Radiation Therapy in the Management of Extensive Giant Condyloma Acuminata With Rectal Involvement: A Case Report.

Giant condyloma acuminata (GCA) is a rare, locally aggressive manifestation of human papillomavirus (HPV) infection, typically affecting the anorectal area. Patients with GCA often have a poor prognosis due to the high risk of malignant transformation. In this case report, we present a 39-year-old man with HIV who developed progressive and refractory anorectal GCA. Despite initially non-cancerous pathology results, there were concerns regarding a malignant component to the mass. Multidisciplinary discussions led to the decision to pursue definitive radiation therapy. This case report and review of the literature highlight the role of radiation in the management of GCA and the importance of a multidisciplinary approach in the treatment of complex cases.

Newly Diagnosed Mental Health Disorders in Patients With Breast Cancer Receiving Radiation Therapy.

PURPOSE: Patients with a mental health disorder (MHD) have higher age-adjusted mortality compared with the general population. Few reports investigate factors contributing to MHD among patients with breast cancer receiving radiation therapy. We report the incidence of acquired MHD after the diagnosis of breast cancer and treatment with radiation therapy. METHODS AND MATERIALS: Using a single institution, prospectively maintained database, we analyzed patients with breast cancer treated with radiation therapy between 2012 and 2017. We cross-referenced these patients with newly acquired International Classification of Diseases, Tenth Revision (ICD-10) MHD codes (F01-F99) within 3 years postbreast cancer diagnosis. The study included baseline National Comprehensive Cancer Network® (NCCN) distress tool scores and area deprivation index (ADI). Univariate and multivariable (MVA) Cox regression analyses were conducted to evaluate factors affecting new MHD onset. RESULTS: Of the 967 included patients, 318 (33%) developed an MHD after their breast cancer diagnosis, which was predominately anxiety (45.1%) and depression (20.1%) related, with a median (IQR) time to diagnosis of 30 (24-33) months. Univariate analysis showed lymph node-positive disease, receipt of chemotherapy, receipt of a mastectomy, high comorbidity index, divorced status, retired status, and fourth-quartile ADI as significant predictors. On MVA, only receipt of chemotherapy (hazard ratio [HR], 1.70; P = .014) and divorced status (HR, 2.04; P = .009) remained significant. Fourth-quartile ADI, retired status, and high comorbidity index showed trends toward significance (HR, 1.78, P = .065; HR, 1.46, P = .094; HR, 1.41, P = .059, respectively). On MVA examining the effects of the radiation therapy type on MHD, whole breast with regional nodal irradiation (HR, 2.31, P = .015) and postmastectomy radiation therapy (HR, 1.88, P = .024) were both strong predictors of MHD development. Additionally, an NCCN distress tool score of >3 was also predictive of MHD onset. CONCLUSIONS: In this cohort, 1 in 3 patients with localized breast cancer developed a new MHD, predominantly related to anxiety and depression. MHD risk was higher among divorced patients, those receiving chemotherapy, and patients receiving postmastectomy radiation therapy or whole breast with regional nodal irradiation. These findings highlight the importance of future studies and targeted interventions to support this vulnerable population.

Predictors of Early Hospice or Death in Patients With Inoperable Lung Cancer Treated With Curative Intent.

