The Value of Targeted Ultrasound for the Primary Evaluation of Breast Symptoms in Pregnant Women of All Ages.

OBJECTIVE: Data on breast imaging in symptomatic pregnant women are limited. Our aim was to assess the value of targeted breast US for the primary evaluation of breast symptoms in pregnant women of all ages. METHODS: This IRB-approved retrospective study included all pregnant patients who underwent targeted US for focal breast symptoms at an academic imaging facility over an 18-year period (2000-2018). Clinical, imaging, and pathology results were reviewed. Malignant outcomes were determined by histology. Benign outcomes were confirmed by pathology or ≥2 years of follow-up. Descriptive statistics and 2 × 2 contingency table analyses were performed at the presentation level. RESULTS: The study cohort comprised 178 presentations in 175 pregnant women. Mean age was 34.7 years (standard deviation, 5.2). The majority (153/178, 86.0%) were more than 30 years old. At presentation, 42.1% (75/178) were in the first trimester of pregnancy, 27.0% (48/178) in the second, and 29.8% (53/178) in the third. The most common presenting symptom was a palpable lump (162/178, 91.0%), followed by focal pain (7/178, 3.9%). The vast majority (174/178, 97.8%) of cases were non-malignant. However, targeted US detected all 4 malignancies (cancer detection rate, 22/1000; negative predictive value 136/136, 100%). Sensitivity and specificity were 100% (4/4) and 78.2% (136/174), respectively. CONCLUSION: Benign causes of symptoms in pregnant women were far more common; malignancy was rare, accounting for only 2.2% (4/178) of cases. Targeted breast US detected all malignancies, supporting US as the primary imaging modality for evaluating symptomatic pregnant women, regardless of age.

Urethral dosimetry and toxicity with high-dose-rate interstitial brachytherapy for vaginal cancer.

PURPOSE: The tolerance and complication rates of the urethra are unknown for the interstitial high-dose-rate brachytherapy (HDR-BT) for vaginal cancer. METHODS AND MATERIALS: Patients with vaginal cancer near/involving the urethra who were treated with HDR-BT between 2008 and 2011 were included. Patients received mean external beam dose of 48.0Gy followed by mean HDR-BT dose of 4.5Gy/fraction for five fractions. With CT-based planning, the urethra was contoured from the bladder neck to the meatus. Doses were converted to the biologically equivalent dose in 2Gy/fraction (EQD2). RESULTS: A total of 16 patients were included, and the EQD2D90 was 74.9Gy. The urethral volume was 1.31cm(3), and the EQD2 to 0.1 and 1cm(3) were 76.2 and 48.9Gy, respectively. Two of the 6 patients with urethral involvement developed urethral necrosis. The D90 for these 2 patients was 76.8Gy, and the urethral doses to 0.1 and 1cm(3) were 95.1 and 45.8, respectively. Those who developed severe urethral toxicity had a trend to urethral EQD2 (95.1Gy vs. 73.4Gy, p=0.1) and significantly higher dose per fraction of HDR-BT to 0.1cm(3) of the urethra (5.7Gy vs. 3.7Gy, p=0.02) when compared with those who did not develop severe urethral toxicity. CONCLUSIONS: This study is among the first to assess urethral dosimetry for patients treated with HDR-BT for vaginal cancer. Patients who received five fractions of higher than 5Gy/fraction to 0.1cm(3) of urethra (estimated EQD2 of 85Gy) are at increased risk of severe urethral toxicity.

Is there an advantage to delivering breast boost in the lateral decubitus position?

BACKGROUND: The purpose of this study was to compare the change in depth of target volume and dosimetric parameters between the supine and lateral decubitus positions for breast boost treatment with electron beam therapy. METHODS: We analyzed 45 patients who were treated, between 2009-2010, with whole breast radiation (WBRT) followed by a tumor bed boost in the lateral decubitius position. Tumor bed volume, distance from skin to the maximal depth of the tumor bed, D90 (dose covering 90% of the tumor bed volume), maximal dose, electron energy and doses to heart and lungs were compared. Additional variables of body mass index (BMI) and tumor bed location were also analyzed to see if there was a benefit limited to any subgroup. RESULTS: Median BMI for the 45 patients treated was 30.6 (20.6-42.4). When comparing the supine scan to the lateral decubitus scan, there was no significant difference in the tumor bed volume (p = 0.116). There was a significant difference between depth to the tumor bed in the supine scan and lateral decubitus scan (p < 0.001). The mean maximum doses and D90 between the two scans were 110.7 (100.0-133.0)% vs 106.1 (95.1-116.9)% (p < 0.05) and 93.9 (81.3-01.0-101.0)% vs. 98.2 (89.1-108.0)% (p = 0.004) respectively. There was no difference in dose delivered to the lungs or heart between the two scans (p = 0.848 and p = 0.992 respectively). On subset analysis, there was a difference in depth to tumor that was seen across all BMI classes, including normal (p ≤ 0.001, overweight (p ≤ 0.001) and obese (p ≤ 0.001). The majority of patients had a tumor in the upper outer quadrant (77.8%) and on subset analysis, there was a significant difference in tumor bed volume (p < 0.01), depth to tumor (p < 0.01), tumor bed coverage [D90] (p < 0.05), maximum dose (p < 0.05) and energy (p < 0.001) for this location. CONCLUSIONS: Delivering a tumor bed boost in the lateral decubitus position reduces the distance to the tumor bed allowing for a lower energy treatment to be used to treat breast cancer. It improves coverage and decreases maximal dose to the target volume, all of which would help reduce skin morbidities and should be considered for patients with upper outer quadrant disease, irrespective of BMI status.

