Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site.

BACKGROUND: Acute ischemic stroke with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO acute ischemic stroke is modified by initial stroke severity (baseline National Institutes of Health Stroke Scale [NIHSS]) and arterial occlusion site. METHODS: Based on the multicenter, retrospective, case-control study of consecutive iPCAO acute ischemic stroke patients (PLATO study [Posterior Cerebral Artery Occlusion Stroke]), we assessed the heterogeneity of EVT outcomes compared with medical management (MM) for iPCAO, according to baseline NIHSS score (≤6 versus >6) and occlusion site (P1 versus P2), using multivariable regression modeling with interaction terms. The primary outcome was the favorable shift of 3-month modified Rankin Scale (mRS). Secondary outcomes included excellent outcome (mRS score 0-1), functional independence (mRS score 0-2), symptomatic intracranial hemorrhage, and mortality. RESULTS: From 1344 patients assessed for eligibility, 1059 were included (median age, 74 years; 43.7% women; 41.3% had intravenous thrombolysis): 364 receiving EVT and 695 receiving MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (Pinteraction=0.312) but did with functional independence (Pinteraction=0.010), with a similar trend on excellent outcome (Pinteraction=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS score >6 (mRS score 0-1, 30.6% versus 17.7%; adjusted odds ratio [aOR], 2.01 [95% CI, 1.22-3.31]; mRS score 0 to 2, 46.1% versus 31.9%; aOR, 1.64 [95% CI, 1.08-2.51]) but not in those with NIHSS score ≤6 (mRS score 0-1, 43.8% versus 46.3%; aOR, 0.90 [95% CI, 0.49-1.64]; mRS score 0-2, 65.3% versus 74.3%; aOR, 0.55 [95% CI, 0.30-1.0]). EVT was associated with more symptomatic intracranial hemorrhage regardless of baseline NIHSS score (Pinteraction=0.467), while the mortality increase was more pronounced in patients with NIHSS score ≤6 (Pinteraction=0.044; NIHSS score ≤6: aOR, 7.95 [95% CI, 3.11-20.28]; NIHSS score >6: aOR, 1.98 [95% CI, 1.08-3.65]). Arterial occlusion site did not modify the association of EVT with outcomes compared with MM. CONCLUSIONS: Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS score >6) had more favorable disability outcomes with EVT than MM, despite increased mortality and symptomatic intracranial hemorrhage.

Outcomes of Bridging Intravenous Thrombolysis Versus Endovascular Therapy Alone in Late-Window Acute Ischemic Stroke.

BACKGROUND: Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS: We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS: Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS: In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.

Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy.

BACKGROUND: The association between sex and outcome after endovascular thrombectomy of acute ischemic stroke is unclear. The aim of this study was to compare the clinical and safety outcomes between men and women treated with endovascular thrombectomy in the late 6-to-24-hour window period. METHODS: This multicenter, retrospective observational cohort study included consecutive patients who underwent endovascular thrombectomy of anterior circulation stroke in the late window from 66 clinical sites in 10 countries from January 2014 to May 2022. The primary outcome was the 90-day ordinal modified Rankin Scale score. Secondary outcomes included 90-day functional independence (FI), return of Rankin (RoR) to prestroke baseline, FI or RoR, symptomatic intracranial hemorrhage, and mortality. Multivariable and inverse probability of treatment weighting methods were used. We explored the interaction of sex with baseline characteristics on the outcomes ordinal modified Rankin Scale and FI or RoR. RESULTS: Of 1932 patients, 1055 were women and 877 were men. Women were older (77 versus 69 years), had higher rates of atrial fibrillation, hypertension, and greater prestroke disability, but there was no difference in baseline National Institutes of Health Stroke Scale score. Inverse probability of treatment weighting analysis showed no difference between women and men in ordinal modified Rankin Scale (odds ratio, 0.98 [95% CI, 0.79-1.21]), FI or RoR (odds ratio, 0.98 [95% CI, 0.78-1.22]), severe disability or mortality (odds ratio, 0.99 [95% CI, 0.80-1.23]). The multivariable analysis of the above end points was concordant. There were no interactions between baseline characteristics and sex on the outcomes of ordinal modified Rankin Scale and FI or RoR. CONCLUSIONS: In late presenting patients with anterior circulation stroke treated with endovascular thrombectomy in the 6 to 24-hour window, there was no difference in clinical or safety outcomes between men and women.

