Prophylactic Radiotherapy for Prevention of Heterotopic Ossification After Periacetabular Fractures: A Review of Efficacy and Associated Conditions.

Prophylactic radiotherapy (XRT) is a commonly used treatment to decrease heterotopic ossification (HO) in patients with traumatic hip injuries. We conducted a retrospective review of patients at risk for HO who underwent XRT. Of the patients reviewed, 27.3% developed radiographic HO, 11.2% developed symptoms, and 2.0% required resection surgery. Patients were divided into primary (n = 71) and secondary prophylaxis (n = 27) cohorts. In the primary group, 25.0% developed radiographic HO, 5.6% developed symptoms, and 0 required surgery. In the secondary cohort, 33.3% of patients developed new radiographic HO, and 25.9% were symptomatic: four had a Brooker score of 3, and three had a score of 4 (p = 0.03), and 7.4% required surgical resection. (Journal of Surgical Orthopaedic Advances 31(2):113-118, 2022).

Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow.

OBJECTIVES: To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included. INTERVENTION: All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery. MAIN OUTCOMES MEASUREMENTS: The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint. RESULTS: Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified. CONCLUSIONS: Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiation Oncology Education Collaborative Study Group Annual Spring Symposium: Initial Impact and Feedback.

The Radiation Oncology Education Collaborative Study Group (ROECSG) is an international collaborative network of radiation oncology (RO) professionals with the goal of improving RO education. This report summarizes the first two ROECSG annual symposia including an overview of presentations and analysis of participant feedback. One-day symposia were held in June 2018 and May 2019. Programs included oral and poster presentations, RO education leadership perspectives, and keynote addresses. Post-symposia surveys were collected. Research presentations were recorded and made available online. The 2018 symposium was had 36 attendees from 25 institutions in three countries. The 2019 symposium had 76 individuals from 41 institutions in five countries. Attendees represented diverse backgrounds including attending physicians (46%), residents (13%), medical students (14%), physicists (2%), nurses (1%), and program coordinators (1%). Fifty-five oral presentations were given with 53 released online. Ninety percent of attendees rated the symposium as improving their knowledge of RO educational scholarship, 98% felt the symposium provided the opportunity to receive feedback on RO education scholarship, and 99% felt that the symposium fostered the development of collaborative RO education projects. ROECSG was rated higher than professional organizations in fostering educational scholarship (p<0.001). All attendees felt that the symposium produced new RO education scholarship ideas and provided unique networking opportunities. The first two ROECSG symposia drew a diverse population of attendees and provided unique opportunities for presentation of RO education scholarship. Future ROECSG symposia will be designed to enhance opportunities to present RO education scholarship and to facilitate networking.

Interprofessional Image Verification Workshop for Physician and Physics Residents: A Multi-Institutional Experience.

PURPOSE: Verification of patient position through pretreatment setup imaging is crucial in modern radiation therapy. As treatment complexity increases and technology evolves, physicist-physician collaboration becomes imperative for safe and successful radiation delivery. Despite the importance of both, residency programs lack formal interprofessional education (IPE) activities or structured training for image verification. Here we show the impact of an interprofessional image verification workshop for residents in a multi-institutional setting. METHODS: The workshop included a lecture by the attending physicist and physician, and hands-on image registration practice by learners (medical physics residents, MP; and radiation oncology residents, RO). All participants filled out pre- and postactivity surveys and rated their comfort from 1 to 10 in (A) selecting what type of imaging to order for a given case and (B) independently assessing the setup quality based on imaging. A paired 1-tailed t test (α = 0.05) was used to evaluate significance; Spearman rank correlation coefficient was used to assess correlation of ratings and RO postgraduate year (PGY). Surveys had free-response questions about IPE and image verification activities in residency. RESULTS: A total of 71 residents from 7 institutions participated between 2018 and 2020. Pre- and postsurveys were completed by 50 residents (38RO, 12MP) and showed an increase in (A) from 5.5 ± 2.2 to 7.1 ± 1.6 (P < .001) and in (B) from 5.1 ± 2.3 to 6.8 ± 1.5 (P < .001), with significant increases per subgroup (AΔ, RO = 1.8 ± 1.7, P < .001; BΔ, RO = 1.9 ± 1.8, P <. 001; AΔ, MP = 1.1 ± 1.4, P = .012; BΔ, MP = 1.2 ± 1.6, P = .016). RO confidence scores moderately correlated with PGY. Survey responses indicated that image verification training is mostly unstructured, with extent of exposure varying by program and attending; most with little-to-no training. Time constraints were identified as the main barrier. IPE was noted as a useful way to incorporate different perspectives into the process. CONCLUSIONS: Formal image verification training increases resident comfort with setup imaging review and provides opportunities for interprofessional collaboration in radiation oncology residency programs.

