greater than or equal to 70, omission of androgen deprivation therapy (ADT), and lower income (P < .05 for all) were all associated with reduced OS. Patients with prostate-specific antigen (PSA) greater than or equal to 33 ng/mL and those receiving ADT had better survival (P < .05). Those with nonmetastatic disease were more likely to undergo prostatectomy and/or prostatic/pelvic radiation (P < .0001). Prostatic/pelvic radiation in the nonmetastatic setting was associated with longer survival (P = .02). Though well powered, our study is limited by the selection bias inherent to all observational studies, despite the statistical methods utilized to reduce this effect. CONCLUSIONS: Although chemotherapy is the mainstay of treatment, radiation to the prostate/pelvis may be beneficial in the nonmetastatic setting. In addition to chemotherapy, ADT may benefit patients with an elevated PSA.

HIV testing in the dental setting: perspectives and practices of experienced dental professionals.

The dental setting is a largely untapped venue to identify patients with undiagnosed HIV infection. Yet, uptake of rapid HIV testing within the dental community remains low. This study sought to better understand the experiences of dental professionals who have administered the test and how these experiences might inform efforts to promote greater uptake of rapid HIV testing in dental settings. Qualitative interviews were conducted with United States dentists (N = 37) and hygienists (N = 5) who offered rapid HIV testing in their practices. The data revealed both the impeding and facilitating factors they experienced in implementing testing in their setting, as well as the reactions of their staff, colleagues, and patients. Overall, participants viewed rapid HIV testing favorably, regarding it as a valuable public health service that is simple to administer, generally well accepted by patients and staff, and easily integrated into clinical practice. Many had experience with a reactive test result. Participants described facilitating factors, such as supportive follow-up resources. However, they also cited persistent barriers that limit acceptance by their dental colleagues, including insufficient reimbursement and perceived incompatibility with scope of practice. The widespread adoption of routine HIV testing amongst dental professionals will likely require an expanded notion of the proper scope of their professional role in overall patient health, along with greater support from national dental organizations, dental education, and dental insurance companies, especially in the form of sufficient reimbursement.

Insurer views on reimbursement of preventive services in the dental setting: results from a qualitative study.

OBJECTIVES: We explored insurers' perceptions regarding barriers to reimbursement for oral rapid HIV testing and other preventive screenings during dental care. METHODS: We conducted semistructured interviews between April and October 2010 with a targeted sample of 13 dental insurance company executives and consultants, whose firms' cumulative market share exceeded 50% of US employer-based dental insurance markets. Participants represented viewpoints from a significant share of the dental insurance industry. RESULTS: Some preventive screenings, such as for oral cancer, received widespread insurer support and reimbursement. Others, such as population-based HIV screening, appeared to face many barriers to insurance reimbursement. The principal barriers were minimal employer demand, limited evidence of effectiveness and return on investment specific to dental settings, implementation and organizational constraints, lack of provider training, and perceived lack of patient acceptance. CONCLUSIONS: The dental setting is a promising venue for preventive screenings, and addressing barriers to insurance reimbursement for such services is a key challenge for public health policy.

Dentists' willingness to provide expanded HIV screening in oral health care settings: results from a nationally representative survey.

OBJECTIVES: Using a nationally representative survey, we determined dentists' willingness to provide oral rapid HIV screening in the oral health care setting. METHODS: From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists' willingness to conduct this screening and perceived compatibility with their professional role. RESULTS: Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention's recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents' agreement with patients' acceptance of HIV testing and colleagues' improved perception of them were also positively associated with willingness. CONCLUSIONS: Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists' willingness to offer screening, there are many barriers, including dentists' perceptions of patients' acceptance, that must be addressed before such screening is likely to be widely implemented.

Differences in Patterns of Care and Referral Between Proton and Photon Therapy.

