Race Does Not Affect Survival in Patients With Prostate Cancer Treated With Radiation Therapy.

BACKGROUND/AIM: Recent evidence has shown that African American men with prostate cancer may have more radiosensitive disease with greater overall survival (OS) with radiotherapy compared to Caucasian men. We compared OS in African American and Caucasian men receiving radiotherapy utilizing the National Cancer Database. PATIENTS AND METHODS: African American or Caucasian men with N0M0 prostate adenocarcinoma diagnosed between 2004 and 2013 were selected and grouped into favorable and unfavorable risk based on clinical T-stage, clinical Gleason score, and prostate-specific antigen. Patients with favorable risk received brachytherapy or dose-escalated external beam radiation (EBRT); those with unfavorable risk received EBRT plus anti-androgen therapy with/without brachytherapy. African American and Caucasian men in each subgroup were propensity score-matched and analyzed for survival. Sensitivity analysis used treatment-race and age-race interaction terms. RESULTS: 27,150 patients met the inclusion criteria, with a median age of 68 (range=38-90) years and median follow-up of 59.93 (range=48-142.62) months. OS was equivalent between African American and Caucasian race in favorable risk [log-rank p=0.82; hazard ratio (HR)=0.928; 95% confidence intervaI (CI)=0.583-1.477, p=0.753] and unfavorable-risk subgroups (log-rank p=0.87, HR=1.078, 95% CI=0.843-1.379, p=0.550). No significant interaction existed between treatment and race for either cohort but there was a significant interaction between race and age in those with unfavorable risk (HR=1.046, 95% CI=1.009-1.084, p=0.015), with greater OS in those of Caucasian race ≤60 years (HR=0.320, 95% CI=0.137-0.752, p=0.009). CONCLUSION: African American and Caucasian men have similar survival when treated with risk-appropriate definitive radiotherapy. However, younger (age ≤60 years) African American men with unfavorable risk have poorer survival than their Caucasian counterparts and may harbor a significantly different biology of disease.

Radical Prostatectomy Without Pelvic Lymph Node Dissection Is Widely Practiced in High-Risk Patients Despite Poorer Survival.

PURPOSE: Radical prostatectomy with pelvic lymph node dissection (PLND) is the standard of care for unfavorable risk prostate cancer. We investigated dissection practice patterns and their impact on overall survival using a large national database. PATIENTS AND METHODS: Men with prostate adenocarcinoma diagnosed between 2004 and 2013 were identified from the National Cancer Data Base. Disease was classified as either favorable or unfavorable on the basis of National Comprehensive Cancer Network guidelines. Minimum follow-up was 4 years. All patients received risk-appropriate surgery: prostatectomy with or without PLND. Prostatectomy alone and prostatectomy with PLND was propensity score matched within each risk cohort. Survival analysis included Kaplan-Meier statistics, Cox proportional hazards model, and multivariate logistic regression. RESULTS: A total of 66,469 subjects met the inclusion criteria. Median (range) age was 63 (27-90) years. Median (range) follow-up was 59.53 (48-143.54) months. Within the cohort of patients with favorable risk disease, 51% did not undergo nodal dissection. Matched analysis demonstrated no difference in survival (P = .926). Within the cohort of patients with unfavorable risk disease, 39.2% did not receive nodal dissection. Matched analysis demonstrated that nodal dissection had superior survival (log-rank P = .002; hazard ratio = 0.624; 95% confidence interval, 0.466-0.835; P = .002). Greater odds of receiving nodal dissection included an open or robot-assisted approach compared to a laparoscopic approach, academic/research programs, and higher risk groups. CONCLUSION: Although PLND is associated with a significant survival benefit in men with unfavorable risk prostate cancer, nearly 40% of patients with unfavorable risk disease did not receive PLND.

The Value of Total Lymph Nodes Examined and Number of Positive Lymph Nodes in Determining the Role of Adjuvant Radiation in Pancreatic Cancer Patients.

