Radiation Exposure and Safety Precautions Following 131Cs Brachytherapy in Patients with Brain Tumors.

Cesium-131 (Cs) brachytherapy is a safe and convenient treatment option for patients with resected brain tumors. This study prospectively analyzes radiation exposure in the patient population who were treated with a maximally safe neurosurgical resection and Cs brachytherapy. Following implantation, radiation dose rate measurements were taken at the surface, 35 cm, and 100 cm distances. Using the half-life of Cs (9.69 d), the dose rates were extrapolated at these distances over a period of time (t = 30 d). Data from dosimetry badges and rings worn by surgeons and radiation oncologists were collected and analyzed. Postoperatively, median dose rate was 0.2475 mSv h, 0.01 mSv h, and 0.001 mSv h and at 30 d post-implant, 0.0298 mSv h, 0.0012 mSv h, and 0.0001 mSv h at the surface, 35 cm, and 100 cm, respectively. All but one badge and ring measured a dose equivalent corresponding to ~0 mSv h, while 1 badge measured 0.02/0.02/0.02 mSv h. There was a significant correlation between the number of seeds implanted and dose rate at the surface (p = 0.0169). When stratified by the number of seeds: 4-15 seeds (n = 14) and 20-50 seeds (n = 4) had median dose rates of 0.1475 mSv h and 0.5565 mSv h, respectively (p = 0.0015). Using National Council on Radiation Protection guidelines, this study shows that dose equivalent from permanent Cs brachytherapy for the treatment of brain tumors is limited, and it maintains safe levels of exposure to family and medical personnel. Such information is critical knowledge for the neurosurgeons, radiation oncologists, nurses, hospital staff, and family as this method is gaining nationwide popularity.

Older Patients With Early-stage Breast Cancer: Adjuvant Radiation Therapy and Predictive Factors for Cancer-related Death.

PURPOSE: Studies have shown that older women are undertreated for breast cancer. Few data are available on cancer-related death in elderly women aged 70 years and older with pathologic stage T1a-b N0 breast cancer and the impact of prognostic factors on cancer-related death. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for women aged 70 years or above diagnosed with pT1a or pT1b, N0 breast cancer who underwent breast conservation surgery from 1999 to 2003. The Kaplan-Meier survival analysis was performed to evaluate breast cause-specific survival (CSS) and overall survival (OS), and the log-rank test was employed to compare CSS/OS between different groups of interest. Multivariable analysis (MVA), using Cox proportional hazards regression analysis, was performed to evaluate the independent effect of age, race, stage, grade, ER status, and radiation treatment on CSS. Adjusted hazard ratios were calculated from the MVA and reflect the increased risk of breast cancer death. Competing-risks survival regression was also performed to adjust the univariate and multivariable CSS hazard ratios for the competing event of death due to causes other than breast cancer. RESULTS: Patients aged 85 and above had a greater risk of breast cancer death compared with patients aged 70 to 74 years (referent category) (adjusted hazard ratio [HRs]=1.98). Race had no effect on CSS. Patients with stage T1bN0 breast cancer had a greater risk of breast cancer death compared with stage T1aN0 patients (adjusted HR=1.35; P=0.09). ER negative patients had a greater risk of breast cancer death compared with ER positive patients (adjusted HR=1.59; P<0.017). Patients with higher grade tumors had a greater risk of breast cancer death compared with patients with grade 1 tumors (referent category) (adjusted HRs=1.69 and 2.96 for grade 2 and 3, respectively). Patients who underwent radiation therapy had a lower risk of breast cancer death compared with patients who did not (adjusted HR=0.55; P<0.0001). CONCLUSIONS: Older patients with higher grade, pT1b, ER-negative breast cancer had increased risk of breast cancer-related death. Adjuvant radiation therapy may provide a CSS benefit in this elderly patient population.

Surgical Technique and Clinically Relevant Resection Cavity Dynamics Following Implantation of Cesium-131 (Cs-131) Brachytherapy in Patients With Brain Metastases.

