Cutaneous T-cell lymphoma developing in surgical scars post cardiac surgery: A case study.

Cutaneous T-cell lymphomas are a class of non-Hodgkin lymphomas characterized by the infiltration of malignant T cells into the skin. Their precise pathogenesis remains incompletely understood, but persistent and specific antigen stimulation of skin-homing CD4+ memory T cells by external or internal factors, combined with an inflammatory cytokine-rich tissue microenvironment, may be critical in the development of cutaneous T-cell lymphomas. We present herein a case of primary cutaneous T-cell lymphoma arising in two surgical scars that developed 6 months post-operatively and were successfully treated with external beam radiotherapy. This case highlights the notion that primary cutaneous T-cell lymphoma can develop locally at the site of injury/foreign body within a relatively short time post trauma/surgery. This work contributes to the literature of cutaneous T-cell lymphomas arising after a trauma, surgery, or a foreign body.

Idiopathic Pneumonitis Syndrome After Total Body Irradiation in Pediatric Patients Undergoing Myeloablative Hematopoietic Stem Cell Transplantation: A PENTEC Comprehensive Review.

PURPOSE: Pulmonary complications, especially idiopathic pneumonitis syndrome (IPS), are potentially life altering or fatal sequelae of hematopoietic cell transplantation (HCT). Total body irradiation (TBI) as part of the conditioning regimen has been implicated in IPS. A comprehensive PENTEC (Pediatric Normal Tissues in the Clinic) review was performed to increase our understanding of the role of TBI in the development of acute, noninfectious IPS. METHODS AND MATERIALS: A systematic literature search was conducted using the MEDLINE, PubMed, and Cochrane library databases for articles describing pulmonary toxicity in children treated with HCT. Data pertaining to TBI and pulmonary endpoints were extracted. Risk of IPS was analyzed in relation to patient age, TBI dose, fractionation, dose rate, lung shielding, timing, and type of transplant, with the goal to better understand factors associated with this complication in children undergoing HCT. A logistic regression model was developed using a subset of studies with comparable transplant regimens and sufficient TBI data. RESULTS: Six studies met criteria for modeling of the correlation of TBI parameters with IPS; all consisted of pediatric patients undergoing allogeneic HCT with a cyclophosphamide-based chemotherapy regimen. IPS was variably defined, but all studies that reported IPS were included in this analysis. The mean incidence of post-HCT IPS was 16% (range, 4%-41%). Mortality from IPS, when it occurred, was high (median, 50%; range, 45%-100%). Fractionated TBI prescription doses encompassed a narrow range of 9 to 14 Gy. Many differing TBI methods were reported, and there was an absence of 3-dimensional dose analysis of lung blocking techniques. Thus, a univariate correlation between IPS and total TBI dose, dose fractionation, dose rate, or TBI technique could not be made. However, a model, built from these studies based on prescribed dose using a normalized dose parameter of equivalent dose in 2-Gy fractions (EQD2), adjusted for dose rate, suggested correlation with the development of IPS (P = .0004). The model-predicted odds ratio for IPS was 24.3 Gy-1 (95% confidence interval, 7.0-84.3). Use of TBI lung dose metrics (eg, midlung point dose) could not be successfully modeled, potentially because of dosimetric uncertainties in the actual delivered volumetric lung dose and imperfections in our modeling process. CONCLUSIONS: This PENTEC report is a comprehensive review of IPS in pediatric patients receiving fractionated TBI regimens for allogenic HCT. IPS was not clearly associated with 1 single TBI factor. Modeling using dose-rate adjusted EQD2 showed a response with IPS for allogeneic HCT using a cyclophosphamide-based chemotherapy regimen. Therefore, this model suggests IPS mitigation strategies can focus on not just the dose and dose per fraction but also the dose rate used in TBI. More data are needed to confirm this model and to determine the influence of chemotherapy regimens and contribution from graft-versus-host disease. The presence of confounding variables (eg, systemic chemotherapies) that affect risk, the narrow range of fractionated TBI doses found in the literature, and limitations of other reported data (eg, lung point dose) may have prevented a more straightforward link between IPS and total dose from being observed.