OBJECTIVES: The aim of this study was to determine the survival benefits by adjuvant radiation therapy (RT) in pancreatic cancer patients with different total lymph nodes examined (TNE), number of positive lymph nodes (NPN), and lymph nodes ratio (LNR). METHODS: National Cancer Database was queried for nonmetastatic pancreatic cancer patients from 2004 to 2015. Cox models were utilized. Interaction terms were applied to evaluate the effect of RT in different NPN, LNR, and margin strata. Multivariate analysis was performed. RESULTS: Of 19,759 patients identified, 10,910 patients qualified. Compared with TNE of 1 to 9, TNE of 10 to 14, 15 to 19, 20 to 24, and 25 or greater had progressive overall survival (OS) benefits. Adjuvant RT had similar OS benefits among them. In negative margin patients, adjuvant RT improved OS when NPN was 2 to 3 (hazards ratio [HR], 0.84; P = 0.01) or LNR was 0.15 to 0.25 (HR, 0.79; P = 0.002). In positive margin patients, adjuvant RT nonsignificantly improved OS when NPN was 1 to 3 (HR, 0.89; P = 0.36) or when NPN was 4 or greater (HR, 0.79; P = 0.07). CONCLUSIONS: Higher TNE correlates with better survival. Adjuvant RT may not compensate for inadequate lymph node dissection. Adjuvant RT improves survival in negative-margin patients with 2 to 3 positive lymph nodes or LNR of 0.15 to 0.25.

Challenging AJCC 8 Staging for Soft Tissue Sarcoma Using the NCDB.

PURPOSE: To determine whether the new American Joint Committee on Cancer (AJCC) 8 grouping of soft tissue sarcoma (STS) with nodal disease (N1M0) and metastatic disease (M1) as stage IV correctly represents the prognosis of these previously separate patient groups, using the National Cancer Database. METHODS AND MATERIALS: Adults with STS identified in the 2004 to 2014 National Cancer Database, classified by the World Health Organization 2013 system into 10 histologic subgroups, were grouped according to AJCC 8 staging and analyzed according to demographic characteristics, histology, primary site, disease extent, and adjuvant treatment. Primary retroperitoneal sites, "other/unusual" histologic subgroups, and those with delays in therapy (>180 days from diagnosis) were excluded. We used χ2 tests, Cox proportional hazard models, and propensity-score matched analyses. RESULTS: Of 82,987 patients identified, 55,417 met inclusion criteria; 29,855 (53.9%) were male, and 25,262 (46.1%) were female. Median age was 60 years (range, 18-90 years). Overall survival (OS) of STS of all sites was significantly different between N1M0 and N0-1M1 patients at 5 years (34.4%; [95% confidence interval {CI}, 30.1%-38.8%] vs 10.1% [95% CI, 9%-11%], respectively) and 10 years (27.3% [95% CI, 22.5%- 32.2%] vs 5.4% [95% CI, 4.5%-6.5%], respectively; log-rank test, P < .001). For STS of trunk and extremities in N1M0 and N0-1M1 patients, the N1M0 cohort was associated with significantly greater OS on multivariate Cox proportional hazards models (hazard ratio, 0.48; 95% CI, 0.41-0.58; P < .001), and this OS difference remained significant for propensity-matched cohorts of all primary sites (HR, 0.53; 95% CI, 0.44-0.64; P < .001). CONCLUSIONS: In adult STS, including those of the trunk and extremity, OS is superior with N1M0 compared with N0-1M1 disease. These results suggest that the AJCC 8th edition grouping of N1 and M1 patients into stage IV may obscure the more favorable prognosis of patients with N1M0 disease.

Brachytherapy improves outcomes in young men (≤60 years) with prostate cancer: A SEER analysis.

