Patterns of care of IMRT usage in postoperative management of uterine cancer.

OBJECTIVE: To analyze the patterns of care regarding intensity modulated radiation therapy (IMRT) usage in the postoperative management of uterine cancer. METHODS: The National Cancer Database was queried to identify women with endometrial adenocarcinoma who underwent hysterectomy followed by external beam radiation between 2004-2012. Descriptive statistics were used to analyze IMRT usage with comparison via the Chi Square test. Overall survival was also compared between IMRT and three dimensional conformal radiation therapy. Multivariable logistic regression and multivariable Cox Regression were used to identify covariables that impact IMRT usage and improved survival respectively. RESULTS: 7839 women were included in this study. IMRT utilization increased from 1.9% in 2004 to 32.4% in 2012 (p<0.001). The adjusted odds ratio (OR) for IMRT in 2012 compared with 2004 was 24.90, 95% CI 15.24-40.67 (p<0.001). Aside from year, other predictors of IMRT usage on multivariate analysis were positive nodes, higher dose, private insurance and higher income. Black race was associated with lower IMRT usage compared to Whites with an OR of 0.60, 95% CI 0.44-0.81 (p=0.001). IMRT was not associated with significantly increased survival (HR 0.86, 95% CI 0.73-1.01, p=0.06). Black race and positive nodes were associated with decreased survival within the group studied whereas private insurance and higher income were associated with improved survival. CONCLUSIONS: In this hospital-based registry, IMRT has significantly increased in utilization for postoperative radiation in uterine cancer between 2004-2012 although not resulting in significantly improved survival. Socioeconomic and racial disparities exist in the allocation of IMRT usage.

Essential Oils Combined with Vitamin D3 or with Probiotic as an Alternative to the Ionophore Monensin Supplemented in High-Energy Diets for Lambs Long-Term Finished under Subtropical Climate.

Supplementation with natural additives such as essential oils (EO) or probiotics has resulted in comparable growth performance to that of supplemental monensin in fattening lambs in hot environments. Supra-supplementation levels of vitamin D3 improved the carcass weight and dressing percentage of steers fattened under tropical conditions. We hypothesized that certain combinations of these natural additives could be complementary. For this reason, a feeding trial was carried out using 48 Pelibuey × Katahdin non-castrated male lambs (107 ± 14 d age; 17.9 ± 2.51 kg LW). Lambs were fed an 88:12 concentrate to forage ratio basal diet supplemented (dry matter basis, DMI) with: (1) no additive (CON); (2) 28 mg monensin/kg diet (MON); (3) 150 mg of essential oils containing a combination of thymol, eugenol, vanillin, guaiac, and limonene plus 0.12 mg vitamin D3 (EO + D3)/kg diet; and (4) 300 mg of essential oils containing a combination of carvacrol and cynamaldehyde plus 2 g probiotic (2.2 × 108 CFU of bacillus subtilis/kg diet, EO + BS). Lambs were grouped by initial weight and assigned within six weight groupings to 24 pens (2 lambs/pen, 6 replicas per treatment) in a randomized complete block design. The experiment lasted 121 days. Daily maximal THI exceeded the 80 "danger or "emergency" range for 119 days of the 121 days of the trial. Lambs supplemented with MON had similar DMI, growth performance, and dietary energetics to those of CON lambs. Lambs supplemented with EO + BS had a greater (9.2%, p ≤ 0.05) average daily gain (ADG) than the CON and MON groups due to enhanced (10.2%, p ≤ 0.05) dry matter intake. Thus, gain efficiency (GF) and estimated dietary energy were similar for CON, MON, and EO + BS. Lambs receiving EO + D3 had similar (0.254 vs. 0.262 kg/d) ADG but a lower DMI (8%, p < 0.05) compared with EO + BS lambs. Consequently, GF and estimated dietary net energy were greater (4.9 and 3.7%, respectively; p ≤ 0.05) for EO + D3 lambs. Even when ambient heat load was elevated, the efficiency of utilization of dietary energy (observed-to-expected dietary net energy) was close to 1.00 (0.992) expected for EO + D3 lambs. In contrast, efficiency of energy utilization was depressed by -4.4% for lambs on the other treatments. Compared with the other treatments, lambs receiving EO + D3 had greater longissimus muscle area (5.6%, p < 0.05) and lower kidney pelvic fat (21.8%, p ≤ 0.05). There were no treatment effects on shoulder tissue composition or whole cuts (expressed as % of cold carcass weight). Compared to CON, lambs that were fed with natural additives showed 3.5% lower (p ≤ 0.05) intestine mass. All supplemental additives decreased visceral fat mass, which was minimal with EO + D3 treatment. Combinations of essential oils with vitamins or probiotics were superior to antibiotic monensin in finishing diets for feedlot lambs. Combining EO with probiotics promoted DM intake and gain but not gain efficiency, while combining EO with vitamin D3 supra-supplementation increased dietary energy efficiency and improved some carcass characteristics in lambs fattening under high ambient heat loads.

