Delphi consensus on stereotactic ablative radiotherapy for oligometastatic and oligoprogressive renal cell carcinoma-a European Society for Radiotherapy and Oncology study endorsed by the European Association of Urology.

The purpose of this European Society for Radiotherapy and Oncology (ESTRO) project, endorsed by the European Association of Urology, is to explore expert opinion on the management of patients with oligometastatic and oligoprogressive renal cell carcinoma by means of stereotactic ablative radiotherapy (SABR) on extracranial metastases, with the aim of developing consensus recommendations for patient selection, treatment doses, and concurrent systemic therapy. A questionnaire on SABR in oligometastatic renal cell carcinoma was prepared by a core group and reviewed by a panel of ten prominent experts in the field. The Delphi consensus methodology was applied, sending three rounds of questionnaires to clinicians identified as key opinion leaders in the field. At the end of the third round, participants were able to find consensus on eight of the 37 questions. Specifically, panellists agreed to apply no restrictions regarding age (25 [100%) of 25) and primary renal cell carcinoma histology (23 [92%] of 25) for SABR candidates, on the upper threshold of three lesions to offer ablative treatment in patients with oligoprogression, and on the concomitant administration of immune checkpoint inhibitor. SABR was indicated as the treatment modality of choice for renal cell carcinoma bone oligometatasis (20 [80%] of 25) and for adrenal oligometastases 22 (88%). No consensus or major agreement was reached regarding the appropriate schedule, but the majority of the poll (54%-58%) retained the every-other-day schedule as the optimal choice for all the investigated sites. The current ESTRO Delphi consensus might provide useful direction for the application of SABR in oligometastatic renal cell carcinoma and highlight the key areas of ongoing debate, perhaps directing future research efforts to close knowledge gaps.

A Comparative Study of Patients With Early-Stage Non-Small Cell Lung Cancer Treated With Stereotactic Body Radiation Therapy Using CyberKnife and Linear Accelerator-Based Volumetric Modulated Arc Therapy.

PURPOSE: Stereotactic body radiation therapy (SBRT) has become the standard of care for medically inoperable early-stage non-small cell lung cancer. We investigated 2 modalities of lung SBRT, CyberKnife (CK) and volumetric modulated arc therapy (VMAT), for differences in dosimetric parameters, tumor control, and clinical outcomes. METHODS AND MATERIALS: Patients who underwent SBRT for T1-2N0M0 non-small cell lung cancer from 2012 to 2018 were included. Dosimetric parameters for target volume coverage and organ-at-risk dose distribution were collected. Survival outcomes were evaluated using the Kaplan-Meier method with log-rank test. A multivariate Cox proportional hazards model was analyzed for local, regional, and distant tumor control; overall survival (OS) and progression-free survival; and radiation pneumonitis. RESULTS: Two hundred twenty-seven patients (142 CK, 85 VMAT SBRT) met inclusion criteria. Overall, the local, regional, and distant control rates were 89.3%, 86.3%, and 87.4% at 2 years, and the OS was 67.5% and 32.8% at 2 and 5 years, respectively. VMAT delivered higher maximum doses to the gross tumor volume and planning target volume and had a lower lung and heart V5. Although there was no difference in local or distant failure, progression-free survival, or OS, VMAT was associated with superior freedom from regional failure (adjusted hazard ratio, 0.26; P = .045). With no difference between treatment modalities, 11.9% of patients developed grade 1 to 2 radiation pneumonitis. There were no grade 3+ events of radiation pneumonitis. CONCLUSIONS: This study revealed that VMAT and CK provided comparable local and distant control and survival outcomes; however, VMAT exhibited better regional control. Further study in this regard is imperative.

Final results of a dose escalation protocol of stereotactic body radiotherapy for poor surgical candidates with localized renal cell carcinoma.

BACKGROUND AND PURPOSE: We previously demonstrated the safety of doses up to 48 Gy in 4 fractions with stereotactic body radiotherapy (SBRT) in poor surgical candidates with localized renal cell carcinoma (RCC). In an additional expansion cohort, we aimed to assess the safety of further dose escalation to 48-60 Gy in 3 fractions. MATERIAL AND METHODS: Patients were required to have localized RCC and be poor surgical candidates due to medical comorbidities. Dose-limiting toxicity (DLT) was defined as acute (<180 days) grade ≥3 gastrointestinal/genitourinary toxicity by CTCAEv4. Tumor response was assessed using RECIST 1.1 criteria measurements every 6 months for 3 years and optional percutaneous biopsy. RESULTS: Groups of 4, 4, and 3 patients received 48, 54, and 60 Gy in 3 fractions, respectively from 2012 to 2016. Median follow-up was 34.3 months. Zero DLTs were observed. Acute toxicities were limited to grade 1 fatigue and nausea in 45.5% and 18.1%. Late grade 2+ and grade 3+ possibly treatment-related events occurred in 18.1% and 9.1%, respectively. Three-year local control was 90% by RECIST 1.1 criteria. Five of 5 post-treatment biopsies in the expansion cohort were positive by Hematoxylin and Eosin staining. Three of the 5 patients with positive biopsies have been observed for 1.2-3.9 years without evidence of progression. CONCLUSION: Dose escalation to 60 Gy in 3 fractions was achieved without DLTs. Favorable local control rates were observed, and the interpretation of post-SBRT biopsies remains uncertain. Further studies comparing SBRT to percutaneous ablation for poor surgical candidates with RCC are warranted.

Institutional practices of withholding enteral feeding from intubated patients.

OBJECTIVE: This study compared the practices of anesthesia, anesthesia critical care, surgical critical care, and medical critical care departments that have training programs for the length of time they withhold enteral feeding from intubated patients before seven scheduled procedures: 1) extubation; 2) tracheostomy; 3) abdominal surgery; 4) nonabdominal surgery; 5) magnetic resonance imaging or computerized tomography; or placing the patient in the 6) Trendelenberg or 7) prone position. DESIGN: One-time survey of 297 anesthesia and critical care training programs in the United States. MEASUREMENTS AND MAIN RESULTS: Eighty programs responded (27%). We compared the median hours of withholding enteral feeding of intubated patients according to training program type for each of the procedures. None of the programs withheld enteral feeds from intubated patients scheduled for magnetic resonance imaging/computerized tomography scans, nor for the Trendelenberg position (median = 0 hour). A significant difference among program types was found for extubation, with anesthesia departments having significantly longer times (median = 6 hours) compared with anesthesia critical care (median = 4 hours), surgical critical care (median = 2 hours), and medical critical care (1.5 hours) departments (chi = 8.77, df = 3, p = 0.032). For scheduled tracheostomy, surgical critical care departments reported shorter times (median = 4 hours) than did all other surveyed departments (median = 6 hours) (chi = 7.28, df = 3, p = 0.063). CONCLUSIONS: Differences in opinion exist among specialty training programs about the length of time necessary for withholding enteral feeding from intubated patients before scheduled procedures, especially extubation and tracheostomy. To resolve physician conflicts and to best serve these patients, best practice guidelines for withholding enteral feeding from intubated patients before scheduled procedures need to be developed jointly by the critical care specialties.