PURPOSE: The aim of the study was to compare prostate cancer-specific mortality (PCSM) in young men with clinically localized prostate cancer treated by either external beam radiation (EBRT) alone or brachytherapy with or without external beam radiation. METHODS AND MATERIALS: Utilizing the Surveillance, Epidemiology and End Results database, 15,505 patients ≤60 years of age diagnosed with prostate cancer between 2004 and 2009 and treated with radiation therapy alone were identified. Incidence of PCSM was determined for both groups and compared using competing risk models. RESULTS: The overall 8-year PCSM for the study population was 1.9% (95% confidence interval [CI]: 1.6-2.2). For patients treated with EBRT or brachytherapy with or without external beam, the 8-year PCSM was found to be 2.8% (CI: 2.2-3.4) and 1.2% (CI: 0.9-1.6), respectively (p < 0.001). Univariable analysis demonstrated that brachytherapy was associated with lower PCSM risk (hazard ratio = 0.40; CI: 0.30-0.54; p < 0.001). High Gleason risk category, black race, higher Tumor (T) stage, and higher grade were all associated with greater mortality risk (p < 0.01). On multivariable analysis, brachytherapy continued to be associated with a significantly lower mortality risk (hazard ratio = 0.65; CI: 0.47-0.89; p = 0.008). Subgroup analyses found that among those with Gleason score ≥8, younger patients had increased risk of PCSM (p = 0.001). CONCLUSIONS: In men ≤60 years of age with prostate cancer, radiation therapy continues to offer excellent outcomes. After adjusting for relevant variables, the use of brachytherapy was associated with reduced PCSM compared to treatment with EBRT alone.

Rectal melanoma: epidemiology, prognosis, and role of adjuvant radiation therapy.

PURPOSE: Rectal melanoma (RM) is a lethal malignancy which is not well understood. While cases are rising, data concerning effective management are limited. The present paper sought to elucidate the epidemiology and prognosis of RM, while also analyzing the role of adjuvant radiation therapy (RT). METHODS: We used the surveillance, epidemiology, and end results program to find all cases of RM diagnosed between 2004 and 2011. Patients 18 or older with non-metastatic disease who had undergone surgery were included. Data regarding the age, race, sex, marital status, stage, and radiation sequence with surgery were extracted from the database and analyzed. Disease-free (DFS) and overall survival (OS) was studied for the group overall and between subgroups. RESULTS: Median age at diagnosis was 69 years. RM is significantly more common in whites compared to nonwhites and occurs equally in males and females. Most patients are diagnosed at an early stage. Prognosis is poor with a median DFS of 27 months and median OS of 22 months. There were no differences in outcomes based on age, sex, marital status, or stage; however, OS was improved in nonwhites as compared to whites (P = 0.04). RT did not improve DFS (27 vs 28 months for surgery vs surgery and radiation, P = 0.82) or OS (19 vs 22 months for surgery vs surgery and radiation P=0.80) regardless of stage. CONCLUSIONS: RM is an aggressive disease primarily affecting older, white patients. RT does not improve survival, regardless of stage. Optimal management of this lethal disease remains to be elucidated.

Molecular biodiversity of Red Sea demosponges.

Sponges are important constituents of coral reef ecosystems, including those around the Arabian Peninsula. Despite their importance, our knowledge on demosponge diversity in this area is insufficient to recognize, for example, faunal changes caused by anthropogenic disturbances. We here report the first assessment of demosponge molecular biodiversity from Arabia, with focus on the Saudi Arabian Red Sea, based on mitochondrial and nuclear ribosomal molecular markers gathered in the framework of the Sponge Barcoding Project. We use a rapid molecular screening approach on Arabian demosponge collections and analyze results in comparison against published material in terms of biodiversity. We use a variable region of 28S rDNA, applied for the first time in the assessment of demosponge molecular diversity. Our data constitutes a solid foundation for a future more comprehensive understanding of sponge biodiversity of the Red Sea and adjacent waters.

The Anatomical Biological Value on Pretreatment (18)F-fluorodeoxyglucose Positron Emission Tomography Computed Tomography Predicts Response and Survival in Locally Advanced Head and Neck Cancer.