Radiomics-based machine learning models to distinguish between metastatic and healthy bone using lesion-center-based geometric regions of interest.

Radiomics-based machine learning classifiers have shown potential for detecting bone metastases (BM) and for evaluating BM response to radiotherapy (RT). However, current radiomics models require large datasets of images with expert-segmented 3D regions of interest (ROIs). Full ROI segmentation is time consuming and oncologists often outline just RT treatment fields in clinical practice. This presents a challenge for real-world radiomics research. As such, a method that simplifies BM identification but does not compromise the power of radiomics is needed. The objective of this study was to investigate the feasibility of radiomics models for BM detection using lesion-center-based geometric ROIs. The planning-CT images of 170 patients with non-metastatic lung cancer and 189 patients with spinal BM were used. The point locations of 631 BM and 674 healthy bone (HB) regions were identified by experts. ROIs with various geometric shapes were centered and automatically delineated on the identified locations, and 107 radiomics features were extracted. Various feature selection methods and machine learning classifiers were evaluated. Our point-based radiomics pipeline was successful in differentiating BM from HB. Lesion-center-based segmentation approach greatly simplifies the process of preparing images for use in radiomics studies and avoids the bottleneck of full ROI segmentation.

Surgical Management and Contralateral Breast Cancer Risk in Women with History of Radiation Therapy for Hodgkin Lymphoma: Results from a Population-Based Cohort.

BACKGROUND: Women with history of chest irradiation for Hodgkin lymphoma are at increased risk of developing bilateral breast cancer, although contralateral breast cancer risk estimates in this population remain undefined. METHODS: We queried the SEER database for women treated with radiation therapy for Hodgkin lymphoma prior to age 30 years and were diagnosed with a subsequent breast cancer between 1990-2016. Trends in surgical management and the 5- and 10-year cumulative incidence of contralateral breast cancer were evaluated. RESULTS: The cohort included 295 women with a median age of 22 years (range 8-30 years) at Hodgkin lymphoma diagnosis, and 42 years (range 22-65 years) at breast cancer diagnosis. Overall, 263 (89.2%) presented with unilateral breast cancer, while 32 (10.8%) presented with synchronous bilateral breast cancer. Breast-conserving surgery was performed in 17.3% of patients, while mastectomy was performed in 82.7%. In 263 patients presenting with unilateral breast cancer, 50 (19.0%) underwent breast-conserving surgery and 213 (81.0%) underwent mastectomy. Subgroup analysis of mastectomy patients demonstrated a 40.5% bilateral mastectomy rate. The 5-year incidence of contralateral breast cancer in women who underwent unilateral surgery was 9.4% [95% confidence interval (CI), 5.6-15.4%], increasing to 20.2% (95% CI, 13.7-29.2%) at 10-year and 29.9% (95% CI, 20.8-41.9%) at 15-year follow-up. CONCLUSIONS: Women with a history of prior chest radiation for Hodgkin lymphoma with a diagnosis of breast cancer have a 10-year contralateral breast cancer risk of 20%. These findings support consideration of contralateral prophylactic mastectomy during surgical decision-making for management of this high-risk patient population.

Clinicopathologic features of breast cancers diagnosed in women treated with prior radiation therapy for Hodgkin lymphoma: Results from a population-based cohort.

