Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends.

BACKGROUND: The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends. METHODS: In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics. RESULTS: Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true. CONCLUSIONS: Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

Recurrence Rates of Mohs Micrographic Surgery vs Radiation Therapy for Basal Cell Carcinoma of the Ear.

Basal cell carcinoma (BCC) of the ear may have aggressive histologic subtypes and a greater propensity for subclinical spread than BCC in other anatomic locations. In this retrospective analysis, we evaluated recurrence rates of BCC of the ear in 102 patients who underwent treatment with Mohs micrographic surgery (MMS) or radiation therapy (RT) at a single institution between January 2017 and December 2019. Data on patient demographics, tumor characteristics, treatment modality, and recurrence rates were collected from medical records. Recurrence rates were assessed over a mean follow-up time of 2.8 years. Although MMS is the gold standard for treatment of BCC of the ear, RT may be a suitable alternative for nonsurgical candidates.

Primary intraocular lymphoma: a review.

Primary intraocular lymphoma (PIOL) is a rare, non-Hodgkin lymphoma considered to be a subtype of primary central nervous system lymphoma. We describe a 65-year-old woman who presented to the Hematology/Oncology Clinic at Scripps Clinic, La Jolla, California, who was diagnosed with bilateral PIOL without systemic disease. She enjoyed a 16-month remission but ultimately recurred in the brain. We reviewed the literature and present a discussion of the diagnostic criteria for PIOL and current strategies for treating PIOL in immunocompetent patients.

Five-year clinical follow-up after intracoronary radiation: results of a randomized clinical trial.

BACKGROUND: Several clinical trials indicate that intracoronary radiation is safe and effective for treatment of restenotic coronary arteries. We previously reported 6-month and 3-year clinical and angiographic follow-up demonstrating significant decreases in target lesion revascularization (TLR) and angiographic restenosis after gamma radiation of restenotic lesions. The objective of this study was to document the clinical outcome 5 years after treatment of restenotic coronary arteries with catheter-based iridium-192 (192Ir). METHODS AND RESULTS: A double-blind, randomized trail compared 192Ir to placebo sources in patients with restenosis after coronary angioplasty. Over a 9-month period, 55 patients were enrolled; 26 were randomized to 192Ir and 29 to placebo. At 5-year follow-up, TLR was significantly lower in the 192Ir group (23.1% versus 48.3%; P=0.05). There were 2 TLRs between years 3 and 5 in patients in the 192Ir group and none in patients in the placebo group. The 5-year event-free survival rate (freedom from death, myocardial infarction, or TLR) was greater in 192Ir-treated patients (61.5% versus 34.5%; P=0.02). CONCLUSIONS: Despite apparent mitigation of efficacy over time, there remains a significant reduction in TLR at 5 years and an improvement in event-free survival in patients treated with intracoronary 192Ir. The early clinical benefits after intracoronary gamma radiation with 192Ir seem durable at 5-year clinical follow-up.

Long-term outcome of patients treated with repeat percutaneous coronary intervention after failure of gamma-brachytherapy for the treatment of in-stent restenosis.

BACKGROUND: Although (192)Ir intracoronary brachytherapy has been demonstrated to dramatically reduce the recurrence of in-stent restenosis, up to 24% of these patients will still require repeat target-vessel revascularization. The short- and long-term outcomes of repeat percutaneous intervention in this population have not been characterized. METHODS AND RESULTS: Analysis was performed of all patients enrolled in the GAMMA-I and GAMMA-II brachytherapy trials who underwent repeat percutaneous target lesion revascularization (TLR) because of restenosis. Subjects were divided into 2 cohorts: those who had received (192)Ir brachytherapy and those randomized to placebo. Forty-five (17.6%) of a total of 256 patients whose index treatment was intracoronary radiation therapy and 36 (29.8%) of 121 patients whose index treatment was placebo required repeat percutaneous TLR. The mean time to this first TLR was 295+/-206 days in the irradiated group and 202+/-167 days in the placebo group (P=0.03). Acute procedural success occurred in 100% of irradiated patients and 94% of placebo controls (P=0.19). After the first TLR, a subsequent TLR was required in 15 (33.3%) of 45 brachytherapy patients versus 17 (47.2%) of 36 placebo failure patients (P=0.26). There was no significant difference in time to second TLR between the 2 groups. Other long-term major adverse event rates in both groups were comparable to those of other contemporary angioplasty/stenting series. CONCLUSIONS: In those patients who "fail" (192)Ir intracoronary brachytherapy for in-stent restenosis, treatment with (192)Ir delays the time to first TLR. Additionally, repeat percutaneous intervention in these patients is safe and efficacious in the short term, with acceptable long-term results.

