Single community-based institutional series of stereotactic body radiation therapy (SBRT) for treatment of liver metastases.

BACKGROUND: Stereotactic body radiation therapy (SBRT) is a safe and effective option for treatment of liver metastases. However, existing data are mostly reported by high-volume centers. There have been reports that advanced radiotherapy techniques performed at low-volume centers result in inferior outcomes. Our goal was to assess the implementation of SBRT for the treatment of liver metastases at a low-volume center by studying the efficacy and toxicity of this technology through retrospective database review at a single, community-based institution. METHODS: We performed an IRB approved patient registry study. Patients had a median age of 65, KPS of at least 70 (median 90) and primary tumor controlled. All patients underwent fiducial marker placement under CT-guidance 1-2 weeks prior to planning scans. Gross tumor volume (GTV) was delineated using contrast enhanced CT scans, as well as fusion with PET and/or MRI scans. GTV was expanded by 5 mm to create the planning target volume (PTV). Treatment was delivered by image guided stereotactic robotic radiosurgery with respiratory motion tracking. Lesions were treated with 3 fractions to a median total dose of 54 Gy. Overall survival, progression-free survival (PFS) and local failure-free survival were estimated using the Kaplan-Meier method. Log-rank statistic was used to compare local control based on GTV volume. RESULTS: Between 2006 and 2016, 42 consecutively treated patients with 81 metastatic liver lesions were treated with SBRT. Median follow-up was 25 months. Major primary tumor sites were colon (n=18) and lung (n=7). Synchronous extrahepatic disease was present in 15% of the treated lesions and 46% had prior local treatment of liver metastases. The number of lesions treated concurrently ranged from 1 to 4. Lesions had a median maximum diameter of 2.5 cm (range, 0.5-9.5 cm), and a mean volume of 53 cc (range, 0.5-363.0 cc). Kaplan-Meier estimated 1- and 2-year overall survival was 72% and 62%. Estimated 1- and 2-year progression free survival was 32% and 23%. Estimated 1- and 2-year local control was 86% and 80%. Two-year local control was worse for lesions >50 cc compared to lesions ≤50 cc (62% vs. 84%, P=0.04). Toxicity occurred in 26% of treatment courses and included grade 1 (n=12) and grade 2 toxicity (n=3). CONCLUSIONS: These results are comparable to available published data regarding the safety and efficacy of liver metastasis SBRT on trial at high volume institutions. Our findings, therefore, demonstrate the successful implementation of a liver metastasis SBRT program in the low-volume, community-hospital setting. These findings suggest that low-volume and high-volume centers are both options for liver metastasis SBRT.

Comparison of planned dose distributions calculated by Monte Carlo and Ray-Trace algorithms for the treatment of lung tumors with cyberknife: a preliminary study in 33 patients.

PURPOSE: To compare dose distributions calculated using the Monte Carlo algorithm (MC) and Ray-Trace algorithm (effective path length method, EPL) for CyberKnife treatments of lung tumors. MATERIALS AND METHODS: An acceptable treatment plan is created using Multiplan 2.1 and MC dose calculation. Dose is prescribed to the isodose line encompassing 95% of the planning target volume (PTV) and this is the plan clinically delivered. For comparison, the Ray-Trace algorithm with heterogeneity correction (EPL) is used to recalculate the dose distribution for this plan using the same beams, beam directions, and monitor units (MUs). RESULTS: The maximum doses calculated by the EPL to target PTV are uniformly larger than the MC plans by up to a factor of 1.63. Up to a factor of four larger maximum dose differences are observed for the critical structures in the chest. More beams traversing larger distances through low density lung are associated with larger differences, consistent with the fact that the EPL overestimates doses in low-density structures and this effect is more pronounced as collimator size decreases. CONCLUSIONS: We establish that changing the treatment plan calculation algorithm from EPL to MC can produce large differences in target and critical organs' dose coverage. The observed discrepancies are larger for plans using smaller collimator sizes and have strong dependency on the anatomical relationship of target-critical structures.

