Policy Priorities in Cancer Care for Transgender People.

This Viewpoint calls for health care systems, oncologists, and staff to prioritize and adopt policies that are inclusive and respectful of transgender patients with cancer.

ACR Appropriateness Criteria® pre-irradiation evaluation and management of brain metastases.

Pretreatment evaluation is performed to determine the number, location, and size of the brain metastases and magnetic resonance imaging (MRI) is the recommended imaging technique, particularly in patients being considered for surgery or stereotactic radiosurgery. A contiguous thin-cut volumetric MRI with gadolinium with newer gadolinium-based agents can improve detection of small brain metastases. A systemic workup and medical evaluation are important, given that subsequent treatment for the brain metastases will also depend on the extent of the extracranial disease and on the age and performance status of the patient. Patients with hydrocephalus or impending brain herniation should be started on high doses of corticosteroids and evaluated for possible neurosurgical intervention. Patients with moderate symptoms should receive approximately 4-8 mg/d of dexamethasone in divided doses. The routine use of corticosteroids in patients without neurologic symptoms is not necessary. There is no proven benefit of anticonvulsants in patient without seizures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria Pediatric Hodgkin Lymphoma.

Pediatric Hodgkin lymphoma is a highly curable malignancy and potential long-term effects of therapy need to be considered in optimizing clinical care. An expert panel was convened to reach consensus on the most appropriate approach to evaluation and treatment of pediatric Hodgkin lymphoma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Four clinical variants were developed to assess common clinical scenarios and render recommendations for evaluation and treatment approaches to pediatric Hodgkin lymphoma. We provide a summary of the literature as well as numerical ratings with commentary. By combining available data in published literature and expert medical opinion, we present a consensus to the approach for management of pediatric Hodgkin lymphoma.

ACR Appropriateness Criteria® on Hodgkin's lymphoma-unfavorable clinical stage I and II.

Combined-modality therapy, consisting of chemotherapy followed by radiation therapy (RT), represents the standard of care for most patients with unfavorable-prognosis early-stage Hodgkin's lymphoma. The most widely accepted chemotherapy regimen is ABVD (Adriamycin, bleomycin, vinblastine, and dacarbazine); however, recent trials have evaluated other regimens such as BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) and Stanford V. After chemotherapy, the standard radiation field is involved-field RT, although there is increasing interest now in involved-node RT. The authors review recent trials on chemotherapy and RT for unfavorable-prognosis early-stage Hodgkin's lymphoma. This article presents illustrative clinical cases, with treatment recommendations from an expert panel of radiation oncologists and medical oncologists.

ACR Appropriateness Criteria: follow-up of Hodgkin's lymphoma.

In the follow-up of Hodgkin's lymphoma patients, the focus in the first 5 years is to detect recurrence, while after 5 years, the focus is on limiting and detecting late effects of treatment. In the first 5 years post-treatment, routine history and physical and computed tomography (CT) imaging (more frequent in the first 2 years) are generally appropriate. However, there are limited data to support the role of positron emission tomography scanning as routine follow-up. Beyond 5 years post-treatment, annual history and physical is appropriate, although there is no longer a role for routine imaging for recurrences. Women irradiated to the chest area at a young age (<35) would benefit from annual mammogram screening given the increased breast cancer risk. Magnetic resonance imaging can be considered, although there is a lack of data supporting its role in this population. Low-dose chest CT for lung cancer screening in patients with history of mediastinal irradiation and/or alkylating chemotherapy exposures and a smoking history can be considered, although data on its utility is lacking. Cardiac screening with echocardiogram and exercise tolerance tests in patients with history of mediastinal irradiation and/or adriamycin exposure may be appropriate, although the optimal screening interval would depend on mediastinal dose, adriamycin dose, presence of other cardiac risk factors and findings at the baseline screening. Patients at risk for cardiac disease due to treatment exposure would also benefit from lipid screening every 1-3 years.

ACR Appropriateness Criteria on Hodgkin's lymphoma: favorable prognosis stage I and II.

The treatment for favorable-prognosis stage I and II Hodgkin's lymphoma has evolved over the past several years. Studies have attempted to reduce long-term treatment-related side effects, such as second malignancies and cardiac toxicity, through reduced chemotherapy or reduced radiotherapy. Randomized trials have compared radiation therapy alone with combined-modality therapy (chemotherapy followed by involved-field radiotherapy). Recent and ongoing trials have evaluated the optimal regimen and number of cycles of chemotherapy and the optimal radiotherapy dose and field size as part of combined-modality therapy, as well as the elimination of radiation therapy. Combined-modality therapy represents the current standard of care for most patients with favorable-prognosis early-stage Hodgkin's lymphoma. Chemotherapy alone could also be an option for selected patients who are at low risk for relapse and high risk for late effects from radiotherapy. This article reviews recent and ongoing studies on treatment for favorable-prognosis early stage Hodgkin's lymphoma. Representative clinical cases are presented, with treatment recommendations from an expert panel of radiation oncologists and medical oncologists.

Loss of expression of the putative tumor suppressor NES1 gene in biopsy-proven ductal carcinoma in situ predicts for invasive carcinoma at definitive surgery.

