Intraoperative radiation therapy for early-stage breast cancer: a single-institution experience.

Background: To assess outcomes and toxicity after low-energy intraoperative radiotherapy (IORT) for early-stage breast cancer (ESBC). Materials and methods: We reviewed patients with unilateral ESBC treated with breast-conserving surgery and 50-kV IORT at our institution. Patients were prescribed 20 Gy to the surface of the spherical applicator, fitted to the surgical cavity during surgery. Patients who did not meet institutional guidelines for IORT alone on final pathology were recommended adjuvant treatment, including additional surgery and/or external-beam radiation therapy (EBRT). We analyzed ipsilateral breast tumor recurrence, overall survival, recurrence-free survival and toxicity. Results: Among 201 patients (median follow-up, 5.1 years; median age, 67 years), 88% were Her2 negative and ER positive and/or PR positive, 98% had invasive ductal carcinoma, 87% had grade 1 or 2, and 95% had clinical T1 disease. Most had pathological stage T1 (93%) N0 (95%) disease. Mean IORT applicator dose at 1-cm depth was 6.3 Gy. Post-IORT treatment included additional surgery, 10%; EBRT, 11%; adjuvant chemotherapy, 9%; and adjuvant hormonal therapy, 74%. Median total EBRT dose was 42.4 (range, 40.05-63) Gy and median dose per fraction was 2.65 Gy. At 5 years, the cumulative incidence of ipsilateral breast tumor recurrence was 2.7%, the overall survival rate was 95% with no breast cancer-related deaths, and the recurrence-free survival rate was 96%. For patients who were deemed unsuitable for postoperative IORT alone and did not receive recommended risk-adapted EBRT, the IBTR rate was 4.7% versus 1.7% (p = 0.23) for patients who were either suitable for IORT alone or unsuitable and received adjuvant EBRT. Cosmetic toxicity data was available for 83%, with 7% experiencing grade 3 breast toxicity and no grade 4-5 toxicity. Conclusions: IORT for select patients with ESBC results in acceptable outcomes in regard to ipsilateral breast tumor recurrence and toxicity.

A Prospective Randomized Trial of the Influence of Music on Anxiety in Patients Starting Radiation Therapy for Cancer.

PURPOSE: One of the most downloaded articles in 2017 from the International Journal of Radiation Oncology, Biology, and Physics was a study suggesting that music therapy during radiation therapy (RT) simulation substantially reduces anxiety. To further evaluate the potential of music's clinical efficacy in the context of radiation therapy, we conducted a randomized trial evaluating the influence of genre-based music chosen by the study participant on anxiety during the first RT treatment session with a method that is applicable to routine clinical practice. METHODS AND MATERIALS: We conducted a prospective randomized trial of music versus no music during the first RT treatment for cancer. We limited the study to women because prior studies document a higher rate of anxiety in female patients with cancer. Anxiety was evaluated before and after the first RT treatment using the State-Trait Anxiety Inventory (STAI) and Symptom Distress Thermometer (SDT). Patients randomized to music had their preferred genre of music played from a web-based application while in the treatment vault. RESULTS: In the study, 102 females were enrolled (51 with and 51 without music). Baseline high anxiety score before RT was recorded in 48% of patients using the STAI and 58% using the SDT. The percent decrease in mean STAI score was 16% with music versus 10% without music (P = .2197). The mean SDT percent changes were a 13% decrease with music versus a 2% increase without music (P = .3298). CONCLUSIONS: This study documents that high anxiety is common in women receiving RT for cancer and that music, as used in this study, does not reduce anxiety to a meaningful degree.

Radiotherapy for Adult Soft Tissue Sarcomas of the Head and Neck.

OBJECTIVE: Surgery followed by postoperative radiation therapy (RT) is the standard of care for soft tissue sarcomas (STS) of the head and neck that are high grade or have close or positive margins. METHODS: The authors retrospectively reviewed adult patients with head and neck STS treated with RT at a single institution between 1981 and 2017. All patients who were 19 years and older with STS of the head and neck-excluding rhabdomyosarcoma, angiosarcoma, and Ewing tumors-were included in this study. Toxicity was graded using Common Terminology Criteria for Adverse Events (CTCAE), version 4. RESULTS: Among 34 patients with head and neck STS treated with postoperative RT (33) or primary RT (1) who met the inclusion criteria, the median age at diagnosis was 45 years (range, 20 to 83). Overall, 37% had T1 tumors, 50% had high-grade histology (grade 3), and 26% had microscopically positive margins. The median RT dose was 65 Gy to the primary site; 29% received elective nodal irradiation. The median follow-up for living patients was 16.6 years (range, 0.6 to 30). At 5 and 10 years, the local control rates were 88% and 80%, the regional control rates were 97% and 97%, the freedom from distant metastases rates were 100% and 100%, the cause-specific survival rates were 88% and 81%, and the overall survival rates were 85% and 69%. Two patients (6%) developed late grade 3+ complications. CONCLUSION: Our study demonstrates that surgery and radiotherapy for STS of the head and neck have excellent disease outcomes.