Evaluation and definitive management of medically inoperable early stage non-small-cell lung cancer. Part 2: newer treatment modalities.

Lung cancer is estimated to be the second most commonly diagnosed cancer in both men and women in 2006, and the leading causes of cancer mortality. Non-small-cell lung cancer represents the majority of such cases. Most of these patients have locally advanced disease at presentation and are not eligible for curative resection. For the minority of patients who are technically resectable at presentation, lobectomy or pneumonectomy and pathologic mediastinal nodal staging offer the best overall survival. The high rate of comorbid medical illness and poor baseline pulmonary function in this population, however, make many such early-stage patients medically inoperable. For these patients, conventional single-modality radiotherapy has been the primary definitive treatment option, as discussed in part 1 of this article, which appeared in last month's issue. Numerous retrospective reports demonstrate long-term disease-free and overall survival data that are modestly superior to that expected after observation, but both local and distant failure continue to be significant risks. Investigation of radiotherapy dose escalation is ongoing, in an effort to improve local control while maintaining minimal toxicity. Additionally, emerging evidence suggests that new modalities, such as stereotactic radiosurgery and radiofrequency ablation, may also be potentially curative treatment alternatives. These modalities are addressed in part 2.

Evaluation and definitive management of medically inoperable early-stage non-small-cell lung cancer. Part 1: Assessment and conventional radiotherapy.

Lung cancer is estimated to be the second most commonly diagnosed cancer in both men and women in 2006, and the leading cause of cancer mortality. Non-small-cell lung cancer represents the majority of such cases. Most of these patients have locally advanced disease at presentation and are not eligible for curative resection. For the minority of patients who are technically resectable at presentation, lobectomy or pneumonectomy and pathologic mediastinal nodal staging offer the best overall survival. The high rate of comorbid medical illness and poor baseline pulmonary function in this population, however, make many such early-stage patients medically inoperable. For these patients, conventional single-modality radiotherapy has been the primary definitive treatment option, as discussed in part 1 of this two-part article. Numerous retrospective reports demonstrate long-term disease-free and overall survival data that are modestly superior to that expected after observation, but both local and distant failure continue to be significant risks. Investigation of radiotherapy dose escalation is ongoing, in an effort to improve local control while maintaining minimal toxicity. Additionally, emerging evidence suggests that new modalities, such as stereotactic radiosurgery and radiofrequency ablation, may also be potentially curative treatment alternatives. These modalities will be addressed in part 2.

Postoperative radiotherapy for stage II or III non-small-cell lung cancer using the surveillance, epidemiology, and end results database.

PURPOSE: To investigate the association between survival and postoperative radiotherapy (PORT) in patients with resected non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Within the Surveillance, Epidemiology, and End Results database, we selected patients with stage II or III NSCLC who underwent a lobectomy or pneumonectomy. Only those patients coded as receiving PORT or observation were included. To account for perioperative mortality, we excluded patients who survived less than 4 months. As a result of our inclusion criteria, we selected a total of 7,465 patients, with a median follow-up time of 3.5 years for patients still alive. RESULTS: Predictors for the use of PORT included age less than 50 years, higher American Joint Committee on Cancer stage, T3-4 tumor stage, larger tumor size, advanced node stage, greater number of lymph nodes involved, and a ratio of lymph nodes involved to lymph nodes sampled approaching 1.00. On multivariate analysis, older age, T3-4 tumor stage, N2 node stage, male sex, fewer sampled lymph nodes, and greater number of involved lymph nodes had a negative impact on survival. The use of PORT did not have a significant impact on survival. However, in subset analysis for patients with N2 nodal disease (hazard ratio [HR] = 0.855; 95% CI, 0.762 to 0.959; P = .0077), PORT was associated with a significant increase in survival. For patients with N0 (HR = 1.176; 95% CI, 1.005 to 1.376; P = .0435) and N1 (HR = 1.097; 95% CI, 1.015 to 1.186; P = .0196) nodal disease, PORT was associated with a significant decrease in survival. CONCLUSION: In a population-based cohort, PORT use is associated with an increase in survival in patients with N2 nodal disease but not in patients with N1 and N0 nodal disease.