Purpose: To report demographic and clinical characteristics of patients who were more likely to receive proton beam therapy (PBT) than photon therapy from facilities with access to proton centers. Materials and Methods: We utilized the national cancer database to identify the facilities with access to PBT between 2004 and 2015 and compared the relative usage of photons and PBT for demographic and clinical scenarios in breast, prostate, and nonsmall cell cancer. Results: In total, 231 facilities with access to proton centers accounted for 168 323 breast, 39 975 lung, and 77 297 prostate cancer patients treated definitively. Proton beam therapy was used in 0.5%, 1.5%, and 8.9% of breast, lung, and prostate cases. Proton beam therapy was correlated with a farther distance traveled and longer start time from diagnosis for each site (P < .05).For breast, demographic correlates of PBT were treatment in the west coast (odds ratio [OR] = 4.81), age <60 (OR = 1.25), white race (OR = 1.94), and metropolitan area (OR = 1.58). Left-sided cancers (OR = 1.28), N2 (OR = 1.71), non-ER+/PR+/Her2Neu- cancers (OR = 1.24), accelerated partial breast irradiation (OR = 1.98), and hypofractionation (OR = 2.35) were predictors of PBT.For nonsmall cell cancer, demographic correlates of PBT were treatment in the south (OR = 2.6), metropolitan area (OR = 1.72), and Medicare insurance (OR = 1.64). Higher comorbid score (OR = 1.36), later year treated (OR = 3.16), and hypofractionation (not SBRT) (OR = 3.7) were predictors of PBT.For prostate, correlates of PBT were treatment in the west coast (OR = 2.48), age <70 (OR = 1.19), white race (OR = 1.41), metropolitan area (OR = 1.25), higher income/education (OR = 1.25), and treatment at an academic center (OR = 33.94). Lower comorbidity score (OR = 1.42), later year treated (OR = 1.37), low-risk disease (OR = 1.45), definitive compared to postoperative (OR = 6.10), and conventional fractionation (OR = 1.64) were predictors of PBT. Conclusion: Even for facilities with established referrals to proton centers, PBT utilization was low; socioeconomic status was potentially a factor. Proton beam therapy was more often used with left-sided breast and low-risk prostate cancers, without a clear clinical pattern in lung cancer.

Validation of the Neoadjuvant Rectal Cancer (NAR) Score for Prognostication Following Total Neoadjuvant Therapy (TNT) for Locally Advanced Rectal Cancer.

PURPOSE: The neoadjuvant rectal cancer (NAR) score is a prognostic tool for locally advanced rectal cancer (LARC) treated with total neoadjuvant therapy (TNT). It has been previously validated as an endpoint that predicts survival more accurately than pathologic complete response (pCR) and is the primary endpoint of the ongoing NRG-GI002 Phase II trial. Using the National Cancer Database (NCDB), we aimed to validate the NAR score's ability to predict survival in a large hospital-based dataset. METHODS: We queried the NCDB to identify locally advanced rectal cancer patients from 2004 to 2015 that received TNT followed by surgical resection. Overall survival (OS) was calculated using Kaplan-Meier curves evaluating NAR score and pCR separately. A multivariable Cox proportional hazards model was used to identify factors associated with survival. Multivariate regression was used to evaluate characteristics associated with a favorable (< 14.98) NAR score. RESULTS: From > 264,000 patients diagnosed with rectal adenocarcinoma in the NCDB, our final cohort yielded 209 patients with a median age of 62 years. Factors associated with worse survival included age > 62 years old (p = 0.04), lower income (p = 0.03), and unfavorable (≥ 14.98) NAR score (p = 0.04). On multivariate regression, tumors with perineural invasion and a higher comorbidity score (> 1) were less likely to have a favorable NAR response (p = 0.01 and p = 0.01). pCR was not associated with improved survival (p = 0.09). CONCLUSIONS: Our study validates the NAR score as a prognostic tool in patients receiving TNT for LARC. Tumors with perineural invasion and patients with a higher comorbidity score had worse NAR scores.

Utilization Patterns of Single-Fraction and Short-Course Radiotherapeutic Schedules in the Management of Bone Metastases.