Rhabdomyosarcoma.

Rhabdomyosarcoma is a heterogeneous disease both in presentation and histology. Improvements in a multimodality therapy resulted in the improved overall survival for patients with a low-risk and intermediate-risk disease but not for patients with a metastatic disease. We reviewed and contrasted the North American and European practice patterns, though ultimately the principles of staging, surgery, radiation therapy, and chemotherapy are similar in both Children's Oncology Group and International Society of Paediatric Oncology treatment approaches. Efforts are underway to investigate improved local control rates in higher risk patients using radiation dose escalation strategies, and delayed primary excision in select cases. The prognostic significance of imaging-based chemotherapy response, proton therapy, novel biomarkers, and targeted drugs will be determined in upcoming clinical trials.

Nurse-Delivered Telephone Intervention to Reduce Oral Mucositis and Prevent Dehydration.

PROBLEM STATEMENT: This study evaluates the feasibility of a nurse-delivered telephone intervention to reduce oral mucositis severity and prevent dehydration in patients with lung or head and neck cancer undergoing chemotherapy and radiation therapy. DESIGN: This study used a two-phase, qualitatively driven, mixed-methods descriptive design. DATA SOURCES: 11 participants were recruited from an academic cancer center in southern Florida. Participants received symptom management education followed by twice-weekly tailored nurse coaching telephone calls. ANALYSIS: Questionnaires measuring symptom severity, health-related quality of life, perceived self-efficacy, and symptom self-management were administered at four data points. Data on unscheduled medical visits were collected. Guided interviews were conducted four weeks post-treatment and analyzed qualitatively using content analysis. FINDINGS: Participants found the intervention to be acceptable. Oral mucositis symptom severity was minimized, and dehydration was avoided. The intervention enabled symptom self-management and improved perceived self-efficacy. IMPLICATIONS FOR PRACTICE: Emotional support provided by the nurse was crucial, exemplifying improvement over an automated system.

The Radiation Oncology Education Collaborative Study Group 2020 Spring Symposium: Is Virtual the New Reality?

PURPOSE: Because of the COVID-19 pandemic, the Radiation Oncology Education Collaborative Study Group (ROECSG) hosted its annual international symposium using a virtual format in May 2020. This report details the experience of hosting a virtual meeting and presents attendee feedback on the platform. METHODS AND MATERIALS: The ROECSG symposium was hosted virtually on May 15, 2020. A postsymposium survey was distributed electronically to assess attendee demographics, participation, and experience. Attendee preference and experience were queried using 3-point and 5-point Likert-type scales, respectively. Symplur LLC was used to generate analytics for the conference hashtag (#ROECSG). RESULTS: The survey was distributed to all 286 registrants, with a response rate of 67% (191 responses). Seventeen nonattendee responses were omitted from this analysis, for a total of 174 included respondents. Eighty-two attendees (47%) were present for the entire symposium. A preference for a virtual symposium was expressed by 78 respondents (45%), whereas 44 (25%) had no preference and 52 (30%) preferred an in-person meeting. A total of 150 respondents (86%) rated the symposium as "extremely" well organized. Respondents who had not attended a prior in-person ROECSG symposium were more likely to prefer the virtual format (P = .03). Seventy-eight respondents (45%) reported a preference for the virtual platform for reviewing scholarly work, and 103 (59%) reported a preference for an in-person platform for networking. On the day of the symposium, #ROECSG had 408 tweets and 432,504 impressions. CONCLUSIONS: The 2020 ROECSG symposium was well received and can serve as a framework for future virtual meetings. Although the virtual setting may facilitate sharing research, networking aspects are more limited. Effort is needed to develop hybrid virtual and in-person meetings that meet the needs of participants in both settings. Social media is a significant avenue for dissemination and discussion of information and may be valuable in the virtual setting.