PURPOSE: The loss of expression of NES1, a novel putative tumor suppressor gene, is an early marker of breast tumorigenesis. NES1 is expressed in normal breast tissue and ductal hyperplasia but is absent or markedly diminished in invasive cancer. In cases of ductal carcinoma in situ (DCIS), NES1 expression has been shown previously to be present in approximately 50% of specimens. This study examined the expression level of NES1 in diagnostic biopsy samples found to contain pure DCIS. These data were then correlated with the pathologic findings found at definitive local surgery. METHODS AND MATERIALS: Twenty-nine cases with initial biopsy showing DCIS without invasive carcinoma followed by subsequent reexcision were discovered and archived. Formalin-fixed tissue specimens were obtained for analysis. Each biopsy specimen was subjected to hematoxylin-eosin staining and reviewed by two pathologists to confirm the diagnosis of pure DCIS. NES1 cDNA (1069 bp), including 238 bp of 5' and 3' untranslated region and the entire protein-coding region, was cloned into a vector. To generate the antisense and sense RNA probes, the plasmid was linearized and the transcription reaction was carried out with polymerases T7 and T3, respectively. The detection of in situ hybridization probes was performed using an mRNAlocator-Biotin Kit. Staining was characterized as negative (0/1+) or positive (2+/3+). Subsequent to an initial biopsy diagnosis of DCIS, all cases had a definitive surgical procedure. Detailed sectioning of the resultant tissue was performed and subjected to hematoxylin-eosin staining to determine the presence or absence of invasive carcinoma. RESULTS: The initial diagnostic biopsy specimens showed that 17 of 17 high-grade, 3 of 7 intermediate-grade, and 3 of 5 low-grade DCIS specimens were negative for NES1 expression. Of the 6 cases of DCIS found to be positive for NES1 expression, none (0%) were subsequently found to have invasive carcinoma at definitive surgery. In contrast, the loss of NES1 expression in the initial diagnostic biopsy was associated with a 40% incidence of invasive carcinoma at definitive surgery. Additional stratification by nuclear grade showed invasive carcinoma in 5 (83%) of 6 NES1-negative, low- to intermediate-grade DCIS (p

The value of breast lumpectomy margin assessment as a predictor of residual tumor burden in ductal carcinoma in situ of the breast.

BACKGROUND: Margin width is considered the most important risk factor for local recurrence in ductal carcinoma in situ (DCIS) of the breast. The purpose of this report is to assess the predictive utility of lumpectomy specimen margin assessment for the presence and extent of residual DCIS. METHODS: Specimens from 253 DCIS cases with lumpectomy and reexcision were studied to determine to the probability of residual DCIS on reexcision. The probability of residual tumor was evaluated with respect to tumor size, margin status, nuclear grade, presence of necrosis, patient age, and the extent of specimen processing (number of sections/volume tissue). Lesions were grouped by size: less than or equal to 2 mm, greater than 2-15 mm, greater than 15-40 mm, or greater than 40 mm. Margin width was recorded as the distance of DCIS to the closest specimen edge or, for positive margins, scored as: extensive (margin involvement in > or =8 sections or >4 low-power fields [LPFs]), moderate (5-7 sections or 2-4 LPFs), minimal (2-4 sections or 1 LPF), or focal (1 section, single focus). The amount of residual tumor was graded by maximum dimension on a semiquantitative basis. RESULTS: Initial excision margin significantly predicted for the presence of residual tumor on reexcision. Residual tumor was found on reexcision in 85% of extensively positive, 68% of moderately positive, 46% of minimally positive, 30% of focally positive, 41% of greater than 0-1 mm, 31% of greater than 1-2 mm, and 0% of greater than 2 mm margins (P < 0.0001). On univariate analysis, margin width and lesion size of initial excision specimens significantly predicted for the presence of residual DCIS on reexcision. Age, grade, necrosis, and extent of specimen processing were not significant prognostic factors. On multivariate analysis, both initial margin width (P < 0.0001) and lesion size (P = 0.02) significantly predicted for residual DCIS. As for amount of residual tumor, margin width and initial lesion dimension both significantly predicted for medium to large residuum, whereas age 45 years or younger was of borderline significance on univariate analysis. On multivariate analysis, margin width and lesion size on initial excision both remained significant predictors of larger volume residual tumor. CONCLUSIONS: The margin status of a DCIS lumpectomy specimen is the most important predictive factor for both the presence and amount of residual disease.

Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: A meta-analysis.

PURPOSE: To compare the outcome of ACL reconstuction using patellar tendon (PAT) to that when using hamstring tendons. Type of Study: Meta-analysis of controlled trials of patellar tendon versus hamstring tendons for ACL reconstruction. METHODS: Meta-analysis is a systematic method for statistical analyses that allows compilation of combined data from various independent studies. This allows one to assess the potential benefits of various treatments when conclusions based on individual studies are difficult to assess. We conducted a meta-analyses (M-A) using controlled trials (CTs) to determine if there are differences between the 2 methods. Although both surgical techniques have potential for good results, we hypothesized that there are differences in outcomes between these techniques. We included CTs that used standard evaluation techniques with a minimum 2-year follow-up. Outcomes evaluated included: return to preinjury level of activity, KT testing, Lachman scores, pivot shift scores, range of motion (ROM) loss in flexion and extension, complications, and failures. Relative risks for each outcome were calculated for each study and pooled across studies using a fixed effects method. RESULTS: Four studies fulfilled our inclusion criteria. Relative risks with 95% confidence intervals and P values were obtained for each of the outcomes listed above. The results show significant differences between PAT and semitendinosus and gracilis tendon (ST&G) reconstructions. PAT patients have a greater chance of attaining a statically stable knee (as measured by KT) and nearly a 20% greater chance of returning to preinjury activity levels. CONCLUSIONS: Although both techniques, as performed in the late 1980s and early 1990s, yielded good results, PAT reconstuction led to higher postoperative activity levels and greater static stability than hamstring reconstruction. This is statistically significant based on this meta-analysis.