(18)F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) has become increasingly relevant in the staging of head and neck cancers, but its prognostic value is controversial. The objective of this study was to evaluate different PET/CT parameters for their ability to predict response to therapy and survival in patients treated for head and neck cancer. A total of 28 consecutive patients with a variety of newly diagnosed head and neck cancers underwent PET/CT scanning at our institution before initiating definitive radiation therapy. All underwent a posttreatment PET/CT to gauge tumor response. Pretreatment PET/CT parameters calculated include the standardized uptake value (SUV) and the anatomical biological value (ABV), which is the product of SUV and greatest tumor diameter. Maximum and mean values were studied for both SUV and ABV, and correlated with response rate and survival. The mean pretreatment tumor ABVmax decreased from 35.5 to 7.9 (P = 0.0001). Of the parameters tested, only pretreatment ABVmax was significantly different among those patients with a complete response (CR) and incomplete response (22.8 vs. 65, respectively, P = 0.021). This difference was maximized at a cut-off ABVmax of 30 and those patients with ABVmax < 30 were significantly more likely to have a CR compared to those with ABVmax of ≥ 30 (93.8% vs. 50%, respectively, P = 0.023). The 5-year overall survival was 80% compared to 36%, respectively, (P = 0.028). Multivariate analysis confirmed that ABVmax was an independent prognostic factor. Our data supports the use of PET/CT, and specifically ABVmax, as a prognostic factor in head and neck cancer. Patients who have an ABVmax ≥ 30 were more likely to have a poor outcome with chemoradiation alone, and a more aggressive trimodality approach may be indicated in these patients.

A predictive model to guide management of the overlap region between target volume and organs at risk in prostate cancer volumetric modulated arc therapy.

PURPOSE: The goal of this study is to determine whether the magnitude of overlap between planning target volume (PTV) and rectum (Rectumoverlap) or PTV and bladder (Bladderoverlap) in prostate cancer volumetric-modulated arc therapy (VMAT) is predictive of the dose-volume relationships achieved after optimization, and to identify predictive equations and cutoff values using these overlap volumes beyond which the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) dose-volume constraints are unlikely to be met. MATERIALS AND METHODS: Fifty-seven patients with prostate cancer underwent VMAT planning using identical optimization conditions and normalization. The PTV (for the 50.4 Gy primary plan and 30.6 Gy boost plan) included 5 to 10 mm margins around the prostate and seminal vesicles. Pearson correlations, linear regression analyses, and receiver operating characteristic (ROC) curves were used to correlate the percentage overlap with dose-volume parameters. RESULTS: The percentage Rectumoverlap and Bladderoverlap correlated with sparing of that organ but minimally impacted other dose-volume parameters, predicted the primary plan rectum V45 and bladder V50 with R(2) = 0.78 and R(2) = 0.83, respectively, and predicted the boost plan rectum V30 and bladder V30 with R(2) = 0.53 and R(2) = 0.81, respectively. The optimal cutoff value of boost Rectumoverlap to predict rectum V75 >15% was 3.5% (sensitivity 100%, specificity 94%, p < 0.01), and the optimal cutoff value of boost Bladderoverlap to predict bladder V80 >10% was 5.0% (sensitivity 83%, specificity 100%, p < 0.01). CONCLUSION: The degree of overlap between PTV and bladder or rectum can be used to accurately guide physicians on the use of interventions to limit the extent of the overlap region prior to optimization.

Comparison study of intensity modulated arc therapy using single or multiple arcs to intensity modulated radiation therapy for high-risk prostate cancer.

