Practical Considerations for the Treatment of an Adrenal Metastasis With Stereotactic Body Radiation Therapy.

The purpose of this paper is to summarize 3 methods for treating adrenal metastases with stereotactic body radiation therapy. This article is not meant to provide consensus guidelines but rather to present 4 practical examples of treatment techniques using different treatment platforms from 3 institutions.

Stereotactic Body Radiation Therapy for the Treatment of Locally Recurrent and Oligoprogressive Non-Small Cell Lung Cancer: A Single Institution Experience.

Objectives: To investigate the efficacy and safety of lung stereotactic body radiation therapy (SBRT) for non-small cell lung cancer (NSCLC) including oligorecurrent and oligoprogressive disease. Methods: Single-institution retrospective analysis of 60 NSCLC patients with 62 discrete lesions treated with SBRT between 2008 and 2017. Patients were stratified into three groups, including early stage, locally recurrent, and oligoprogressive disease. Group 1 included early stage local disease with no prior local therapy. Group 2 included locally recurrent disease after local treatment of a primary lesion, and group 3 included regional or well-controlled distant metastatic disease receiving SBRT for a treatment naive lung lesion (oligoprogressive disease). Patient/tumor characteristics and adverse effects were recorded. Local failure free survival (LFFS), progression free survival (PFS), and overall survival (OS) were estimated using the Kaplan Meier method. Results: At median follow-up of 34 months, 67% of the study population remained alive. The estimated 3-year LFFS for group 1, group 2, and group 3 patients was 95% (95% CI: 86%-100%), 82%(62% - 100%), and 83% (58-100%), respectively. The estimated 3-year PFS was 59% (42-83%), 40% (21%-78%), and 33% (12%-95%), and the estimated 3-year OS was 58% (41-82%), 60% (37-96%), and 58% (31-100%)), respectively for each group. When adjusted for age and size of lesion, no significant difference in OS, LFFS, and PFS emerged between groups (p > 0.05). No patients experienced grade 3 to 5 toxicity. Eighteen patients (29%) experienced grade 1 to 2 toxicity. The most common toxicities reported were cough and fatigue. Conclusions: Our data demonstrates control rates in group 1 patients comparable to historical controls. Our study also reveals comparable clinical results for SBRT in the treatment of NSCLC by demonstrating similar rates of LFFS and OS in group 2 and group 3 patients with locally recurrent and treatment naïve lung lesion with well-controlled distant metastatic disease.

The utility of radiographic assessment of the internal mammary arteries in chest wall irradiated patients.

PURPOSE: The internal mammary arteries (IMA's) are historically recognized to be protected against atherosclerosis. Whether chest wall-irradiation for breast cancer leads to significant IMA damage remains unclear. The utility of computed tomography (CT) and mammography to detect radiation-induced damage to the IMA's and its branches is not known. The objective of this study is to assess the susceptibility of IMA's to radiation-induced atherosclerosis, and the utility of CT scan and mammography in the assessment of IMA and its branches. METHODS: A retrospective analysis of breast cancer patients who received chest wall-radiotherapy was performed. Patients with CT scans and/or mammograms ≥5 years post-radiotherapy were included. Baseline characteristics, coronary artery calcification (CAC), the presence of IMA damage assessed by CT scan, and IMA branch calcifications by mammography were recorded. RESULTS: None of the 66 patients with CT scans post-radiotherapy revealed IMA atherosclerosis. There were 28 (42.4%) patients with CAC, of which four (14.3% of CAC subgroup or 6.1% of the total cohort) had calcifications on either side on mammogram (Chi-square test, p = 0.74). Out of the 222 patients with mammograms, 36 (16.2%) had IMA branch calcifications. Two hundred and ten patients received unilateral radiotherapy, and 27 (12.9%) of these patients had calcifications on the irradiated side, and 26 patients (12.4%) had calcifications on the contralateral side (OR = 1.0). CONCLUSION: IMA's do not exhibit signs of radiation-induced atherosclerosis when evaluated by CT scan. In addition, there is no association between radiotherapy for breast cancer and the presence of IMA branch calcification on mammograms.