BACKGROUND: Childhood and young adult survivors of Hodgkin lymphoma (HL) are at elevated risk of developing breast cancer, yet little data exist on the tumor characteristics that develop in this high-risk patient population. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results database was used to identify breast cancers diagnosed between 1990 and 2016 in women who had received prior radiation therapy for HL at age 30 years or younger. Clinicopathologic features of subsequent breast cancers (breast cancer after radiation therapy for HL [BC-HL]) were examined and compared with breast cancers diagnosed in women who had no prior malignancy (breast cancer with no prior malignancy [BC-NPM]). RESULTS: In total, 321 breast cancers were identified in 257 women who had a history of radiation therapy for HL. The median age at HL diagnosis was 22 years (interquartile range, 18-26 years), and nearly all patients in the BC-HL group (97.9%) were diagnosed ≥8 years after radiation therapy. Overall, 56 patients in the BC-HL group (21.8%) developed bilateral breast cancer. Compared with women who had BC-NPM, those who had BC-HL were younger (43 vs 60 years; P < .001) and were less likely to present with ductal carcinoma in situ (8.4% vs 14.9%; P = .001). On multivariable analysis that included adjustment for age, invasive BC-HL was associated with smaller (≤2 cm) tumor size (odds ratio, 1.64; 95% CI, 1.25-2.15) and upper outer quadrant tumors (odds ratio, 1.37; 95% CI, 1.04-1.81) compared with BC-NPM. In a subset analysis of 102 women who had HER2/neu status available, the distribution of biologic subtype was not significantly different between BC-HL and BC-NPM (P = .16). CONCLUSIONS: Breast cancers in women who previously received radiation therapy for HL are characterized by earlier onset disease, although most remain estrogen receptor-positive and have early stage disease at presentation. LAY SUMMARY: Women who have had radiation therapy for Hodgkin lymphoma at a young age are at increased risk of developing early onset breast cancer; however, most of these breast cancers are sensitive to hormones (estrogen receptor-positive) and are diagnosed at early stages. Because these breast tumors are estrogen receptor-positive, medications that prevent breast cancer by blocking the effect of or lowering hormone levels (also termed endocrine prevention) may be useful in this group of high-risk women.

Development of a generalizable natural language processing pipeline to extract physician-reported pain from clinical reports: Generated using publicly-available datasets and tested on institutional clinical reports for cancer patients with bone metastases.

OBJECTIVE: The majority of cancer patients suffer from severe pain at the advanced stage of their illness. In most cases, cancer pain is underestimated by clinical staff and is not properly managed until it reaches a critical stage. Therefore, detecting and addressing cancer pain early can potentially improve the quality of life of cancer patients. The objective of this research project was to develop a generalizable Natural Language Processing (NLP) pipeline to find and classify physician-reported pain in the radiation oncology consultation notes of cancer patients with bone metastases. MATERIALS AND METHODS: The texts of 1249 publicly-available hospital discharge notes in the i2b2 database were used as a training and validation set. The MetaMap and NegEx algorithms were implemented for medical terms extraction. Sets of NLP rules were developed to score pain terms in each note. By averaging pain scores, each note was assigned to one of the three verbally-declared pain (VDP) labels, including no pain, pain, and no mention of pain. Without further training, the generalizability of our pipeline in scoring individual pain terms was tested independently using 30 hospital discharge notes from the MIMIC-III database and 30 consultation notes of cancer patients with bone metastasis from our institution's radiation oncology electronic health record. Finally, 150 notes from our institution were used to assess the pipeline's performance at assigning VDP. RESULTS: Our NLP pipeline successfully detected and quantified pain in the i2b2 summary notes with 93% overall precision and 92% overall recall. Testing on the MIMIC-III database achieved precision and recall of 91% and 86% respectively. The pipeline successfully detected pain with 89% precision and 82% recall on our institutional radiation oncology corpus. Finally, our pipeline assigned a VDP to each note in our institutional corpus with 84% and 82% precision and recall, respectively. CONCLUSION: Our NLP pipeline enables the detection and classification of physician-reported pain in our radiation oncology corpus. This portable and ready-to-use pipeline can be used to automatically extract and classify physician-reported pain from clinical notes where the pain is not otherwise documented through structured data entry.

