Esophagectomy Timing After Neoadjuvant Therapy for Distal Esophageal Adenocarcinoma.

BACKGROUND: The time elapsed between completion of neoadjuvant therapy and esophagectomy may influence response rate and possibly allow for avoidance of surgical intervention in selected cases ("wait and see" approach). However, a very long postradiation interval has been associated with worsened surgical outcomes in esophageal carcinoma. Therefore we analyzed outcomes of patients with invasive distal esophageal adenocarcinoma treated with neoadjuvant chemoradiation and esophagectomy based on the time elapsed between completion of neoadjuvant chemoradiation and resection. METHODS: Patients with invasive distal esophageal carcinoma diagnosed between 2003 and 2011 and treated by neoadjuvant chemoradiation followed by esophagectomy within 26 weeks were identified in the National Cancer Data Base (NCDB). Primary outcome measures were 30- and 90-day postsurgical mortality and overall survival. RESULTS: In all, 4,284 patients aged 60.3 ± 9.4 years were analyzed (mean ± standard deviation). The interval after radiation therapy until esophagectomy was 7.8 ± 3.4 weeks (median, 7.1 weeks). The postradiation interval was 8 weeks or more in 35% of patients. Thirty-day mortality was 2.9% (n = 127), and 90-day mortality was 7.8% (n = 336). A postradiation interval of 9 weeks or more was associated with increased perioperative mortality odds both at the 30-day (adjusted odds ratio [OR], 2.160; 95% confidence interval, 1.099-4.242; p = 0.025) and 90-day follow-up (adjusted OR, 1.912; 95% confidence interval, 1.290-2.835; p < 0.001). Similarly, a postradiation interval of 9 weeks or more was associated with an increased mortality risk (adjusted hazard ratio [HR], 1.194; 95% confidence interval, 1.032-1.380; p = 0.017). CONCLUSIONS: Perioperative mortality and overall survival are significantly associated with the time interval between neoadjuvant chemoradiation and esophagectomy. A "wait and see" approach after neoadjuvant therapy for esophageal adenocarcinoma may not be safe. Further studies based on more detailed data are needed.

Frameless stereotactic radiosurgery for recurrent head and neck carcinoma.

The aim of this study was to assess the feasibility and toxicity of stereotactic radiosurgery (CK-SRS) using the CyberKnife Frameless Radiosurgery System (Accuray Inc., Sunnyvale, CA) in the management of recurrent squamous cell carcinoma of the head and neck region (SCCHN). Between November 2001 and February 2004, 22 patients with recurrent, previously irradiated SCCHN were treated with CK-SRS. The following endpoints were assessed post-CK-SRS: local control (LC), cause-specific survival (CSS), overall survival (OS), symptom relief, and acute and late toxicity. Kaplan-Meier survival analyses were used to estimate the LC, CSS, and OS rates. Clinical symptoms were graded as "improved," "stable," or "progressed" after CK-SRS. Acute and late toxicity were graded according to the National Cancer Institute Common Toxicity Criteria (CTC) scale, version 2.0. Seventeen patients were followed until their death. The median follow-up in the remaining five patients was 19 months (range 11-40 months). The median survival time for the entire cohort was 12 months from the time of CK-SRS. The 2-year LC, CSS, and OS rates were 26%, 26%, and 22%, respectively. After CK-SRS, symptoms were improved or stable in all but one patient who reported increasing pain. The treatment was well tolerated, with one case each of Grade 2 and 3 mucositis. There were no acute Grade 4 or 5 CTC toxicities. There were no late toxicities in this cohort. Frameless stereotactic radiosurgery for recurrent SCCHN is feasible and safe in the setting of high doses of prior irradiation. The majority of patients experienced palliation of disease without excess toxicity.

Intraoperative (125)I Vicryl mesh brachytherapy after sublobar resection for high-risk stage I non-small cell lung cancer.