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.

HIV Infection Is Associated With Poor Outcomes for Patients With Anal Cancer in the Highly Active Antiretroviral Therapy Era.

BACKGROUND: HIV status may affect outcomes after definitive chemoradiotherapy for anal cancer. OBJECTIVE: Here, we report a large series in the highly active antiretroviral therapy era comparing outcomes between HIV-positive and HIV-negative patients with anal cancer. DESIGN: This was a retrospective chart review. SETTINGS: The study was conducted at an outpatient oncology clinic at large academic center. PATIENTS: A total of 107 patients were reviewed, 39 HIV positive and 68 HIV negative. All of the patients underwent definitive chemoradiation for anal cancer. MAIN OUTCOME MEASURES: Data on patient characteristics, treatment, toxicity, and outcomes were collected. Overall survival, colostomy-free survival, local recurrence-free survival, and distant metastasis-free survival were analyzed. RESULTS: Median follow-up was 15 months. HIV-positive patients were younger (median, 52 vs 64 years; p < 0.001) and predominantly men (82% men vs 49% men; p = 0.001). There were no significant differences in T, N, or stage groups. HIV-positive patients had a significantly longer duration from biopsy to start of chemoradiation (mean number of days, 82 vs 54; p = 0.042). There were no differences in rates of acute toxicities including diarrhea, fatigue, or dermatitis. HIV-positive patients had significantly higher rates of hospitalization (33% vs 15%; p = 0.024). The 3-year overall survival rate was 42% in HIV-positive and 76% in HIV-negative patients (p = 0.037; HR, 2.335 (95% CI, 1.032-5.283)). Three-year colostomy-free survival was 67% in HIV-positive and 88% in HIV-negative patients (p = 0.036; HR, 3.231 (95% CI, 1.014-10.299)). Differences in overall survival rates were not significant on multivariate analysis. LIMITATIONS: This study was limited by its retrospective design and small patient numbers. CONCLUSIONS: In this cohort, HIV-positive patients had significantly worse overall and colostomy-free survival rates than HIV-negative patients. However, differences in survival were not significant on multivariate analysis. Additional studies are necessary to establish the etiology of this difference.

Comparison of anal cancer outcomes in public and private hospital patients treated at a single radiation oncology center.

OBJECTIVE: To compare clinical and treatment characteristics and outcomes in locally advanced anal cancer, a potentially curable disease, in patients referred from a public or private hospital. METHODS: We retrospectively reviewed 112 anal cancer patients from a public and a private hospital who received definitive chemoradiotherapy at the same cancer center between 2004 and 2013. Tumor stage, radiotherapy delay, radiotherapy duration, and unplanned treatment breaks ≥10 days were compared using t-test and χ(2) test. Overall survival (OS), disease free survival (DFS), and colostomy free survival (CFS) were examined using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazard models for OS and DFS were developed. RESULTS: The follow-up was 14.9 months (range, 0.7-94.8 months). Public hospital patients presented with significantly higher clinical T stage (P<0.05) and clinical stage group (P<0.05), had significantly longer radiotherapy delays (P<0.05) and radiotherapy duration (P<0.05), and had more frequent radiation therapy (RT) breaks ≥10 days (P<0.05). Three-year OS showed a marked trend in favor of private hospital patients for 3-year OS (72.8% vs. 48.9%; P=0.171), 3-year DFS (66.3% vs. 42.7%, P=0.352), and 3-year CFS (86.4% vs. 68.9%, P=0.299). Referral hospital was not predictive of OS or DFS on multivariate analysis. CONCLUSIONS: Public hospital patients presented at later stage and experienced more delays in initiating and completing radiotherapy, which may contribute to the trend in poorer DFS and OS. These findings emphasize the need for identifying clinical and treatment factors that contribute to decreased survival in low socioeconomic status (SES) populations.

Toxicity and disease-related outcomes after radiotherapy for head and neck cancer in human immunodeficiency virus-positive patients.

