Novel Pilot Curriculum for International Education of Lymphoma Management Using E-Contouring.

PURPOSE: The International Lymphoma Radiation Oncology Group (ILROG) published consensus guidelines on the management of Hodgkin disease (HD) and nodal non-Hodgkin lymphoma (NHL), which became the most downloaded articles from International Journal of Radiation Oncology, Biology, and Physics. E-contouring workshops allow for interactive didactic sessions, allowing participants to see case-based contouring in real time. A pilot 1-hour curriculum was developed with the objective of reviewing ILROG guidelines for HD and NHL management with incorporation of e-contouring tools. This represents the first international education intervention in Spanish using e-contouring with a pre- and postintervention questionnaire. METHODS: A 1-hour presentation was prepared in Spanish reviewing the ILROG recommendations for HD and NHL. The review was followed by the author's demonstration of contour creation using patients with HD and NHL prepared for the American Society for Radiation Oncology's 2015 e-contouring lymphoma session. A five- question evaluation was prepared and administered before and after intervention. A two-tailed paired t test was performed to evaluate any significant change in test value before and after intervention. RESULTS: A total of nine quizzes were collected before and after the intervention. The average test score before the intervention was 75.6%, and the average test score after the intervention was 86.7% ( P = .051). Four students scored 100% on both the pre- and postintervention evaluations, and no student had a decrease in score from pre- to postintervention evaluation. The topic with the lowest score tested dose consideration. CONCLUSION: A substantial but nonsignificant improvement in test evaluation was seen with this pilot curriculum. This pilot intervention identified obstacles for truly interactive didactic sessions that, when addressed, can lead to fully developed interactive didactic sessions.

Prognostic Impact of Missed Chemotherapy Doses During Chemoradiation Therapy for Non-Small Cell Lung Cancer.

OBJECTIVE: The aim of this study is to investigate the impact of missed chemotherapy administrations (MCA) on the prognosis of non-small cell lung cancer (NSCLC) patients treated with definitive chemoradiation therapy (CRT). MATERIALS AND METHODS: In total, 97 patients with NSCLC treated with definitive CRT were assessed for MCA due to toxicities. Logistic regression was used to determine factors associated with MCA. Kaplan-Meier curves, log-rank tests, and Cox Proportional Hazards models were conducted. RESULTS: MCA occurred in 39% (n=38) of the patients. Median overall survival was 9.6 months for patients with MCA compared with 24.3 months for those receiving all doses (P=0.004). MCA due to decline in performance status was associated with the worst survival (4.6 mo) followed by allergic reaction (10.0 mo), hematologic toxicity (11 mo), and esophagitis (17.2 mo, P=0.027). In multivariate models, MCA was associated with higher mortality (hazard ratio, 1.97; P=0.01) and worse progression-free survival (hazard ratio, 1.96; P=0. 009). CONCLUSIONS: MCA correlated with worse prognosis and increased mortality. Methods to reduce toxicity may improve administration of all chemotherapy doses and increase overall survival in NSCLC treated with CRT.

Modern radiotherapy using image guidance for unresectable non-small cell lung cancer can improve outcomes in patients treated with chemoradiation therapy.

BACKGROUND: To investigate the impact of advances in image-guided radiotherapy (IGRT) on the outcomes of patients with non-small cell lung cancer (NSCLC) treated with chemoradiation therapy (CRT). METHODS: We retrospectively reviewed 91 patients with NSCLC treated with definitive CRT using image guidance with daily orthogonal kilovoltage (kV) imaging compared to standard weekly megavoltage (MV) portal verifications. Kaplan-Meier curves for overall survival and locoregional failure were computed and stratified by image guidance techniques. Log-rank tests were used to compare strata. Cox Proportional Hazards models were used to identify risk factors for worse mortality and locoregional control. RESULTS: Fifty-four percent (n=49) of patients received weekly MV portal imaging, while 46% (n=42) underwent IGRT using daily orthogonal kV imaging. kV IGRT was associated with longer median survival (36.4 months) compared to MV imaging (14.9 months; P=0.01). kV imaging was also marginally associated with lower risk of locoregional failure. Median time to local progression in patients imaged with kV was 21.4 months compared to 10.9 months (P=0.065) for those treated with MV portal imaging. CONCLUSIONS: Daily kV imaging appears to be marginally associated with better survival and disease control when compared to MV imaging. Given the small study size and the numerable factors tested, these finding require additional confirmation.