Trends in cerebral venous thrombosis before and during the COVID-19 pandemic: Analysis of the National Inpatient Sample.

OBJECTIVES: We sought to provide updated incidence and trend data for cerebral venous thrombosis (CVT) in the United States from 2016-2020, examine the impact of the COVID-19 pandemic on CVT, and identify predictors of in-hospital mortality. MATERIALS AND METHODS: Validated ICD-10 codes were used to identify discharges with CVT in the National Inpatient Sample (NIS). Sample weights were applied to generate nationally representative estimates, and census data were used to compute incidence rates. The first wave of the COVID-19 pandemic was defined as January-May 2020. Trend analysis was completed using Joinpoint regression. RESULTS: From 2016 to 2020, the incidence of CVT increased from 24.34 per 1,000,000 population per year (MPY) to 33.63 per MPY (Annual Percentage Change (APC) 8.6 %; p < 0.001). All-cause in-hospital mortality was 4.9 % [95 % CI 4.5-5.4]. On multivariable analysis, use of thrombectomy, increased age, atrial fibrillation, stroke diagnosis, infection, presence of prothrombotic hematologic conditions, lowest quartile of income, intracranial hemorrhage, and male sex were associated with in-hospital mortality. CVT incidence was similar comparing the first 5 months of 2020 and 2019 (31.37 vs 32.04; p = 0.322) with no difference in median NIHSS (2 [IQR 1-10] vs. 2 [1-9]; p = 0.959) or mortality (4.2 % vs. 5.6 %; p = 0.176). CONCLUSIONS: CVT incidence increased in the US from 2016 to 2020 while mortality did not change. Increased age, prothrombotic state, stroke diagnosis, infection, atrial fibrillation, male sex, lowest quartile of income, intracranial hemorrhage, and use of thrombectomy were associated with in-hospital mortality following CVT. During the first wave of the COVID-19 pandemic, CVT volumes and mortality were similar to the prior year.

Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study.

BACKGROUND: The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. METHODS: This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. RESULTS: Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). CONCLUSIONS: In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.

Change in stage after neoadjuvant chemoradiation is associated with survival in patients with esophageal cancer.

BACKGROUND: The aim of this study was to determine if change in stage after neoadjuvant chemoradiation (CRT) was associated with improved survival in esophageal cancer using a national database. METHODS: Using the National Cancer Database, patients with non-metastatic, resectable esophageal cancer who received neoadjuvant CRT and surgery were identified. Comparing clinical to the pathologic stage, change in stage was classified as pathologic complete response (pCR), downstaged, same-staged, or upstaged. Univariable and multivariable Cox regression models were used to identify factors associated with survival. RESULTS: A total of 7745 patients were identified. The median overall survival (OS) was 34.9 months. Median OS was 60.3 months if pCR, 39.1 months if downstaged, 28.3 months if same-staged, and 23.4 months if upstaged (p < 0.0001). On multivariable analysis, pCR was associated with improved OS compared to the other groups (downstaged: hazard ratio [HR]: 1.32 [95% confidence interval [CI]: 1.18-1.46]; same-staged: HR: 1.89 [95% CI: 1.68-2.13]; upstaged: HR: 2.54 [95% CI: 2.25-2.86]; all p < 0.0001). CONCLUSIONS: In this large database study, change in stage after neoadjuvant CRT was strongly associated with survival for patients with non-metastatic, resectable esophageal cancer. There was a significant stepwise decline in survival, in descending order of pCR, downstaged tumor, same-staged tumor, and upstaged tumor.

Longitudinal Outcomes of Medical Student Research Mentorship: a 15-Year Analysis of the Radiation Oncology Mentorship Initiative.