Quantitative-qualitative analyses of patient-reported pain response after palliative radiation therapy.

PURPOSE: While the 0-10 pain scale is often used to assess treatment response, it may not accurately reflect change in pain over time. The purpose of this study is to correlate pain improvement using the 0-10 pain scale to patients' perceived improvement in pain following palliative radiation therapy (RT), and to qualitatively characterize themes of pain assessment. METHODS: Patients age ≥ 20 receiving RT for spinal metastases were enrolled. Patients rated their pain (0-10) at the treatment site at RT start, and 1 and 4 weeks post-RT completion. At 1 and 4 weeks post-RT, patients reported their perceived percent improvement in pain (pPIP) (0-100%), which was compared to calculated percent improvement in pain (cPIP) based on the 0-10 pain scores. At 4 weeks post-RT, 20 randomly selected patients participated in a qualitative pain assessment. RESULTS: Sixty-four patients treated at 1-2 sites were analyzed. At 1 week post-RT completion, 53.7% (36/67) reported pPIP within 10 percentage points of cPIP, 32.8% (22/67) reported pPIP > 10 percentage points higher than cPIP, and 13.4% (9/67) reported pPIP > 10 percentage points lower than cPIP. Similar degrees of discordance were seen at 4 weeks post-RT. Qualitative analysis revealed five themes: pain quality (n = 19), activities (n = 9), function (n = 7), medication use (n = 2), and radiation side effects (n = 1). CONCLUSIONS: About half of patients reported a pPIP substantially disparate from their cPIP, and the change in pain measured by the 0-10 scale tended to underestimate the degree of perceived pain improvement. Multiple themes were identified in qualitative analysis of pain response.

Ethical issues in patients referred for palliative radiation therapy.

BACKGROUND: As patients with advanced cancer approach end of life, ethical issues may arise. We describe ethical issues encountered by radiation oncologists in this setting. METHODS: A prospective, survey-based study assessed 162 consecutive consults for palliative radiation therapy (PRT) over 4 months at 3 hospitals. Consulting radiation clinicians completed a survey assessing palliative care issues encountered, based on national guidelines. Ethical issues included 5 subthemes (conflict between clinicians, caregiver-clinician conflict, internal conflict, feeling unable to do what was best for the patient, and violation of personal morals), an option for unclassified issues, and open-ended responses. Multivariate analyses (MVA) assessed potential patient-related predictors of ethical issues: gender, performance status (PS), PRT indication, physical symptoms, and presence of psychosocial, goals of care, care coordination, cultural, or spiritual issues. RESULTS: Of 162 surveys, 140 were completed (response rate =86%). Overall, 14 (10%) surveys identified ethical issues relevant to care; 11 of 14 (78%) identified more than 1 ethical issue. Half (7; 50%) involved conflict between clinicians and clinician-caregiver conflict; 6 (43%) involved clinician distress or internal conflict; and 2 (14%) felt impeded from doing what they felt was best for the patient. Open-ended responses revealed differences in opinion between medical specialties (n=6, 43%), and conflict related to coordination of care among clinicians (n=3, 21%). On UVA, ethical issues were associated with PRT referrals for bleeding, dyspnea, or dysphagia due to visceral metastases (30%) versus CNS indications such as brain metastases or cord compression (7%) or for bony metastases (4%) P<0.001. On MVA, ethical issues were associated with PRT for visceral metastases (OR 13.0; 95% CI, 2.3-74.6; P<0.001) and presence of spiritual issues (OR 4.0; 95% CI, 1.1-14.5; P=0.04). CONCLUSIONS: At least 1 in 10 referrals for PRT involve ethical issues. Further studies are warranted to assess the ability of radiation oncologists to manage ethical issues.

Patterns of symptom control and palliative care-focused original research articles in the International Journal of Radiation Oncology *Biology* Physics and the Radiotherapy and Oncology Journal, 2005-2014.