Introductory Radiation Oncology Curriculum: Report of a National Needs Assessment and Multi-institutional Pilot Implementation.

PURPOSE: To assess the optimal structure of an introductory curriculum (IC) for radiation oncology residents, including the perceived utility of a 2-day off-site "boot camp," and evaluate the success of a pilot introductory radiation oncology curriculum (IROC) based on these initial data. METHODS AND MATERIALS: In the first phase, anonymous, web-based surveys were sent to US radiation oncology program directors and residents. Likert-type scores (1, not at all; 5, extremely) are reported as the median and interquartile range. Using the phase 1 results, IROC was developed, piloted, and evaluated. RESULTS: Of the 89 program directors and 697 residents, 47 (53%) and 165 (24%) responded, respectively. Of the 89 program directors, 37 (79%) reported offering a formal IC. However, only 83 residents (50%) reported having a formal IC. Program directors reported resident preparation for clinical training as "moderate" (median 3, interquartile range 2-3) on entering residency and "moderate" (median 3, interquartile range 3-4) after IC completion (P = .03). However, residents only believed they were "slightly" prepared (median 2, interquartile range 1-2) on entering residency and "moderately" (median 3, interquartile range 2-3) prepared after IC completion (P < .01). Program directors believed an off-site boot camp would be of "moderate" utility (median 3, interquartile range 3-4) with participation limited by funding (57%). Residents without an IC reported that having an IC would be "quite" beneficial (median 4, interquartile range 3-5). Residents preferred instruction before the clinical training (49%) and over 1 week (40%). Both program directors and residents rated lectures on radiation emergencies and simulation highly. Using these data, IROC was developed and piloted with incoming residents at 4 institutions. After IROC, residents reported improvement in overall preparedness for clinical training (before: median 1, interquartile range 1-2; vs after: median 3, interquartile range 2-3; P < .01) and among specific practice domains. CONCLUSIONS: Beginning radiation oncology residents frequently lack structured introductory curricula but desire instruction before the clinical training with a focus on practical aspects (emergency management, contouring). Program directors recognize the value of both off-site and on-site boot camps. An on-site IC could mitigate funding barriers. A standardized IC, IROC, piloted at 4 programs, showed promising outcomes.

Local recurrence of soft-tissue sarcoma: issues in imaging surveillance strategy.

Soft-tissue sarcomas pose diagnostic and therapeutic challenges to physicians, owing to the large number of subtypes, aggressive tumor biology, lack of consensus on management, and controversy surrounding interval and duration of surveillance scans. Advances in multidisciplinary management have improved the care of sarcoma patients, but controversy remains regarding strategies for surveillance following definitive local control. This review provides an updated, comprehensive overview of the current understanding of the risk of local recurrence of soft-tissue sarcoma, by examining the literature based on features such as histological type and grade, tumor size, and resection margin status, with the aim of helping clinicians, surgeons, and radiologists to develop a tailored approach to local imaging surveillance.

Factors Associated With Receipt of Radiation Therapy for Rectal Cancer.