Education and Training Needs in Radiation Oncology in India: Opportunities for Indo-US Collaborations.

PURPOSE: To conduct a survey of radiation oncologists in India, to better understand specific educational needs of radiation oncology in India and define areas of collaboration with US institutions. METHODS AND MATERIALS: A 20-question survey was distributed to members of the Association of Indian Radiation Oncologists and the Indian Brachytherapy Society between November 2013 and May 2014. RESULTS: We received a total of 132 responses. Over 50% of the physicians treat more than 200 patients per day, use 2-dimensional or 3-dimensional treatment planning techniques, and approximately 50% use image guided techniques. For education needs, most respondents agreed that further education in intensity modulated radiation therapy, image guided radiation therapy, stereotactic radiation therapy, biostatistics, and research methods for medical residents would be useful areas of collaboration with institutions in the United States. Other areas of collaboration include developing a structured training module for nursing, physics training, and developing a second-opinion clinic for difficult cases with faculty in the United States. CONCLUSION: Various areas of potential collaboration in radiation oncology education were identified through this survey. These include the following: establishing education programs focused on current technology, facilitating exchange programs for trainees in India to the United States, promoting training in research methods, establishing training modules for physicists and oncology nurses, and creating an Indo-US. Tumor Board. It would require collaboration between the Association of Indian Radiation Oncologists and the American Society for Radiation Oncology to develop these educational initiatives.

Coronary artery radiation therapy for the prevention of restenosis after percutaneous coronary angioplasty, II: Outcomes of clinical trials.

Coronary artery radiation therapy (CART) has become the standard of care for the treatment of coronary in-stent restenosis after repeat angioplasty. More than 5,000 patients have been enrolled into various clinical trials using 3 major systems. Based on the results of GAMMA I and START trials, both the Checkmate system using (192)Ir and the Betacath system using (90)Sr/Y have been approved for routine clinical use in the treatment of in-stent restenosis. The Galileo system using (32)P with data from INHIBIT trial is pending premarketing approval. With a better understanding and application of radiation oncology concepts to vascular brachytherapy, problems such as geographic miss and/or edge failure should be overcome. The complication of late thrombosis should also become less notable by eliminating restenting at the brachytherapy procedure and the prolonged use of antiplatelet therapy. Although there are other competing modalities in the very early phases of clinical trials, the future of CART appears bright. The durability of results, lack of any important complications, and confirmation of the efficacy in other sites will further consolidate the role of CART in preventing vascular restenosis.

An Internet-ready database for prospective randomized clinical trials of high-dose-rate brachytherapy for adenocarcinoma of the prostate.

PURPOSE: To demonstrate a new interactive Internet-ready database for prospective clinical trials in high-dose-rate (HDR) brachytherapy for prostate cancer. METHODS AND MATERIALS: An Internet-ready database was created that allows common data acquisition and statistical analysis. Patient anonymity and confidentiality are preserved. These data forms include all common elements found from a survey of the databases. The forms allow the user to view patient data in a view-only or edit mode. Eight linked forms document patient data before and after receiving HDR therapy. The pretreatment forms are divided into four categories: staging, comorbid diseases, external beam radiotherapy data, and signs and symptoms. The posttreatment forms separate data by HDR implant information, HDR medications, posttreatment signs and symptoms, and follow-up data. The forms were tested for clinical usefulness. CONCLUSION: This Internet-based database enables the user to record and later analyze all relevant medical data and may become a reliable instrument for the follow-up of patients and evaluation of treatment results.

Intravascular brachytherapy: indications and management of adverse events.