INTRODUCTION: Treatment for inoperable stage II to III non-small cell lung cancer (NSCLC) involves chemo-radiotherapy (CRT). However, some patients transition to hospice or die early during their treatment course. We present a model to prognosticate early poor outcomes in NSCLC patients treated with curative-intent CRT. METHODS AND MATERIALS: Across a statewide consortium, data was prospectively collected on stage II to III NSCLC patients who received CRT between 2012 and 2019. Early poor outcomes included hospice enrollment or death within 3 months of completing CRT. Logistic regression models were used to assess predictors in prognostic models. LASSO regression with multiple imputation were used to build a final multivariate model, accounting for missing covariates. RESULTS: Of the 2267 included patients, 128 experienced early poor outcomes. Mean age was 71 years and 59% received concurrent chemotherapy. The best predictive model, created parsimoniously from statistically significant univariate predictors, included age, ECOG, planning target volume (PTV), mean heart dose, pretreatment lack of energy, and cough. The estimated area under the ROC curve for this multivariable model was 0.71, with a negative predictive value of 95%, specificity of 97%, positive predictive value of 23%, and sensitivity of 16% at a predicted risk threshold of 20%. CONCLUSIONS: This multivariate model identified a combination of clinical variables and patient reported factors that may identify individuals with inoperable NSCLC undergoing curative intent chemo-radiotherapy who are at higher risk for early poor outcomes.

Bibliometric Analysis and Applications of a Modified H-Index Examining the Research Productivity of Neurosurgery Faculty at High-Ranking Academic Institutions.

OBJECTIVE: A major critique of the h-index is that it may be inflated by noncritical authorship. We propose a modified h-index (hm), incorporating critical authorship, complementary to the h-index. We analyze its relationship to the traditional h-index, and how each varies across professional categories relevant to academic neurosurgery. This analysis is not meant to critique authorship decisions, affect career development, alter academic legacy, or imply that the concepts of team science or midlevel authorship contributions are not valuable. METHODS: H-indices and hms were gathered and computed for clinical neurosurgical faculty at the top 32 ranked academic neurosurgical programs based on the current literature. Hm was computed for faculty at each program, using articles in which the individual was first, second, last, or co-corresponding author. Individuals were further identified based on chair status, leadership status, neurosurgical subspecialty, and National Institutes of Health funding status. Further analysis was performed to determine factors influencing h-index and hm. RESULTS: The median h-index for the 225 physicians included in the final dataset is 48 (interquartile range [IQR], 39-61), whereas the median hm was 32 (IQR, 24-43). The median difference between h-index and hm is 15 (IQR, 10-23). The median hm/h was 64% (IQR, 57-74). National Institutes of Health funding and subspecialty (neurosurgical oncology, neurocritical care, and cerebrovascular) were associated with significant change from h to hm. CONCLUSIONS: The h-index can be influenced by noncritical authorship, and hm, using critical contributions, can be used as a complement reflecting critical academic output in neurosurgery. Leaders deciding on hiring or promotion should consider disparities in productivity predicated on noncritical authorship contributions.

Longer Wait Times Do Not Adversely Impact 90-Day Mortality in Patients With Stages I-III Gastric Cancer.

Introduction Gastric cancer is one of the leading causes of cancer-related death in the United States. Surgery remains integral to the curative management of non-metastatic gastric cancer. However, delays to the date of surgery for gastric cancer patients are commonplace. To investigate the impact of treatment delays on gastric cancer mortality, we conducted a multivariable analysis of over 36,000 patients. Materials & methods After querying the National Cancer Database and excluding patients who did not meet inclusion criteria, our sample included 36,598 patients with stage I-III gastric cancer. We ran multivariable logistic regressions by regressing 90-day mortality on wait time. Other co-variables included sex, race, age, area of residence, comorbidities, insurance, histology, tumor grade, tumor stage, resection margins, treatment facility type, and treatment with chemotherapy. Results Our results demonstrated that each day of increased waiting time is associated with a 0.5% decrease in 90-day mortality. Other statistically significant predictors of higher 90-day mortality risk included male sex, black or white race, living in a small metropolitan or non-metropolitan area, older age, more severe comorbidities, non-private insurance, non-gastric stromal tumor cancer, non-well differentiated tumors, worse clinical stage, residual cancer, treatment at non-academic center, and no adjuvant/neoadjuvant chemotherapy. Conclusion These findings demonstrate that patients with longer wait times until surgery do not experience worse outcomes. These results are reassuring and can be cited to alleviate patient concerns.