PURPOSE: To assess the feasibility and outcomes of (125)I Vicryl mesh brachytherapy after sublobar resection in stage I non small cell lung cancer (NSCLC) patients with poor pulmonary function. METHODS AND MATERIALS: Between January 1997 and July 2004, patients with poor cardiopulmonary reserve who had stage IA and IB (T1-2 N0 M0) NSCLC and a forced expiratory volume in 1s (FEV(1)) of > micro=0.6L were considered for limited surgical resection either by an open or video-assisted thoracoscopic procedure and for a subsequent (125)I Vicryl mesh brachytherapy implant. Mediastinal and hilar lymph node staging was performed routinely in all patients. After clear margins were obtained grossly and on frozen section, a single-plane (125)I implant was designed to encompass a plane consisting of the staple line and a 2-cm margin of surrounding visceral pleura. The implant was introduced through the surgical incision and sutured to the visceral pleura. A prescribed dose of 100-120 y was delivered to a volume within 0.5 cm rom the plane of the implant. Follow-up orthogonal films or CTs were obtained for dosimetric analysis. Kaplan-Meier analyses were used to estimate the local control, locoregional control, and overall survival rates. RESULTS: Of the 110 patients, 65 had stage IA and 45 had stage IB NSCLC. The mean preoperative FEV(1) was 47% of the predicted volume. With a median follow-up of 11 months (range 1-68 months), there were four recurrences within the radiation volume. The estimated 5-year local (in-field) control, locoregional control, and overall survival rates were 90%, 61%, and 18%, respectively. CONCLUSION: Vicryl mesh brachytherapy after sublobar resection for high-risk stage I NSCLC patients is a feasible procedure, which results in an excellent local (in-field) control rate.

Acoustic neuroma radiosurgery with marginal tumor doses of 12 to 13 Gy.

PURPOSE: To define tumor control and clinical outcomes of radiosurgery to marginal tumor doses of 12-13 Gy for unilateral acoustic neuroma patients. METHODS AND MATERIALS: Three hundred thirteen patients with previously untreated unilateral acoustic neuromas (vestibular schwannomas) underwent gamma knife radiosurgery between February 1991 and February 2001 with marginal tumor doses of 12-13 Gy (median, 13 Gy). Median follow-up was 24 months (maximum, 115 months; 36 patients with > or =60 months). Maximum doses were 20-26 Gy (median, 26 Gy), and treatment volumes were 0.04-21.4 mL (median, 1.1 mL). RESULTS: The actuarial 6-year clinical tumor control rate (no requirement for surgical intervention) for the entire series was 98.6 +/- 1.1%. Two patients required tumor resection; one had a complete resection for solid tumor growth and one required partial resection for an enlarging adjacent subarachnoid cyst. Six-year actuarial rates for preservation of facial nerve function, normal trigeminal nerve function, unchanged hearing level, and useful hearing were 100%, 95.6 +/- 1.8%, 70.3 +/- 5.8%, and 78.6 +/- 5.1%, respectively. The risk of developing trigeminal neuropathy correlated with increasing tumor volume (p = 0.038). CONCLUSIONS: Acoustic neuroma radiosurgery with doses of 12-13 Gy provides high rates of tumor control and cranial nerve preservation.

Treatment of recurrent malignant gliomas with stereotactic intensity modulated radiation therapy.

Malignant gliomas are usually refractory to aggressive combined-modality therapy, and the incidence of recurrence and death after treatment is very high. State-of-the-art techniques such as stereotactic intensity-modulated radiation therapy (IMRT) are now available to deliver a high dose of radiation to the tumor with relative preservation of surrounding tissues to achieve optimal tumor coverage with minimal toxicity. We report 10 patients (median age 48 years) with recurrent malignant gliomas that were treated with stereotactic directed IMRT. Initial tumor histologies included one low grade glioma (upgraded to anaplastic astrocytoma at recurrence), four anaplastic astrocytomas, and four glioblastomas multiforme. One patient was originally presumed to have a brain metastasis secondary to renal cell carcinoma but was pathologically confirmed as having glioblastoma multiforme at the time of recurrence. Before recurrence, all patients had been treated with external beam radiation therapy (median 59.7 Gy). All recurrences were confirmed by a subtotal resection (5/10) or by imaging (5/10). The median Karnofsky performance score at the time of IMRT was 80. The median tumor volume was 34.69 cm. Treatment was delivered on a 10-MV linear accelerator with a mini-multileaf collimator, MIMiC, and planned with Peacock/Corvus software. Radiation was delivered in daily fractions of 5 Gy, to a total median dose of 30 Gy at the 71% to 93% median isodose line. Median overall survival time was 10.1 months from the date of stereotactic treatment, with 1- and 2-year survival rates of 50% and 33.3%, respectively. Fractionated stereotactic intensity modulated radiation therapy is a novel technique used in the treatment of recurrent malignant gliomas, which produces results comparable to other currently used stereotactic techniques.