Intravascular brachytherapy has become the standard of care for the treatment of coronary in-stent restenosis after repeat angioplasty. More than 5000 patients have been treated as part of various clinical trials. Based on the results of the GAMMA I trial, the START ((90)Sr Treatment of Angiographic Restenosis Trial), and the INHIBIT (INtimal Hyperplasia Inhibition with Beta In-stent restenosis Trial), the Checkmate system using (192)Ir, the Betacath system using (90)Sr/Y, and the Galileo system using (32)P, have been approved for the treatment of in-stent restenosis. With a better understanding and application of radiation oncology concepts to vascular brachytherapy, problems such as edge failure are being overcome. The complication of late thrombosis has also become less significant with the elimination of restenting at the brachytherapy procedure, and the prolonged use of antiplatelet therapy. There are other competing modalities in the early phases of clinical trials. The durability of results, lack of any significant long-term complications and the confirmation of the efficacy in other sites will further consolidate the role of radiation in treating in-stent restenosis.

Standardizing naming conventions in radiation oncology.

PURPOSE: The aim of this study was to report on the development of a standardized target and organ-at-risk naming convention for use in radiation therapy and to present the nomenclature for structure naming for interinstitutional data sharing, clinical trial repositories, integrated multi-institutional collaborative databases, and quality control centers. This taxonomy should also enable improved plan benchmarking between clinical institutions and vendors and facilitation of automated treatment plan quality control. MATERIALS AND METHODS: The Advanced Technology Consortium, Washington University in St. Louis, Radiation Therapy Oncology Group, Dutch Radiation Oncology Society, and the Clinical Trials RT QA Harmonization Group collaborated in creating this new naming convention. The International Commission on Radiation Units and Measurements guidelines have been used to create standardized nomenclature for target volumes (clinical target volume, internal target volume, planning target volume, etc.), organs at risk, and planning organ-at-risk volumes in radiation therapy. The nomenclature also includes rules for specifying laterality and margins for various structures. The naming rules distinguish tumor and nodal planning target volumes, with correspondence to their respective tumor/nodal clinical target volumes. It also provides rules for basic structure naming, as well as an option for more detailed names. Names of nonstandard structures used mainly for plan optimization or evaluation (rings, islands of dose avoidance, islands where additional dose is needed [dose painting]) are identified separately. RESULTS: In addition to its use in 16 ongoing Radiation Therapy Oncology Group advanced technology clinical trial protocols and several new European Organization for Research and Treatment of Cancer protocols, a pilot version of this naming convention has been evaluated using patient data sets with varying treatment sites. All structures in these data sets were satisfactorily identified using this nomenclature. CONCLUSIONS: Use of standardized naming conventions is important to facilitate comparison of dosimetry across patient datasets. The guidelines presented here will facilitate international acceptance across a wide range of efforts, including groups organizing clinical trials, Radiation Oncology Institute, Dutch Radiation Oncology Society, Integrating the Healthcare Enterprise, Radiation Oncology domain (IHE-RO), and Digital Imaging and Communication in Medicine (DICOM).

Radiation therapy in early-stage invasive breast cancer.

The treatment of breast cancer involves a multi-disciplinary approach with radiation therapy playing a key role. Breast-conserving surgery has been an option for women with early-stage breast cancer for over two decades now. Multiple randomized trials now have demonstrated the efficacy of breast-conserving surgery followed by radiation therapy. With the advancements in breast imaging and the successful campaign for early detection of breast cancer, more women today are found to have early-stage small breast cancers. Patient factors (breast size, tumor location, history of prior radiation therapy, preexisting conditions such as collagen vascular disease, age, having prosthetically augmented breasts), pathological factors (margin status, tumor size, presence of extensive intraductal component requiring multiple surgical excisions), as well as patient preference are all taken into consideration prior to surgical management of breast cancer. Whole-breast fractionated radiation therapy between 5 and 7 weeks is considered as the standard of care treatment following breast-conserving surgery. However, new radiation treatment strategies have been developed in recent years to provide alternatives to the conventional 5-7 week whole-breast radiation therapy for some patients. Accelerated partial breast radiation therapy (APBI) was introduced because the frequency of breast recurrences outside of the surgical cavity has been shown to be low. This technique allows treatments to be delivered quicker (usually 1 week, twice daily) to a limited volume. Often times, this treatment involves the use of a brachytherapy applicator to be placed into the surgical cavity following breast-conserving surgery. Accelerated hypofractionated whole-breast irradiation may be another faster way to deliver radiation therapy following breast-conserving surgery. This journal article reviews the role of radiation therapy in women with early-stage breast cancer addressing patient selection in breast-conserving therapy, a review of pertinent trials in breast-conserving therapy, as well as the different treatment techniques available to women following breast-conserving surgery.