PURPOSE: Appropriate treatment for cancer is vital to increasing the likelihood of survival; however, for rectal cancer, there are demonstrated disparities in receipt of treatment by race/ethnicity and socioeconomic status. We evaluated factors associated with receipt of appropriate radiation therapy for rectal cancer using data from the Florida Cancer Data System that had been previously enriched with detailed treatment information collected from a Centers for Disease Control and Prevention Comparative Effectiveness Research study. This treatment information is not routinely available in cancer registry data and represents a unique data resource. MATERIALS AND METHODS: Using multivariable regression, we evaluated factors associated with receiving radiation therapy among rectal cancer cases stage II/III. Our sample (n=403) included cases diagnosed in Florida in 2011 who were 18 years and older. Cases clinically staged as 0/I/IV were excluded. RESULTS: Older age (odds ratio=0.96; 95% confidence interval, 0.94-0.97), the presence of one or more comorbidities (0.61; 0.39-0.96), and receipt of surgical intervention (0.44; 0.22-0.90) were associated with lack of radiation. CONCLUSIONS: In this cohort of patients, sociodemographic factors such as race/ethnicity, insurance status, and socioeconomic status, did not influence the receipt of radiation. Further research is needed, however, to understand why aging, greater comorbidity, and having surgery present a barrier to radiation therapy, particularly given that it is a well-tolerated treatment in most patients.

Delineation of Tumor Habitats based on Dynamic Contrast Enhanced MRI.

Tumor heterogeneity can be elucidated by mapping subregions of the lesion with differential imaging characteristics, called habitats. Dynamic Contrast Enhanced (DCE-)MRI can depict the tumor microenvironments by identifying areas with variable perfusion and vascular permeability, since individual tumor habitats vary in the rate and magnitude of the contrast uptake and washout. Of particular interest is identifying areas of hypoxia, characterized by inadequate perfusion and hyper-permeable vasculature. An automatic procedure for delineation of tumor habitats from DCE-MRI was developed as a two-part process involving: (1) statistical testing in order to determine the number of the underlying habitats; and (2) an unsupervised pattern recognition technique to recover the temporal contrast patterns and locations of the associated habitats. The technique is examined on simulated data and DCE-MRI, obtained from prostate and brain pre-clinical cancer models, as well as clinical data from sarcoma and prostate cancer patients. The procedure successfully identified habitats previously associated with well-perfused, hypoxic and/or necrotic tumor compartments. Given the association of tumor hypoxia with more aggressive tumor phenotypes, the obtained in vivo information could impact management of cancer patients considerably.

Stereotactic Body Radiotherapy for Elderly Patients With Medically Inoperable Pancreatic Cancer.

OBJECTIVES: People over the age of 75 years account for approximately 40% of patients diagnosed with pancreatic cancer, many with comorbidities that may limit their treatment options. This study reports on the use of stereotactic body radiation therapy (SBRT) in this population. MATERIALS AND METHODS: Twenty consecutively treated patients over the age of 75 with pathologically proven localized pancreatic cancer were included in this retrospective review. All had been evaluated by a multidisciplinary team as unable to tolerate surgery or combined chemoradiation therapy. Patient outcomes were analyzed to determine the safety and efficacy of SBRT in this elderly cohort. RESULTS: The median age was 83.2 years (minimum 77 y, maximum 90 y). Eighteen patients were treated at time of initial diagnosis, and 2 for recurrence after surgery. Eleven (55%) of the patients had an Adult Comorbidity Evaluation-27 comorbidity index score of 3 (severe) and 6 (30%) had a score of 2 (moderate). Fourteen patients were treated with 35 Gy in 5 fractions, 5 with 30 Gy in 5 fractions, and 1 patient with 36 Gy in 3 fractions. Seven (35%) patients had common terminology criteria for adverse events (CTCAE) V4.0 toxicity grade of 1-2, and 3 patients had a CTCAE V4.0 toxicity grade of 3-4, 2 with dehydration, and 1 had episodes of gastrointestinal bleeding. Three patients recurred locally, 10 had distant metastases, 4 of whom were found on the first posttreatment scan. Median overall survival was 6.4 months (95% confidence interval, 3.5-10.8 mo). Median recurrence-free survival was 6.8 months (95% confidence interval, 1.3-23.5 mo). Two patients survived >23 months. CONCLUSION: SBRT for pancreatic cancer appears to be a safe and effective method for treatment of elderly patients, even in the setting of severe comorbidities.