Preliminary efficacy and safety analysis: 12-month results in 83 patients using a novel approach of widefield radiation therapy for extensive skin field cancerization with or without keratinocyte cancers.

PURPOSE: Evaluate the use of widefield radiation therapy (RT) in the management of extensive skin field cancerization (ESFC) with/without keratinocyte cancer (KC). METHODS: The National Dermatology Radiation Oncology Registry is a multidisciplinary collaboration (dermatologists and radiation oncologists). It captures disease description, prior therapies, radiation prescription, clinical effect, skin cosmesis scores, and toxicity data. This analysis included 12-month follow-up data on 89 treated fields from a subset of 83 patients. RESULTS: Clinical success (>90% field clearance) was 96% (ESFC, n = 63) and 88% (ESFC with KC, n = 26). Complete lesion response was seen in 96% of evaluable (n = 25) ESFC with KC. Recurrence (4/89 [5%]) and appearance of new lesions (10/89 [11%]) were minimal. Cosmetic outcome was excellent/good in 98% ESFC and 96% ESFC with KC. Grade 1-2 acute radiation dermatitis occurred in up to 80% of treated fields. The frequency of Grade 3 acute skin toxicities was low. CONCLUSIONS: Registry data demonstrate the potential for widefield RT to treat patients with significant skin pathology who have exhausted other therapies and require durable, minimally invasive treatment options. At 12 months, observed clinical success rates were higher than those reported for topical interventions for ESFC. Ongoing follow-up is required to determine longer term outcomes.

'Measuring up': A comparison of two response expectancy assessment formats completed by men treated with radiotherapy for prostate cancer.

OBJECTIVE: Response expectancies of cancer treatment toxicities are often, but not always, associated with subsequent experiences. A recent meta-analysis indicated that response expectancies, measured using different assessment formats, reveal different effect sizes, potentially explaining mixed outcomes. Utilizing a clinical sample, we compared 5-point assessments and visual analogue scales, as measures of response expectancies for the incidence and severity of subsequent toxicities. METHODS: Four weeks pre-radiotherapy, 45 men with prostate cancer rated their response expectancies of the same 18 toxicities on 5-point assessments and visual analogue scales, presented in random order. Descriptors anchored each end of visual analogue scales and every point of 5-point assessments was labelled, including an 'unsure' midpoint. Toxicities were subsequently assessed 2-weeks into radiotherapy on 100-point visual analogue scales. RESULTS: Across all toxicities, 17.5-62.8% of patients selected 'unsure' on 5-point assessments. No response expectancies were reported on 5-point assessments for 'blood in stools' or 'rectal urgency' yet 54.8%-64.3% of patients indicated response expectancies for these toxicities on visual analogue scales. Visual analogue scales and 5-point scales demonstrated small-to-moderate associations (r = 0.30-0.58) as measures of response expectancy incidence, but mostly large associations when visual analogue scales captured severity (r = 0.43-0.76). Response expectancies measured with visual analogue scales predicted more toxicities to a moderate degree or greater (68.8%) than 5-point assessments (37.5%). CONCLUSION: This novel investigation demonstrated an 'unsure' midpoint is often selected, potentially reducing the sensitivity of 5-point assessments. Based on their associations, and outcomes, these assessment formats should be considered independent in response expectancy research of cancer treatment toxicities.

"Just As I Expected": A Longitudinal Cohort Study of the Impact of Response Expectancies on Side Effect Experiences During Radiotherapy for Prostate Cancer.

CONTEXT: Previous research has indicated that pretreatment response expectancies of side effects often predict subsequent toxicity severity. However, this has been largely based on female patients undergoing chemotherapy. OBJECTIVES: We tested whether this association also occurred in a novel cohort, men with prostate cancer undergoing radiotherapy. We investigated these associations throughout treatment (before and after side effects were medically predicted to occur), controlling known and novel variables. METHODS: Homogenous male patients scheduled for radiotherapy (N = 35, mean age 71 years) completed baseline (pretreatment) measures; response expectancies of 18 treatment-related side effects; questions about baseline health and hormonal treatment, emotional state, and coping style. Response expectancies of the side effects were again measured two weeks into treatment. The severity of the same 18 toxicities was assessed two and seven weeks into treatment. RESULTS: Hierarchical multiple linear regressions revealed baseline response expectancies significantly and independently predicted six of 18 toxicities two weeks into radiotherapy, contributing 12%-30% of explained variance (ß = 0.39-0.59). Response expectancies assessed two weeks into treatment significantly and uniquely predicted seven of 17 experienced toxicities at seven weeks, explaining 17%-50% of variance (ß = 0.49-0.91). Sexual toxicity response expectancies revealed the strongest associations with experience throughout treatment (ß = 0.46-0.91), with "inability to reach orgasm" showing the largest effect. CONCLUSION: In this older male sample, response expectancies of side effects predicted experiences throughout treatment, including the period before toxicities were medically expected. Response expectancies of sexual side effects were robust, independent predictors of subsequent toxicities across treatment, especially issues with orgasm, warranting focus in practice and future research.