BACKGROUND: A significant portion of radiation treatment (30-40%) is delivered with palliative intent. Given the frequency of palliative care (PC) in radiation oncology, we determined the patterns of research focusing on symptom control and palliative care (SCPC) in two prominent radiation oncology journals from 2005-2014. METHODS: Original research manuscripts published from 2005-2014 in the International Journal of Radiation Oncology *Biology* Physics (Red Journal) and the Radiotherapy and Oncology Journal (Green Journal) were reviewed to categorize articles as PC and/or SCPC. Articles were categorized as PC if it pertained to any aspect of treatment of metastatic cancer, and as SCPC if symptom control in the metastatic cancer setting was the goal of the research inquiry and/or any domain of palliative clinical practice guidelines was the goal of research inquiry. RESULTS: From 2005-2014, 4.9% (312/6,386) of original research articles published in the Red Journal and 3.5% (84/2,406) published in the Green Journal pertained to metastatic cancer, and were categorized as PC. In the Red Journal, 1.3% (84/6,386) of original research articles were categorized as SCPC; 1.3% (32/2,406) of articles in the Green Journal were categorized as SCPC. There was no trend observed in the proportion of SCPC articles published over time in the Red Journal (P=0.76), the Green Journal (P=0.48), or both journals in aggregate (P=0.38). CONCLUSIONS: Despite the fact that palliative radiotherapy is a critical part of radiation oncology practice, PC and SCPC-focused original research is poorly represented in the Red Journal and the Green Journal.

Assessing the utility of the spinal instability neoplastic score (SINS) to predict fracture after conventional radiation therapy (RT) for spinal metastases.

PURPOSE: Assessing the stability of spinal metastases is critical for making treatment decisions. The spinal instability neoplastic score (SINS) was developed by the Spine Oncology Study Group to categorize tumor-related lesions; however, data describing its utility in predicting fractures in patients with spinal metastases are limited. The purpose of this study is to assess the validity of SINS in predicting new or worsening fracture after radiation therapy (RT) to spine metastases. METHODS AND MATERIALS: This is a retrospective analysis of patients treated with conventional RT alone (median total dose, 30 Gy; range, 8-47 Gy; median number of fractions, 10; range, 1-25) for spinal metastasis at Dana-Farber/Brigham and Women's Cancer Center from 2006 to 2013. SINS was calculated for each lesion (range, 0-18). The primary endpoint was time from RT start to radiographically documented new or worsening fracture or last disease assessment. RESULTS: A total of 203 patients and 250 lesions were included in analysis. The percentages of lesions with SINS of 0 to 6, 7 to 12, and 13 to 18 were 38.8%, 54.8%, and 6.4%, respectively. Of 250 lesions, 20.4% developed new or worsening fractures; 14.4% for SINS 0 to 6, 21.2% for SINS 7 to 12, and 50.0% for SINS 13 to 18. Multivariate analysis adjusted for sex, age, Eastern Cooperative Oncology Group, histology, and total dose indicated that, compared with stable lesions (SINS 0-6), potentially unstable lesions (SINS 7-12) demonstrated a greater likelihood of new or worsening fracture that was not statistically significant (hazard ratio, 1.66; 95% confidence interval, 0.85-3.22; P = .14), and unstable lesions (SINS 13-18) were significantly more likely to develop to new or worsening fracture (hazard ratio, HR,4.37, 95% confidence interval, 1.80-10.61; P = .001). CONCLUSIONS: In this study of patients undergoing RT for spinal metastases, 20.4% developed new or worsening vertebral fractures. SINS is demonstrated to be a useful tool to assess fracture risk after RT.

Impact of a dedicated palliative radiation oncology service on the use of single fraction and hypofractionated radiation therapy among patients with bone metastases.