Purpose: Bone metastases are common, occurring in 60% to 70% of patients with advanced malignancies. Historically, bone-directed radiation therapy regimens of 30 Gy over 10 fractions were used. However, prospective randomized data suggest equivalent pain relief with shorter-course regimens. The American Society for Radiation Oncology Choosing Wisely Campaign encourages clinicians to consider shorter-course palliative regimens in patients with limited prognosis. A retrospective analysis was performed to assess patterns of short-course and single-fraction radiation therapy during the past 5 years. Methods and Materials: We queried our electronic medical record (MOSAIQ) from 2016 to 2020 for patients with bone metastases who received palliative radiation therapy. Patients receiving >10 fractions or Medicare-approved palliative courses of radiation (30 Gy/10 fractions, 24 Gy/6 fractions, 20 Gy/5 fractions, 8 Gy/1 fraction) were included. Treatment department was defined as academic (n = 2) versus community (n = 12). Short-course treatment was defined as <6 fractions, whereas long-course included patients receiving >10 fractions. Patients were subdivided based on age and disease site. Physicians were grouped according to their year of residency completion. Multivariable logistic regression analysis identified predictors of short-course and single-fraction treatment. Results: We identified 1004 patients with 1768 bony metastases meeting inclusion criteria. The spine was the most common site, followed by pelvis/hip, extremity, and other site. Use of short-course treatment increased from 40% in 2016 to 50% in 2020. Single-fraction treatment increased from 7% in 2016 to 11% in 2020. Predictors of shorter courses included treatment at academic centers, more recent treatment, patient age >76 years, and nonspine anatomic site. Predictors of single-fraction treatment included treatment at academic centers, treating physician residency completion after 2010, patient age >76 years, and treatment to extremity or other site. Conclusions: Rates of short-course and single-fraction bone-directed radiation therapy increased within our health system over time. Treatment receipt at academic centers was associated with both short-course and single-fraction regimens. Physicians completing residency after 2010 were more likely to deliver single-fraction therapy.

Urachal carcinoma: A novel staging system utilizing the National Cancer Database.

BACKGROUND: Urachal carcinoma (UrC) is a rare, aggressive cancer with a poor prognosis that is frequently diagnosed in advanced stages. Due to its rarity, the current staging systems, namely Sheldon, Mayo, and Ontario were established based on relatively small patient cohorts, necessitating further validation. We used a large patient population from the National Cancer Database to model a novel staging system based on the Tumor (T), Node(N), and Metastasis (M) (TNM) staging system and compared it to established staging systems. METHODS: We identified patients diagnosed with UrC between the years of 2004-2016. To determine median overall survival (OS), a Kaplan-Meier (KM) curve was generated using the Sheldon, Mayo, Ontario, and TNM staging system. A cox proportional-hazards regression model was developed to highlight predictors of overall survival. RESULTS: A total of 626 patients were included in the analysis. The OS for the entire cohort was 58.2 months (50.1-67.8) with survival rates at 12, 24, and 60 months of 83%, 70%, and 49%, respectively (p < 0.0001). As compared to the Sheldon, Mayo, and Ontario staging system, our TNM staging system had a more balanced sample and survival distribution per stage and no overlap among stages on KM survival curves. The Mayo, Ontario, and TNM staging systems were more accurate in terms of stage-survival correlation than the Sheldon staging system (p < 0.05 for all stages). CONCLUSIONS: The proposed novel TNM staging system for UrC has a more balanced sample distribution and a more accurate stage-survival correlation than the traditional Mayo, Sheldon, and Ontario staging systems. It is clinically applicable and enables better risk stratification, prognosis, and therapeutic decision-making.

Rapid HIV testing in dental practices.

Despite increasing discussion about the dental care setting as a logical, potentially fruitful venue for rapid HIV testing, dentists' willingness to take on this task is unclear. Semistructured interviews with 40 private practice dentists revealed their principal concerns regarding offering patients HIV testing were false results, offending patients, viewing HIV testing as outside the scope of licensure, anticipating low patient acceptance of HIV testing in a dental setting, expecting inadequate reimbursement, and potential negative impact on the practice. Dentists were typically not concerned about transmission risks, staff opposition to testing, or making referrals for follow-up after a positive result. A larger cultural change may be required to engage dentists more actively in primary prevention and population-based HIV screening.

