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1.
Brachytherapy ; 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32249178

RESUMO

AIMS: To report on the PSA outcomes in men undergoing prostate seed implant (PSI) with Cesium-131 at a single institution. MATERIALS AND METHODS: All patients who underwent prostate brachytherapy with Cesium-131 (131Cs) at our institution and had the potential for at least 24 months of follow up were included in this study. Results are reported for the by NCCN risk group (low, low/high-intermediate, and high), as well as by treatment received (monotherapy, combination external beam radiation + PSI, or trimodal therapy with androgen deprivation). The Phoenix definition (absolute nadir plus 2 ng/mL) was used to define biochemical freedom from disease (BFD). RESULTS: Eight hundred and six men have undergone prostate brachytherapy with Cesium-131 at our institution, and 669 men were included in analysis. Median follow up was 60.0 months (range: 0-144 months). According to NCCN risk categories, 29.9% were low-, 55.6% intermediate-, and 14.5% high-risk. Using the Phoenix criteria, 5/10-year BFD was 97.1/95.3% for patients in the low-risk category, 94.0/90.1% for patients in the intermediate-risk category, and 86.2/56.6% for patients in the high-risk category. PSA ≤0.2 ng/dL at 4 years was predictive of 10 year biochemical control: 96.3% vs 70.4%, p < 0.001. CONCLUSIONS: The present study demonstrates that prostate brachytherapy with 131Cs achieves excellent long-term biochemical control.

5.
Gynecol Oncol ; 156(3): 583-590, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31924333

RESUMO

OBJECTIVE: Studies examining temporal trends in cervical brachytherapy use are conflicting and examined different health insurance populations. This study examined brachytherapy utilization over time by health insurance type and whether reported declines in brachytherapy have reversed. METHODS: The National Cancer Database (NCDB) was queried for patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy between 2004 and 2014, identifying 17,442 patients. Brachytherapy utilization over time and by insurance type and other sociodemographic factors were compared using binary logistic regression. A sensitivity analysis was done in a sub-cohort of patients using the boost modality variable in the NCDB. RESULTS: Brachytherapy utilization declined during 2008-10 (52.6%) compared to 2004-2007 (54.4%; odds ratio [OR] 0.93, 95% confidence interval [CI] 0.86-1.01) and declines were disproportionately larger for patients with government insurance (49.4% vs 52.3%, respectively) than privately-insured patients (57.6% vs 58.9%, respectively). However, rates of brachytherapy use subsequently recovered during 2011-14 in all insurance groups (58.0%, OR 1.24, 95% CI 1.16-1.34) and was especially improved for Medicaid (OR 1.44, 95% CI 1.26-1.65) and uninsured patients (OR 1.28, 95% CI 1.03-1.57). Sensitivity analysis using the boost modality variable confirmed these trends. CONCLUSIONS: In patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy from 2004 to 2014, brachytherapy utilization declined during the late 2000s and disproportionately affected patients with government insurance, but subsequently recovered in the early 2010s. Since government insurance covers vulnerable patient populations at-risk for future declines in brachytherapy use, proposed alternative payment models should incentivize cervical brachytherapy to solidify gains in brachytherapy utilization.

7.
Brachytherapy ; 19(2): 127-138, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31917178

RESUMO

PURPOSE: Recurrences of previously irradiated gynecological malignancies are uncommon. Standardized management of these cases is not well established. We aim to provide an in-depth literature review and present current practice patterns among an international group of experienced practitioners in the reirradiation setting of gynecologic cancers. METHODS AND MATERIALS: An extensive literature search was performed and 35 articles were selected based on preset criteria. A 20-question online survey of 10 experts regarding their retreatment practices was also conducted. RESULTS: The reviewed publications include a diverse group of patients, multiple treatment techniques, a range of total doses, local control, overall survival, and toxicity outcomes. Overall, local control ranged from 44% to 88% over 1-5 years with OS in the range of 39.5-82% at 2-5 years. Late G3-4 toxicity varied very broadly from 0% to 42.9%, with most papers reporting serious toxicities greater than 15%. The most common reirradiation technique utilized was brachytherapy. Some low-dose-rate data suggest improved outcomes with doses >50 Gy. The high-dose-rate data are more varied with some studies suggesting improved local control with doses >40 Gy. In general, a longer time interval between the first and second course of radiation as well as recurrences <2-4 cm tend to have improved outcomes. CONCLUSIONS: Reirradiation with brachytherapy results in relatively reasonable local control and toxicities for women with recurrent gynecologic cancers. The appropriate dose for each case needs to be individualized given the heterogeneity of cases. Multidisciplinary management is critical to develop individualized plans and to clearly communicate potential side effects and expected treatment outcomes. TAKE HOME MESSAGE: Reirradiation with brachytherapy is an acceptable effective organ preserving approach for recurrent gynecologic cancers with a reasonable local control and toxicity profile. Each case requires multidisciplinary management to develop an individualized approach. Monitoring for potential long-term toxicities is essential.