BACKGROUND: Radiation therapy (RT) is frequently used to palliate symptomatic bone metastases. While high quality literature has shown that for uncomplicated bone metastases, shorter radiotherapy courses are just as effective as longer courses for the treatment of pain, shorter courses remain under-utilized. We aimed to assess the impact of a dedicated palliative radiation oncology service on the frequency of single fraction RT (SF-RT) and hypofractionated radiation (hypo-RT) (≤5 fractions) among patients with bone metastases. METHODS: We identified 2,086 instances of palliative radiation (RT) for complicated and uncomplicated bone metastases between April 10, 2008 and September 17, 2014. We used multivariable logistic regression analysis (MVA) to estimate the association of the Supportive and Palliative Radiation Oncology (SPRO) service with the likelihood of receiving SF-RT or hypo-RT after controlling for age, sex, tumor type, and treatment site. RESULTS: Prior to SPRO's implementation on July 1, 2011, the proportion of SF-RT and hypo-RT for bone metastases was 6.4% and 27.6% respectively. After SPRO's implementation, the proportion of SF-RT and hypo-RT increased to 22.3% (P<0.001) and 53.5% (P<0.001) respectively. In MVA, patients were more likely to receive SF-RT [odds ratio (OR) =3.3, 95% confidence interval (CI) =2.4-4.7, P<0.001], and hypo-RT (OR =2.5, 95% CI =2.0-3.1, P<0.001) after SPRO's implementation. Compared to sites without a dedicated palliative service, patients receiving care at the SPRO affiliated department were more likely to receive SF-RT (OR =1.9, 95% CI =1.1-3.2, P=0.02) and hypo-RT (OR =1.5, 95% CI =1.1-2.0, P=0.004) for bone metastases. After SPRO's implementation, the average number of RT courses delivered for bone metastases increased from 17.4 to 25.6 per month, (+8.3, 95% CI =4.99-11.55, P<0.001). Despite greater SF-RT and hypo-RT, the average total fractions per month of palliative RT for bone metastases increased from 163.5 pre-SPRO to 166.8 post-SPRO, though not significantly (+3.22, P=NS). CONCLUSIONS: Implementation of a dedicated palliative radiation oncology service was associated with increased use of SF and hypo-RT and with greater courses of RT delivered for bone metastases.

Assessing the utility of a prognostication model to predict 1-year mortality in patients undergoing radiation therapy for spinal metastases.

BACKGROUND CONTEXT: Predicting survival outcomes after radiation therapy (RT) alone for metastatic disease of the spine is a challenging task that is important to guiding treatment decisions (eg, determining dose fractionation and intensity). The New England Spinal Metastasis Score (NESMS) was recently introduced and validated in independent cohorts as a tool to predict 1-year survival following surgery for spinal metastases. This metric is composed of three factors: preoperative albumin, ambulatory status, and modified Bauer score, with the total score ranging from 0 to 3. PURPOSE: The purpose of this study was to assess the applicability of the NESMS model to predict 1-year survival among patients treated with RT alone for spinal metastases. STUDY DESIGN/SETTING: This study is a retrospective analysis. PATIENT SAMPLE: This sample included 290 patients who underwent conventional RT alone for spinal metastases. OUTCOME MEASURES: Patients' NESMS (composed of ambulatory status, pretreatment serum albumin, and modified Bauer score) were assessed, as well as their 1-year overall survival rates following radiation for metastatic disease of the spine. MATERIALS AND METHODS: This study is a single-institution retrospective analysis of 290 patients treated with conventional radiation alone for spinal metastases from 2008 to 2013. The predictive value of the NESMS was assessed using multivariable logistic regression modeling, adjusted for potential confounding variables. RESULTS: This analysis indicated that patients with lower NESMSs had higher rates of 1-year mortality. Multivariable analysis demonstrated a strong association between lower NESMSs and lower rates of survival. CONCLUSIONS: The NESMS is a simple prognostic scheme that requires clinical data that are often readily available and have been validated in independent cohorts of surgical patients. This study serves to validate the utility of the NESMS composite score to predict 1-year mortality in patients treated with radiation alone for spinal metastases.