Patterns of care and outcomes of postoperative radiation for low-grade gliomas in United States hospitals.

It is unclear whether there is a survival benefit with postoperative radiation for low-grade gliomas deemed to be high-risk. We sought to analyze patterns of care and outcomes of radiation use. We accessed the National Cancer Database to identify patients with WHO grade II oligodendroglioma or astrocytoma between 2010 and 2012. Multivariable logistic regression was used to identify predictors of radiation use and multivariable Cox regression was used to identify covariables associated with differences in survival. There were 1952 patients included in this study, of which 518 (26.5%) received postoperative radiation. The majority had oligodendroglioma histology (n = 1121, 57.4%) compared to astrocytoma (n = 831, 42.6%). There were 1626 patients who were either ≥40 years old or underwent a subtotal resection ("high-risk"), and from these 495 (30.4%) received postoperative radiation. On multivariable logistic regression treatment at an academic facility (OR 0.72) was associated with a lower likelihood of receiving postoperative radiation. Astrocytoma histology (OR 2.08), age ≥40 years (OR 2.23), tumor size ≥6 cm (OR 1.64), subtotal resection (OR 1.55), and chemotherapy use (OR 3.93) were associated with an increased likelihood of postoperative radiation. On multivariable analysis, astrocytoma histology (HR 3.49, p < 0.001) and receipt of radiation (HR 2.06, p < 0.001) were associated with worse overall survival. GTR (HR 0.51, p = 0.001) was associated with improved overall survival. Patients treated in United States hospitals are not routinely referred for postoperative radiation for high-risk, low-grade gliomas. Patients who received radiation did not do better than those who did not receive radiation.

Impact of Timing of Adjuvant Chemoradiation for Glioblastoma in a Large Hospital Database.

BACKGROUND: Although the standard of care for glioblastoma remains maximal safe resection followed by chemoradiation, conflicting reports have emerged regarding the importance of the time interval between these 2 treatments. OBJECTIVE: To assess whether differences in the duration between surgery and initiation of chemoradiation for glioblastoma had an impact on overall survival (OS) in a large hospital-based database. METHODS: The National Cancer Database was queried to identify patients diagnosed with glioblastoma between 2010 and 2012 treated with surgery followed by chemoradiation. Patients who received biopsy only were excluded. The time from surgery to initiation of radiation therapy was divided into 4 equal quartiles of ≤24, 25 to 30, 31 to 37, and >37 d. Patient characteristics were compared between groups using Pearson Chi Square and Fisher's Exact test. OS was analyzed via the Kaplan-Meier method and compared via the log-rank test. Univariable and multivariable Cox regression were performed to assess for impact of covariables on OS. RESULTS: A total of 11 652 patients were included in the analysis. Median duration from surgery to radiation was 30 d. On multivariable regression, black race, larger tumor, gross-total resection, methyguanine-methyl transferase (MGMT+), and treatment at an academic facility were associated with a duration >30 d. On multivariable analysis, there were no significant differences when comparing start within 24 d to 25 to 30 d (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.90-1.01, P = .13) or > 37 d (HR 0.97, 95% CI 0.91-1.03, P = .26), although a small OS improvement was seen if initiated within 31 to 37 d (HR 0.93, 95% CI 0.88-0.99, P = .02). CONCLUSION: There was no clear association between duration from surgery to initiation of chemoradiation on OS.

