Clinical outcomes with utilization of high-potency topical steroids in patients with lichen sclerosus-associated vulvar cancer.

OBJECTIVES: To evaluate the impact of high-potency topical steroid use on risk of recurrence of lichen sclerosus-associated vulvar cancer. METHODS: This is a retrospective cohort study evaluating patients with lichen sclerosus (LS)- associated vulvar squamous cell cancer (VSCC). Demographic and clinical outcome data were compared between two comparison groups: patients who received steroids, mainly clobetasol, and patients who did not receive steroids following treatment of LS-related vulvar cancer. Categorical variables were compared using Fisher's exact test or chi-square test. Continuous variables were compared using a two-sided student's t-test. Time to recurrence (TTR) and overall survival (OS) were analyzed using Kaplan-Meier survival plot and compared using Mantel-Cox log rank test. Cox proportional hazard regression models were conducted to generate hazard ratios for both TTR and OS. A p value of <0.05 was considered statistically significant. RESULTS: A total of 49 patients were included, with 36 patients receiving steroid treatment and 13 patients in the expectant management group. The median age of diagnosis was 68. The average BMI was 31.7 +/- 7.0. The median length of follow up was 41 months. The majority of patients were diagnosed with stage I VSCC. There was no difference in demographics or oncologic management of vulvar cancer between the two cohorts. Overall recurrence was decreased among patients who received steroid treatment when compared to patients who did not, 12 patients (33.3%) versus 9 patients (69.2%) respectively (p = 0.048). CONCLUSIONS: High-potency topical steroid use following treatment of lichen sclerosus-associated vulvar squamous cell carcinoma is associated with decreased risk of recurrence and prolonged median time to recurrence.

National trends in the treatment of adult diffuse midline gliomas: a rare clinical scenario.

PURPOSE: Diffuse midline gliomas (DMG) include all midline gliomas with a point mutation to the histone H3 gene resulting in the substitution of a lysine with a methionine (K27M). These tumors are classified as World Health Organization grade 4 with a mean survival between 9- and 19-months following diagnosis. There is currently no standard of care for DMG, and palliative radiation therapy has been proven to only extend survival by months. Our current study aims to report current treatment trends and predictors of the overall survival of DMG. METHODS: We searched the National Cancer Database for adult patients treated for DMG from 2016 to 2020. Patients were required to have been treated with primary radiation directed at the brain with or without concurrent chemotherapy. Univariable and multivariable Cox regressions were used to determine predictors of overall survival. RESULTS: Of the 131 patients meeting the inclusion criteria, 113 (86%) received radiation and chemotherapy. Based on multivariable Cox regression, significant predictors of survival were Charlson-Deyo comorbidity index and race. Patients with a Charlson-Deyo score of 1 had 2.72 times higher odds of mortality than those with a score of 0. Patients not identifying as White or Black had 2.67 times higher odds of mortality than those identifying as White. The median survival for all patients was 19 months. CONCLUSIONS: Despite being considered ineffective, chemotherapy is still administered in most adult patients diagnosed with DMG. Significant predictors of survival were Charlson-Deyo comorbidity index and race.

Prognostic Effect of Mismatch Repair Status in Early-Stage Endometrial Cancer Treated With Adjuvant Radiation: A Multi-institutional Analysis.

PURPOSE: The aim of this work was to report the effect of mismatch repair (MMR) status on outcomes of patients with stage I-II endometrioid endometrial adenocarcinoma (EEC) who receive adjuvant radiation therapy. METHODS AND MATERIALS: This is a multi-institutional retrospective cohort study across 11 institutions in North America. Patients with known MMR status and stage I-II EEC status postsurgical staging were included. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated via the Kaplan-Meier method. Univariable and multivariable analyses were performed via Cox proportional hazard models for RFS and OS. Statistical analyses were conducted using SPSS version 27. RESULTS: In total, 744 patients with a median age at diagnosis of 65 years (IQR, 58-71) were included. Most patients were White (69.4%) and had Federation of Obstetrics and Gynecology 2009 stage I (84%) and Federation of Obstetrics and Gynecology grade 1 to 2 (73%). MMR deficiency was reported in 234 patients (31.5%), whereas 510 patients (68.5%) had preserved MMR. External beam radiation therapy with or without vaginal brachytherapy was delivered to 186 patients (25%), whereas 558 patients (75%) received vaginal brachytherapy alone. At a median follow-up of 43.5 months, the estimated crude OS and RFS rates for the entire cohort were 92.5% and 84%, respectively. MMR status was significantly correlated with RFS. RFS was inferior for MMR deficiency compared with preserved MMR (74.3% vs 88.6%, P < .001). However, no difference in OS was seen (90.8% vs 93.2%, P = .5). On multivariable analysis, MMR deficiency status was associated with worse RFS (hazard ratio, 1.86; P = .001) but not OS. CONCLUSIONS: MMR status was independently associated with RFS but not OS in patients with early-stage EEC who were treated with adjuvant radiation therapy. These findings suggest that differential approaches to surveillance and/or treatment based on MMR status could be warranted.