BACKGROUND: Cesium-131 (Cs-131) brachytherapy is used to reduce local recurrence of resected brain metastases. In order to ensure dose homogeneity and reduce risk of radiation necrosis, inter-seed distance and cavity volume must remain stable during delivery. OBJECTIVE: To investigate the efficacy of the "seeds-on-a-string" technique with intracavitary fibrin glue in achieving cavity volume stability. METHODS: We placed intra-operative Cs-131 brachytherapy in 30 cavities post-resection of brain metastases. Seeds-on-a-string were placed like barrel staves within the cavity with fibrin glue. Serial MRI imaging occurred post-operatively. Pre-operative tumor volumes were compared with post-operative cavity volumes to evaluate volume stability. Thirty patients who underwent post-resective stereotactic radiosurgery (SRS) were used as a control group for volumetric comparison. RESULTS: Cs-131 and SRS patients exhibited consistent cavity shrinkage over the median 110-day follow-up (p<.001), with total median shrinkage of 56.5% (Cs-131) and 84.8% (SRS). During the first month when ~88% of Cs-131 dosage is delivered, however, there was non-significant volume decrease in the Cs-131 group (median 22.0%; p=.063), while SRS patients showed significantly more shrinkage (46.7%; p=.042). No events of radiation necrosis occurred in either group. CONCLUSION: Cs-131 patients exhibited significantly less cavity shrinkage than SRS patients during the first critical month with 88% Cs-131 dose delivery. This significant difference in shrinkage suggests that the intracavitary seeds-on-a-string technique facilitates increased cavity stability, promoting more homogenous dose delivery.

Clinical comparison of brachytherapy versus hypofractionated external beam radiation versus standard fractionation external beam radiation for non-melanomatous skin cancers.

PURPOSE: Non-melanomatous skin cancer (NMSC) is the single most common cancer in the US. Radiation therapy is an excellent treatment alternative to surgery. High-dose-rate (HDR) brachytherapy and external beam radiotherapy (EBRT) are commonly used radiation treatment modalities but little data is published comparing these modalities. We present our institution's experience and outcomes with these therapeutic options. MATERIAL AND METHODS: From June 2005 to March 2013, 61 patients were treated with HDR brachytherapy (n = 9), hypofractionated EBRT (n = 30), or standard fractionation EBRT (n = 22) for NMSC. The primary outcome measure was local control at most remote follow-up and secondary outcome measures were overall survival, cosmetic outcome, and toxicity. Univariate analysis was performed to compare outcomes between treatment modalities. Kaplan-Meier analysis and log-rank test were used to compare overall survival. RESULTS: Median follow-up was 30 months. The most common histologies were BCC (47%) and SCC (44%); mean patient age was 83.3 years. Local control was 81% and 2-year actuarial overall survival was 89%. There was no statistical difference in local control or overall survival between treatment modalities. There was no statistical difference in cosmetic outcome or toxicity between treatment modalities, although five of six "poor" cosmetic outcomes and the only grade 3 toxic events were found in the standard fractionation EBRT group. CONCLUSIONS: All modalities investigated represent effective treatments for NMSC and have good cosmetic outcomes and acceptable toxicity profiles. The finding of higher grade toxicity and a greater portion of patients experiencing toxicity among standard fractionation therapy is counter to expectations. There was no statistical significance to the finding and it is not likely to be meaningful.

Adjuvant Pelvic Radiation Therapy±Vaginal Brachytherapy in Patients With High-risk Stage I or Stage II Uterine Papillary Serous, Clear Cell, and High-grade Endometrioid Carcinoma.

PURPOSE: Radiation therapy (RT) for stages I-II uterine papillary serous carcinoma (UPSC), clear cell (CC), and high-grade endometrioid (HGE) carcinoma present a treatment challenge. Regimens include external beam radiotherapy (EBRT) with or without brachytherapy. We examine the use of these radiation modalities in these endometrial cancers (EC) with respect to cause-specific survival (CSS). METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with AJCC stages I-II UPSC, CC, or HGE cancer treated with hysterectomy and RT between 1998 and 2008. Patients who did not receive adjuvant RT or received brachytherapy alone were excluded. CSS was evaluated by the Kaplan-Meier survival analysis and the log-rank test was used to compare CSS. Multivariate analysis was performed using the Cox proportional hazards regression model. Adjusted hazard ratios (HR) were calculated for risk of EC death. RESULTS: There were 1653 patients included in this analysis. The overall 100-month CSS for the entire cohort was 81.0%. The 100-month CSS was 85.3% for EBRT alone and 86.5% for EBRT+brachytherapy (P=0.72). Stage IC/IIA/IIB patients had a greater risk of EC death compared with stage IA/IB patients (adjusted HR=2.39; P<0.0001). Patients with UPSC and CC had a slightly higher risk of EC death compared with HGE (adjusted HR=1.01 [P=0.97] and 1.42 [P=0.02], respectively). On subset analysis, there was no difference in CSS with the addition of brachytherapy for UPSC (P=0.37), CC (P=0.27), or HGE cancer patients (P=0.42). Patients treated with brachytherapy in addition to EBRT did not demonstrate a reduced adjusted risk of EC death compared with EBRT alone (P=0.38). CONCLUSIONS: The addition of brachytherapy to adjuvant EBRT in stages I-II UPSC, CC, and HGE cancer did not demonstrate superior CSS. Thus, patients may not benefit from the addition of brachytherapy to EBRT.