8.
Med Dosim ; 45(1): 28-33, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31153678

RESUMO

We evaluated daily setup reproducibility of deep inspiration breath hold (DIBH) using mega voltage (MV) imaging for left breast cancer radiation therapy. Analysis of 109 left breast cancer patients across UPMC Hillman Cancer Center network treated using DIBH technique with daily MV imaging was done. Patient characteristics, MV imaging procedure used and inter-fraction directional shifts were collected. For the statistical analyses, we separated all patients into 2 groups in each of the following 3 categories; (1) obese (BMI ≥ 30) vs nonobese, (2) mastectomy vs lumpectomy, (3) internal mammary node (IMN) treatment vs no IMN treatment. The group mean inter-fraction directional shifts were as following: (1) 0.7 mm (superior), 0.8 mm (inferior); (2) 0.65 mm (left), 0.64 mm (right); (3) 0.89 mm (anterior), 0.83 mm (posterior). Also, any directional shift ≥ 2 mm, ≥ 3 mm, ≥ 4 mm, ≥ 5 mm, ≥ 10 mm was found to be 52.9%, 37.6%, 30.9%, 21.9%, 3.7% of total fractions, respectively. In the stratified analysis, obese patients had larger directional shifts (p < 0.05) and highly associated with number of fractions for ≥ 5 mm in any directional shift compared to nonobese patients (29% vs 17%; p = 0.04). DIBH setup for left breast cancer treatment at our large cancer center network was reproducible with any mean directional shifts less than 1.0 mm using MV imaging. Daily imaging would be more beneficial for obese patients compared to nonobese patients.

9.
Int J Radiat Oncol Biol Phys ; 106(1): 37-42, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31229573

RESUMO

PURPOSE: We sought to characterize temporal trends of radiation oncology resident-reported external beam radiation therapy (EBRT) case experience with respect to various disease sites, including trends in stereotactic radiosurgery and stereotactic body radiation therapy cases. METHODS AND MATERIALS: Summarized, deidentified case logs for graduating radiation oncology residents between 2007 and 2018 were obtained from the Accreditation Council for Graduate Medical Education national summary data report. Mean number of cumulative cases and standard deviations per graduating resident by year were evaluated. Cases were subdivided into 12 disease-site categories using the Accreditation Council for Graduate Medical Education classification. Analysis of variance was used to determine significant differences, and strength of association was evaluated using Pearson correlation. RESULTS: The number of graduating residents per year increased by 66% from 114 in 2007 to 189 in 2018 (P < .001, r = 0.88). The overall mean number of EBRT cases per graduating resident decreased by 13.2% from 521.9 in 2007 to 478.5 in 2018, with a decrease in the ratio of nonmetastatic to metastatic cases per graduating resident. There was significant variation among the disease categories analyzed; however, the largest proportionate decreases were seen in hematologic, lung, and genitourinary malignancies. Stereotactic radiosurgery volume per graduating resident increased from an average of 27.9 cases in 2007 to 50.3 in 2018 (P < .001, r = 0.96). Stereotactic body radiation therapy volume per graduating resident increased as well, from a mean of 6 cases in 2007 to 55.6 cases in 2018 (P < .001, r = 0.99). CONCLUSIONS: We report a longitudinal summary of resident-reported experience in EBRT cases. These findings have implications for future efforts to optimize residency training programs and requirements.