Utilization of functional MRI in the diagnosis and management of cervical cancer.

Introduction: Imaging is integral part of cervical cancer management. Currently, MRI is used for staging, follow up and image guided adaptive brachytherapy. The ongoing IQ-EMBRACE sub-study is evaluating the use of MRI for functional imaging to aid in the assessment of hypoxia, metabolism, hemodynamics and tissue structure. This study reviews the current and potential future utilization of functional MRI imaging in diagnosis and management of cervical cancer. Methods: We searched PubMed for articles characterizing the uses of functional MRI (fMRI) for cervical cancer. The current literature regarding these techniques in diagnosis and outcomes for cervical cancer were then reviewed. Results: The most used fMRI techniques identified for use in cervical cancer include diffusion weighted imaging (DWI) and dynamic contrast enhancement (DCE). DCE-MRI indirectly reflects tumor perfusion and hypoxia. This has been utilized to either characterize a functional risk volume of tumor with low perfusion or to characterize at-risk tumor voxels by analyzing signal intensity both pre-treatment and during treatment. DCE imaging in these situations has been associated with local control and disease-free survival and may have predictive/prognostic significance, however this has not yet been clinically validated. DWI allows for creation of ADC maps, that assists with diagnosis of local malignancy or nodal disease with high sensitivity and specificity. DWI findings have also been correlated with local control and overall survival in patients with an incomplete response after definitive chemoradiotherapy and thus may assist with post-treatment follow up. Other imaging techniques used in some instances are MR-spectroscopy and perfusion weighted imaging. T2-weighted imaging remains the standard technique used for diagnosis and radiation treatment planning. In many instances, it is unclear what additional information functional-MRI techniques provide compared to standard MRI imaging. Conclusions: Functional MRI provides potential for improved diagnosis, prediction of treatment response and prognostication in cervical cancer. Specific sequences such as DCE, DWI and ADC need to be validated in a large prospective setting prior to widespread use. The ongoing IQ-EMBRACE study will provide important clinical information regarding these imaging modalities.

Fertility-sparing treatment of locally advanced vulvar squamous cell carcinoma in a young patient.

•Locally advanced vulvar cancer has been diagnosed in a young patient who desires fertility.•Treatment of vulvar cancer in young patients will need to consider future reproductive planning.•Fertility-sparing radiation techniques for treatment of vulvar cancer are effective in achieving long-term disease control.

Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region.

Tumor Treating Fields (TTFields) are electric fields, delivered via wearable arrays placed on or near the tumor site, that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. As a first-in-class treatment, TTFields therapy is approved for use in newly diagnosed glioblastoma, recurrent glioblastoma, and pleural mesothelioma. Additionally, TTFields therapy is being investigated in non-small cell lung cancer (NSCLC), brain metastases from NSCLC, pancreatic cancer, ovarian cancer, hepatocellular carcinoma, and gastric adenocarcinoma. Because TTFields therapy is well tolerated and delivery is locoregional, there is low risk of additive systemic adverse events (AEs) when used with other cancer treatment modalities. The most common AE associated with TTFields therapy is mild-to-moderate skin events, which can be treated with topical agents and may be managed without significant treatment interruptions. Currently, there are no guidelines for oncologists regarding the management of TTFields therapy-related skin AEs in the thoracic region, applicable for patients with pleural mesothelioma or NSCLC. This publication aims to provide guidance on preventing, minimizing, and managing dermatologic AEs in the thoracic region to help improve patient quality of life and reduce treatment interruptions that may impact outcomes with TTFields therapy.

