Role of Stereotactic Radiation Therapy in Operable and Inoperable Early-Stage Non-small Cell Lung Cancer.

OPINION STATEMENT: Radiation therapy is becoming an increasingly important part of non-small cell lung cancer (NSCLC) management. Approximately 60% of all cancer patients require radiation therapy (RT) as part of their treatment. For lung cancer, this number is even higher, reaching approximately 77% of all patients, from radical to palliative modalities of RT. This percentage may even be underestimated, as it may not account for the more recent use of RT in oligometastatic lung cancer patients. Thus, we can estimate that each year there will be approximately 21,890 new lung cancer patients in the USA requiring RT. These numbers are expected to continue to rise, as lung cancer radiation techniques continue to improve. There is growing interest in determining the best treatment options for early-stage NSCLC patients. There is well-established data showing the benefit of RT for inoperable patients, and more recent encouraging data even in operable patients.

Urinary infection or radiation cystitis? A prospective evaluation of urinary symptoms in patients submitted to pelvic radiotherapy.

OBJECTIVES: The purpose of this study was to evaluate the incidence of urinary tract infection (UTI) in patients with cystitis symptoms who underwent pelvic radiation therapy and identify correlated predictive factors. METHODS: A prospective cohort study was conducted of patients who met the following: primary pelvic cancer treated with curative intent, older than 18 years old, and good performance status. The exclusion criteria were patients being treated for a UTI, using a urinary catheter, in dialysis or with cystostomy or nephrostomy, and using antibiotics during treatment. Urinalysis and urine culture were collected before the beginning of radiation therapy. Weekly evaluations of urinary symptoms were subsequently performed. In cases of new or worsening symptoms, a questionnaire was applied, and new urine exams were collected. The UTI diagnosis was defined by uroculture as bacterial growth greater than 104 CFU/mL. RESULTS: From September 2014 to November 2015, 112 patients were sequentially recruited, and 72 (64%) fulfilled the inclusion criteria. During follow-up, 24 (33%) patients had new urinary symptoms or worse preexisting symptoms. A UTI was confirmed in the second urinary culture in only one (1.4%) patient. CONCLUSIONS: The incidence of UTI was much lower than expected, suggesting that asymptomatic bacteriuria develops symptoms due to radiotherapy. Due to the low rate of UTI, no predictive factor was identified.

Neoadjuvant Chemotherapy With Cisplatin and Gemcitabine Followed by Chemoradiation Versus Chemoradiation for Locally Advanced Cervical Cancer: A Randomized Phase II Trial.

PURPOSE: Although chemoradiation therapy (CRT) with cisplatin remains the standard treatment of patients with locally advanced cervical cancer (LACC), 40% of patients present with disease recurrence. Additional treatment strategies are required to improve outcomes. We conducted a trial to evaluate the efficacy and safety of neoadjuvant chemotherapy (NAC) with cisplatin and gemcitabine followed by CRT. METHODS: In this phase II trial, patients with LACC (International Federation of Gynecology and Obstetrics stage IIB to IVA or with positive lymph nodes) were randomly assigned to three cycles of NAC with cisplatin and gemcitabine followed by standard CRT with weekly cisplatin plus pelvic radiotherapy or to standard CRT alone. The primary end point was 3-year progression-free survival (PFS). Secondary end points were response rate, 3-year locoregional control, 3-year overall survival (OS), safety, and quality of life. RESULTS: From 107 patients enrolled in the trial, 55 were randomly assigned to the NAC arm and 52 to the CRT-alone arm. The majority of patients had squamous cell carcinoma (87.8%). After a median follow-up of 31.7 months, NAC was associated with an inferior PFS, with 3-year PFS rates of 40.9% v 60.4% in the CRT arm (hazard ratio, 1.84; 95% CI, 1.04 to 3.26; P = .033). NAC also was associated with a lower OS (3-year OS rate, 60.7% v 86.8%; hazard ratio, 2.79; 95% CI, 1.29 to 6.01; P = .006). After treatment completion, complete response rates were 56.3% in the NAC arm and 80.3% in the CRT arm (P = .008). Toxicities were similar in both arms, with the exception of hypomagnesemia and neuropathy being more common with NAC. CONCLUSION: This study shows that the addition of NAC consisting of cisplatin and gemcitabine to standard CRT is not superior and is possibly inferior to CRT alone for the treatment of LACC.

Prophylactic Cranial Irradiation for Extensive-Stage Small-Cell Lung Cancer: A Retrospective Analysis.

PURPOSE: Extensive-stage small-cell lung cancer (esSCLC) is an incurable disease and represents a therapeutic challenge because of its poor prognosis. Studies in prophylactic cranial irradiation (PCI) in esSCLC have shown a decreased incidence of symptomatic brain metastases in patients who respond to systemic chemotherapy. However, its effect on overall survival is debatable. We evaluated the benefit of PCI in patients with esSCLC in terms of overall survival, progression-free survival, incidence of brain metastases, recurrence rate, and exposure to postrecurrence therapies. MATERIALS AND METHODS: We retrospectively reviewed electronic charts from patients diagnosed with esSCLC from 2008 to 2014 at our institution. All patients had negative baseline brain imaging before chemotherapy and PCI and received at least 4 cycles of platinum-based chemotherapy in the first-line setting without progressive disease on follow-up. PCI was performed at the discretion of the treating physician. Analyses were based on descriptive statistics. Survival curves were calculated by Kaplan-Meier method. RESULTS: Among 46 eligible patients, 16 (35%) received PCI and 30 (65%) did not. Compared with no PCI, PCI led to improved progression-free survival (median, 10.32 v 7.66 months; hazard ratio, 0.4521; 95% CI, 0.2481 to 0.8237; P < .001) and overall survival (median, 20.94 v 11.05 months; hazard ratio, 0.2655; 95% CI, 0.1420 to 0.4964; P < .001) as well as lower incidence of brain metastases (19% v 53%; P = .0273) and higher exposure to second-line chemotherapy (87% v 57%; P = .0479). CONCLUSION: Careful patient selection for PCI can improve not only brain metastases control and higher second-line chemotherapy exposure but also patient survival.