PURPOSE: Intensity modulated arc therapy (IMAT) is a form of intensity modulated radiation therapy (IMRT) that delivers dose in single or multiple arcs. We compared IMRT plans versus single-arc field (1ARC) and multi-arc fields (3ARC) IMAT plans in high-risk prostate cancer. MATERIALS AND METHODS: Sixteen patients were studied. Prostate (PTV P ), right pelvic (PTV RtLN ) and left pelvic lymph nodes (PTV LtLN ), and organs at risk were contoured. PTV P , PTV RtLN , and PTV LtLN received 50.40 Gy followed by a boost to PTV B of 28.80 Gy. Three plans were per patient generated: IMRT, 1ARC, and 3ARC. We recorded the dose to the PTV, the mean dose (D MEAN ) to the organs at risk, and volume covered by the 50% isodose. Efficiency was evaluated by monitor units (MU) and beam on time (BOT). Conformity index (CI), Paddick gradient index, and homogeneity index (HI) were also calculated. RESULTS: Average Radiation Therapy Oncology Group CI was 1.17, 1.20, and 1.15 for IMRT, 1ARC, and 3ARC, respectively. The plans' HI were within 1% of each other. The D MEAN of bladder was within 2% of each other. The rectum D MEAN in IMRT plans was 10% lower dose than the arc plans (p < 0.0001). The GI of the 3ARC was superior to IMRT by 27.4% (p = 0.006). The average MU was highest in the IMRT plans (1686) versus 1ARC (575) versus 3ARC (1079). The average BOT was 6 minutes for IMRT compared to 1.3 and 2.9 for 1ARC and 3ARC IMAT (p < 0.05). CONCLUSION: For high-risk prostate cancer, IMAT may offer a favorable dose gradient profile, conformity, MU and BOT compared to IMRT.

The role of PET/CT in decreasing inter-observer variability in treatment planning and evaluation of response for cervical cancer.

We have previously introduced anatomic biologic contouring (ABC) with PET/CT, using a distinct "halo" to unify contouring methods in treatment planning for lung and head and neck cancers. The objective of this study is to assess the utility of PET/CT in planning and treatment response for cervical cancer. Forty-two patients with stages II-IIIB cervix cancer were planned for irradiation using PET/CT. A CT-based Gross Tumor Volume (GTV-CT) was delineated by two independent observers while the PET remained obscured. The Planning Target Volume (PTV) was obtained by adding a 1.5 cm margin around the GTV. The same volumes were recontoured using PET/CT data and termed GTV-ABC and PTV-ABC, respectively. The values of GTV-CT and GTV-ABC and the absolute differences between the two observers were analyzed. Additionally, 23 of these patients had PET/CT performed 3 months after treatment. The anatomic biologic value (ABV) was calculated using the product of maximum diameter and mean SUV of the cervical tumor. The pre- and post-treatment ABVs were compared. A "halo" was observed around areas of maximal SUV uptake. The mean halo SUV was 1.91 ± 0.56 (SD). The mean halo thickness was 2.12 ± 0.5 (SD) mm. Inter-observer GTV variability decreased from a mean volume difference of 55.36 cm(3) in CT-based planning to 12.29 cm(3) in PET/CT-based planning with a respective decrease in standard deviation (SD) from 55.78 to 10.24 (p <0.001). Comparison of mean pre-treatment and post-treatment ABV's revealed a decrease of ABV from 48.2 to 7.8 (p<0.001). PET/CT is a valuable tool in radiation therapy planning and evaluation of treatment response for cervical cancer. A clearly visualized "halo" was successfully implemented in GTV contouring in cervical cancer, resulting in decreased inter-observer variability in planning. PET/CT has the ability to quantify treatment response using anatomic biologic value.

Case series analysis of post-brachytherapy prostate edema and its relevance to post-implant dosimetry. Post-implant prostate edema and dosimetry.