Single Fraction Frameless Stereotactic Radiosurgery on the Gamma Knife Icon for Patients With Brain Metastases: Time to Abandon the Frame?

PURPOSE: The latest version of the Gamma Knife, the Icon, allows for immobilization with a mask in lieu of the traditional frame during stereotactic radiosurgery. There have been some concerns regarding extent of immobilization during single fraction frameless treatment and potential effect on outcomes. As such, we reviewed outcomes in patients with brain metastases treated in a single fraction using either a frame or mask on the Gamma Knife Icon at our institution. METHODS AND MATERIALS: We reviewed the records of 95 patients with a total of 374 metastases treated between May 2019 and January 2021. Thirty-nine patients (41%) were treated using the Leksell frame with the remainder being immobilized with a mask. The median number of metastatic lesions was 2 (1-20). The median prescription dose was 20 Gy (11.5-24 Gy). Odds ratios were generated to identify predictors of mask use. Kaplan-Meier analysis was used to calculate survival, local failure, and distant failure rates. Cox regression was used to identify predictors of survival. Propensity matching was used to account for indication bias. RESULTS: Of the 95 patients treated, 88 (93%) had follow-up with a median duration of 5 months (1-18). Frame utilization was more likely with 6 to 10 brain metastases. Median overall survival was not reached and was 70% and 60% at 6 and 12 months for the entire cohort, respectively. There was no significant difference in survival by immobilization method (P = .12). Six patients had local failure in 10 total lesions (3 patients in each group). After propensity matching the 12 month tumor local control was 96% and 85% for framed and frameless cases, respectively (P = .07). CONCLUSIONS: Frameless mask-based stereotactic radiosurgery using the Gamma Knife Icon is feasible and maintains the excellent local control seen with the use of the headframe.

Medical Marijuana for Cancer: Perspective From a Radiation Oncologist Credentialed to Certify in Pennsylvania.

I am a radiation oncologist with a busy clinical practice in Pennsylvania. I am credentialed to certify patients for medical marijuana and recommend that my patients try medical marijuana when symptom control with other options is suboptimal. This invited contribution is a brief summary of information that may help radiation oncologists understand their potential role in getting patients access to medical marijuana and my perspective on its potential value in the care of our patients.

Hippocampal-sparing whole brain volumetric modulated arc therapy (VMAT) planning in Monaco: a "How-to" not pull your hair out.

NRG-CC001 recently reported positive results on hippocampal-sparing IMRT (HS-IMRT) in conjunction with memantine for the reduction in cognitive decline compared to conventional whole brain radiation therapy. Herein, we report our experience in planning volumetric modulated arc therapy (VMAT) cases in Monaco® with the anticipation of increased utilization of the planning technique for delivery on Elekta linear accelerators. Twelve patients previously treated with whole brain radiation therapy who would have been eligible for NRG-CC001 were replanned with VMAT HS-IMRT for to a dose of 30Gy/10fx using constraints from the trial. All 12 patients were able to be planned with VMAT and achieve NRG-CC001 dose constraints. Median maximum and D100% to the right and left hippocampi were: 13.37Gy and 13.43Gy, respectively and 8.76Gy and 8.86Gy, respectively. Median coverage of the brain minus the hippocampi with 30Gy was 96.53%. All cases passed quality assurance testing with 3%/3 mm and 2%/2 mm criterion. Hippocampal-sparing IMRT whole brain radiation therapy can be feasibly planned with VMAT technique in Monaco® and delivered on Elekta linear accelerators.

Intraprostatic calcification and biochemical recurrence in men treated with cesium-131 prostate brachytherapy.