At our institution, students can be mentored by radiation oncology faculty through structured research programs, such as the Medical Student Summer Research Program (MSSRP). The purpose of this study is to report the research productivity of students who engaged in radiation oncology research mentorship, whether through the MSSRP or other avenues of research mentorship. We compiled a database of abstracts and manuscripts co-authored by 58 students who conducted research with radiation oncology faculty from 2005 to 2020. The means, medians, ranges, and interquartile ranges (IQR) of co-authorships and first authorships were calculated for the overall cohort and compared for MSSRP and non-MSSRP students, who matched into radiation oncology and those who did not, and male versus female students. Among all 58 students, 106 abstracts and 70 manuscripts were identified. Of those students, 54 (93.1%) published at least one abstract or manuscript. The mean number of abstract co-authorships per student was 3.07 (median 2, range 0-25, IQR 0-4), and the mean number of manuscript co-authorships per student was 2.22 (median 1, range 0-18, IQR 1-3). There were no significant differences in research output between MSSRP and non-MSSRP students or male and female students. However, the students who matched into radiation oncology published more co-author (3.67 vs. 1.63, p = 0.01) and first-author (1.62 vs. 0.53, p = 0.006) manuscripts than those who did not. Further research is warranted to assess whether skills gained from student-directed research translate into residency and beyond.

Reperfusion Without Functional Independence in Late Presentation of Stroke With Large Vessel Occlusion.

BACKGROUND: Reperfusion without functional independence (RFI) is an undesired outcome following thrombectomy in acute ischemic stroke. The primary objective was to evaluate, in patients presenting with proximal anterior circulation occlusion stroke in the extended time window, whether selection with computed tomography (CT) perfusion or magnetic resonance imaging is associated with RFI, mortality, or symptomatic intracranial hemorrhage (sICH) compared with noncontrast CT selected patients. METHODS: The CLEAR study (CT for Late Endovascular Reperfusion) was a multicenter, retrospective cohort study of stroke patients undergoing thrombectomy in the extended time window. Inclusion criteria for this analysis were baseline National Institutes of Health Stroke Scale score ≥6, internal carotid artery, M1 or M2 segment occlusion, prestroke modified Rankin Scale score of 0 to 2, time-last-seen-well to treatment 6 to 24 hours, and successful reperfusion (modified Thrombolysis in Cerebral Infarction 2c-3). RESULTS: Of 2304 patients in the CLEAR study, 715 patients met inclusion criteria. Of these, 364 patients (50.9%) showed RFI (ie, mRS score of 3-6 at 90 days despite successful reperfusion), 37 patients (5.2%) suffered sICH, and 127 patients (17.8%) died within 90 days. Neither imaging selection modality for thrombectomy candidacy (noncontrast CT versus CT perfusion versus magnetic resonance imaging) was associated with RFI, sICH, or mortality. Older age, higher baseline National Institutes of Health Stroke Scale, higher prestroke disability, transfer to a comprehensive stroke center, and a longer interval to puncture were associated with RFI. The presence of M2 occlusion and higher baseline Alberta Stroke Program Early CT Score were inversely associated with RFI. Hypertension was associated with sICH. CONCLUSIONS: RFI is a frequent phenomenon in the extended time window. Neither magnetic resonance imaging nor CT perfusion selection for mechanical thrombectomy was associated with RFI, sICH, and mortality compared to noncontrast CT selection alone. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04096248.

Oral cancer patients achieve comparable survival at high safety-net burden hospitals.

PURPOSE: To evaluate the impact of hospital safety-net burden and social demographics on the overall survival of patients with oral cavity squamous cell carcinoma. MATERIALS AND METHODS: We identified 48,176 oral cancer patients diagnosed between the years 2004 to 2015 from the National Cancer Database and categorized treatment facilities as no, low, or high safety-net burden hospitals based on the percentage of uninsured or Medicaid patients treated. Using the Kaplan Meier method and multivariate analysis, we examined the effect of hospital safety-net burden, sociodemographic variables, and clinical factors on overall survival. RESULTS: Of the 1269 treatment facilities assessed, the median percentage of uninsured/Medicaid patients treated was 0% at no, 11.6% at low, and 23.5% at high safety-net burden hospitals and median survival was 68.6, 74.8, and 55.0 months, respectively (p < 0.0001). High safety-net burden hospitals treated more non-white populations (15.4%), lower median household income (<$30,000) (23.2%), and advanced stage cancers (AJCC III/IV) (54.6%). Patients treated at low (aHR = 0.97; 95% CI = 0.91-1.04, p = 0.405) and high (aHR = 1.05; 95% CI = 0.98-1.13, p = 0.175) safety-net burden hospitals did not experience worse survival outcomes compared to patients treated at no safety-net burden hospitals. CONCLUSION: High safety-net burden hospitals treated more oral cancer patients of lower socioeconomic status and advanced disease. Multivariate analysis showed high safety-net burden hospitals achieved comparable patient survival to lower burden hospitals.

