Virtual multi-institutional tumor board: a strategy for personalized diagnoses and management of rare CNS tumors.

PURPOSE: Multidisciplinary tumor boards (MTBs) integrate clinical, molecular, and radiological information and facilitate coordination of neuro-oncology care. During the COVID-19 pandemic, our MTB transitioned to a virtual and multi-institutional format. We hypothesized that this expansion would allow expert review of challenging neuro-oncology cases and contribute to the care of patients with limited access to specialized centers. METHODS: We retrospectively reviewed records from virtual MTBs held between 04/2020-03/2021. Data collected included measures of potential clinical impact, including referrals to observational or therapeutic studies, referrals for specialized neuropathology analysis, and whether molecular findings led to a change in diagnosis and/or guided management suggestions. RESULTS: During 25 meetings, 32 presenters discussed 44 cases. Approximately half (n = 20; 48%) involved a rare central nervous system (CNS) tumor. In 21% (n = 9) the diagnosis was changed or refined based on molecular profiling obtained at the NIH and in 36% (n = 15) molecular findings guided management. Clinical trial suggestions were offered to 31% (n = 13), enrollment in the observational NCI Natural History Study to 21% (n = 9), neuropathology review and molecular testing at the NIH to 17% (n = 7), and all received management suggestions. CONCLUSION: Virtual multi-institutional MTBs enable remote expert review of CNS tumors. We propose them as a strategy to facilitate expert opinions from specialized centers, especially for rare CNS tumors, helping mitigate geographic barriers to patient care and serving as a pre-screening tool for studies. Advanced molecular testing is key to obtaining a precise diagnosis, discovering potentially actionable targets, and guiding management.

Breast Squamous Cell Carcinoma Following Breast Augmentation.

Breast augmentation is the most common cosmetic surgery in the United States. Squamous cell carcinoma (SCC) of the breast raises suspicion of possibly metastatic origin. Here, we report an unusual case of implant-associated SCC of the breast post silicone gel breast implant. The patient is a 46-year-old female with SCC of the breast. She initially had silicone gel breast implantation for breast augmentation in 1995. She had multiple revisions due to swelling and hardening. In 2016, she underwent bilateral prosthesis explantation and bilateral capsulectomy. The pathology demonstrated a 4-cm tumor that was moderately differentiated invasive SCC. On slide review, it was noted that there was squamous epithelization of the implant capsule with benign squamous epithelium on both sides. She received external beam radiation to the right breast; no adjuvant chemotherapy was offered due to the rare histology and paucity of data. Follow-up within a year showed metastasis to the liver, lungs and retroperitoneum. She was admitted and ultimately transferred from the medical intensive care unit to the palliative care unit for comfort care. She expired of her disease in July 2017.

Prophylactic versus reactive gastrostomy tube placement in advanced head and neck cancer treated with definitive chemoradiotherapy: A systematic review.

Although chemoradiotherapy (CRT) has improved disease outcomes in advanced head and neck cancer (aHNC), toxicity remains a major concern. Treatment interruptions and decreased quality of life (QOL) can occur due to malnutrition, secondary to mucositis, dysphagia and odynophagia. Gastrostomy tubes are used in many patients to improve nutrition during CRT. The optimal timing of PEG placement in patients with aHNC undergoing CRT remains controversial. Using the PubMed database, we performed a systematic review of published CRT series in aHNC to guide decision-making regarding optimal timing of percutaneous endoscopic gastrostomy (PEG) placement. We aimed to compare outcomes when patients are treated with prophylactic PEG (pPEG) versus reactive PEG (rPEG). Twenty-two studies examining the role of PEG placement in CRT for aHNC were reviewed. pPEG reduces the number of malnourished patients (defined as >10% of body weight), but average weight loss at various time points following treatment appears similar to patients with rPEG. pPEG is also associated with improved QOL at 6 months, and greater long term PEG dependence. Clinical and dosimetric parameters that correlate with malnutrition in patients without pPEG include advanced age, percent weight loss preceding treatment, and radiation dose to the pharyngeal constrictor muscles. Based on this evidence, our institutional strategy is to encourage pPEG in those patients deemed at greatest risk of becoming malnourished during the course of treatment, and to approach the remainder of patients with rPEG.

Stereotactic radiosurgery for single brain metastases from non-small cell lung cancer: progression of extracranial disease correlates with distant intracranial failure.

BACKGROUND: Limited data exist regarding management of patients with a single brain lesion with extracranial disease due to non-small cell lung cancer (NSCLC). METHODS: Eighty-eight consecutive patients with a single brain lesion from NSCLC in the presence of extracranial disease were treated with stereotactic radiosurgery (SRS) alone. Local control (LC), distant intracranial failure (DIF), overall survival (OS), and toxicity were assessed. The logrank test was used to identify prognostic variables. RESULTS: Median OS was 10.6 months. One-year DIF was 61%; LC 89%. Treatments were delivered in 1-5 fractions to median BED10 = 60 Gy. Five patients developed radionecrosis. Factors associated with shortened OS included poor performance status (PS) (p = 0.0002) and higher Recursive Partitioning Analysis class (p = 0.017). For patients with PS 0, median survival was 22 months. DIF was associated with systemic disease status (progressive vs. stable) (p = 0.0001), as was BED (p = 0.021) on univariate analysis, but only systemic disease (p = 0.0008) on multivariate analysis. CONCLUSIONS: This study identifies a patient population that may have durable intracranial control after treatment with SRS alone. These data support the need for prospective studies to optimize patient selection for up-front SRS and to characterize the impact of DIF on patients' quality of life.

The impact of radiosurgery fractionation and tumor radiobiology on the local control of brain metastases.

OBJECT: Experience with whole-brain radiation therapy for metastatic tumors in the brain has identified a subset of tumors that exhibit decreased local control with fractionated regimens and are thus termed radioresistant. With the advent of frameless radiosurgery, fractionated radiosurgery (2-5 fractions) is being used increasingly for metastatic tumors deemed too large or too close to crucial structures to be treated in a single session. The authors retrospectively reviewed metastatic brain tumors treated at 2 centers to analyze the dependency of local control rates on tumor radiobiology and dose fractionation. METHODS: The medical records of 214 patients from 2 institutions with radiation-naive metastatic tumors in the brain treated with radiosurgery given either as a single dose or in 2-5 fractions were analyzed retrospectively. The authors compared the local control rates of the radiosensitive with the radioresistant tumors after either single-fraction or fractionated radiosurgery. RESULTS: There was no difference in local tumor control rates in patients receiving single-fraction radiosurgery between radioresistant and radiosensitive tumors (p = 0.69). However, after fractionated radiosurgery, treatment for radioresistant tumors failed at a higher rate than for radiosensitive tumors with an OR of 5.37 (95% CI 3.83-6.91, p = 0.032). CONCLUSIONS: Single-fraction radiosurgery is equally effective in the treatment of radioresistant and radiosensitive metastatic tumors in the brain. However, fractionated stereotactic radiosurgery is less effective in radioresistant tumor subtypes. The authors recommend that radioresistant tumors be treated in a single fraction when possible and techniques for facilitating single-fraction treatment or dose escalation be considered for larger radioresistant lesions.