PURPOSE: Baseline intraprostatic calcification (IC) has been shown to be associated with a higher rate of biochemical recurrence (BCR) in men treated with iodine-125 prostate brachytherapy (PB). We evaluated this association in a cohort of men treated with cesium-131 PB. METHODS AND MATERIALS: We retrospectively reviewed the charts of all low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- external beam radiotherapy (EBRT) at our institution from 2/2011 to 7/2018. Patients with < 24 months of follow up or those who received androgen deprivation therapy were excluded. Baseline IC status (defined as one or more ICs ≥ 5 mm) was determined on post-PB CT scans. Cox analysis was used to assess predictors of BCR and Kaplan-Meier survival curves were calculated. RESULTS: Two hundred and sixteen low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- EBRT were included. Median follow up was 56.9 months (range 24.1-111.4). Overall, 76 (35.2%) patients had baseline IC and 140 (64.8%) did not. Baseline disease characteristics did not differ significantly between groups. On univariate Cox analysis, only risk group (p = 0.047) and initial PSA (p = 0.016) were significant predictors of BCR, whereas baseline IC was not (p = 0.11). The 5-year BCR-free survival in patients with versus without baseline IC was 97.7% versus 93.8% (p = 0.405), respectively. CONCLUSIONS: In a cohort of low- and intermediate-risk prostate cancer patients treated with cesium-131 PB, the rate of BCR in men with baseline IC was low and baseline IC was not associated with a higher risk of BCR.

Optimal overall treatment time for adjuvant therapy for women with completely resected, node-positive vulvar cancer.

INTRODUCTION: The optimal overall treatment time (OTT) from radical surgery to the end of adjuvant radiation therapy for some squamous cell carcinomas has been found to impact treatment outcomes. This study aims to identify the impact of OTT on overall survival (OS) for women with completely resected, node-positive squamous cell carcinomas of the vulva. MATERIALS AND METHODS: The National Cancer Data Base was queried for women with surgically resected, node-positive vulvar squamous cell carcinomas between 2004 and 2016 who were treated with adjuvant radiation therapy. Kaplan-Meier analysis with log-rank test and Cox proportional hazards tests were utilized for OS calculations. RESULTS: A total of 1500 women met inclusion criteria. The median OTT was 104 days. Shorter OTT was associated with age, facility volume, private insurance, and duration of post-operative hospitalization. Median OS with OTT ≤ 104 days was 56.1 months vs 45.4 months if ≥105 days (p = 0.015). On multivariable Cox analysis, OTT was independently associated with an increased risk of death of 0.4% per additional day (95%CI 1.001-1.007, p = 0.003), as were age at diagnosis (HR 1.031 [95%CI 1.024-1.037], p < 0.001), number of nodes positive (HR 1.031 [95%CI 1.024-1.037], p = 0.006), the use of concurrent chemotherapy (HR 0.815 [95%CI 0.693-0.960], p = 0.014) and increasing pT/pN stage. After propensity adjustment for factors predicting a shorter OTT, OTT continued to be associated with an increased risk of death per additional day (HR 1.004 [95%CI 1.001-1.007], p = 0.007). CONCLUSION: Overall treatment time is an independent risk factor for death in women being treated with adjuvant radiation therapy following complete resection of node-positive squamous cell carcinoma of the vulva.

External beam radiation and brachytherapy boost at different facilities is associated with increased treatment delays in cervical cancer.

INTRODUCTION: Due to variation in facility expertise and capabilities, patients commonly complete external beam radiation therapy at one facility and brachytherapy boost at another. We evaluated the association of external beam radiation therapy and brachytherapy at the same facility versus different facilities with treatment delays and survival. METHODS: Patients receiving definitive external beam radiation therapy and brachytherapy for non-metastatic cervical cancer from 2004 to 2015 were identified in the National Cancer Database. Treatment delays were classified based on published thresholds: a course of >56 days was considered delayed, >65 days moderately delayed, and >77 days severely delayed. Fisher's exact test and logistic regression were used to evaluate the association of same facility versus different facilities with treatment delays and predictors of same facility versus different facility treatment. RESULTS: We identified 23 911 patients meeting the inclusion criteria at a median follow-up of 39.7 months (IQR 21.0-72.6 months), with 17 391 patients (72.7%) receiving same facility treatment and 6520 patients (27.3%) receiving different facility treatment. Any treatment delay was found in 49.3% of same facility treatments versus 51.9% of different facility treatments (p<0.001); moderate or worse delays in 24.8% of same facility versus 29.4% of different facility treatments (p<0.001); severe treatment delays in 11.3% of same facility versus 15.5% of different facility treatments (p<0.001). Receipt of same facility versus different facility treatment was independently associated with treatment delays (OR 1.28, 95% CI 1.20 to 1.37; p<0.001). Both treatment delays, particularly moderate delays (HR 1.20, 95% CI 1.13 to 1.28; p<0.001) and severe delays (HR 1.32, 95% CI 1.24 to 1.41; p<0.001), and different facility treatments (HR 1.11, 95% CI 1.06 to 1.16; p<0.001) were associated with worse survival. CONCLUSIONS: Delivery of external beam radiation therapy and brachytherapy at different facilities was associated with treatment delays and worse survival. Our findings underscore the importance of care coordination in cervical cancer management.