PURPOSE: We evaluated the post-operative pattern of prostate volume (PV) changes following prostate brachytherapy (PB) and analyzed variables which affect swelling. MATERIAL AND METHODS: Twenty-nine patients treated with brachytherapy (14) or combined brachytherapy and external beam radiotherapy modality (15) underwent pre- and post-implant computed tomography (CT). Prostate volume measurements were done on post-operative days 1, 9, 30, and 60. An observer performed 139 prostate volume (PV) measurements. We analyzed the influence of pre-implant PV, number of needles and insertion attempts, number and activity of seeds, Gleason score, use of hormonal therapy and external beam radiation therapy on the extent of edema. We computed a volume correction factor (CF) to account for dosimetric changes between day 1 and day 30. Using the calculated CF, the dose received by 90% (D(90)) of the prostate on day 30 (D(90)Day30) was obtained by dividing day 1 (D(90)Day1) by the CF. RESULTS: The mean PV recorded on post-operative day 1 was 67.7 cm(3), 18.8 cm(3) greater than average pre-op value (SD 15.6 cm(3)). Swelling returned to pre-implant volume by day 30. Seed activity, treatment modality, and Gleason score were significant variables. The calculated CF was 0.76. After assessment using the CF, the mean difference between estimated and actual D(90)Day30 was not significant. CONCLUSIONS: We observed maximum prostate size on post-operative day 1, returning to pre-implant volume by day 30. This suggests that post-implant dosimetry should be obtained on or after post-operative day 30. If necessary, day 30 dosimetry can be estimated by dividing D(90)Day1 by a correction factor of 0.76.

Acupuncture for the alleviation of hot flashes in men treated with androgen ablation therapy.

PURPOSE: Hot flashes are common side effect due to androgen ablation therapy (AAT). The utility of acupuncture for hot flashes in men has not been thoroughly studied. We prospectively studied the effect of acupuncture in men with hot flashes. METHODS AND MATERIALS: The study was approved by internal review board. Seventeen men with hot flashes and history of AAT for prostate cancer were enrolled. Three men declined participation before receiving any treatment. A hot flash score (HFS) was used to measure daily hot flashes. The composite daily score was calculated as the product of frequency × severity. The baseline daily scores were compared with scores taken at 2 and 6 weeks and at 8-month average follow-up. RESULTS: No side effects were encountered during, immediately after treatment, or at 8 months. The mean initial HFS was 28.3; it dropped to 10.3 (p = 0.0001) at 2 weeks posttreatment, 7.5 (p = 0.0001) at 6 weeks, and 7.0 (p = 0.001) at 8 months. Clinical improvement for each patient is defined as the percent decrease in the mean HFS at each time point. The mean improvement at Weeks 2 and 6 was 68.4% (mean HFS decreased from 37.409 to 11.836, p = 0.001) and 89.2% (mean HFS decreased from 37.409 to 4.05, p = 0.0078) respectively. The improvement at 8 months was 80.3% (mean HFS decreased from 37.409 to 7.385, p = 0.002). CONCLUSIONS: Acupuncture provides excellent control of hot flashes in men with a history of AAT. The absence of side effects and the durable response at 8 months are likely to be appealing to patients. Prospective randomized study is warranted to further evaluate this modality against medical therapy.

Percutaneous tumor curettage and interstitial delivery of samarium-153 coupled with kyphoplasty for treatment of vertebral metastases.

OBJECT: The object of this study was to investigate the use of a minimally invasive technique for treating metastatic tumors of the vertebral body, aimed at relieving pain, preventing further tumor growth, and minimizing the adverse effects of systemic use of samarium-153 ((153)Sm). METHODS: The procedure is performed in the same fashion as a kyphoplasty, using a unilateral extrapedicular approach under local anesthesia/mild general sedation, with the patient in the lateral decubitus position. The tumor is accessed as in a standard kyphoplasty. The side is chosen according to the location of the metastasis. Prior to inflation of the balloon the tumor is debulked by percutaneous curettage. Balloon inflation is carried out as per standard kyphoplasty in an attempt to create a larger space and reduce a possible kyphotic deformity. Three mCi of (153)Sm-EDTMP (ethylenediaminetetramethylenephosphonic acid) is then mixed with bone cement (polymethylmethacrylate) and injected into the void created by the balloon tamp. RESULTS: Twenty-four procedures were performed in 19 patients. There was reliable and reproducible delivery of the radiolabeled (153)Sm-EDTMP to the metastatic site, without spillage. The procedure was safe. There were no procedure-related complications. There was no hematological toxicity with the low doses of (153)Sm used. Pain improved in all patients. The long-term results related to tumor control continue to be investigated. CONCLUSIONS: Combined percutaneous debulking of confined vertebral metastases and administration of local (153)Sm is feasible and safe. Furthermore, this technique leads to immediate relief of cancer-related pain and may help prevent or slow down the progression of vertebral metastatic tumors.