Perceptions on basilar artery occlusion management in China versus other countries: Analysis of the after the BEST of BASICS (ABBA) survey.

INTRODUCTION: Uncertainty remains on the optimal management of basilar artery occlusion (BAO). Two large randomized controlled trials (RCTs) in 2019 and 2021 demonstrated neutral results with respect to the use of endovascular therapy (EVT) for BAO. This study aimed to understand regional variation in physicians' perceptions towards the treatment of BAO as stratified by physician respondents from China versus outside China, prior to the publication of studies demonstrating a benefit of EVT for BAO. METHODS: An international online survey was conducted of stroke neurologists and neurointerventionalists from January to March 2022. Survey questions evaluated physician opinions toward the use of EVT in BAO, as well as the clinical and imaging features underlying treatment decisions. Respondents were dichotomized as either from China or from other countries and differences between groups were analyzed. RESULTS: There were 1245 physician respondents across 73 countries of which 295 (23.7%) were from China. Compared to respondents from the rest of the world, respondents from China were more likely to be interventionalists (71.5% vs 35.0%; p < 0.0001). Overall, more than 95% of respondents believed that EVT was superior to medical therapy under certain circumstances. Chinese respondents were more likely to believe that further RCTs were necessary than respondents from other countries (93.6% vs 76.2%; p < 0.0001). Chinese respondents were more likely to use advanced imaging in later time windows and use a premorbid mRS threshold of ≤2 for BAO selection to EVT. CONCLUSION: Most stroke physicians believe EVT is beneficial in selected patients with BAO. Clinical and imaging modality differences were observed in the selection criteria used for EVT. There was greater inclination to enroll all trial eligible patients in a BAO RCT by respondents from China as compared to other parts of the world.

Notification System for Overdue Radiology Recommendations Improves Rates of Follow-Up and Diagnosis.

OBJECTIVE. The purpose of this study was to quantify improved rates of follow-up and additional important diagnoses made after notification for overdue workups recommended by radiologists. MATERIALS AND METHODS. Standard reports from imaging studies performed at our institution from October through November 2016 were searched for the words "recommend" or "advised," yielding 9784 studies. Of these, 5245 were excluded, yielding 4539 studies; reports for 1599 of these 4539 consecutive studies were reviewed to identify firm or soft recommendations or findings requiring immediate management. If recommended follow-ups were incomplete within 1 month of the advised time, providers were notified. Compliance was calculated before and after notification and was compared using a one-sample test of proportion. RESULTS. Of 1599 patients, 92 were excluded because they had findings requiring immediate management, and 684 were excluded because of soft recommendations, yielding 823 patients. Of these patients, 125 were not yet overdue for follow-up and were excluded, and 18 were excluded because of death or transfer to another institution. Of the remaining 680 patients, follow-up was completed for 503 (74.0%). A total of 177 (26.0%) of the 680 patients were overdue for follow-up, and providers were notified. Of these 177 patients, 36 (20.3%) completed their follow-ups after notification, 34 (19.2%) had follow-up designated by the provider as nonindicated, and 107 (60.5%) were lost to follow-up, yielding four clinically important diagnoses: one biopsy-proven malignancy, one growing mass, and two thyroid nodules requiring biopsy. The rate of incomplete follow-ups after communication decreased from 26.0% (177/680) to 20.7% (141/680) (95% CI, 17.7-23.9%; p = .002), with a 20.4% reduction in relative risk of noncompliance, and 39.5% (70/177) of overdue cases were resolved when nonindicated studies were included. CONCLUSION. Notification of overdue imaging recommendations reduces incomplete follow-ups and yields clinically important diagnoses.