Radiotherapy is Important for Local Control at Primary and Metastatic Sites in Pediatric Rhabdomyosarcoma.

PURPOSE: The current recommended practice for pediatric patients with metastatic rhabdomyosarcoma includes full-dose radiotherapy to each metastatic site. We wished to question this practice, which can cause side-effects and is often logistically challenging, by studying the pattern of failure in our pediatric and teenage patient population. METHODS AND MATERIALS: Our institution's cancer registry was queried for patients diagnosed with rhabdomyosarcoma aged 18 or less from January 1990 until January 2014. Twenty-nine patients were found and, of these, six had metastatic disease. Five of the six were treated with standard chemotherapy together with radiotherapy to the primary and metastatic sites with doses and fractionation according to the site. Progression-free survival was calculated from the end of radiotherapy until radiological or pathological evidence of disease progression or death. RESULTS: Median age was 13 years (range: 12-18). Three were girls. All had alveolar histology and unfavorable primary sites. Twelve metastatic sites were treated with radiotherapy. Doses used were 41.4 - 50.4 Gy in 1.8 Gy fractions for most sites, and 15 Gy in 1.5 Gy fractions for whole lung radiotherapy. The median number of sites treated per patient was two (range: 1 - 6). Median time to progression was 10.1 months (range: 1.9 - 15.7). Local control was 100% for all metastatic sites. Median overall survival (OS) was 31.8 months (range: 20.4 - 95.4 months). Three patients developed progressive disease outside the treated field. One patient died from a secondary hematological malignancy without evidence of disease progression. One patient remains progression-free at 88.6 months post-radiotherapy. CONCLUSIONS: Radiotherapy to metastatic disease sites prevented in-field progression in all five patients with metastatic alveolar rhabdomyosarcoma. However, failure at sites outside of the radiotherapy volume occurred in three of five of patients and overall survival was very poor despite aggressive treatment to all sites of disease. Radiotherapy has a role in metastatic disease, although future studies evaluating dose and fractionation are needed.

Metabolic activity measured on PET/CT correlates with clinical outcomes in patients with limb and girdle sarcomas.

OBJECTIVE: To explore the relationship between metabolic activity and outcome in patients with extremity sarcomas. METHODS: Between June 2004 and December 2011, 120 patients with newly diagnosed limb and girdle sarcomas underwent FDG-PET/CT for disease staging prior to curative intent treatment. The maximum standardized uptake value (SUV(max)) was measured for each primary tumor and correlated with outcome. Progression-free survival and overall survival (OS) were analyzed using the Kaplan-Meier method. RESULTS: Soft-tissue sarcomas were more frequent (68%) than bone (27%) or cartilage (5%) tumors. Median follow-up was 33.2 months. 51% of patients progressed during the follow-up interval and 38% died. SUV(max) was dichotomized with a cut-point of 10.3. Patients with SUV(max) < 10.3 had better DFS and OS compared with patients with SUV(max) ≥ 10.3 (P < 0.001 and P < 0.001, respectively [log-rank test]). Multivariate analysis confirmed that even after adjusting for age, sex, site, tumor type (bone vs. soft-tissue), grade, and stage; an SUV(max) ≥ 10.3 correlated with a twofold risk of progression and 2.4 times greater risk of death (hazard ratio [HR] 2.0, 95% CI, 1.1-3.7, and HR, 2.4, 95% CI, 1.1-4.9). CONCLUSION: SUV(max) is an independent adverse prognostic factor for both progression and OS in patients with extremity sarcomas.

Necrosis on FDG PET/CT correlates with prognosis and mortality in sarcomas.