Phase I trial of vertebral intracavitary cement and samarium (VICS): novel technique for treatment of painful vertebral metastasis.

PURPOSE: Kyphoplasty is an effective procedure to alleviate pain in vertebral metastases. However, it has no proven anticancer activity. Samarium-153-ethylene diamine tetramethylene phosphonate ((153)Sm-EDTMP) is used for palliative treatment of bone metastases. A standard dose of 1 mCi/kg is administrated intravenously. The present study was conducted to determine the feasibility of intravertebral administration of (153)Sm with kyphoplasty. METHODS AND MATERIALS: A total of 33 procedures were performed in 26 patients. Of these 26 patients, 7 underwent procedures performed at two vertebral levels. The mean age of the cohort was 64 years (range, 33-86). The kyphoplasty procedure was performed using a known protocol; 1-4 mCi of (153)Sm was admixed with the bone cement and administered under tight radiation safety measures. Serial nuclear body scans were obtained. Pain assessment was evaluated using a visual analog pain score. RESULTS: All patients tolerated the procedure well. No procedure-related morbidities were noted. No significant change had occurred in the blood counts at 1 month after the procedure. One case was not technically satisfactory. Nuclear scans revealed clear radiotracer uptake in the other 32 vertebrae injected. Except for the first patient, no radiation leakage was encountered. The mean pain score using the visual analog scale improved from 8.6 before to 2.8 after the procedure (p < .0001). Follow-up bone scans demonstrated a 43% decrease in the tracer uptake. CONCLUSION: The results of our study have shown that the combination of intravertebral administration of (153)Sm and kyphoplasty is well tolerated with adequate pain control. No hematologic adverse effects were found. A reduction of the bone scan tracer uptake was observed in the injected vertebrae. Longer follow-up is needed to study the antineoplastic effect of the procedure.

The contribution of integrated PET/CT to the evolving definition of treatment volumes in radiation treatment planning in lung cancer.