Patterns of care and outcomes for glioblastoma in patients with poor performance status.

PURPOSE/OBJECTIVES: While treatment with tumor resection followed by chemoradiation is generally the accepted standard of care for glioblastoma (GBM), the treatment for patients with poor performance status remains uncertain. Therefore we sought to examine patterns of care and survival outcomes among patients with poor performance status utilizing a large hospital database. METHODS/MATERIALS: We queried the National Cancer Database (NCDB) for patients with GBM and Karnofsky performance status (KPS) <60 between 2010 and 2013. Data was collected regarding surgery, radiation therapy and chemotherapy. Logistic regression was used to analyze predictors for utilization of chemoradiation. The Kaplan-Meier method was used to compare survival between those who received chemoradiation to radiation alone and Cox regression was performed to assess covariates associated with survival. RESULTS: There were 488 patients included in the analysis of which 51.2% received chemoradiation and 46.1% underwent subtotal or gross total resection. None of the factors analyzed were significantly associated with increased likelihood of receiving chemoradiation over radiation alone. Survival data was available for 236 patients that received radiation therapy with and without combination chemotherapy. The median overall survival for those receiving radiation alone was 3.6 months and 8.7 months in those who received chemoradiation (p < 0.001). On multivariable Cox regression, increasing age (HR 1.80-2.10, p = 0.001) was associated with worse survival while subtotal/gross total resection (HR 0.60, p = 0.003) and chemoradiation (HR 0.57, CI 0.40-0.83, p = 0.003) were associated with improved survival. CONCLUSION: Even patients with poor performance status had better survival outcomes when they received treatment with chemoradiation over radiation alone.

Bilateral diffuse grade 5 radiation pneumonitis after intensity modulated radiation therapy for localized lung cancer.

We are reporting a case of fatal radiation pneumonitis that developed six months following chemoradiation for limited stage small cell lung cancer. The patient was a 67-year-old man with a past medical history of Hashimoto's thyroiditis and remote suspicion for CREST, neither of which were active in the years leading up to treatment. He received 6600 cGy delivered in 200 cGy daily fractions via intensity modulated radiation therapy with concurrent cisplatin/etoposide followed by additional chemotherapy with dose-reduced cisplatin/etoposide and carboplatin/etoposide and then received prophylactic cranial irradiation. The subsequent months were notable for progressively worsening episodes of respiratory compromise despite administration of prolonged steroids and he ultimately expired. Imaging demonstrated bilateral interstitial and airspace opacities. Autopsy findings were consistent with pneumonitis secondary to chemoradiation as well as lymphangitic spread of small cell carcinoma. The process was diffuse bilaterally although his radiation was delivered focally to the right lung and mediastinum.

Definitive Radiotherapy for Local Recurrence of NSCLC After Surgery.

INTRODUCTION: Locoregional recurrence after resection of non-small-cell lung cancer (NSCLC) is common. We examined outcomes after definitive radiotherapy (RT) to identify prognostic factors for survival and further recurrence. PATIENTS AND METHODS: We reviewed 152 patients who received RT for locoregional recurrent (LR)-NSCLC, and analyzed subsequent overall survival (OS), locoregional failure (LRF), distant metastasis (DM), and any disease progression (LRF and DM). RESULTS: Two- and 5-year OS were 49% and 28%, respectively. Two- and 5-year LRF, DM, and any disease progression rates were 40% and 45%, 33% and 37%, and 53% and 57%, respectively. Performance status and intensity-modulated RT (IMRT) were independently associated with OS, as was RT dose ≥ 60 Gy. Stage, chemotherapy at recurrence, and surgery to recurrence interval were not independently associated with outcome. Chemotherapy at initial presentation, adenocarcinoma histology, and male sex were independently associated with higher rates of DM. CONCLUSION: To our knowledge, this is the largest reported series of LR-NSCLC treated with definitive RT. Survival appears comparable to or greater than that of primary NSCLC. Subsequent LRF is more common than distant failure. Established prognostic factors for primary NSCLC, such as chemotherapy and stage, were not clearly prognostic in this analysis. IMRT and higher RT doses were associated with improved survival, though IMRT patients were also treated more recently. These data support definitive-intent RT with optimal dose and technique in such patients.