Treatment of a Non-syndromic Carotid Body Paraganglioma Using Fast Neutron Radiotherapy: A Case Report and Review of Literature.

Non-syndromic carotid body paragangliomas (CBPs) are the most common head and neck CBPs. Malignant transformation or symptomatic presentation is rare, but patients may occasionally endorse tinnitus, cranial nerve (CN) deficits, and ear pulsations. Historically, treatment of CBP was primarily through surgical intervention, which predisposed patients to CN deficits and significant blood loss due to the neurovascular structures in close proximity to these tumors. More recently, the utilization of pre-treatment embolization and radiotherapy has allowed for the reduction in treatment morbidity. Stereotactic radiosurgery (SRS) and external beam radiotherapy (EBRT) have been investigated as alternatives to traditional surgical intervention, with a documented reduction in the incidence of postoperative morbidity. While several retrospective studies and meta-analyses compare outcomes following surgical and traditional radiotherapeutic interventions, currently no literature exists regarding the potential utility of fast neutron therapy in treating this disease. In this case report, we highlight a patient with a non-syndromic CBP treated with pre-treatment embolization and fast neutron therapy, review the post-treatment course, and present a review of the extant literature on the subject.

The Treatment of a Novel Epidermal Growth Factor Receptor (EGFR)-GRB2 Genetic Mutation Using Osimertinib in Metastatic Non-Small Cell Lung Cancer.

Mutations in the epidermal growth factor receptor (EGFR) have been implicated in nearly one-third of non-small-cell lung cancers. For patients harboring non-traditional mutations, genomic and transcriptomic sequencing can help direct treatment. As cancer genomics evolves, novel driver mutations continue to be uncovered. We report on a unique EGFR-GRB2 fusion in a 48-year-old female never-smoker. This patient presented with stage IV lung adenocarcinoma (T2aN3M1) with metastatic disease in the iliac wing and liver. Despite systemic treatment, this patient continued to progress. On whole transcriptome sequencing, this patient was found to have a novel EGFR-GRB2 RNA fusion transcript similar to other EGFR fusions described in the literature. After treatment with osimertinib, this patient experienced remarkable clinical and radiological improvements. We believe that, especially for patients with metastatic lung cancer, the presence of novel driver mutations should be investigated. Potentially, patients harboring similar mutations may demonstrate analogous improvements with targeted treatment using the most recent generation of tyrosine kinase inhibitors.

Positive Impact of Implementing a Comprehensive Genetic Testing Protocol for Prostate Cancer Patients in a Multi-disciplinary Uro-oncology Practice.

INTRODUCTION: Prior to the 2017 Philadelphia Consensus Conference guidelines, genetic testing for prostate cancer was conducted based on personal and family history of malignancy pursuant to National Comprehensive Cancer Network recommendations. The updated 2019 guidelines addressed the subject of genetic testing by endorsing point-of-care genetic testing and referral to genetic counseling. However, limited literature is available regarding successful implementation of a streamlined method for genetic testing. This paper explores the benefits of implementing an on-site guideline-based genetic testing process for prostate cancer patients. METHODS: Data were retrospectively reviewed for 552 prostate cancer patients seen in a uro-oncology clinic since January 2017. Prior to September 2018 genetic testing was recommended based on National Comprehensive Cancer Network guidelines, and swabs for testing were procured off-site 1 mile from the clinic (n = 78). After September 2018 genetic testing was recommended based on the Philadelphia Consensus Conference guidelines, and swabs for testing were procured at the clinic itself (n = 474). RESULTS: A statistically significant increase in testing compliance was observed after the implementation of on-site, guideline-based testing. Genetic testing compliance increased from 33.3% to 98.7%. The time to receive the genetic test results was also reduced from 38 days to 21 days. CONCLUSIONS: The implementation of an on-site, guideline-based genetic testing model for prostate cancer patients significantly improved compliance with genetic testing to 98.7% and decreased the time to receive genetic test results by 17 days. Adopting a guideline-based model with on-site genetic testing can significantly improve the detection rate for pathogenic and actionable mutations and increase the utilization of targeted therapies.