Effects of breast-conserving therapy on lactation after pregnancy.

BACKGROUND: As the incidence of breast-conserving therapy in women of childbearing years increases, patient concerns regarding subsequent pregnancies and lactation have become more prevalent. There is a paucity of data regarding lactation outcomes in women who have undergone breast-conserving therapy and then sustained full-term pregnancies. Our objective was to evaluate lactation outcomes in patients with early-stage breast cancer treated with breast-conserving therapy. METHODS: We reviewed a database of over 3,000 patients treated from 1965 to 2003 to identify our cohort of premenopausal women who underwent breast-conserving therapy and subsequently sustained full-term pregnancies. Lactation outcome parameters (breast swelling, ability to lactate, and volume of lactation in the treated and untreated breasts) were the main outcome measures. RESULTS: We identified 28 pregnancies in 21 patients. The median age at diagnosis was 32 years. One patient underwent bilateral breast treatment; therefore, a total of 22 breasts were irradiated. All patients interviewed reported little or no swelling of the treated breast during pregnancy. Of the patients studied, 4 (18.2%) elected pharmacological suppression of lactation. Of the remaining 18 breasts, lactation occurred in 10 (55.6%), did not occur in 7 (38.9%) and was unknown for 1 (5.5%). The volume was reported as significantly diminished in 80% of breasts treated. Lactation in the contralateral breast occurred in all patients who did not undergo pharmacological suppression. CONCLUSION: Patients can experience successful lactation in the contralateral, untreated breast after breast-conserving therapy. In the treated breast, functional lactation is possible but is significantly diminished in the majority of patients.

Management of suspicious or indeterminate calcifications and impact on local control.

BACKGROUND: The current study was undertaken to determine the potential advantage associated with complete removal of suspicious or indeterminate calcifications (SIC) before the initiation of irradiation as part of breast conservation therapy (BCT). METHODS: Of 2045 patients treated with BCT at Yale University School of Medicine (New Haven, Connecticut) and satellite facilities before 2002, 111 women, included 3 patients with bilateral disease, had a postexcision preirradiation mammogram (PREMAMMO) to evaluate residual SIC. Thus, 114 breasts were at risk for local disease recurrence. Seventy-five breasts at risk had no residual SIC and proceeded to undergo radiotherapy (XRT) without further surgery or mammography. Of the remaining 39 breasts at risk, only 3 underwent a PREMAMMO with documented removal of all calcifications (DRC). Thirty-six breasts at risk proceeded to XRT with either known SIC or with nondocumented removal of calcifications (NDRC) after another excision. RESULTS: Of the 78 breasts at risk with DRC via PREMAMMO, there were 7 local failures (LF) and 1 distant failure. Of the 36 breasts with NDRC via PREMAMMO, there were 7 LF and 1 regional failure. Of the 34 breasts who underwent reexcision after detection of SIC by PREMAMMO, 20 (59%) were found to have residual disease. CONCLUSIONS: Patients with DRC were found to have better local control than patients with NDRC. In addition, the presence of SIC on a PREMAMMO was associated with a high probability of detecting residual disease.

Nutritional support of patients undergoing radiation therapy for head and neck cancer.