Excellent Long-term Breast Preservation Rate After Accelerated Partial Breast Irradiation Using a Balloon Device.

BACKGROUND: Accelerated partial breast irradiation (APBI) using a balloon device has been well tolerated. A recent retrospective population-based study showed an increase in the rate of subsequent mastectomy for patients who undergo APBI compared with whole breast radiation therapy. Our aim was to analyze the long-term results of patients treated with APBI at our institution to determine the salvage mastectomy and locoregional recurrence rates and cosmesis outcomes. MATERIALS AND METHODS: After institutional review board approval, we conducted a retrospective review of 111 patients treated from June 2003 to October 2014 at our institution for early-stage breast cancer using a balloon device. After lumpectomy and nodal staging, the patients underwent APBI with high-dose rate iridium-192 brachytherapy. A computed tomography-based 3-dimensional plan was created, and a dose of 34 Gy in 10 fractions was given twice daily, 6 hours apart, over 5 days. Follow-up examinations were performed 2 to 3 times annually by either a surgeon and/or a radiation oncologist. Annual mammograms were obtained. The patients included postmenopausal women with node-negative early-stage invasive ductal carcinoma with a tumor size < 3 cm (n = 93) or ductal carcinoma in situ (n = 18). Cosmesis was evaluated using the Harvard criteria, as excellent, good, fair, or poor. RESULTS: At a median follow-up period of 66 months (range, 1-139 months) after completing treatment, with a minimum of 5 years of follow-up data for 62 patients (55.9%), the incidence of ipsilateral breast tumor recurrence (IBTR) was 2.7% (n = 3) and the incidence of ipsilateral axilla nodal recurrence was 1.8% (n = 2). The ipsilateral breast preservation rate was 97.3%. The salvage mastectomy rate was 2.7% (n = 3), and the 5-year salvage mastectomy-free rate was 98.7% (95% confidence interval, 91.0%-99.8%). No distant failure developed, and no breast cancer-related deaths occurred. The 5-year overall survival rate was 91.7% (95% confidence interval, 83.2%-96.0%), and the 10-year breast cancer-specific survival rate was 100%. Of the 3 cases of IBTR, 2 were estrogen receptor negative (P = .076). The mean interval to IBTR was 78.7 ± 27.5 months from treatment completion. A significant association was noted between African-American ethnicity and IBTR (P = .0398). Excellent to good cosmesis was observed in 98.1% of the patients. The maximum skin dose (mean value) for patients with excellent, good, and fair cosmesis was 302.2 Gy, 315.4 Gy, and 372.5 Gy (88.9%, 92.7%, and 109.5% of the prescription dose), respectively. The maximum skin dose was < 340 Gy (100% of the prescribed dose) in 69.9% of patients with excellent to good cosmesis. CONCLUSION: The long-term follow-up data of patients receiving APBI with a balloon device showed a low salvage mastectomy rate with durable long-term breast preservation. Excellent local control with good cosmesis was noted in these postmenopausal patients treated with APBI.

Adjuvant radiation therapy in uterine carcinosarcoma: A population-based analysis of patient demographic and clinical characteristics, patterns of care and outcomes.

OBJECTIVE: To examine clinical and demographic characteristics of a population-based cohort of patients with uterine carcinosarcoma (UCS), to assess access to treatment and survival patterns. METHODS: Surveillance, Epidemiology and End Results database was queried for patients diagnosed in 1999-2010 and treated with surgery with or without adjuvant radiation therapy (aRT). The Kaplan-Meier method was used to estimate survival functions, and Cox proportional hazards regression - to analyze the effect of covariates on survival. RESULTS: 2342 patients were eligible. African Americans presented with more advanced AJCC stages than other races (35.4% vs. 29.1%; p<0.01). African Americans vs. others, and women diagnosed in 1999-2004 vs. in 2005-2010, received aRT at a similar rate: 36.5% vs. 39.9% (p=NS), and 39.5% vs. 38.9% (p=NS), respectively. There was a trend towards higher aRT utilization among patients younger than 65 vs. older (41.4% vs. 37.5%; p<0.06). We observed better overall and cause-specific survival in the aRT group: 42 vs. 22 (p<0.0001) and 57 vs. 28months (p<0.0001), respectively. Black race, diagnosis in 1999-2004, advanced stage and age≥65years carried a higher risk of UCS death. CONCLUSIONS: We observed greater survival rate in the aRT group. African Americans were more likely to present with later stage disease and die of UCS than non-African Americans. Age and stage, but not race, influenced receipt of aRT. Patients treated more recently survived longer.