A national cancer database analysis on stereotactic body radiation therapy of head and neck cancers.

BACKGROUND: To evaluate demographic, clinicopathological, treatment factors including biological effective radiation dose (BED) that influence overall survival in head and neck cancer (HNC) patients treated with stereotactic body radiation therapy (SBRT). METHODS: Between 2004 and 2015, 591 SBRT-treated HNC patients were identified from the National Cancer Data Base. A BED using an alpha/beta ratio of 10 (BED10), was used to compare dose fractionation of different SBRT regimens. Overall survival was estimated using the Kaplan Meier method, and log-rank tests were used to determine statistical significance. Cox regression modeling was used to compute crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Median follow-up was 11.9 (interquartile range, 5.5 to 26.7) months. The 5-year overall survival rate was 15.5%. On multivariate analysis, older age, Charlson-Deyo comorbidity score ≥ 1, history of cancer, tumor, nodal and metastatic stage, and receiving treatment at academic/research program were associated with poor survival. Compared to SBRT alone, superior survival was observed with SBRT with chemotherapy, surgery with SBRT, but not surgery with SBRT and chemotherapy. Improved survival was observed with aa BED10 of ≥59.5 Gy (adjusted HR 0.57, 95% CI 0.46-0.70, P < 0.0001). CONCLUSIONS: Factors affecting associated with worse survival in HNC patients treated with SBRT included older age, patient comorbidities, advanced tumor stage, cancer history, and lower biological effective SBRT dose. LEVEL OF EVIDENCE: 2b (individual cohort study).

Racial differences in genomic testing and receipt of endocrine therapy in early-stage breast cancer.

PURPOSE: Genomic testing in early-stage hormone-positive breast cancer is the standard of care. However, decisions based on genomic testing results are predicated on the assumption that patients receive endocrine treatment. We sought to investigate racial differences in genomic testing and adjuvant treatment in breast cancer. METHODS: A retrospective, population-based hospital registry study using the National Cancer Database. Participants included women with stages I-II, ER + breast cancer between 2010 and 2014. Sociodemographic factors were analyzed. Primary outcomes were the utilization of genomic testing and receipt of endocrine therapy. Logistic regression modeling was used to compute crude and adjusted odds of genomic testing and receipt of endocrine therapy. RESULTS: Among a total sample size of 387,008 patients, 147,863 (38.2%) underwent genomic testing. Older age (≥ 70 years) was associated with a lower adjusted odd of genomic testing (OR 0.33; 95% CI 0.32-0.34, p = < 0.0001). Black patients had lower odds of receiving genomic testing on multivariate analysis compared to Whites (OR 0.82; 95% CI 0.80-0.85, p = < 0.0001). In patients who underwent a genomic test, compared to Whites, Blacks had a lower odds of receiving endocrine therapy (OR 0.86; 95% CI 0.80-0.93, p = < 0.0001) even if they did not receive adjuvant chemotherapy (OR 0.90; 95% CI 0.82-0.98, p = 0.014). CONCLUSIONS: In a national sample of breast cancer patients, Black women are less likely to get genomic testing and receive hormonal therapy, even when adjuvant chemotherapy is omitted. A priority in addressing breast cancer disparities is to ensure adherence to hormonal therapy among all women, including those who do not receive adjuvant chemotherapy.

Hypofractionated radiotherapy and surgery compared to standard radiotherapy in early glottic cancer.