Race-driven survival differential in women diagnosed with endometrial cancers in the USA.

OBJECTIVE: African American women are increasingly being diagnosed with advanced and type II histology endometrial cancers. Outcomes have been observed to be worse in African American women, but whether or not race itself is a factor is unclear. We sought to evaluate the rates of diagnosis and outcomes on a stage-by-stage basis with respect to race using a large national cancer registry database. METHODS: The National Cancer Data Base was searched for patients with surgically staged non-metastatic endometrial cancer between 2004 and 2015. Women were excluded if surgical stage/histology was unknown, there was no follow-up, or no information on subsequent treatment. Pairwise comparison was used to determine temporal trends and Cox hazards tests with Bonferroni correction were used to determine overall survival. RESULTS: A total of 286 920 women were diagnosed with endometrial cancer and met the criteria for analysis. Median follow-up was 51 months (IQR 25.7-85.3). In multivariable models, in women with stage I disease, African American women had a higher risk of death than Caucasian women (HR 1.262, 95% CI 1.191 to 1.338, p<0.001) and Asian/Pacific Islander women had a lower risk of death than Caucasian women (HR 0.742, 95% CI 0.689 to 0.801, p<0.001). This held for African American women with stage II type I and type II disease (HR 1.26, 95% CI 1.109 to 1.444, p<0.001 and HR 1.235, 95% CI 1.098 to 1.388, p<0.001) but not for Asian/Pacific Islander women. African American women with stage IIIA-B disease also had a higher risk of death for type I and type II disease versus Caucasian women (HR 1.221, 95% CI 1.045 to 1.422, p=0.010 and HR 1.295, 95% CI 1.155 to 1.452, p<0.001). Asian/Pacific Islander women had a lower risk of death than Caucasian women with type I disease (HR 0.783, 95% CI 0.638 to 0.960, p=0.019) and type II disease (HR 0.790, 95% CI 0.624 to 0.999, p=0.05). African American women with stage IIIC1-2 had a higher risk of death with type I disease (HR 1.343, 95% CI 1.207 to 1.494, p<0.001) and type II disease (HR 1.141, 95% CI 1.055 to 1.233, p=0.001) whereas there was no significant difference between Caucasian women and Asian/Pacific Islander women. CONCLUSION: Race appears to play an independent role in survival from endometrial cancer in the USA, with African American women having worse survival on a stage-for-stage basis compared with Caucasian women.

Adaptation of a Gamma Knife Icon stereotactic radiosurgery program in the face of the COVID-19 pandemic.

Objective: The COVID-19 pandemic necessitated drastic and rapid changes throughout the field of radiation oncology, some of which were unique to the discipline of radiosurgery. Guidelines called for reduced frame use and reducing the number of fractions. Our institution implemented these guidelines, and herein we show the resultant effect on patient treatments on our Gamma Knife Icon program. Methods: In early March 2020 we rapidly implemented suggested changes according to ASTRO and other consensus guidelines as they relate to stereotactic radiosurgery in the COVID-19 era. We reviewed the GK Icon schedule at our institution between January 01 and April 30, 2020. We documented age, condition treated, technique (frame vs. mask), and number of fractions. We then tabulated and graphed the number of patients, framed cases, and fractions delivered. Results: Seventy-seven patients were treated on the GK Icon over that period, for a total of 231 fractions. The number of unique patients varied from 18 (April) to 22 (January). Of the 77 patients only 5 were treated using a frame. The number of fractions per month decreased significantly over time, from 70 in January to 36 in April. Likewise, the percentage of single fraction cases increased from 4.5% per month in January to 67% in April. Conclusions: The results presented here show that it is possible to quickly and efficiently change work flows to allow for reduced fractionation and frame use in the time of a global pandemic. Multidisciplinary cooperation and ongoing communication are integral to the success of such programs.