The cost-effectiveness of surgical resection and cesium-131 intraoperative brachytherapy versus surgical resection and stereotactic radiosurgery in the treatment of metastatic brain tumors.

This study aims to evaluate the cost-effectiveness of surgical resection (S) and Cesium-131 (Cs-131) [S + Cs-131] intraoperative brachytherapy versus S and stereotactic radiosurgery (SRS) [S + SRS] for the treatment of brain metastases. Treatment records as well as hospital and outpatient charts of 49 patients with brain metastases between 2008 and 2012 who underwent S + Cs-131 (n = 24) and S + SRS (n = 25) were retrospectively reviewed. Hospital charges were compared for the single treatment in question. Means and curves of survival time were defined by the Kaplan-Meier estimator, with the cost analysis focusing on the time period of the relevant treatment. Quality adjusted life years (QALY) and Incremental cost-effectiveness ratios (ICER) were calculated for each treatment option as a measure of cost-effectiveness. The direct hospital costs of treatments per patient were: S + Cs131 = $19,271 and S + SRS = $44,219. The median survival times of S + Cs-131 and S + SRS were 15.5 and 11.3 months, and the 12 month survival rates were 61 % and 49 % (P = 0.137). The QALY for S + SRS when compared to S + Cs-131 yielded a p < 0.0001, making it significantly more cost-effective. The ICER also revealed that when compared to S + Cs-131, S + SRS was significantly inferior (p < 0.0001). S + Cs-131 is more cost-effective compared with S + SRS based on hospital charges as well as QALYs and ICER. Cost effectiveness, in addition to efficacy and risk, should factor into the comparison between these two treatment modalities for patients with surgically resectable brain metastases.

Differences in survival outcome between stage I and stage II glottic cancer: A SEER-based analysis.

OBJECTIVE: The purpose of this study was to investigate and compare the cause-specific survival (CSS) of stage I (tumor [T]1 node [N]0 metastasis [M]0) versus stage II (T2N0M0) glottic cancer in a large population cohort. STUDY DESIGN: We analyzed data from the Surveillance, Epidemiology, and End Results 18 database from 1973 to 2009, comprising patients diagnosed with T1N0M0 or T2N0M0 squamous cell glottic cancer. Kaplan-Meier survival analysis, multivariable Cox proportional hazards regression analysis, and competing-risks survival regression were used for statistical analysis. RESULTS: There were 4,422 patients who met all inclusion criteria. The 36-month CSS was 93.9% for stage I verus 86.5% for stage II, with P < 0.0001. Stage II status conferred a 2.494 hazard ratio for increased risk of cause-specific death compared to stage I. CONCLUSIONS: Stage II glottic cancers have a significantly worse prognosis and may need a different approach to management than stage I tumors. LEVEL OF EVIDENCE: 4.

Equivalent Survival With Mastectomy or Breast-conserving Surgery Plus Radiation in Young Women Aged < 40 Years With Early-Stage Breast Cancer: A National Registry-based Stage-by-Stage Comparison.

BACKGROUND: Studies have shown that young patients with early-stage breast cancer (BC) are increasingly undergoing mastectomy instead of breast-conserving therapy (BCT) consisting of lumpectomy and radiation. We examined the difference in outcomes in young women (aged < 40 years) who had undergone BCT versus mastectomy. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results database was queried for women aged < 40 years with stage I or II invasive BC treated with surgery from 1998 to 2003. Breast cancer-specific survival (BCSS) and overall survival (OS) were evaluated using Kaplan-Meier survival analysis and the log-rank test between treatment types. RESULTS: Of the 7665 women, 3249 received BCT and 2627 underwent mastectomy without radiation. When separated by stage (I, IIA, and IIB), with a median follow-up duration of 111 months, the BCT and mastectomy-only groups showed no statistically significant differences in BCSS and OS. Overall, the age group of 35 to 39 years (66% of total) was associated with better 10-year BCSS (88%) and OS (86.1%) compared with the younger patients aged 20 to 34 years (34% of total). The latter group had a 10-year BCSS and OS of 84.1% and 82.3%, respectively (P < .001 for both BCSS and OS). However, when the patients of each age group were further subdivided by stage, the BCT group continued to show noninferior BCSS and OS compared with the mastectomy group in all subgroups. CONCLUSION: The results of our study suggest that although young age might be a poor prognostic factor for BC, no evidence has shown that these patients will have better outcomes after mastectomy than after BCT.