PURPOSE: Early-stage glottic laryngeal cancer is treated with surgery or radiotherapy (RT), but limited randomized data exists to support one modality over the other. This study evaluates survival differences in early glottic cancer patients treated with either surgery or RT. MATERIALS AND METHODS: 14,498 patients with early glottic cancer diagnosed from 2004 to 2015 and treated with surgery or RT were identified in the National Cancer Database. Kaplan-Meier method was used to analyze differences in overall survival (OS) by treatment (surgery vs. RT) and radiation dose fractionation. Cox regression modeling and propensity score-matched (PSM) analysis were performed. Adjusted hazard ratios (aHR) with 95% confidence intervals (95% CI) were computed. RESULTS: Median follow-up and median OS for all patients were 49.5 and 118 months, respectively. The estimated 5-year OS for surgery and RT was 77.5% and 72.6%, respectively (P < 0.0001). On multivariate analysis, aHR (95% CI) for surgery compared to RT was 0.87 (0.81-0.94, P = 0.0004). Compared to RT regimen 63-67.5 Gray (Gy) in 28-30 fractions, worse survival was noted for RT regimen 66-70 Gy in 33-35 fractions (aHR 1.15, 95% CI 1.07-1.23, P = 0.0003). When compared with hypofractionated RT (63-67.5 Gy in 28-30 fractions), patients undergoing surgery no longer showed improved OS (aHR 0.94, 95% CI 0.86-1.02, P = 0.154). The finding was confirmed on PSM analysis (surgery aHR 0.95, 95% CI 0.87-1.05, P = 0.322). CONCLUSION: In early glottic tumors, patients treated with surgery demonstrated improved survival compared to RT, but when hypofractionation was considered, there were no significant differences in OS between patients undergoing surgery or RT.

Comparing surgical and nonsurgical larynx-preserving treatments with total laryngectomy for locally advanced laryngeal cancer.

BACKGROUND: The declining 5-year overall survival (OS) of patients with laryngeal cancer has been associated with increased nonsurgical management of stage III/IV disease. To further assess this hypothesis, the authors evaluated recent OS trends and patterns of use between larynx-preserving approaches with chemoradiation (CRT) or partial laryngectomy (PL) and total laryngectomy (TL) stratified by tumor and nodal burden. METHODS: The National Cancer Data Base was used to identify 8703 patients with stage III/IV (excluding T1 tumors) laryngeal squamous cell carcinoma treated between 2003 and 2011 with CRT or upfront PL or TL with or without adjuvant therapy. OS was analyzed using the Kaplan-Meier method and a Cox proportional hazards model. RESULTS: Among patients with non-T4, low nodal burden (T2N1 or T3N0-N1) disease, no survival differences were observed between CRT, PL, and TL. Patients who had non-T4, high nodal burden (T2-T3N2-N3) disease who underwent TL with or without adjuvant treatment had a higher risk of death compared with those who received CRT (hazard ratio, 1.25; 95% CI, 1.04-1.51; P = .016). For T4N0-N3 tumors, TL compared with CRT was associated with improved OS (hazard ratio, 0.80; 95% CI, 0.62-0.92; P = .002). No statistically significant difference in outcome was noted between CRT and PL for all stage groups. The use of CRT has declined and receipt of TL has increased since 2006 for T4 disease, whereas PL rates have remained stably low. CONCLUSIONS: No survival differences were noted between surgical and nonsurgical approaches for patients with non-T4, low nodal burden laryngeal cancer. Patients with non-T4, high nodal burden disease may benefit from definitive CRT. Total laryngectomy remains advantageous in patients with T4 disease.

Demographics and outcomes of stage I and II Merkel cell carcinoma treated with Mohs micrographic surgery compared with wide local excision in the National Cancer Database.

BACKGROUND: The optimal surgical approach (wide local excision [WLE] vs Mohs micrographic surgery [MMS]) for treating Merkel cell carcinoma (MCC) is yet to be determined. OBJECTIVE: To compare survival outcomes in patients with early-stage MCC treated with MMS versus with WLE. METHODS: A retrospective review of all cases in the National Cancer Database (NCDB) of MCC of clinical stage I or II MCC treated with WLE or MMS was performed. RESULTS: A total of 1795 cases of stage I or II MCC who underwent WLE (n = 1685) or MMS (n = 110) were identified. There was no difference in residual tumor on surgical margins between the 2 treatment groups (P = .588). On multivariate analysis, there was no difference in overall survival between the treatment modalities (adjusted hazard ratio, 1.02; 95% confidence interval, 0.72-1.45; P = .897). There was no difference in overall survival between the 2 groups on propensity score-matched analysis. LIMITATIONS: Disease-specific survival was not reported, as these data are not available in the National Cancer Database. CONCLUSIONS: MMS appears to be as effective as WLE in treating early-stage MCC.