Complete metabolic response after definitive radiation therapy for cervical cancer: patterns and factors predicting for recurrence.

PURPOSE: The purpose of this study was to determine the patterns of failure in patients diagnosed with cervical cancer treated with definitive radiotherapy and who subsequently had complete metabolic response (CMR) seen on early post-therapy (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging. Additionally, we sought to determine what factors predict disease recurrence in this patient population. METHODS AND MATERIALS: We reviewed the records of 155 patients diagnosed with cervical cancer from stages IB1 to IVA who were treated with definitive chemoradiation therapy between 2003 and 2011 and had a FDG-PET at 10-16 weeks following completion of therapy. One hundred and twelve (72.0%) had CMR on follow-up FDG-PET and comprised the patients in this study. RESULTS: The median age of patients with CMR was 51 years and the median tumor size 4.9 cm. Median follow up was 15 months. Of the 112 patients, 11 (9.8%) had a recurrence and six (5.4%) had isolated local recurrences, and five (4.5%) had distant recurrence. Median time to recurrence was 9 months. Three-year actuarial disease-free survival and overall survival rates were 78.9% and 88.0% respectively. On Cox regression multivariate analysis, tumor size was predictive of increased risk of local recurrence in these patients with CMR with p<0.025. Age, stage, histology and nodal positivity were not significant for predicting local, distant or any recurrence. CONCLUSION: Patients treated with concurrent chemoradiation had a CMR which demonstrated good clinical outcomes in terms of local control. There were equal numbers of patients suffering local and distant recurrences. In patients with a CMR, only tumor size was an independent predictor for local recurrence.

High-dose-rate interstitial computed tomography-based brachytherapy for the treatment of cervical cancer: early results.

PURPOSE: There is limited published data on high-dose-rate interstitial brachytherapy (HDRBT) for cervical cancer resulting in no consensus on a fractionation schedule. This study reports our experience of CT-based HDRBT for treating locally advanced cervical cancer. METHODS AND MATERIALS: Forty-seven patients diagnosed with Stage IIB-IVA cervical cancer not suitable for intracavitary brachytherapy were treated with HDRBT from March 2005 to November 2010. All patients received external beam radiation therapy with a median dose of 45Gy and all had one interstitial implantation followed by 3.75-5Gy×5 fractions in a twice daily (BID) schedule. Total doses for clinical target volume and organs at risk, including rectum, bladder, and sigmoid, were summated and normalized to a biologically equivalent dose of 2Gy per fraction. At 3 months posttherapy, early response was assessed with clinical examination and positron emission tomography (PET/CT) imaging. RESULTS: Median clinical target volume D(90) (dose delivered to 90% of the clinical target volume) was 76.3 (59.0-86.9) Gy and the 2cc dose to the bladder, rectum, and sigmoid colon organs were 70.2 (55.9-77.7), 65.8 (54.9-80.6), and 56.5 (45.0-71.2) Gy, respectively. Posttreatment, 12 patients had evidence of persistent disease on PET/CT. Eleven of the 35 patients who had complete response developed recurrences. Two patients developed late Radiation Therapy Oncology Group ≥3 rectal toxicities. Two-year actuarial local control, disease-free survival, overall survival, and Grade ≥3 toxicities were 61%, 43%, 59%, and 10%, respectively. CONCLUSION: Our approach of a single implantation procedure followed by five fractions of HDRBT was well tolerated with early results demonstrating a moderate response and local control rate with acceptable toxicities.

Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511 cases.

OBJECTIVE: To analyze the impact of body mass indices on postbariatric reconstructive surgery complications. BACKGROUND: An increasing number of patients are presenting after massive weight loss due to bariatric surgery or diet and exercise. Many of these patients have residual obesity, which may compromise outcomes. METHODS: 449 patients were enrolled in a prospective registry over 6 years. Measures included medical complications and comorbidities. All cases were analyzed together as well as in two subgroups: single procedure cases (Group I) and multiple procedure cases (Group II). RESULTS: 449 patients (407 female, 42 male) with a mean age of 44.5 +/- 10.3 underwent 511 separate operations. Mean pre-weight loss BMI (Max BMI) was 51.6 +/- 9.5 kg/m2, post-weigh loss BMI (Current BMI) was 29.3 +/- 5.0 and the DeltaBMI was 22.3 +/- 7.5. For all cases (n = 511), the presence of a surgical complication was directly related to Max BMI (P = 0.002) and DeltaBMI (P = 0.002) but not Current BMI.Group I consisted of 194 single procedure cases. Complications in Group I were related to Max BMI (P = 0.006) and Current BMI (P = 0.02) but not DeltaBMI. Max BMI impacted infections (P = 0.003) while Current BMI impacted dehiscence (P = 0.009) and infections (P = 0.03). Group II consisted of 317 cases with only DeltaBMI directly related to overall complications (P = 0.01). CONCLUSIONS: Body mass indices influence complications in postbariatric reconstructive surgery. Current BMI may impact complications in single-procedure cases, but appears to play less of a role in larger cases. Careful patient selection, assessment of surgical complexity, and recognition of the particular risks increased by residual obesity can help to optimize outcomes in this patient population.