Integrating the healthcare enterprise in radiation oncology plug and play--the future of radiation oncology?

PURPOSE: To describe the processes and benefits of the integrating healthcare enterprises in radiation oncology (IHE-RO). METHODS: The IHE-RO process includes five basic steps. The first step is to identify common interoperability issues encountered in radiation treatment planning and the delivery process. IHE-RO committees partner with vendors to develop solutions (integration profiles) to interoperability problems. The broad application of these integration profiles across a variety of vender platforms is tested annually at the Connectathon event. Demonstration of the seamless integration and transfer of patient data to the potential users are then presented by vendors at the public demonstration event. Users can then integrate these profiles into requests for proposals and vendor contracts by institutions. RESULTS: Incorporation of completed integration profiles into requests for proposals can be done when purchasing new equipment. Vendors can publish IHE integration statements to document the integration profiles supported by their products. As a result, users can reference integration profiles in requests for proposals, simplifying the systems acquisition process. These IHE-RO solutions are now available in many of the commercial radiation oncology-related treatment planning, delivery, and information systems. They are also implemented at cancer care sites around the world. CONCLUSIONS: IHE-RO serves an important purpose for the radiation oncology community at large.

Beta endovascular brachytherapy using CO2-filled centering catheter for treatment of recurrent superficial femoropopliteal artery disease.

BACKGROUND: Recurrent disease (restenosis) after endovascular treatment of the superficial femoral artery (SFA) remains a major problem. We evaluated the efficacy of beta-endovascular brachytherapy using the CORONA centering catheter in patients with SFA restenosis in a single-arm Phase II trial. METHODS AND RESULTS: A total of 28 patients (mean age 70 years; 16 female, 12 male) with recurrent SFA stenosis were treated, and in-stent restenosis was present in 17 patients (61%). Brachytherapy was performed with strontium-90 beta source using a 7-French CO(2)-filled one-segment centering catheter. New stents had to be applied in two cases. Mean interventional length was 129 mm (range 20-240 mm). A dose of 14 Gy in vessel radius (postinterventional) plus 2 mm was applied in 24 patients and 18.4 Gy in four patients. Treatment time was 7 min 32 s per radiation segment. No major adverse events occurred. Patients were followed by ankle-brachial index and duplex sonography for a median of 42 months. Cumulative restenosis rates at 1, 2, and 3 years were 9%, 28%, and 40%, respectively. Target vessel revascularization was performed in seven cases (25%). CONCLUSIONS: In comparison to literature data, the treatment of SFA restenosis with beta brachytherapy may improve long-term patency.

A multicenter, randomized, dose-finding study of gamma intracoronary radiation therapy to inhibit recurrent restenosis after stenting.

OBJECTIVES: The objective of this double-blind, randomized study was to determine the safety and efficacy of intracoronary radiation therapy (ICRT) with a dose of 17 Gray (Gy) compared to the currently recommended dose prescription of 14 Gy for the treatment of in-stent restenosis within bare metal stents. BACKGROUND: While gamma ICRT for in-stent restenosis has been proven efficacious, the optimal dose is unknown, and radiation failure due to recurrent neointimal hyperplasia remains a significant clinical problem for some patients. A higher radiation dose may improve outcomes, but may potentially increase adverse events. METHODS: Following coronary intervention, 336 patients with in-stent restenosis were randomly assigned to receive ICRT with either 14 Gy or 17 Gy at 2 mm from an 192-iridium source. RESULTS: At 8-month follow up, fewer patients in the 17 Gy group underwent target lesion revascularization (TLR = 15.2% versus 27.2%; p = 0.01), target vessel revascularization (21.3% versus 33.1%; p = 0.02), or reached the composite endpoint of death, myocardial infarction, thrombosis, or TLR (17.1% versus 28.4%; p = 0.02). There were no differences in late thrombosis or mortality between treatment groups. There was a strong trend toward reduced in-lesion late loss (0.36 +/- 0.63 mm vs. 0.51 +/- 0.64 mm; p = 0.09) and a significantly lower rate of binary restenosis (23.9% versus 38.1%; p = 0.031) in the high dose group. CONCLUSIONS: Gamma ICRT with 17 Gy is safe and, compared to 14 Gy, reduces recurrent stenosis and clinical events at 8-month follow up. An increase in the currently recommended gamma radiation dose prescription from 14 Gy to 17 Gy should be strongly considered.