Radiotherapeutic treatment of brain metastases in patients with gynecologic malignancies: A nationwide analysis.

Objectives: Brain metastases are a rare finding in patients with primary gynecologic malignancies having a poor outcome despite treatment. We sought to use the National Cancer Database (NCDB) to characterize the incidence of brain metastases and types of treatment administered. Methods: We queried the NCDB from 2010-16 for patients with endometrial, cervical, and ovarian primaries with brain metastases at diagnosis treated with radiation-whole brain radiation (WBRT) or stereotactic radiosurgery (SRS). We tabulated baseline characteristics and performed a multivariable logistic regression to identify predictors of SRS. Multivariable Cox regression was used to identify predictors of death. Propensity matching was done to account for indication bias. Results: We identified 765 patients meeting above criteria, representing <1% of patients. Of patients with brain metastases, 287 received radiation to the brain. The median age was 60 (40-90). The majority of patients (80%) received WBRT. On multivariable logistic regression the only predictor of SRS was receipt of chemotherapy. Median follow up was 4.9 months. The overall survival for the entire cohort was 5.2 months. On Cox regression predictors of improved survival were receipt of chemotherapy, no extracranial disease, and SRS. After propensity matching, median survival was 8.3 months compared to 6.3 months in favor of SRS. Conclusions: This study represents the largest series to date of patients with brain metastases from gynecologic malignancies, confirming an incidence of <1% and overall poor prognosis. Radiation remains a viable treatment option.

Melanoma brain metastases: is it time to eliminate radiotherapy?

PURPOSE: Immunotherapy has demonstrated efficacy in treatment of intracranial metastasis from melanoma, calling into question the role of intracranial radiotherapy (RT). Herein, we assessed the utilization patterns of intracranial RT in patients with melanoma brain metastasis and compared outcomes in patients treated with immunotherapy alone versus immunotherapy in addition to intracranial RT. METHODS: We queried the National Cancer Database (NCDB) for patients with melanoma brain metastases treated with immunotherapy and intracranial RT or immunotherapy alone. Multivariable logistic regression identified variables associated with increased likelihood of receiving immunotherapy alone. Multivariable Cox regression was used to identify co-variates predictive of overall survival (OS). Propensity matching was used to account for indication bias. RESULTS: We identified 528 and 142 patients that were treated with combination therapy and immunotherapy alone, respectively. Patients with lower comorbidity score were more likely to receive immunotherapy alone. Extracranial disease and treatment at a non-academic center were associated with worse OS. Median OS for all patients was 11.0 months. Treatment with stereotactic radiosurgery (SRS) in addition to immunotherapy was superior to immunotherapy alone, median OS of 19.0 versus 11.5 months (p = 0.006). Whole brain radiation therapy (WBRT) in combination with immunotherapy performed worse than immunotherapy alone, median OS of 7.7 versus 11.5 months (p = 0.0255). CONCLUSIONS: For melanoma patients requiring WBRT, immunotherapy alone may be reasonable in asymptomatic patients. For those eligible for SRS, combination therapy may provide better outcomes. Results of ongoing prospective studies will help provide guidance regarding the use of radioimmunotherapy in this population.

Cesium-131 prostate brachytherapy: A single institutional long-term experience.

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.

Management of Clinically Lymph Node-Positive Malignant Pleural Mesothelioma.

Nodal involvement in malignant pleural mesothelioma (MPM) is a poor prognostic factor, and management remains highly debated. Because there are no prospective trials for this population, this investigation addressed a major knowledge gap by examining national practice patterns as well as survival outcomes. The National Cancer Database was queried for newly diagnosed cN1-3M0 MPM. Multivariable logistic regression ascertained factors associated with administering surgery. Kaplan-Meier analysis assessed overall survival (OS); multivariable Cox proportional hazards modeling examined factors associated with OS. No statistical intergroup comparisons were made herein. This was primarily owing to undeniable selection biases in these heterogeneous datasets; the presence of incomplete and inadequately granular clinical information (eg, intent and selection of treatment, preoperative assessment) cannot be accounted for by propensity matching or other such algorithms, thus potentially leading to misinterpretation. Of 2548 patients, 20%, 70%, and 9% had N1, N2, and N3 disease, respectively. Overall, 13% received surgery/chemotherapy, 47% underwent chemotherapy alone, 30% were observed, and 5% received resection without chemotherapy (5% had unknown treatment information). The median OS for all patients was 9.2 months. Relative to N1 cases, N2+ subjects were less likely to undergo resection, and they also experienced lower OS (P < 0.05 for both). The median OS in N1, N2, and N3 patients was 10.0, 9.1, and 8.5 months, respectively. In summary, nodal status is a prognostic factor in cN+ MPM. Expected outcomes for the overall population and by nodal classification are described, which should be considered when patients and multidisciplinary providers jointly weigh management options. Careful patient selection in this population is necessary, encompassing factors such as histology, age, performance status, and location(s) of nodal burden.