When is an acoustic neuroma not an acoustic neuroma? Pitfalls for radiosurgeons.

INTRODUCTION: Because acoustic neuroma (AN), also termed vestibular schwannoma, constitutes by far the commonest intracranial schwannoma and cerebello-pontine angle (CPA) tumour, there is a risk of overlooking rarer alternative diagnoses with similar clinical and/or radiological features. The purpose of this article is to highlight to radiosurgeons the potentially serious implications of this problem through illustrative case studies. METHODS: Our linac stereotactic radiosurgery (SRS) technique has been previously described, with stereotactic headring fixation and treatment delivered via cones or micro-multileaf collimators using multiple arcs or static beams. RESULTS: Between November 1993 and October 2014, we treated 132 patients referred with a clinical diagnosis of AN, the vast majority with 12 Gy marginal dose. Three of these (2.3%), evident either at the time of treatment (2) or subsequently (1), had features instead consistent with cochlear schwannoma, facial schwannoma and meningioma, respectively. Each warranted significant modification to standard AN outlining and fields. The meningioma progressed due to geographic miss. One other patient with recurrent facial schwannoma (not yet needing SRS) was also referred with an incorrect diagnosis of AN. CONCLUSION: When rare variants of common medical problems are not identified before referral, there is a risk that 'blinkering' can lead to misdiagnosis and suboptimal treatment. Radiosurgeons need to be particularly mindful of this issue with AN, which can mimic several other tumours occurring in the CPA region, albeit with different patterns of spread. Optimal imaging, high-quality radiology reporting and neuroradiology input at the time of SRS planning within the setting of a specialised multidisciplinary team are highly desirable.

LINAC radiosurgery for cerebral arteriovenous malformations: a single centre prospective analysis and review of the literature.

Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment option for patients diagnosed with cerebral arteriovenous malformations (AVM). We present the experience in linear accelerator-based SRS for cerebral AVM treated over 14 years. We prospectively followed 67 patients with 69 AVM treated with SRS from 1994 to 2008, inclusive. The mean patient age was 37 years (range 7-69) with 36 women and 31 men. The median AVM size, as defined by maximal diameter, was 2.5 cm (range 0.5-4.6 cm) and the median marginal dose was 18 Gy in one fraction. The crude angiographic obliteration rate was 55% with a 3 and 5 year actuarial rate of 39% and 65%, respectively. Median time to obliteration was 4.2 years. Higher treatment dose (p<0.0001) and smaller maximal AVM diameter (p=0.002) were associated with an increased obliteration rate. There were no deaths from treatment. Post-treatment neurological complications occurred in 10 patients (15%) including hemorrhage in two. Twelve patients (18%) required a second SRS procedure. Larger AVM diameter was associated with increased odds of requiring re-treatment (p=0.02). Radiosurgery for intracerebral AVM is a non-invasive therapeutic option with low morbidity and a reasonable likelihood of nidus obliteration. Treatment dose and AVM diameter are the main determinants of obliteration.

Enhanced intrinsic radiosensitivity after treatment with stereotactic radiosurgery for an acoustic neuroma.

Enhanced radiosensitivity is an uncommon phenomenon attributable to deficient DNA repair after radiotherapy which can be assessed with the γ-H2AX assay. Reports of radiosensitivity after stereotactic radiosurgery (SRS) are uncommon. We describe a case where the clinical, radiological and laboratory findings suggest enhanced radiosensitivity after SRS for an acoustic neuroma.

Male breast cancer: a 30-year experience in South Australia.