Reimbursing dentists for smoking cessation treatment: views from dental insurers.

INTRODUCTION: Screening and delivery of evidence-based interventions by dentists is an effective way to reduce tobacco use. However, dental visits remain an underutilized opportunity for the treatment of tobacco dependence. This is, in part, because the current reimbursement structure does not support expansion of dental providers' role in this arena. The purpose of this study was to interview dental insurers to assess attitudes toward tobacco use treatment in dental practice, pros and cons of offering dental provider reimbursement, and barriers to instituting a tobacco use treatment-related payment policy for dental providers. METHODS: Semi-structured interviews were conducted with 11 dental insurance company executives. Participants were identified using a targeted sampling method and represented viewpoints from a significant share of companies within the dental insurance industry. RESULTS: All insurers believed that screening and intervention for tobacco use was an appropriate part of routine care during a dental visit. Several indicated a need for more evidence of clinical and cost-effectiveness before reimbursement for these services could be actualized. Lack of purchaser demand, questionable returns on investment, and segregation of the medical and dental insurance markets were cited as additional barriers to coverage. CONCLUSIONS: Dissemination of findings on efficacy and additional research on financial returns could help to promote uptake of coverage by insurers. Wider issues of integration between dental and medical care and payment systems must be addressed in order to expand opportunities for preventive services in dental care settings.

Trends in the use of radiation for meningioma across the United States.

PURPOSE: Meningiomas are tumors originating from arachnoid cap cells on the surface of the brain or spinal cord. Treatment differs by grade but can consist of observation, surgery, radiation therapy or both. We utilized the National Cancer Database (NCDB) to compare trends in the use stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) in the management of meningioma. MATERIALS AND METHODS: We queried the NCDB from 2004-2015 for meningioma patients (grade 1-3) treated with radiation therapy, either SRS or EBRT. Multivariable logistic regression was used to identify predictors of each treatment and to generate a propensity score. Propensity adjusted Kaplan-Meier survival curve analysis and multivariable Cox hazards ratios were used to identify predictors of survival. RESULTS: We identified 5,406 patients with meningioma meeting above criteria with 45%, 44%, and 11% having World Health Organization (WHO) grade 1, 2, and 3 disease, respectively. Median follow up was 43 months. Predictors for SRS were grade 1 disease, distance from treatment facility, and histology. The only predictor of EBRT was grade 3 disease. Treatment year, histology, race and female sex were associated with improved survival. Five- and 10-year survival rates were 89.2% versus 72.6% (p < 0.0001) and 80.3% versus 61.4% (p = 0.29) for SRS and EBRT respectively. After propensity matching 226 pairs were generated. For SRS, 5-year survival was not significantly improved at 88.2% compared with EBRT (p = 0.056). CONCLUSION: In the present analysis, predictors of SRS utilization in management of meningioma include WHO grade 1 disease, distance from treatment facility and histology whereas conventional EBRT utilization was associated with grade 2 and 3 disease. Future studies need to be performed in order to optimize management of atypical and malignant meningioma.

Analysis of Post-operative Adjuvant Chemotherapy Versus Adjuvant Chemoradiation Therapy Outcomes in Non-metastatic Cholangiocarcinoma: an NCDB Review.