Long-term Outcomes After Definitive Radiation Therapy for Solitary Plasmacytoma.

OBJECTIVE: Definitive radiotherapy (RT) with or without surgery is the standard of care for solitary plasmacytoma. Here, we report clinical outcomes for this rare malignant neoplasm. PATIENTS AND METHODS: We retrospectively reviewed the medical records of adults with solitary plasmacytoma treated with definitive RT between 1963 and 2015 at a single institution, and assessed disease control, survival, and toxicity per Common Terminology Criteria for Adverse Events (CTCAE), version 4. RESULTS: A total of 42 patients with solitary plasmacytoma of the bone (SPB, n=27) or extramedullary plasmacytoma (EMP, n=15) were treated with definitive RT with (n=11) or without (n=31) surgical resection. The median age at diagnosis was 59 years (range: 28 to 76 y).Twenty-two patients had tumors ≥5 cm and 20 had tumors <5 cm. Immunoglobulins were elevated in 23 patients and M-protein in 14. The median RT dose was 45 Gy (range: 15 to 54 Gy) over a median 25 fractions (range: 1 to 38 fractions) with 3 patients receiving twice-daily fractionation and 6 received elective nodal irradiation. No patients received adjuvant chemotherapy. The median follow-up was 10.3 years. The 10-year local control rate after RT was 88%. Five patients who developed a local recurrence had SPB ≥5 cm. The 10-year multiple myeloma-free survival rates were: overall, 47%; SPB, 24%; and EMP, 87% (P=0.0012). The 10-year cause-specific survival rate was 75%: 64% for SPB versus 93% for EMP (P=0.0116). The 10-year overall survival rate was 60%. Three patients experienced late grade 2+ toxicity. CONCLUSIONS: Definitive RT with moderate doses results in excellent local control. We observed a higher rate of progression to multiple myeloma and lower survival in patients with SPB compared with EMP.

Pulmonary Function after Proton Therapy for Hodgkin Lymphoma.

PURPOSE: Acute and late toxicity from chemotherapy, targeted therapy, and radiation therapy can cause significant morbidity among survivors of Hodgkin lymphoma (HL), including pulmonary dysfunction. Improved dosimetry may influence pulmonary function tests (PFTs), an objective and clinically significant measure of pulmonary toxicity. The present study investigates the impact of proton therapy on PFTs among HL survivors. PATIENTS AND METHODS: We monitored 15 patients with mediastinal HL who were enrolled in an institutional HL trial. All patients were treated with combination chemotherapy plus involved-node proton therapy. All patients were to undergo PFTs before starting treatment and at approximately 6 and 12 months after completing proton therapy. RESULTS: Twelve patients were included in the analysis and 3 excluded. The mean forced vital capacity (FVC) was 96.2% ± 16.5% (mean ± SD) predicted at baseline and 98.2% ± 19.4% predicted at 12 months. The mean forced expiratory volume in 1 second (FEV1) was 96.7% ± 17.2% predicted at baseline and 97% ± 15.1% predicted at 12 months. The mean FEV1/FVC ratio was 99.5 ± 8.29 at baseline and 97.8 ± 8.02 at 12 months. The mean diffusing capacity of the lung for carbon monoxide was 81.4% ± 18.4% predicted at baseline and 95.7% ± 23.5% predicted at 12 months. CONCLUSION: No unexpected changes were observed to the lungs as illustrated through follow-up PFTs. Long-term follow-up and validation in a larger cohort are needed.

Challenging the concept that late recurrence and death from tumor are common after fractionated radiotherapy for benign meningioma.