Assuntos
Internato e Residência/tendências , Neoplasias/radioterapia , Radioterapia (Especialidade)/tendências , Carga de Trabalho , Análise de Variância , Competência Clínica , Neoplasias Hematológicas/radioterapia , Humanos , Internato e Residência/estatística & dados numéricos , Estudos Longitudinais , Neoplasias Pulmonares/radioterapia , Metástase Neoplásica/radioterapia , Neoplasias/classificação , Radioterapia (Especialidade)/estatística & dados numéricos , Radiocirurgia/estatística & dados numéricos , Radiocirurgia/tendências , Radioterapia/estatística & dados numéricos , Radioterapia/tendências , Estudos Retrospectivos , Fatores de Tempo , Neoplasias Urogenitais/radioterapia , Carga de Trabalho/estatística & dados numéricos
10.
Ann Thorac Surg ; 109(3): 921-926, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31846643

RESUMO

BACKGROUND: Neoadjuvant chemoradiation, followed by esophagectomy, is a standard of care for locally advanced esophageal cancers. The ChemoRadiOtherapy plus Surgery versus Surgery alone (CROSS) trial reported a 30-day mortality rate of 6%. We sought to evaluate 30- and 90-day mortality in similar patients in the United States and identify predictors of higher mortality rates. METHODS: The National Cancer Database was used to identify patients with cT3-4/N+ esophageal cancers treated with neoadjuvant chemoradiation followed by esophagectomy. Bivariate univariable and multivariable regression analysis was used to identify predictors of 30- and 90-day mortality. RESULTS: We identified 7691 patients. Readmission within 30 days of surgery occurred in 6.0% of patients. Mortality was 2.9% at 30 days and 7.2% at 90 days. Positive surgical margins conferred a more than doubled risk of 30- and 90-day mortality, 5.5% vs 2.7% and 14.6% vs 6.8% (both P < .001). Facility surgical volume impacted 30-day mortality, whereas readmission was associated with 90-day mortality, both exceeding 10% (P = .004 and P = .001, respectively). In patients undergoing minimally invasive surgery converted to open, 90-day mortality was 12.1% (P < .01). For patients 69 years and older, 90-day mortality was also 12.1% (P < .001). Patients who underwent esophagectomy more than 45 days from completion of chemoradiation also had higher 90-day mortality at 8.3% vs 6.2% (P < .001). CONCLUSIONS: Postoperative death at 30 and 90 days after neoadjuvant chemoradiation and esophagectomy appears to be on par with randomized data. Positive surgical margins, squamous cell carcinomas, age 69 and older, readmission within 30 days, and conversion from a minimally invasive operation to an open operation all carry a 90-day mortality risk exceeding 10%.

11.
Brachytherapy ; 2019 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-31839568

RESUMO

PURPOSE: We sought to characterize temporal trends of radiation oncology resident-reported case experience with intracavitary brachytherapy (ICBT) and interstitial brachytherapy (ISBT). METHODS AND MATERIALS: Summarized, deidentified case logs for graduating radiation oncology residents (GRORs) between 2007 and 2018 were obtained from the Accreditation Council for Graduate Medical Education national summary data report. Cases were subdivided based on the site of treatment. Analysis of variance was used to determine differences, and strength of association was evaluated using the Pearson correlation. RESULTS: The number of GRORs increased by 66% from 114 in 2007 to 189 in 2018 (p < 0.001). Average number of gynecologic ICBT cases per GROR increased, from 39.6 in 2007 to 48.7 in 2018 (p < 0.005). Average number of ISBT cases per GROR decreased, from 34.5 to 20.6 (p < 0.001), due to decreasing prostate volume, from 21.5 to 12 (p < 0.001). Experience with gynecologic ISBT cases remained low at an average of 4.5 cases per year. CONCLUSIONS: The average number of ICBT cases per GROR has increased, although this does not differentiate between cylinder and tandem-based insertions currently. There has been a steady decline in ISBT experience. These findings may have implications for the development of Accreditation Council for Graduate Medical Education case minimums for residency programs.