Drivers of 30- and 90-day Postoperative Death After Neoadjuvant Chemoradiation for Esophageal Cancer.

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%.

Old vs new: Risk factors predicting early onset colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of all cancer related deaths in the United States and Europe. Although the incidence has been decreasing for individuals' ≥ 50, it has been on the rise for individuals < 50. AIM: To identify potential risk factors for early-onset CRC. METHODS: A population-based cohort analysis using a national database, Explorys, screened all patients with an active electronic medical record from January 2012 to December 2016 with a diagnosis of CRC. Subgroups were stratified based on age (25 - 49 years vs ≥ 50 years). Demographics, comorbidities, and symptom profiles were recorded and compared between both age groups. Furthermore, the younger group was also compared with a control group consisting of individuals aged 25-49 years within the same timeframe without a diagnosis of CRC. Twenty-data points for CRC related factors were analyzed to identify potential risk factors specific to early-onset CRC. RESULTS: A total of 68860 patients were identified with CRC, of which 5710 (8.3%) were younger than 50 years old, with 4140 (73%) between 40-49 years of age. Multivariable analysis was reported using odds ratio (OR) with 95%CI and demonstrated that several factors were associated with an increased risk of CRC in the early-onset group versus the later-onset group. These factors included: African-American race (OR 1.18, 95%CI: 1.09-1.27, P < 0.001), presenting symptoms of abdominal pain (OR 1.82, 95%CI: 1.72-1.92, P <0.001), rectal pain (OR 1.50, 95%CI: 1.28-1.77, P < 0.001), altered bowel function (OR 1.12, 95%CI: 1.05-1.19, P = 0.0005), having a family history of any cancer (OR 1.78, 95%CI: 1.67-1.90, P < 0.001), gastrointestinal (GI) malignancy (OR 2.36, 95%CI: 2.18-2.55, P < 0.001), polyps (OR 1.41, 95%CI: 1.08-1.20, P < 0.001), and obesity (OR 1.14, 95%CI: 1.08-1.20, P < 0.001). Comparing the early-onset cohort versus the control group, factors that were associated with an increased risk of CRC were: male gender (OR 1.34, 95%CI: 1.27-1.41), P < 0.001), Caucasian (OR 1.48, 95%CI: 1.40-1.57, P < 0.001) and African-American race (OR 1.25, 95%CI: 1.17-1.35, P < 0.001), presenting symptoms of abdominal pain (OR 4.73, 95%CI: 4.49-4.98, P < 0.001), rectal pain (OR 7.48, 95%CI: 6.42-8.72, P < 0.001), altered bowel function (OR 5.51, 95%CI: 5.19-5.85, P < 0.001), rectal bleeding (OR 9.83, 95%CI: 9.12-10.6, P < 0.001), weight loss (OR 7.43, 95%CI: 6.77-8.15, P < 0.001), having a family history of cancer (OR 11.66, 95%CI: 10.97-12.39, P < 0.001), GI malignancy (OR 28.67, 95%CI: 26.64-30.86, P < 0.001), polyps (OR 8.15, 95%CI: 6.31-10.52, P < 0.001), tobacco use (OR 2.46, 95%CI: 2.33-2.59, P < 0.001), alcohol use (OR 1.71, 95%CI: 1.62-1.80, P < 0.001), presence of colitis (OR 4.10, 95%CI: 3.79-4.43, P < 0.001), and obesity (OR 2.88, 95%CI: 2.74-3.04, P < 0.001). CONCLUSION: Pending further investigation, these potential risk factors should lower the threshold of suspicion for early CRC and potentially be used to optimize guidelines for early screening.