OBJECTIVE: The purpose of this study was to determine if there is an association between necrosis as identified on staging (18)F-FDG PET/CT and overall survival (OS) and progression-free survival (PFS) in patients with sarcoma. MATERIALS AND METHODS: Sixty-six patients with newly diagnosed limb and girdle sarcoma underwent PET/CT at our institution between June 2004 and July 2009 for sarcoma staging before treatment with curative intent. The tumor maximum standardized up-take values (SUVmax), the presence of necrosis, and the volume of necrosis were measured for each primary tumor and correlated with follow-up data. PFS and OS were analyzed using the Kaplan-Meier method. Proportional hazards models were used to estimate hazard ratios. RESULTS: Median patient age was 49 years, and 51.6% of the patients were men. Sarcomas were categorized as soft tissue (69.2%), bone (23.5%), or other (7.3%). Mean follow-up time was 33.3 months. During the follow-up interval, 53% of patients experienced disease progression, and 40.9% died. There was a statistically significant relationship between the presence of necrosis and OS (by log-rank test, p = 0.001), as well as PFS (by log-rank test, p = 0.0001). Twenty-four-month OS was 96%, 65%, and 38% in patients with tumors with absence necrosis, those with presence of necrosis, and with necrosis volume greater than 50%, respectively. Forty-eight-month OS was 81% in patients with absence of necrosis and 41% in patients with presence of necrosis. Twelve-month PFS was 96%, 60%, and 42% in patients with tumors with absence of necrosis, those with presence of necrosis, and those with necrosis volume greater than 50%, respectively. Twenty-four-month PFS was 83%, 38%, and 22%, respectively, in these groups. CONCLUSION: The presence of necrosis and the volume of necrosis, as identified on the staging FDG PET/CT and after adjusting for SUVmax, are strong independent adverse prognostic factors for disease recurrence and death in patients with limb and girdle sarcomas.

Correlating metabolic activity on 18F-FDG PET/CT with histopathologic characteristics of osseous and soft-tissue sarcomas: a retrospective review of 136 patients.

OBJECTIVE: The objective of our study was to determine whether there is a statistically significant correlation between metabolic activity of osseous and soft-tissue sarcomas as measured by the maximum standardized uptake value (SUV(max)) on (18)F-FDG PET/CT and histopathologic characteristics such as mitotic counts, the presence of necrosis, and the presence of a myxoid component. MATERIALS AND METHODS: We retrospectively evaluated 238 consecutive patients with known soft-tissue or osseous sarcoma who underwent (18)F-FDG PET/CT for initial staging or assessment for recurrence of disease. The SUV(max) of each primary or of the most intense metastatic lesion was measured and was compared with the histologic data provided in the final pathology reports. RESULTS: Histopathologic data were available for 136 sarcomas. The median SUV(max) values of sarcomas with mitotic counts of less than 2.00 (per 10 high-power fields [HPF]), 2.00-6.99, 7.00-16.24, and 16.25 or greater were 5.0, 6.6, 10.3, and 13.0, respectively (p = 0.0003). The median SUV(max) for the sarcomas with necrosis (90 patients) was 8.6 and for those without necrosis (43 patients), 6.0 (p = 0.026). The median SUV(max) for the sarcomas without a myxoid component (118 patients) was 7.7 and with a myxoid component (16 patients) was 6.2 (p = 0.28). CONCLUSION: There was a statistically significant correlation between the mitotic count and the SUV(max) as well as between the presence of tumor necrosis and the SUV(max). Although a correlation between the presence of a myxoid component and SUV(max) was shown, it was not found to be statistically significant. These findings improve on the current information in the literature regarding the use of PET/CT for guidance in sarcoma biopsy. Correlating the SUV(max) with histologic markers that also feature prominently in major sarcoma grading systems may help improve the accuracy of grading and of prognostication by allowing the SUV(max) to potentially serve as a surrogate marker in these grading systems, particularly in cases in which there is interobserver disagreement in the pathologic diagnosis or in cases in which the sarcoma cannot be properly classified on the basis of histopathologic evaluation alone.