Modern induction chemotherapy before chemoradiation for bulky locally-advanced nonsmall cell lung cancer improves survival.

BACKGROUND: We seek to investigate whether carboplatin-based induction chemotherapy before modern day concurrent chemoradiotherapy (CCRT) improves survival in patients with bulky, locally advanced nonsmall cell lung cancer (NSCLC). MATERIALS AND METHODS: This analysis included 105 patients with Stage II and III NSCLC treated with definitive CCRT from 2003 to 2013. All patients underwent definitive treatment with weekly platinum-based doublet chemotherapy delivered concurrently with 60-66 Gy of thoracic radiotherapy. Thirty patients who received induction chemotherapy before CCRT had T4 disease, N3 disease, or gross tumor volume (GTV) of >150 cm 3. These patients were compared to those with unresectable disease who received CCRT alone without induction chemotherapy. Statistical analysis included univariate and multivariate methods. RESULTS: Mean follow-up time was 15.6 months. Patients treated with carboplatin based induction chemotherapy demonstrated prolonged overall survival (28.2 vs. 14.2 months, P = 0.04), progression free survival (12.6 vs. 9.0 months, P = 0.02), and distant metastasis free survival (15.8 vs. 10.1months, P = 0.05) compared to those who received CCRT alone without induction chemotherapy. Univariate analysis revealed older age, larger GTV, and squamous pathology as negative prognostic factors. When controlling for these factors, Cox regression analysis indicated a trend toward significantly improved overall survival in the induction cohort (P = 0.10). CONCLUSION: In patients with large tumors or bulky nodal NSCLC, carboplatin-based induction chemotherapy may be an important addition to definitive CCRT in the modern era. Our findings strongly support further investigation induction chemotherapy in this population.

Clinical characteristics and dose-volume histogram parameters associated with the development of pleural effusions in non-small cell lung cancer patients treated with chemoradiation therapy.

BACKGROUND: To investigate descriptive characteristics and dose metric (DM) parameters associated with development of pleural effusions (PlEf) in non-small cell lung cancer (NSCLC) treated with definitive chemoradiation therapy (CRT). MATERIALS AND METHODS: We retrospectively assessed treatment records and follow-up imaging of 66 NSCLC patients to identify PlEf formation after CRT. PlEf association between mean heart dose (MHD), mean lung dose (MLD), heart V5-V60 (HV), and lung V5-V60 (LV) were evaluated using Cox Proportional Hazard Models. RESULTS: A total of 52% (34 of 66 patients) of our population developed PlEf and the actuarial rates at 6 months, 12 months, and 18 months were 7%, 30%, and 42%, respectively. Median time to diagnosis was five months (range 0.06-27 months). The majority of PlEfs were grade one (67%) and developed at a median of four (0.06-13) months, followed by grade two (15%) at a median 11 (5-12) months, and grade three (18%) at a median of 11 (3-27) months. On multivariate analysis, increasing HV5-HV50, LV5-LV50, MHD, and MLD were associated with greater risk of PlEf. Higher grade PlEf was also associated with higher doses of radiation to the heart, while lung DM parameters were not significantly associated with higher PlEf grades. At five-months post-CRT, MHD of 25 Gy was associated with a 100% chance of grade one PlEf, an 82% risk of grade two PlEf, and a 19% risk of grade three PlEf. CONCLUSIONS: Post-CRT PlEf is common in NSCLC with the majority being grade one. Increasing heart and lung irradiation was associated with increased risk of PlEf. Increasing heart irradiation also correlated with development of increasing grades of PlEf. The impact of potential cardiopulmonary toxicity and resultant PlEfs after CRT requires additional study.

Thoracic Vertebral Body Irradiation Contributes to Acute Hematologic Toxicity During Chemoradiation Therapy for Non-Small Cell Lung Cancer.