The Diagnosis of Urinary Tract Infections Using a Novel At-home Testing Protocol to Enhance Telemedicine: A Retrospective Analysis.

OBJECTIVE: To retrospectively analyze a novel courier-based home urine collection strategy for patients with symptoms of urinary tract infections (UTIs). This model was developed to provide patient care using telehealth during the coronavirus 2019 pandemic. METHODS: We analyzed data from 2206 patients with symptomatic UTIs to investigate the efficacy of a home urine collection protocol. The primary outcome was the impact of home versus office collection. RESULTS: We analyzed the results of 1112 patient samples collected in-office and 1084 patient samples collected at home. There was no difference in the rate of bacterial identification between females in the office and home collection groups. However, males in the office collection group had a higher rate of bacterial identification (p = .002). The turnaround time was significantly faster in the home collection group than the office collection group (4.08 hours shorter, p < 0.0014). Antibiotic use prior to sample collection was significantly higher in the home collection group for both males (p = .0004) and females (p = .004). Changes in antibiotics were significantly higher in the home collection group than in the office collection group for both males (p = .0009) and females (p = .0006). CONCLUSION: Our home collection protocol is a viable method to provide prompt and reliable outpatient care to urology patients suffering from UTIs. Furthermore, this approach resulted in adequate management and quicker turnaround times. Our findings demonstrate the clinical viability of a decentralized healthcare model to treat UTIs.

Long-Term Reoperation Rates After Open versus Minimally Invasive Spine Surgery for Degenerative Lumbar Disease: Five Year Follow-Up of 2130 Patients.

BACKGROUND: Minimally Invasive Spine Surgery (MISS) is a growing alternative to Open Spine Surgery (OSS). The preservation of musculature and minimization of iatrogenic injury is hypothesized to decrease the need for reoperation by preserving normal anatomy. Our objective is to compare the relative long-term reoperation rates after MISS and OSS for the treatment of degenerative disease of the lumbar spine. METHODS: This retrospective analysis compares the long-term reoperation rates after MISS and OSS. Eligible patients were adults with a primary lumbar intervention carried out between 5/1/2004 and 1/31/2014 to allow for at least 5 years of follow up. Patients without sufficient descriptive metrics or follow-up data were excluded. The primary outcome was the rate of lumbar spine reoperation. RESULTS: A total of 2130 patients met the inclusion criteria-1895 underwent OSS and 235 underwent MISS. On average and across all surgery types (decompression and decompression with fusion), 28% of OSS patients required reoperation during the minimum 5-year follow up period while only 14% of MISS patients required reoperation (P = 0.001). The MISS group was statistically identical to the OSS group in all categories except that the MISS group was on average 1.8 years older (62.25 vs. 60.45, P = 0.039) and had a higher incidence of diabetes (26% vs. 17%, P = 0.000), but had a lower average body mass index than the OSS group (28.35 vs. 29.60, P = 0.002). CONCLUSIONS: In the setting of degenerative lumbar spine disease, MISS has the potential to reduce the long-term need for reoperation when compared with OSS.

Minimally-Invasive Assisted Robotic Spine Surgery (MARSS).

Minimally-Invasive robotic spine surgery (MARSS) has expanded the surgeons armamentarium to treat a variety of spinal disorders. In the last decade, robotic developments in spine surgery have improved the safety, accuracy and efficacy of instrumentation placement. Additionally, robotic instruments have been applied to remove tumors in difficult locations while maintaining minimally invasive access. Gross movements by the surgeon are translated into fine, precise movements by the robot. This is exemplified in this chapter with the use of the da Vinci robot to remove apical thoracic tumors. In this chapter, we will review the development, technological advancements, and cases that have been conducted using MARSS to treat spine pathology in a minimally invasive fashion.