12.
J Appl Clin Med Phys ; 20(11): 111-120, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31660682

RESUMO

PURPOSE: Varian Halcyon linear accelerator version 2 (The Halcyon 2.0) was recently released with new upgraded features. The aim of this study was to report our clinical experience with Halcyon 2.0 for a dual-isocenter intensity-modulated radiation therapy (IMRT) planning and delivery for gynecological cancer patients and examine the feasibility of in vivo portal dosimetry. METHODS: Twelve gynecological cancer patients were treated with extended-field IMRT technique using two isocenters on Halcyon 2.0 to treat pelvis and pelvic/or para-aortic nodes region. The prescription dose was 45 Gy in 25 fractions (fxs) with simultaneous integrated boost (SIB) dose of 55 or 57.5 Gy in 25 fxs to involved nodes. All treatment plans, pretreatment patient-specific QA and treatment delivery records including daily in vivo portal dosimetry were retrospectively reviewed. For in vivo daily portal dosimetry analysis, each fraction was compared to the reference baseline (1st fraction) using gamma analysis criteria of 4 %/4 mm with 90% of total pixels in the portal image planar dose. RESULTS: All 12 extended-field IMRT plans met the planning criteria and delivered as planned (a total of 300 fractions). Conformity Index (CI) for the primary target was achieved with the range of 0.99-1.14. For organs at risks, most were well within the dose volume criteria. Treatment delivery time was from 5.0 to 6.5 min. Interfractional in vivo dose variation exceeded gamma analysis threshold for 8 fractions out of total 300 (2.7%). These eight fractions were found to have a relatively large difference in small bowel filling and SSD change at the isocenter compared to the baseline. CONCLUSION: Halcyon 2.0 is effective to create complex extended-field IMRT plans using two isocenters with efficient delivery. Also Halcyon in vivo dosimetry is feasible for daily treatment monitoring for organ motion, internal or external anatomy, and body weight which could further lead to adaptive radiation therapy.

13.
Am J Clin Oncol ; 42(11): 837-844, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31644441

RESUMO

OBJECTIVES: Current National Comprehensive Cancer Network (NCCN) guidelines support systemic therapy based on mutational status in stage IV non-small cell lung cancer (NSCLC), with stereotactic body radiation therapy (SBRT) reserved for oligoprogression. We aimed to evaluate the cost-effectiveness of the routine addition of SBRT to upfront therapy in stage IV NSCLC by mutational subgroup. MATERIALS AND METHODS: A Markov state transition model was constructed to perform a cost-effectiveness analysis comparing SBRT plus maintenance therapy with maintenance therapy alone for oligometastatic NSCLC. Three hypothetical cohorts were analyzed: epidermal growth factor receptor or anaplastic lymphoma kinase mutation-positive, programmed death ligand-1 expressing, and mutation-negative group. Clinical parameters were obtained largely from clinical trial data, and cost data were based on 2018 Medicare reimbursement. Strategies were compared using the incremental cost-effectiveness ratio with effectiveness in quality-adjusted life years (QALYs) and evaluated with a willingness to pay threshold of $100,000 per QALY gained. RESULTS: SBRT plus maintenance therapy was not cost-effective at a $100,000/QALY gained threshold, assuming the same survival for both treatments, resulting in an incremental cost effectiveness ratio of $564,186 and $299,248 per QALY gained for the epidermal growth factor receptor or anaplastic lymphoma kinase positive and programmed death ligand-1 positive cohorts, respectively. Results were most sensitive to the cost of maintenance therapy. A large overall survival gain with SBRT could potentially result in upfront SBRT becoming cost-effective. For the mutation-negative cohort, upfront SBRT was nearly cost-effective, costing $128,424 per QALY gained. CONCLUSION: Adding SBRT to maintenance therapy is not a cost-effective strategy for oligometastatic NSCLC compared with maintenance therapy alone for mutation-positive groups. However, this should be validated via randomized trials.

14.
Int J Gynecol Cancer ; 29(7): 1086-1093, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31474587

RESUMO

BACKGROUND: Randomized trials describe differing sets of high-intermediate risk criteria. OBJECTIVE: To use the National Cancer Database to compare the impact of radiation therapy in patients with stage I endometrial cancer meeting different criteria, and define a classification of "unfavorable risk." METHODS: Patients with stage I endometrial cancer between January 2010 and December 2014 were identified in the National Cancer Database and stratified into two cohorts: (1) patients meeting Gynecologic Oncology Group (GOG)-99 criteria only for high-intermediate risk, but not Post-Operative Radiation Therapy in Endometrial Carcinoma (PORTEC)-1 criteria and (2) those meeting PORTEC-1 criteria only. High-risk stage I patients with both FIGO stage IB (under FIGO 2009 staging) and grade 3 disease were excluded. In each cohort, propensity score-matched survival analyses were performed. Based on these analyses, we propose a new classification of unfavorable risk. We then analyzed the association of adjuvant radiation with survival, stratified by this classification. RESULTS: We identified 117,272 patients with stage I endometrial cancer. Of these, 11,207 patients met GOG-99 criteria only and 5,920 patients met PORTEC-1 criteria only. After propensity score matching, adjuvant radiation therapy improved survival (HR=0.73; 95% CI 0.60 to 0.89; p=0.002) in the GOG-99 only cohort. However, there was no benefit of adjuvant radiation (HR=0.89; 95% CI 0.69 to 1.14; p=0.355) in the PORTEC-1 only cohort. We, therefore, defined unfavorable risk stage I endometrial cancer as two or more of the following risk factors: lymphovascular invasion, age ≥70, grade 2-3 disease, and FIGO stage IB. Adjuvant radiation improved survival in stage I patients with adverse risk factors (HR=0.74; 95% CI 0.68 to 0.80; p<0.001), but not in other stage I patients (HR=1.02; 95% CI 0.91 to 1.15; p=0.710; p interaction <0.001). CONCLUSION: Our study showed that adjuvant radiation was associated with an overall survival benefit in patients meeting GOG-99 criteria only; however, no survival benefit was seen in patients meeting PORTEC-1 criteria only. We propose a definition of unfavorable risk stage I endometrial cancer: ≥2 risk factors from among lymphovascular invasion, age ≥70, grade 2-3 disease, and FIGO stage IB disease.