Analysis of stereotactic radiation vs. wedge resection vs. wedge resection plus Cesium-131 brachytherapy in early stage lung cancer.

PURPOSE: The purpose of the study was to evaluate the outcomes for wedge resection (WR), WR plus brachytherapy (WRB), or stereotactic body radiation therapy (SBRT) for early stage non-small lung cancer. METHODS AND MATERIALS: Retrospectively collected data of patients treated with WR, WRB, or SBRT (1993-2012). Cesium-131 (Cs131) used in WRB group in patients with close or positive margins based on surgical assessment. Kaplan-Meier survival analysis, log-rank test used to compare disease-free survival/overall survival between different groups. Multivariable analysis, using Cox proportional hazards regression analysis, was performed to evaluate the independent effect of age, gender, and treatment procedure on disease-free survival. RESULTS: A total of 272 patients were included in the study (123 WR, 52 WR+Cs-131, 97 SBRT). Cs-131 was used with WRs that the surgeons deemed high risk. Local control (LC) was similar in the three groups and was achieved in 92.2% for WR group vs. 96.2% for WR+Cs-131 and 95.5% for SBRT (p = 0.60). On multivariate analysis, although females showed a higher LC, neither LC nor distant metastasis were associated with age or gender (p = 0.65 and p = 0.41, respectively). Five-year overall survival was 100% in the WR+B group, 97.7% in the WR group, and 89.6% in the SBRT group (p = 0.02). Toxicity was similar in the three groups. CONCLUSION: WR, WR+ Cs-131, or SBRT are all excellent treatment options for patients with early stage non-small cell lung cancer that are not candidates for lobectomy. For high risk WRs, we favor use of Cesim-131 brachytherapy. Until a prospective randomized comparative study is done to evaluate the best treatment approach for early stage NSCLC, treatment selection should be based on a multidisciplinary team approach.

Comparison of primary radiation versus robotic surgery plus adjuvant radiation in high-risk prostate cancer: a single center experience.

OBJECTIVE: The objective of this study was to compare robotic-prostatectomy plus adjuvant radiation therapy (RPRAT) versus primary RT for high-risk prostate cancer (HRPCa). MATERIALS AND METHODS: A retrospective chart review was performed for the HRPCa patients treated in our institution between 2000 and 2010. One hundred and twenty-three patients with high-risk disease were identified. The Chi-square test and Fisher's exact test were used to compare local control and distant failure rates between the two treatment modalities. For prostate-specific antigen comparisons between groups, Wilcoxon rank-sum test was used. RESULTS: The median follow-up was 49 months (range: 3-138 months). Local control, biochemical recurrence rate, distant metastasis, toxicity, and disease-free survival were similar in the two groups. CONCLUSIONS: Primary RT is an excellent treatment option in patients with HRPCa, is equally effective and less expensive treatment compared with RPRAT. A prospective randomized study is required to guide treatment for patients with HRPCa.

Current and emerging roles of functional imaging in radiation therapy.

The advent of functional imaging facilitates the acquisition of patient-specific tumor characteristics, including its metabolic state and regional oxygen tension. Recent advances promote incorporating this information with data obtained from current imaging techniques, such as MRI and CT, to manage various malignancies. Functional imaging's vital roles progressively evolved to include: aiding in diagnosis, improving radiation treatment planning, differentiating tumor volume from surrounding normal tissues which enables dose escalation to the former while improving sparing of the latter, adapting radiation therapy regimens according to a tumor's response to initial treatment, and assessing radiation therapy response and toxicity. This review explores functional imaging in radiation oncology in the context of these five applications, as well as its comparison to, and integration with, existing imaging modalities. In parallel with advances in functional imaging and understanding of tumor microbiology, the emergence of diverse tracers provides a plethora of options to distinguish and manage malignancies on the basis of specific metabolic processes and changing microenvironmental cues. Current limitations, potential concerns, and future innovations of functional imaging are also discussed.

Disease-free survival according to the use of postmastectomy radiation therapy after neoadjuvant chemotherapy.