Malnutrition plays a key role in the morbidity of head and neck cancer patients receiving surgery, chemotherapy, radiotherapy, or combined-modality therapy. In addition to weight lost prior to the diagnosis of head and neck cancer, the patient may lose an additional 10% of pretherapy body weight during radiotherapy or combined-modality treatment. A reduction of greater than 20% of total body weight results in an increase in toxicity and mortality. Severe toxicity can result in prolonged treatment time, which has been implicated in poor clinical outcome. Early intervention with nutritional supplementation can reduce the chance of inferior outcome in patients at high risk of weight loss. The preferred route of nutritional support for these patients is enteral nutrition. Two commonly used methods for enteral feedings are nasoenteric and percutaneous endoscopic gastrostomy. It is important to take into account the ethical considerations involved in providing long-term nutritional support, particularly for patients with terminal conditions. Nutritional directives are best evaluated through multidisciplinary efforts, including input from the patient as well as members of the nursing, nutritionist, and medical staff.

Evaluation of local recurrence and second malignancy in patients with T1 and T2 squamous cell carcinoma of the larynx.

PURPOSE: Evaluate outcome in patients with T1 and T2 laryngeal cancer treated with radiation therapy. PATIENTS AND METHODS: Retrospective review of 190 patients with SCC of the larynx, stage T1(63%) orT2 (37%), treated with primary radiation therapy from 1/75 through 12/93. Median age was 61 years and median follow-up was 16.6 years. Median field size was 6.0 cm x 6.0 cm with a median fraction size of 2 Gy delivered in 33 daily fractions over 48 days. Energy used was 2 MV (19%), 4 MV (46%), 6 MV (26%), or other (9%). Univariate Cox proportional hazards regression analysis was performed using the following variables: gender, age, T stage, anterior commissure involvement, treatment energy, treatment interruption, alcohol use, smoking history, and tobacco use during treatment. RESULTS: Overall actuarial 5-year survival was 76%, and 10-year survival was 56%. Actuarial local recurrence free survival (LRFS) at 5 years was 81%, and 10 years LRFS was 79%. Local relapse correlated with T stage (9% T1 versus 28% T2, P = 0.0009) and smoking history (14% for less than 100 pack-year versus 29% for greater than 100 pack-year, P = 0.02). Gender, age, anterior commissure involvement, treatment energy, treatment interruption, alcohol history, alcohol use during treatment, and tobacco use during treatment had no influence on outcomes. Actuarial second malignancies rate at 5 years was 18%. CONCLUSION: Heavy tobacco use and T stage appears to correlate with an increase in local relapse rates. Gender, age, anteriorcommissure involvement, treatment energy, treatment interruption, and alcohol use did not significantly correlate with local relapse rates. The risk of second malignancies is comparable to that of local relapse.

Is there an optimal hemoglobin level for patients with glioblastoma multiforme?

PURPOSE: The purpose of this study was to assess the relationship between hemoglobin levels and survival for patients treated with radiation therapy for glioblastoma multiforme. METHODS/MATERIALS: Between 1992 and 2001, 89 patients with newly diagnosed glioblastoma multiforme were treated with a minimum of 50 Gy of radiation therapy. The primary study endpoint was overall survival. The independent variables analyzed included peak hemoglobin level, age, sex, extent of surgery, and duration of therapy. The peak hemoglobin level was the highest hemoglobin value obtained within 1 week before the initiation of radiation therapy or at some point during radiation therapy. The peak hemoglobinlevel was stratified into values of less than or equal and values greater than for each of the following hemoglobin values: 11.0, 11.5, 12.0, 12.5, 13.0, 13.5, and 14.0 g/dL. RESULTS: On univariate analysis, age (< or = 50 years of age) and surgical treatment (resection) were significant for increased survival at 1 year. When univariate analysis was performed on the stratification of the peak hemoglobin, levels greater than 11.0, 13.5, and 14.0 g/dL reached statistical significance for increased survival. Multivariate analysis was then performed on models composed of the hemoglobin levels that reached significance, and the other independent variables were investigated. In all models, both age and the peak hemoglobin level tested were prognostic for survival. However, for the hemoglobin level of 11.0 g/dL, an interaction was detected between hemoglobin and age. CONCLUSION: We found that increasing hemoglobin levels may have prognostic implications and could thus influence clinical outcome. We will be seeking to verify our results in larger cohorts.