16.
J Natl Compr Canc Netw ; 17(8): 922-930, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31390593

RESUMO

BACKGROUND: Vulvar cancer with pelvic nodal involvement is considered metastatic (M1) disease per AJCC staging. The role of definitive therapy and its resulting impact on survival have not been defined. PATIENTS AND METHODS: Patients with pelvic lymph node-positive vulvar cancer diagnosed in 2009 through 2015 were evaluated from the National Cancer Database. Patients with known distant metastatic disease were excluded. Logistic regression was used to evaluate use of surgery and radiation therapy (RT). Overall survival (OS) was evaluated with log-rank test and Cox proportional hazards modeling (multivariate analysis [MVA]). A 2-month conditional landmark analysis was performed. RESULTS: A total of 1,304 women met the inclusion criteria. Median follow-up was 38 months for survivors. Chemotherapy, RT, and surgery were used in 54%, 74%, and 62% of patients, respectively. Surgery was associated with prolonged OS (hazard ratio [HR], 0.58; P<.001) but had multiple significant differences in baseline characteristics compared with nonsurgical patients. In patients managed nonsurgically, RT was associated with prolonged OS (HR, 0.66; P=.019) in MVA. In patients undergoing surgery, RT was associated with better OS (3-year OS, 55% vs 48%; P=.033). Factors predicting use of RT were identified. MVA revealed that RT was associated with prolonged OS (HR, 0.75; P=.004). CONCLUSIONS: In this cohort of women with vulvar cancer and positive pelvic lymph nodes, use of RT was associated with prolonged survival in those who did not undergo surgery. Surgery followed by adjuvant RT was associated with prolonged survival compared with surgery alone.

17.
Brachytherapy ; 18(6): 780-786, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31439465

RESUMO

Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.

18.
Prostate ; 79(12): 1457-1461, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31294484

RESUMO

BACKGROUND: Small cell carcinoma (SCC) of the prostate is a rare, aggressive disease. Evidence is limited; however, the current standard of care is chemotherapy. The benefit of local treatment modalities is unknown. METHODS: We queried the National Cancer Database identifying all SCC/neuroendocrine cases of the prostate, excluding those with unknown nodal or metastatic status, unknown treatment, or those not receiving chemotherapy. Overall survival (OS) was calculated using Kaplan-Meier curves. Multivariable Cox proportional hazards model was used to identify factors associated with survival. A further subgroup analysis was performed on the utility of local therapy on survival in the nonmetastatic setting. RESULTS: Our final cohort included 657 patients with a median age of 68. Most patients had positive lymph nodes (60.1%) and metastatic disease (70.0%). Median survival was 12 months (95% confidence interval [95% CI], 11.1-13.3 months) with a median follow-up of 11.8 months. Metastatic disease, age greater than or equal to 70, omission of androgen deprivation therapy (ADT), and lower income (P < .05 for all) were all associated with reduced OS. Patients with prostate-specific antigen (PSA) greater than or equal to 33 ng/mL and those receiving ADT had better survival (P < .05). Those with nonmetastatic disease were more likely to undergo prostatectomy and/or prostatic/pelvic radiation (P < .0001). Prostatic/pelvic radiation in the nonmetastatic setting was associated with longer survival (P = .02). Though well powered, our study is limited by the selection bias inherent to all observational studies, despite the statistical methods utilized to reduce this effect. CONCLUSIONS: Although chemotherapy is the mainstay of treatment, radiation to the prostate/pelvis may be beneficial in the nonmetastatic setting. In addition to chemotherapy, ADT may benefit patients with an elevated PSA.