BACKGROUND: Human immunodeficiency virus (HIV) seropositivity may be associated with higher risk of local recurrence and poor survival in multiple malignancies. However, long-term disease control in HIV-positive patients with head and neck cancer (HNC) is not well described. The purpose of this study is to review the disease-related outcomes of HIV-positive patients who underwent radiotherapy (RT) or chemoradiotherapy (CRT) at our institution. METHODS: We retrospectively reviewed 24 HIV-positive patients who underwent RT for HNC between 2004 and 2013. Patient characteristics, treatment details, and outcomes were collected. Overall survival (OS) and local recurrence-free survival (LRFS) were investigated. Kaplan-Meier estimated survival was calculated. RESULTS: Median follow-up was 21 months. All patients were treated with curative intent. Eighty-three percent had stage III-IV. Primary sites of disease included oropharynx (n = 12), larynx (n = 6), oral cavity (n = 2), unknown primary (n = 2), nasal cavity (n = 1), and paranasal sinuses (n = 1). Four patients (17%) had definitive RT alone and nine had definitive CRT (38%; eight cisplatin and one cetuximab). Eleven (46%) were treated in the adjuvant setting after surgical resection; six with RT alone and five with concurrent cisplatin. Eight patients had acute Grade 3 toxicity with no acute Grade 4 or 5 toxicities. Fifteen patients (63%) were alive and disease-free. Two- and 5-year OS was 67 and 59%, respectively. LRFS at 2-years was 82%. Median OS was 83 months. CONCLUSION: In this cohort, HIV-positive patients treated aggressively with curative intent had excellent OS and local control following RT or CRT for HNC compared to historical controls. Treatment was relatively well tolerated. This group of patients should be managed aggressively with intent to cure.

Is there a role for an external beam boost in cervical cancer radiotherapy?

OBJECTIVES: Some patients are medically unfit for or averse to undergoing a brachytherapy boost as part of cervical cancer radiotherapy. In order to be able to definitively treat these patients, we assessed whether we could achieve a boost plan that would mimic our brachytherapy plans using external beam radiotherapy. METHODS: High dose rate brachytherapy plans of 20 patients with stage IIB cervical cancer treated with definitive chemoradiotherapy were included in this study. Patients had undergone computer tomography (CT) simulations with tandem and ovoids in place. Point "A" dose was 600-700 cGy. We attempted to replicate the boost dose distribution from brachytherapy plans using intensity-modulated radiotherapy (Varian Medical Systems, Palo Alto, CA, USA), volumetric modulated arc therapy (Rapid Arc, Varian Medical Systems, Palo Alto, CA, USA), or TomoTherapy (Accuray, Inc., Sunnyvale, CA, USA) with the brachytherapy 100% isodose line as our target. Target coverage, normal tissue dose, and brachytherapy point doses were compared with ANOVA. Two-sided p-values ≤0.05 were considered significant. RESULTS: External beam plans had excellent planning target volume (PTV) coverage, with no difference in mean PTV V95% among planning techniques (range 98-100%). External beam plans had lower bladder Dmax, small intestine Dmax, and vaginal mucosal point dose than brachytherapy plans, with no difference in bladder point dose, mean bladder dose, mean small intestine dose, or rectal dose. Femoral head dose, parametria point dose, and pelvic sidewall point dose were higher with external beam techniques than brachytherapy. CONCLUSIONS: External beam plans had comparable target coverage and potential for improved sparing of most normal tissues compared to tandem and ovoid brachytherapy.

A novel modified dynamic conformal arc technique for treatment of peripheral lung tumors using stereotactic body radiation therapy.