PURPOSE: To determine the relationships between radiation doses to the thoracic bone marrow and declines in blood cell counts in non-small cell lung cancer (NSCLC) patients treated with chemoradiation therapy (CRT). METHODS AND MATERIALS: We included 52 patients with NSCLC treated with definitive concurrent carboplatin-paclitaxel and RT. Dose-volume histogram (DVH) parameters for the thoracic vertebrae (TV), sternum, scapulae, clavicles, and ribs were assessed for associations with changes in blood counts during the course of CRT. Linear and logistic regression analyses were performed to identify associations between hematologic nadirs and DVH parameters. A DVH parameter of Vx was the percentage of the total organ volume exceeding x radiation dose. RESULTS: Grade ≥ 3 hematologic toxicity including neutropenia developed in 21% (n=11), leukopenia in 42% (n=22), anemia in 6% (n=3), and throbocytopenia in 2% (n=1) of patients. Greater RT dose to the TV was associated with higher risk of grade ≥ 3 leukopenia across multiple DVH parameters, including TV V20 (TVV) (odds ratio [OR] 1.06; P=.025), TVV30 (OR 1.07; P=.013), and mean vertebral dose (MVD) (OR 1.13; P=.026). On multiple regression analysis, TVV30 (ß = -0.004; P=.018) and TVV20 (ß = -0.003; P=.048) were associated with white blood cell nadir. Additional bone marrow sites (scapulae, clavicles, and ribs) did not affect hematologic toxicity. A 20% chance of grade ≥ 3 leukopenia was associated with a MVD of 13.5 Gy and a TTV30 of 28%. Cutoff values to avoid grade ≥ 3 leukopenia were MVD ≤ 23.9 Gy, TVV20 ≤ 56.0%, and TVV30 ≤ 52.1%. CONCLUSIONS: Hematologic toxicity is associated with greater RT doses to the TV during CRT for NSCLC. Sparing of the TV using advanced radiation techniques may improve tolerance of CRT and result in improved tolerance of concurrent chemotherapy.

Ambulatory pulse oximetry as a clinical aid for the diagnosis and treatment response of radiation pneumonitis.

PURPOSE: Radiation pneumonitis (RP) is a clinical diagnosis, with no single best method of detection currently available. This study evaluated whether a decline between resting (rPO) and ambulatory (aPO) pulse oximetry (PO) levels after concurrent chemotherapy and radiation therapy (RT) can serve as a clinical aid in diagnosing and evaluating treatment response of grade 2-3 RP. METHODS AND MATERIALS: Between March 2007 and November 2013, rPO and aPO values were obtained from 55 patients immediately after definitive thoracic RT and at each subsequent visit, for up to 4 visits. Median values of the decline from rPO to aPO were compared between those with and without subsequent RP. A logistic regression model was used to determine an association between a drop in PO and, independently, clinically defined RP. RESULTS: RP was identified in 19 of 55 patients, with a median time to diagnosis of 56 days after RT. Twelve patients (22%) were diagnosed with grade 2 RP and 7 (13%) with grade 3 RP. According to a Wilcoxon rank sum test, the median calculated drop between rPO and aPO was greater in RP patients than in those without RP (median 4.21 and 1.01, respectively; P<.0001). After adjustment for total tumor dose and age, multivariate analyses revealed a 64.8% increase in the chance of RP development with every unit of decline in PO (P=.0014). After initiation of treatment with a corticosteroid, the mean difference in PO drop was compared with patients' baselines and demonstrated a statistically significant improvement, with peak PO value recovery after 2 weeks of corticosteroid therapy (P=.0001). CONCLUSIONS: Patients diagnosed with RP demonstrated an early, measurable drop between rPO and aPO that was detected at or before diagnosis. Consequent recovery in PO followed treatment with corticosteroids. PO measurements are cost-effective and readily available, and they can be a valuable tool to aid in diagnosing RP and gauging treatment response.

Impact of metformin use on survival in locally-advanced, inoperable non-small cell lung cancer treated with definitive chemoradiation.