Assuntos
Carcinoma de Células Pequenas/epidemiologia , Carcinoma de Células Pequenas/terapia , Tumores Neuroendócrinos/epidemiologia , Tumores Neuroendócrinos/terapia , Neoplasias da Próstata/epidemiologia , Neoplasias da Próstata/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Pequenas/mortalidade , Bases de Dados Factuais , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/mortalidade , Neoplasias da Próstata/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia
19.
Lung Cancer ; 133: 136-143, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31200820

RESUMO

OBJECTIVES: Optimal adjuvant therapy in patients with clinically N2 (cN2) non-small cell lung cancer (NSCLC) who undergo neoadjuvant chemotherapy followed by surgery is controversial. We evaluated the impact of adjuvant chemotherapy (CT) and/or radiation (RT) in this patient population. MATERIALS AND METHODS: Patients with non-metastatic, cN2 NSCLC diagnosed from 2004 to 2015 were identified from the National Cancer Database, which captures 70% of cancer cases diagnosed in the United States. Patients underwent neoadjuvant CT and surgical resection. Patients couldn't receive RT before surgery. Survival was compared using log-rank and Cox proportional hazards modeling. Subset analyses were performed based on post-chemotherapy surgical nodal staging (ypN0-2) and lymph node ratio (LNR), including 0%, 1-15%, or >15% involvement. LNR was defined as number of nodes involved by tumor divided by number of nodes examined. RESULTS AND CONCLUSIONS: We identified 1541 patients. The percentage of patients who received adjuvant CT and RT was 18.9% and 35.7% respectively. ypN status and LNR were predictive of survival on univariate analysis, but only LNR maintained significance on multivariate analysis. There was no benefit observed for adjuvant CT or RT in the entire cohort. On subset analyses, a survival benefit was observed in ypN2 patients with receipt of CT or RT (HRs 0.77 and 0.81, respectively, p < 0.05). In patients with LNR > 15%, there was a significant benefit of RT (HR 0.76, p = 0.007) and borderline benefit of CT (HR 0.78, p = 0.058). Patients with cN2 disease with subsequent ypN0-1 and/or LNR < 15% following induction chemotherapy do not benefit from adjuvant therapy. Patients with persistent N2 disease and LNR > 15% who receive adjuvant CT and RT have improved survival. Aggressive consolidative therapy appears to improve survival in patients with persistent or high nodal burden disease.

20.
Pract Radiat Oncol ; 9(6): 418-425, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31150869

RESUMO

PURPOSE: To determine the feasibility of stereotactic body radiation therapy (SBRT) for isolated nodal recurrences of gynecologic malignancies within a previously irradiated area. METHODS AND MATERIALS: A retrospective review was performed on 20 patients who underwent 21 curative-intent reirradiation SBRT treatments for locoregional recurrences of gynecologic malignancies. Disease control and survival outcomes were analyzed with the Kaplan-Meier method and log-rank test. Treatment toxicities were graded according to Common Terminology Criteria for Adverse Events version 4.03. RESULTS: All patients had an isolated pelvic, paraortic, or intra-abdominal nodal recurrence, with the exception of 1 patient who had a concurrent paraortic and right acetabulum metastasis, both of which were irradiated with SBRT. Primary sites included cervix (30.0%), uterus (55.0%), vulva (5.0%), vagina (5.0%), and ovary (5.0%). Median prior external beam radiation therapy dose was 45 Gy. Recurrences were in field in 14 (66.7%) and marginal in 7 (33.3%). SBRT was directed to the pelvis in 13 cases (61.9%) and to paraortic or celiac nodes in 8 (38.1%). The most common SBRT regimen was 40 to 45 Gy in 5 fractions (n = 12). At a median follow-up of 31.2 months, 3-year actuarial in-field local control, distant progression-free survival, and overall survival were 61.4%, 44.0%, and 51.9%, respectively. At the time of last follow-up, 9 (45.0%) patients remained alive without evidence of disease. Actuarial 3-year risk of grade ≥2 and grade ≥3 late toxicities was 38.1% and 14.3%, respectively. CONCLUSIONS: SBRT for isolated pelvic or intra-abdominal recurrences of gynecologic malignancies within a previously irradiated field is feasible with an acceptable toxicity rate. With this approach, about half of patients achieved durable disease-free survival.

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