PURPOSE: To describe and compare a novel, modified dynamic conformal arc (MDCA) technique for lung stereotactic body radiation therapy with the standard noncoplanar beam (NCB) technique based on stereotactic body radiation therapy (SBRT) coverage, dose conformality, normal tissue constraints, and treatment time. MATERIALS AND METHODS: Twenty consecutive medically inoperable patients with early stage, peripheral, non-small cell lung cancer treated with SBRT using an NCB technique were re-planned with a novel MDCA technique. Treatment plans were compared based on Radiation Therapy Oncology Group (RTOG) 0236 criteria for planning treatment volume (PTV) coverage and normal tissue dose constraints, as well as high- and moderate-dose conformality. Treatment times necessary to deliver the NCB plans were compared with the times of a separate group of 12 consecutive patients treated with the MDCA technique at our institution. RESULTS: The MDCA technique resulted in improved coverage of the cranial and caudal regions of the PTV and generated plans that were significantly more conformal by all high-dose criteria proposed by the RTOG protocol. In terms of moderate-dose criteria, MDCA plans had a significantly lower maximum dose (2 cm from the PTV), whereas the ratio of the 50% dose volume to the volume of the PTV was equivalent between the 2 techniques. All normal tissue dose constraints proposed in the RTOG 0236 protocol were met by each plan, although the median lung V20 and mean lung dose were slightly higher in the MDCA plans, whereas the chest wall dose was slightly lower. A 42% reduction in treatment time was observed when patients treated with the NCB technique were compared with a separate cohort of 12 patients treated with the MDCA technique (P < .0001). CONCLUSIONS: The new MDCA technique described in this study resulted in enhanced PTV coverage, improved high- and moderate-dose conformality, simplified treatment planning, and reduced treatment time compared with results using the standard NCB technique.

Toxicity of head-and-neck radiation therapy in human immunodeficiency virus-positive patients.

PURPOSE: To examine the acute morbidity of high dose head and neck RT and CRT in patients with infected with HIV. METHODS AND MATERIALS: All HIV-positive patients who underwent radiation therapy for head and neck cancer in our department between 2004 and 2008 were reviewed. Treatment related data were examined. All treatments were delivered with megavoltage photon beams or electron beams. Patients were evaluated by an attending radiation oncologist for toxicity and response on a weekly basis during therapy and monthly after treatment in a multidisciplinary clinic. Acute toxicities were recorded using the Radiation Therapy and Oncology Group (RTOG) common toxicity criteria. Response to treatment was based on both physical exam as well as post-treatment imaging as indicated. RESULTS: Thirteen patients who underwent RT with a diagnosis of HIV were identified. Median age was 53 years and median follow-up was 22 months. Twelve had squamous cell carcinoma and one had lymphoproliferative parotiditis. Median radiation dose was 66.4 Gy and median duration of treatment was 51 days. The median number of scheduled radiotherapy days missed was zero (range 0 to 7). One patient (8%) developed Grade 4 confluent moist desquamation. Eight patients (61%) developed Grade 3 toxicity. CONCLUSION: Based on our results, HIV-positive individuals appear to tolerate treatment for head and neck cancer, with toxicity similar to that in HIV-negative individuals.

Excess mortality in the aftermath of Hurricane Katrina: a preliminary report.

BACKGROUND: Reports that death notices in the Times-Picayune, the New Orleans daily newspaper, increased dramatically in 2006 prompted local health officials to determine whether death notice surveillance could serve as a valid alternative means to confirm suspicions of excess mortality requiring immediate preventive actions and intervention. METHODS: Monthly totals of death notices from the Times-Picayune were used to obtain frequency and proportion of deaths from January to June 2006. To validate this methodology the authors compared 2002 to 2003 monthly death frequency and proportions between death notices and top 10 causes of death from state vital statistics. RESULTS: A significant (47%) increase in proportion of deaths was seen compared with the known baseline population. From January to June 2006, there were on average 1317 deaths notices per month for a mortality rate of 91.37 deaths per 100,000 population, compared with a 2002-2004 average of 924 deaths per month for a mortality rate of 62.17 deaths per 100,000 population. Differences between 2002 and 2003 death notices and top 10 causes of death were insignificant and had high correlation. DISCUSSION: Death notices from local daily newspaper sources may serve as an alternative source of mortality information. Problems with delayed reporting, timely analysis, and interoperability between state and local health departments may be solved by the implementation of electronic death registration.