Quantitative variations in texture analysis features dependent on MRI scanning parameters: A phantom model.

OBJECTIVES: To evaluate the influence of MRI scanning parameters on texture analysis features. METHODS: Publicly available data from the Reference Image Database to Evaluate Therapy Response (RIDER) project sponsored by The Cancer Imaging Archive included MRIs on a phantom comprised of 18 25-mm doped, gel-filled tubes, and 1 20-mm tube containing 0.25 mM Gd-DTPA (EuroSpinII Test Object5, Diagnostic Sonar, Ltd, West Lothian, Scotland). MRIs performed on a 1.5 T GE HD, 1.5 T Siemens Espree (VB13), or 3.0 T GE HD with TwinSpeed gradients with an eight-channel head coil included T1WIs with multiple flip angles (flip-angle = 2,5,10,15,20,25,30), TR/TE = 4.09-5.47/0.90-1.35 ms, NEX = 1 and DCE with 30° flip-angle, TR/TE=4.09-5.47/0.90-1.35, and NEX = 1,4. DICOM data were imported into an in-house developed texture analysis program which extracted 41-texture features including histogram, gray-level co-occurrence matrix (GLCM), and gray-level run-length (GLRL). Two-tailed t tests, corrected for multiple comparisons (Q values) were calculated to compare changes in texture features with variations in MRI scanning parameters (magnet strength, flip-angle, number of excitations (NEX), scanner platform). RESULTS: Significant differences were seen in histogram features (mean, median, standard deviation, range) with variations in NEX (Q = 0.003-0.045) and scanner platform (Q < 0.0001), GLCM features (entropy, contrast, energy, and homogeneity) with NEX (Q = 0.001-0.018) and scanner platform (Q < 0.0001), GLRL features (long-run emphasis, high gray-level run emphasis, high gray-level emphasis) with magnet strength (Q = 0.0003), NEX (Q = 0.003-0.022) and scanner platform (Q < 0.0001). CONCLUSION: Significant differences were seen in many texture features with variations in MRI acquisition emphasizing the need for standardized MRI technique.

Application of texture analysis on parametric T1 and T2 maps for detection of hepatic fibrosis.

PURPOSE: To assess the utility of texture analysis of T1 and T2 maps for the detection of hepatic fibrosis in a murine model of hepatic fibrosis. MATERIALS AND METHODS: Following Institutional Animal Care and Use Committee approval, a dietary model of hepatic fibrosis was used and 15 ex vivo murine livers were examined. Images were acquired using a 30 mm bore 11.7T magnetic resonance imaging (MRI) scanner with a rapid acquisition with relaxation enhancement sequence. Texture analysis was then employed, extracting texture features including histogram-based, gray-level co-occurrence matrix-based (GLCM), gray-level run-length-based features (GLRL), gray-level gradient matrix (GLGM), and Laws' features. Areas under the curve (AUCs) were then calculated to determine the ability of texture features to detect hepatic fibrosis. RESULTS: Texture analysis of T1 maps identified very good to excellent discriminators of hepatic fibrosis within the histogram and GLGM categories. Histogram feature interquartile range (IQR) achieved an AUC value of 0.90 (P < 0.0001) and GLGM feature variance gradient achieved an AUC of 0.91 (P < 0.0001). Texture analysis of T2 maps identified very good to excellent discriminators of hepatic fibrosis within the histogram, GLCM, GLRL, and GLGM categories. GLGM feature kurtosis was the best discriminator of hepatic fibrosis, achieving an AUC value of 0.90 (P < 0.0001). CONCLUSION: This study demonstrates the utility of texture analysis for the detection of hepatic fibrosis when applied to T1 and T2 maps in a murine model of hepatic fibrosis and validates the potential use of this technique for the noninvasive, quantitative assessment of hepatic fibrosis. LEVEL OF EVIDENCE: 1 J. Magn. Reson. Imaging 2017;45:250-259.