Adjuvant Carboplatin and Paclitaxel Chemotherapy Followed by Radiotherapy in High-Risk Endometrial Cancer: A Retrospective Analysis.

PURPOSE: The best adjuvant treatment in high-risk endometrial cancer remains unclear. Although adjuvant chemotherapy seems to improve overall survival (OS) in locally advanced disease, the role of adding radiotherapy is not certain. We evaluated the outcomes of patients with high-risk endometrial cancer treated with adjuvant chemotherapy followed by radiotherapy. PATIENTS AND METHODS: We performed a retrospective analysis of patients with high-risk endometrial cancer (endometrioid histology stages III to IVA or carcinosarcoma, clear cell, or serous histology stages I to IVA) treated with adjuvant carboplatin and paclitaxel, followed by radiotherapy, from 2010 to 2017 at a Brazilian cancer center. The Kaplan-Meier method was used for survival analysis, and prognostic factors were analyzed using the Cox proportional hazards model. RESULTS: One hundred forty-six consecutive patients were evaluated. The OS rates were 86.2% at 3 years and 75.4% at 5 years. OS was significantly affected by pelvic lymphadenectomy ( P = .001) and positive peritoneal cytology ( P < .001). Three- and 5-year disease-free survival (DFS) rates were 78.3% and 69.5%, respectively. The initial site of recurrence was limited to the pelvis in 4.1% of patients, within the abdomen in 1.3%, and extra-abdominal in 11.6%. Patients with grade 1 or 2 endometrioid carcinoma had better prognosis than patients with endometrioid carcinoma grade 3 or nonendometrioid histology (3-year DFS, 93.67% v 68.5%, respectively; P = .0017). CONCLUSION: Adjuvant carboplatin and paclitaxel, followed by radiotherapy, is effective in high-risk endometrial cancer and associated with low rates of pelvic recurrence, which might be explained by the addition of radiotherapy. The high-risk group is heterogeneous, and the benefit of adjuvant treatment in patients with grade 1 or 2 endometrioid carcinoma is less clear.

PROGRAD - An observational study of the prognosis of inpatients evaluated for palliative radiotherapy.

BACKGROUND AND PURPOSE: Low-and-middle-income countries have resource constraints and waiting lists for radiotherapy (RT). In this context, we sought to determine the survival of inpatients evaluated for palliative RT in a large referral cancer center in Brazil. MATERIAL AND METHODS: From November 2014 through December 2015, we enrolled 333 inpatients with palliative RT evaluation requests in this prospective observational study. We applied Palliative Prognostic Index (PPI) and Survival Prediction Score using Number of Risk Factors (NRF). Primary endpoint was overall survival. Secondary endpoints were survival by PPI and NRF. (ClinicalTrials.gov number, NCT02312791). RESULTS: Median survival (MS) for the entire cohort was 73 days. PPI ≤2 had MS of 120 days; PPI 2.5-4 had MS of 55 days (HR 1.84; 95% CI, 1.07-3.16); PPI >4 had MS of 39 days (HR 3.45; 95% CI, 2.07-5.74) (p < .0001). NRF 0-1 had MS of 129 days; NRF 2 had MS of 73 days (HR 1.74; 95% CI 0.89-3.38); NRF 3 had MS of 40 days (HR 2.95; 95% CI, 1.50-5.78) (p < .0001). CONCLUSION: Inpatients with palliative RT requests seem to have an overall poor survival. PPI and NRF can define subgroups with different prognosis. This could help hospitals and healthcare systems to standardize criteria for prioritization and contribute for fairness.

Outcomes of high-dose intensity-modulated radiotherapy alone with 1 cm planning target volume posterior margin for localized prostate cancer.

BACKGROUND: Clinically localized prostate cancer may be treated by different approaches of radiation therapy. The aim of this study was to report the results of disease control and toxicity in patients with clinically localized prostate cancer treated with high dose IMRT alone with 1 cm PTV posterior margin. METHODS: From September 2001 to April 2008, 140 patients with localized prostate cancer were treated with definitive IMRT (dose ≥ 74 Gy) without hormone therapy. Outcomes were measured from the conclusion of radiotherapy. Biochemical failure was defined as PSA nadir + 2.0 ng/dL. Toxicities were assessed using the NCI-CTCAE-version 3.0. Median follow-up was 58 months. RESULTS: Biochemical failure occurred in 13.6% of patients. Actuarial 5-year biochemical control rates were 91.7%, 82.5% and 85.9% for low-, intermediate-, and high-risk patients, respectively. Stage T2 patients presented a risk of biochemical failure almost three times higher than stage T1 (RR = 2.91; 95% CI: 1.04; 8.17). Distant metastases occurred in 3 (2%) patients. Five-year metastasis-free and overall survivals were 96% and 97.5%, respectively. Late grade 3 genitourinary and gastrointestinal toxicity rates were, respectively, 1.6% and 3%. CONCLUSION: High-dose IMRT alone with 1 cm posterior PTV margin was effective and safe for patients with localized prostate cancer.