AIMS: Male breast cancer (MBC) is an uncommon disease with a paucity of information in the literature. The treatment of MBC has traditionally been extrapolated from experience with female breast cancer. This study reports on the treatment and outcomes of this disease in South Australia over a 30-year period. METHODS: From 1977 to 2007 63 patients with a median age of 62 years (range 33-85 years) were identified and treated for MBC. Data obtained, included initial stage, pathological features, treatment and outcomes. RESULTS: With a median follow up of 4.9 years (range 2 months to 19 years) the 5-year overall survival (OS) rate was 85% with median survival of 5.5 years. In all, 18 (29%) were diagnosed with recurrent disease, while 45 (72%) remained disease free. The median time to recurrence was 2.5 years. One patient failed locally, three (4%) had locoregional recurrence and distant recurrence was noted in 14 patients (22%). Disease stage at presentation was a significant predictor of 5-year OS and recurrence (P = 0.012 and P = 0.0001). Tumor diameter was also a significant predictor of 5-year OS and recurrence (P = 0.006 and P = 0.021). CONCLUSION: This retrospective series has a 5-year OS that compares favorably with other published series of MBC. The positive findings may help change the misperception that MBC is an inherently aggressive disease process with a poor clinical outcome. Further studies are needed to carefully and thoroughly investigate this rare but treatable disease.

Stereotactic radiosurgery for acoustic neuromas: what happens long term?

PURPOSE: To determine the clinical outcomes for acoustic neuroma treated with low-dose linear accelerator stereotactic radiosurgery (SRS) >10 years earlier at the Royal Adelaide Hospital using data collected prospectively at a dedicated SRS clinic. METHODS AND MATERIALS: Between November 1993 and December 2000, 51 patients underwent SRS for acoustic neuroma. For the 44 patients with primary SRS for sporadic (unilateral) lesions, the median age was 63 years, the median of the maximal tumor diameter was 21 mm (range, 11-34), and the marginal dose was 14 Gy for the first 4 patients and 12 Gy for the other 40. RESULTS: The crude tumor control rate was 97.7% (1 patient required salvage surgery for progression at 9.75 years). Only 8 (29%) of 28 patients ultimately retained useful hearing (interaural pure tone average ≤50 dB). Also, although the Kaplan-Meier estimated rate of hearing preservation at 5 years was 57% (95% confidence interval, 38-74%), this decreased to 24% (95% confidence interval, 11-44%) at 10 years. New or worsened V and VII cranial neuropathy occurred in 11% and 2% of patients, respectively; all cases were transient. No case of radiation oncogenesis developed. CONCLUSIONS: The long-term follow-up data of low-dose (12-14 Gy) linear accelerator SRS for acoustic neuroma have confirmed excellent tumor control and acceptable cranial neuropathy rates but a continual decrease in hearing preservation out to ≥10 years.

Hearing preservation after low dose linac radiosurgery for acoustic neuroma depends on initial hearing and time.

PURPOSE: To assess long term outcomes and factors determining hearing preservation after low dose linac stereotactic radiosurgery (SRS) for acoustic neuroma (AN) at the Royal Adelaide Hospital using prospectively collected data. MATERIAL AND METHODS: Between 1994 and 2010, 102 patients had SRS for AN. Five patients had neurofibromatosis type 2, six sporadic cases had relapsed after surgery, and the remaining 91 sporadic cases had primary SRS. Dose was 12 or 14 Gy. Sustained changes ≥ 2 mm in any diameter were deemed significant, and useful hearing was defined as inter-aural pure tone average (PTA) ≤ 50 dB. Possible prognostic factors for hearing retention were tested by dividing the patients at pre-specified cutpoints: age (60 years), maximum tumour diameter (20mm), initial PTA (20 dB) and dose (12 vs 14 Gy). RESULTS: Eighty-four of the 91 sporadic primary SRS cases were evaluable for tumour control with at least one post-treatment MRI. Their median follow-up was 65 mo (range 10-184 mo). Eighty-two (97.6%) were controlled, the remaining two requiring salvage surgery for progression at 5.75 and 9.75 years. Also, one of the post-operative cases required surgery at 2.1 years after SRS. For the 50 sporadic primary SRS patients with initially useful hearing, median age was 56 (range 21-76), median initial PTA 16 dB (range -11 to +45 dB) and median tumour diameter 21 mm (range 10-33 mm). Four received 14 Gy, the rest 12 Gy. After SRS, 19 patients (38%) retained useful hearing. The Kaplan-Meier estimated preservation rate at 5 years was 50% (95% CI 36-64%) but by 10 years, this had fallen to 23% (95% CI 12-41%). On univariate analysis, the only significant factor was initial PTA (P < 0.0001). The estimated risk of hearing loss after SRS for patients with initial PTA ≥ 20 dB was 5.0 (95% CI 2.2-11.2) times that with PTA < 20 dB. CONCLUSIONS: Tumour control was excellent (99/102=97% freedom from surgical salvage). Hearing preservation was strongly dependent on initial PTA, but there was a steady fall-off in hearing out to at least 10 years.