PURPOSE: Positron emission tomography (PET) with the glucose analog [18F]fluro-2-deoxy-D-glucose (FDG) has been accepted as a valuable tool for the staging of lung cancer, but the use of PET/CT in radiation treatment planning is still not yet clearly defined. By the use of (PET/computed tomography (CT) images in treatment planning, we were able to define a new gross treatment volume using anatomic biologic contour (ABC), delineated directly on PET/CT images. We prospectively addressed three issues in this study: (1) How to contour treatment volumes on PET/CT images, (2) Assessment of the degree of correlation between CT-based gross tumor volume/planning target volume (GTV/PTV) (GTV-CT and PTV-CT) and the corresponding PET/CT-based ABC treatment volumes (GTV-ABC and PTV-ABC), (3) Magnitude of interobserver (radiation oncologist planner) variability in the delineation of ABC treatment volumes (using our contouring method). METHODS AND MATERIALS: Nineteen patients with Stages II-IIIB non-small-cell lung cancer were planned for radiation treatments using a fully integrated PET/CT device. Median patient age was 74 years (range: 52-82 years), and median Karnofsky performance status was 70. Thermoplastic or vacuum-molded immobilization devices required for conformal radiation therapy were custom fabricated for the patient before the injection of [18]f-FDG. Integrated, coregistered PET/CT images were obtained and transferred to the radiation planning workstation (Xeleris). While the PET data remained obscured, a CT-based gross tumor volume (GTV-CT) was delineated by two independent observers. The PTV was obtained by adding a 1.5-cm margin around the GTV. The same volumes were recontoured using PET/CT data and termed GTV-ABC and PTV-ABC, correspondingly. RESULTS: We observed a distinct "halo" around areas of maximal standardized uptake value (SUV). The halo was identified by its distinct color at the periphery of all areas of maximal SUV uptake, independent of PET/CT gain ratio; the halo had an SUV of 2 +/- 0.4 and thickness of 2 mm +/- 0.5 mm. Whereas the center of our contoured treatment volume expressed the maximum SUV level, a steady decline of SUV was noted peripherally until SUV levels of 2 +/- 0.4 were reached at the peripheral edge of our contoured volume, coinciding with the observed halo region. This halo was always included in the contoured GTV-ABC. Because of the contribution of PET/CT to treatment planning, a clinically significant (> or =25%) treatment volume modification was observed between the GTV-CT and GTV-ABC in 10/19 (52%) cases, 5 of which resulted in an increase in GTV-ABC volume vs. GTV-CT. The modification of GTV between CT-based and PET/CT-based treatment planning resulted in an alteration of PTV exceeding 20% in 8 out of 19 patients (42%). Interobserver GTV variability decreased from a mean volume difference of 28.3 cm3 (in CT-based planning) to 9.12 cm3 (in PET/CT-based planning) with a respective decrease in standard deviation (SD) from 20.99 to 6.47. Interobserver PTV variability also decreased from 69.8 cm3 (SD +/- 82.76) in CT-based planning to 23.9 cm3 (SD +/- 15.31) with the use of PET/CT in planning. The concordance in treatment planning between observers was increased by the use of PET/CT; 16 (84%) had < or =10% difference from mean of GTVs using PET/CT compared to 7 cases (37%) using CT alone (p = 0.0035). CONCLUSION: Position emission tomography/CT-based radiation treatment planning is a useful tool resulting in modification of GTV in 52% and improvement of interobserver variability up to 84%. The use of PET/CT-based ABC can potentially replace the use of GTV. The anatomic biologic halo can be used for delineation of volumes.

Elevated liver enzymes following open Roux-en-Y gastric bypass for morbid obesity - does timing of liver retraction affect the rise in the levels of transaminases?

BACKGROUND: Liver retraction in open Roux-en-Y gastric bypass (RYGBP) for morbid obesity may cause an elevation in liver transaminase levels postoperatively. This study attempts to ascertain whether timing of placement of the liver retractor would have any effect on the degree of derangement of the liver function tests. METHODS: 12 patients undergoing open RYGBP were prospectively randomized into 2 groups. One group had the liver retractor applied early on in the operation, and had the gastric pouch constructed first, followed by construction of the jejunojejunostomy and Roux-en-Y gastrojejunostomy. The second group had the jejunojejunostomy performed first, followed by placement of the liver retractor to allow construction of the gastric pouch and Roux-en-Y gastro-jejunostomy. Liver function tests were monitored postoperatively in both groups, and these were then statistically analyzed with respect to the duration of liver retraction. RESULTS: Delayed liver retraction resulted in statistically significantly smaller increases in aspartate transaminase (AST) and alanine transaminase (ALT) compared with early liver retraction. AST levels returned to normal values within 1 week in both groups of patients. ALT levels returned to normal values within 1 week in the delayed liver retraction group, whereas levels took >1 week to return to normal in the early liver retraction group. CONCLUSIONS: Liver retraction causes abnormal transaminase levels following open RYGBP. Delayed liver retraction results in less rise in the AST and ALT levels compared with early liver retraction. Surgeons should construct the Roux-en-Y limb and jejunoje junostomy first, before proceeding with construction of the gastric pouch and gastrojejunostomy, thereby decreasing the duration of liver retraction and consequent relative liver ischemia.