BACKGROUND: There is debate about the curability of benign meningioma and the value of long-term follow-up. A major Scandinavian study reports a high recurrence rate after surgery alone, with the majority of recurrences presenting after 10 years and death from tumor in the majority of patients with recurrence. The purpose of our study is to report the rate and time-course of recurrence ≥10 years after fractionated radiotherapy for benign meningioma with visible tumor at the time of RT and to compare these results to surgery-alone series. METHODS: A single-institution study of all (149) adults treated with fractionated radiotherapy (50-52 Gy at 1.7-1.8 Gy in the vast majority) for visible intracranial benign meningioma between 1984 and 2006. The median follow-up in patients alive at last follow-up was 12.0 years. RESULTS: Seven (5%) of 149 patients developed recurrent meningioma with an actuarial recurrence rate of 3% at 10 years, 5% at 15 years, and 8% at 20 years. The majority (58%) of recurrences presented at least 10 years after radiotherapy. Only 4% of 149 patients died of recurrent meningioma but death was the result of recurrent meningioma in almost all (86%) patients with recurrence. CONCLUSION: Our results contradict the conclusion based on patients treated with surgery-alone that recurrence of benign meningioma is common with long-term follow-up. After fractionated radiotherapy, the 20-year control rate is approximately 90%. Our results confirm that a substantial percentage of recurrences present >10 years after treatment. These findings have important implications for the choice of initial treatment and follow-up duration.

Challenging the Requirement to Treat the Contralateral Neck in Cases With >4 mm Tumor Thickness in Patients Receiving Postoperative Radiation Therapy for Squamous Cell Carcinoma of the Oral Tongue or Floor of Mouth.

HYPOTHESIS: While treating patients with postoperative radiotherapy (RT) for squamous cell carcinoma of the oral tongue or floor of mouth, we hypothesized a low risk of tumor recurrence in the contralateral neck in the absence of contralateral neck RT when the primary tumor is >1 cm from the midline regardless of tumor thickness (TT) or depth of invasion (DOI)>4 mm. OBJECTIVE: The policy at our institution for many years has been to limit postoperative RT to the ipsilateral side when the primary tumor does not cross the midline, regardless of TT or DOI. We report the rate of isolated contralateral neck failure in this group. MATERIALS AND METHODS: We retrospectively reviewed all patients treated with postoperative RT at our institution between 1998 and 2014 for pathologic stage T1-T4 N1-N2b squamous cell carcinoma of the oral tongue or floor of mouth that did not cross the midline and thus were treated with RT limited to the primary site +/- ipsilateral neck. RESULTS: Our study population included 32 patients: 75% with close (<5 mm) or positive margins and 38% with perineural invasion. No patients had a tumor that crossed the midline. TT was ≥4 mm in 75% of patients. DOI was >5 mm in 68% of patients. There were no isolated contralateral neck recurrences with a median follow-up of 5 years. CONCLUSION: While delivering postoperative RT for oral tongue or floor of mouth cancer with pathologic neck stage N0-2b, the risk of not irradiating the contralateral neck is very low when the primary tumor does not cross the midline, regardless of other factors at the primary site, such as TT and DOI.

Advances in the management of craniopharyngioma.

Craniopharyngioma is a curable benign tumor, but owing to its intimate relationship to critical structures in the central brain-such as the optic apparatus, pituitary, hypothalamus, intracranial vasculature, brain stem, and temporal lobes-its management introduces the risk of long-term treatment morbidity. Today, the most common treatment approach is conservative subtotal resection followed by radiotherapy, and the goal is to limit long-term toxicity. Many recent advances in the treatment of craniopharyngioma are attributable to improved surgical techniques and radiotherapy technologies.

Pertuzumab and trastuzumab infusion related cytokine release syndrome in a chemotherapy naive patient with metastatic breast cancer.

Pertuzumab is a monoclonal antibody that targets and down regulates HER-2/neu expression in ductal breast tumors. Other HER-2/neu monoclonal antibodies, particularly trastuzumab, have been implicated to induce infusion related reactions such as cytokine release syndrome (CRS). Here, we report a case of pertuzumab associated CRS prior to infusion of trastuzumab which warranted hospitalization for symptom management.

An approach to contouring the dorsal vagal complex for radiotherapy planning.

Multiple studies suggest that radiation dose to the area of the brainstem called the "dorsal vagal complex (DVC)" influences the frequency of nausea and vomiting during radiotherapy. The purpose of this didactic article is to describe the step-by-step process that we use to contour the general area of the DVC on axial computed tomography (CT) images as would be done for radiotherapy planning. The contouring procedure that we describe for contouring the area of the DVC is useful to medical dosimetrists and radiation oncologists.