BACKGROUND: Each year, approximately 8000 cases of cholangiocarcinoma are recorded in the USA. Surgical resection is considered to be the only curative option. Despite surgery as a curative approach, many patients will require adjuvant therapies in the form of chemotherapy (ChT) or chemoradiotherapy (CRT). As such, we sought to analyze outcomes in patients with non-metastatic cholangiocarcinoma receiving adjuvant ChT or CRT following surgical resection. METHODS: We queried the National Cancer Database (NCDB) for patients with a diagnosis of non-metastatic cholangiocarcinoma between the years 2010 and 2015 who underwent adjuvant ChT or CRT following surgery. Overall survival (OS) was calculated using Kaplan Meier method. Cox proportional hazard ratios were used to identify predictors of overall survival, and logistic regression was used to identify predictors of receiving each treatment. RESULTS: A total of 875 patients were identified who met the above eligibility criteria. Of these patients, 818 received adjuvant chemotherapy alone with 57 patients receiving adjuvant chemoradiation therapy. The median OS in patients receiving CRT was 19.8 months versus 11.9 months for ChT (p value < 0.0238). The 1- and 5-year survival rates between ChT and CRT were 50% vs 61% and 6% vs 13%, respectively (hazard ratio 0.7005; 95% CI 0.51-0.97; p value < 0.0294). CONCLUSION: The results of this study suggest a potential benefit of chemoradiation therapy in the adjuvant setting, although the trends appear to show rare utilization. Given the limitations of our study, prospective corroboration is warranted.

Asymptomatic macrothrombocytopenia in a young pure-bred beagle dog: a case report.

During baseline evaluation prior to a preclinical safety study, a 10-month-old male pure-bred Beagle dog was found to have marked thrombocytopenia (6 × 10(3) platelets [PLT]/µL) associated with a mean platelet volume (MPV) of 17.9 fL. Tests for Rickettsia rickettsii, Ehrlichia canis, and Borrelia burgdorferi were negative. Buccal bleeding time was normal. Over 3 months, PLT were 4 to 141 × 10(3) PLT/µL, and MPV was 11.4 to 25.1 fL; however, PLT were <50 × 10(3) PLT/µL and MPV was >16 fL during most of this period. Antinuclear antibody (ANA) and anti-PLT antibody tests were negative. Genotyping for the presence of a beta 1-tubulin mutation demonstrated the normal wild-type gene. Treatment with prednisone resulted in normal values after only 3 days. Ultrastructure of enlarged PLT was consistent with that of immature PLT, characterized by reduced numbers of peripheral microtubules and the presence of rough endoplasmic reticulum, free ribosomes, Golgi apparatus, and a prominent canalicular system. PLT ultrastructure and glucocorticoid responsiveness supported a diagnosis of immune-mediated thrombocytopenia that was masked by the cyclic nature of PLT decreases and lack of clinical signs. Inclusion of such a dog in a preclinical safety study could result in misinterpretation of clinical pathology findings.

The use of adjuvant radiation therapy in male breast cancer and its impact on outcomes.

BACKGROUND: Male breast cancer (MBC) accounts for 1% of all breast cancers and there is a paucity of data on factors impacting the treatment strategies and outcomes. We sought to use a large national database to examine trends and predictors of the use of adjuvant radiation (Adj-RT), as well as any association with outcome. METHODS: We queried the National Cancer Database (NCDB) for patients with stages I-III MBC treated with surgery (breast conservation surgery-BCS or mastectomy-MS) within 180 days of diagnosis (years 2004-2015). Multivariable logistic regression identified predictors of adj-RT receipt. Multivariable Cox regression evaluated predictors of survival. Propensity matching for adj-RT was used to account for indication biases. RESULTS: We identified 6,217 patients meeting the eligibility criteria (1457 BCS vs. 4760 MS). The majority of patients were Caucasian (85%) and in an age range of 50-80 years (74%). Although adj-RT was omitted for 30% of BCS patients, the utilization was higher compared to MS (OR=26, p-value=0.001). The predictors of adj-RT use included African-American race, more advanced stage, higher grade, presence of lymphovascular invasion, and ER/Her-2 positivity for the entire cohort and increased age, urban location and higher income for BCS. Adj-RT was associated with lower mortality in the propensity matched model (overall HR for BCS=0.28, p-value<0.001; overall HR for MS=0.62, p-value=0.001). CONCLUSION: This study demonstrates that while adj-RT after BCS is associated with decreased mortality in MBC patients, adj-RT is omitted in up to a third of cases of MBC after BCS despite being standard of care.