BACKGROUND: We investigated survival outcomes in diabetic patients with non-small cell lung cancer (NSCLC) treated with concurrent metformin and definitive chemoradiation. METHODS: This single-institution, retrospective cohort study included 166 patients with NSCLC who were treated definitively with chemoradiation between 1999 and 2013. Of 40 patients who had type II diabetes, 20 (50%) were on metformin, and 20 (50%) were not on metformin. The primary outcome was overall survival (OS), and secondary outcomes included progression-free survival (PFS), locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS). Kaplan Meier method and log-rank test were performed in survival analysis. Cox regression was utilized in univariate analysis of potential confounders. RESULTS: Median follow-up was 17.0 months. Compared with non-diabetic patients, diabetic patients on metformin demonstrated similar OS (16.3 vs. 14.3 mo, P=0.23), PFS (11.6 vs. 9.7 mo, P=0.26), LRRFS (14.1 vs. 11.9 mo, P=0.78), and DMFS (13.4 vs. 10.0 mo, P=0.69). Compared with diabetic patients not on metformin, diabetic patients on metformin also exhibited similar OS (14.3 vs. 19.2 mo, P=0.18), PFS (19.7 vs. 10.1 mo, P=0.38), LRRFS (11.9 vs. 15.5 mo, P=0.69), and DMFS (10.0 vs. 17.4 mo, P=0.12). Identified negative prognostic factors on included squamous cell histology, lower performance status, higher T stage, and non-caucasian ethnicity. CONCLUSIONS: No statistically significant differences in survival or patterns of failure were found among the three cohorts in this small set of patients. No statistically significant differences in survival or patterns of failure were found between the three cohorts in this small set of patients. Though it is possible that metformin use may in fact have no effect on survival in NSCLC patients treated with definitive RT, larger-scale retrospective and prospective studies are implicated for clarification.

Non-operative therapies for colorectal liver metastases.

Locoregional therapies for colorectal liver metastases complement systemic therapy by providing an opportunity for local control of hepatic spread. The armamentarium for liver-directed therapy includes ablative therapies, embolization, and stereotactic body radiation therapy. At this time, prospective studies comparing these modalities are limited and decision-making relies on a multidisciplinary approach for optimal patient management. Herein, we describe multiple therapeutic non-surgical procedures and an overview of the results of these treatments.

A unique presentation of occult primary breast cancer with a review of the literature.

We are reporting a case of a 34-year-old woman with occult primary breast cancer discovered after initially presenting with neurological symptoms. She was successfully treated with neoadjuvant chemotherapy followed by definitive axillary lymph node dissection and ipsilateral whole breast radiotherapy. The case presented is unique due to the rarity of occult primary breast cancer, especially in light of her initial confounding neurological signs and symptoms, which highlights the importance of careful staging.

High dose radiotherapy to automated implantable cardioverter-defibrillator: a case report and review of the literature.

We report a case of successful full-dose chemoradiotherapy to stage IIIB nonsmall cell lung cancer (NSCLC) in a 59-year-old man with extensive cardiac history and an automated implantable cardioverter-defibrillator (AICD) located within the radiotherapeutic field. In this case, the AICD was a St. Jude Medical Fortify Assura VR 1257-40Q ICD, and it was implanted prophylactically during bypass grafting. Although we do not recommend routine radiotherapy dose to exceed recommended current guidelines due to the potential risks to the patient, this is a situation where relocation of the device was not possible. Fortunately, our patient was not AICD-dependent; so following much discussion and deliberation, the decision was made to treat the patient with AICD in place. The patient completed definitive chemoradiotherapy with concurrent cisplatin and etoposide and thoracic irradiation to 69.6 Gy. The minimum, maximum, and mean doses to the AICD directly were 13.5 Gy, 52.4 Gy, and 29.3 Gy, respectively. The device withstood full thoracic radiation dose, and the patient denied cardiac symptoms during the time before, during, and after completion of therapy. We sought to offer this case for both teaching and guidance in practice and to contribute to the published literature currently available in this area.

Technical aspects of radiation therapy for anal cancer.

Historically treated with surgery, current practice recommends anal carcinoma to be treated with a combination of chemotherapy and radiation. This review will examine the anatomy, modes of disease spread and recurrence, and evaluate the existing evidence for treatment options for these tumors. An in-depth examination of specific radiation therapy (RT) techniques-such as conventional 3D-conformal RT and intensity-modulated RT-will be discussed along with modern dose constraints. RT field arrangement, patient setup, and recommended gross and clinical target volume (CTV) contours will be considered. Areas in need of further investigation, such as the role in treatment for positron emission tomography (PET) will be explored.