A single-institution, randomized, pilot study evaluating the efficacy of gabapentin and methadone for patients undergoing chemoradiation for head and neck squamous cell cancer.

BACKGROUND: The objective of the current study was to compare the safety and efficacy between 2 analgesic regimens for patients with head and neck cancer (HNC) undergoing definitive chemoradiation (CRT). METHODS: The current study was a prospective, single-institution, 2-arm, randomized pilot study. Patients with American Joint Committee on Cancer seventh edition stage II to stage IV squamous cell carcinoma of the head and neck who were undergoing CRT were randomized to either arm 1, which entailed high-dose gabapentin (2700 mg daily) with the institutional standard of care (hydrocodone and/or acetaminophen progressing to fentanyl as needed), or arm 2, which comprised low-dose gabapentin (900 mg daily) with methadone. The primary endpoints were safety and toxicity. Secondary endpoints were pain, opioid requirement, and quality of life (QOL). Differences between the treatment arms at multiple time points were compared using a generalized linear mixed regression model with Sidak correction. RESULTS: A total of 60 patients (31 in arm 1 and 29 in arm 2) were enrolled from April 2015 to August 2017. There was no difference between the treatment arms with regard to adverse events or serious adverse events. Pain was not found to be different between the treatment arms. More patients in arm 1 did not require an opioid during treatment (42% vs 7%; P = .002). Patients in arm 2 experienced significantly better QOL outcomes across multiple domains, including overall health (P = .05), physical functioning (P = .04), role functioning (P = .01), and social functioning (P = .01). CONCLUSIONS: High-dose prophylactic gabapentin increased the percentage of patients who required no opioid during treatment. Methadone may improve QOL compared with a regimen of short-acting opioids and fentanyl. However, pain was found to significantly worsen throughout treatment regardless of treatment arm, necessitating further studies to identify a more optimal regimen.

Dosimetric comparison of deep-inspiration breath-hold and free-breathing treatment delivery techniques for left-sided breast cancer using 3D surface tracking.

INTRODUCTION: While radiation therapy has been shown to increase local control and overall survival for breast cancer, late cardiac toxicity remains a concern. Morbidity and mortality have been shown to increase proportionally to the mean heart dose. Deep inspiration breath-hold (DIBH) can reduce heart dose compared to free-breathing (FB) by increasing the heart-to-chest wall distance, especially in left-sided breast cancer. We present our clinical experience with DIBH in left breast and chest-wall irradiation using 3D optical surface tracking. MATERIALS & METHODS: 29 patients were treated with DIBH using a surface tracking system that provides a real time 3D surface image of the patient. Comparisons of maximum and mean heart dose, heart-chest wall separation, and the percentage of lung volume that receives 20 or more Gy (V20) between the DIBH and hypothetical FB treatment plans were conducted with the Student's t-test. Correlation coefficients were also calculated for heart-chest wall separation, heart volume, and lung volume. RESULTS: Comparing DIBH and FB plans showed a decrease in mean and maximum heart doses in all patients. Individual mean heart doses decreased by an average of 1.12 Gy, and the average mean heart dose for DIBH plans was significantly lower than corresponding FB plans (1.02 vs. 2.12 Gy; p < 0.0001). Maximum heart dose decreased by an average of 11.88 Gy and was significantly lower in DIBH versus FB plans (28.33 vs. 43.7 Gy; p = 0.0001). The average difference in heart to chest-wall separation between DIBH and FB images was 2.41 cm. DIBH left lung volume and measured increases in volume on inspiration inversely correlated with maximum heart dose (R = 0.39) and left lung V20 (R = 0.32). CONCLUSIONS: DIBH with 3D surface tracking can significantly benefit patients with left sided disease by limiting the mean and maximum heart dose. DIBH appears to viably reduce heart dose for left-breast cancer patients and thus potentially reduce long-term complications without prolonging treatment delivery.

Minimally invasive rib-sparing video-assisted thoracoscopic surgery resections with high-dose-rate intraoperative brachytherapy for selected chest wall tumors.

BACKGROUND: By avoiding chest wall resection, iridium-192 (Ir-192) high-dose-rate (HDR) intraoperative brachytherapy (IOBT) and video-assisted thoracoscopic surgery (VATS) might improve outcomes for high-risk patients requiring surgical resection for pulmonary malignancy with limited pleura and/or chest wall involvement. METHODS AND MATERIALS: Seven patients with non-small cell lung cancer involving the pleura or chest wall underwent VATS pulmonary resections combined with HDR IOBT. After tumor extraction, an Ir-192 source was delivered via a Freiburg applicator to intrathoracic sites with potential for R1-positive surgical margins. The number of catheters, dwell position along each catheter, prescription depth, and dose were customized based on clinical needs. RESULTS: Six patients had pT3N0M0 non-small cell lung cancers. A seventh case was a recurrent sarcomatoid carcinoma. One case required conversion to open thoracotomy for pneumonectomy with en bloc chest wall resection. There were no intraoperative complications and average operative time was 5.8 hours. Five of seven patients without transmural chest wall involvement underwent rib-sparing resection. Four of the 6 patients treated with VATS and IORT remain alive in follow-up without evidence of local recurrence (median follow-up, 25 months). Noted toxicities were recurrent postoperative pneumothorax, pleural effusion with persistent chest wall pain, avid fibrosis at 2 years of follow-up, and a late traumatic rib fracture. CONCLUSIONS: HDR IOBT with Ir-192 via VATS is technically feasible and safe for intrathoracic disease with pleural and/or limited chest wall involvement. Short-term morbidity associated with chest wall resection may be reduced. Additional study is required to define long-term benefits.

Single-fraction stereotactic body radiation therapy for sinonasal malignant melanoma.

BACKGROUND: A rare head and neck disease that may benefit from definitive or palliative stereotactic body radiation therapy (SBRT) is sinonasal malignant melanoma. These tumors can be very aggressive and often lead to severe epistaxis and significant mass effect. Results from only a handful of head and neck sinonasal malignant melanoma treated with SBRT are available in the current literature. METHODS: The following reports on 2 cases of sinonasal malignant melanoma that recurred postoperatively and were subsequently treated at Roswell Park with SBRT. Both were treated with a single fraction of 15 Gy. RESULTS: Nearly instant relief of their chronic epistaxis and complete responses were seen in both patients. One patient is alive and free of disease 7 years after radiation. CONCLUSION: These patients with sinonasal malignant melanoma achieved symptomatic relief of severe bleeding and airway issues from single-fraction SBRT. SBRT should be considered as a treatment option in patients with unresectable sinonasal malignant melanoma.

Radiation for bone metastases.

PURPOSE OF REVIEW: To synopsize the current state-of-the-art for radiation and treatment of painful bone metastases with a focus on prostate cancer. RECENT FINDINGS: Although external beam radiation has long been known to palliate painful bone metastatic disease for patients with prostate cancer, new studies continue to evolve in this area. Data from randomized studies over the past decade emphasize that palliation can be achieved with single-fraction radiation strategies. Despite these data, and various supportive national and international guidelines, single-fraction regimens are relatively underutilized in the USA as compared with other countries. In addition to external beam radiation, beta-emitting isotopes are also effective as systemic agents for the palliation of painful bone metastases. New alpha-emitters such as Alpharadin (radium-223) are under current development but remain unproven at this time and recent data indicate that this agent can prolong survival in patients with advanced prostate cancer. SUMMARY: Radiation in various forms is highly effective for palliation of pain associated with bone metastases.