INTRODUCTION: The purpose of the study was to determine predictors of recurrence for patients treated with neoadjuvant chemotherapy (NAC) and mastectomy according to the use of postmastectomy radiation therapy (PMRT). PATIENTS AND METHODS: An analysis of 161 clinically staged T1 to T3/N0 to N3 patients treated with NAC and mastectomy with and without PMRT at our institution from 2003 to 2010 was conducted. The Kaplan-Meier product limit method was used to estimate survival and time to recurrence rates and the log-rank test was used to compare groups. A Cox proportional hazard regression analysis was carried out for time to recurrence, radiation therapy, and their interaction in the model. RESULTS: The median follow-up period was 48 months and 18 patients developed a recurrence. The 5-year recurrence rate and overall survival was 16.1% (95% confidence interval [CI], 9.6%-26.3%) and 93.6% (95% CI, 88.2%-97.0%), respectively. Patients who underwent PMRT had a decreased risk of recurrence compared with patients who did not (hazard ratio [HR], 0.25; 95% CI, 0.097-0.661; P < .005). The 5-year disease-free survival (DFS) rate for those who received PMRT was 91.3% (95% CI, 82.8%-95.7%) and 64.8% (95% CI, 37.8%-82.4%) for those who did not (P = .0126). Among all clinicopathologic factors examined, pathologic T stage (ypT) and pathological N stage (ypN) significantly correlated with the risk of recurrence (P < .05). Patients with any pathological nodal disease had an increased risk of recurrence compared with patients who were pathologically node-negative (HR, 7.196; 95% CI, 2.05-25.264; P < .002). CONCLUSION: Patients treated with NAC and mastectomy, but without PMRT had a higher risk recurrence with increasing ypT and ypN stages. PMRT might increase DFS.

Second cancer, breast cancer, and cardiac mortality in stage T1aN0 breast cancer patients with or without external beam radiation therapy: a national registry study.

INTRODUCTION/BACKGROUND: With improved BC screening and treatment, the risk for long-term toxicities of treatments must be considered, especially in good prognosis patients. In this study we examined the outcome, risks of second cancers, and cardiac mortality with RT for early-stage BC from recent years. MATERIALS AND METHODS: Analysis of the SEER database was conducted for women who had stage T1aN0 BC as their first primary malignancy between 1990 and 1997 and were treated with partial or complete mastectomy with or without external beam RT. The overall survival (OS), BC-specific survival (BCSS), cardiac cause-specific survival (CCS), and deaths from second cancers in the chest area were compared between the RT and no-RT groups. RESULTS: Of the 6515 women identified, 2796 received RT and 3719 did not. The median age group (60-64 years) and follow-up lengths (approximately 15 years) were similar. Compared with the RT group, the no-RT group was associated with lower 10-year OS (85.5% vs. 79.3%; P < .0001), BCSS (97.3% vs. 96.4%; P = .04), and CCS (97.0% vs. 93.8%; P < .0001). In the RT group, left-sided BC was not associated with higher cardiac mortality. There were no statistically significant incidences in mortality due to subsequent cancers. The most common second cancer mortality included 114 (2%) lung, 25 (0.4%) lymphoma, 19 (0.3%) leukemia, 3 (0.05%) soft tissue, and 2 (0.03%) esophagus. CONCLUSION: This review of SEER data suggests that secondary malignancy in the chest area and cardiac mortality are rare after RT in the 1990s for T1aN0 BC.

Cesium-131 brachytherapy in high risk and recurrent head and neck cancers: first report of long-term outcomes.

PURPOSE: The feasibility and efficacy of re-irradiation using contemporary radiation techniques to treat recurrent head and neck cancer has been demonstrated but the role of brachytherapy is unclear. Here we describe the use of (131)Cs brachytherapy with concurrent salvage surgery in 18 patients. MATERIAL AND METHODS: Eligible patients underwent maximal gross resection of the tumor with implantation of brachytherapy seeds delivering a minimum dose of 80 Gy to the tumor bed. Rates of overall survival, locoregional progression free survival, disease-free survival, and radiation-induced toxicity were analyzed. RESULTS: Retrospective Kaplan-Meier analysis shows median overall survival was 15 months and disease free survival was 12 months. Two patients developed grade 3 toxicity; all other complications were grade 1-2 with no grade 4 or 5 complications. CONCLUSIONS: Compared to prior literature, our study shows comparable rates of survival with a decreased rate of radiation-induced toxicity.

Comparing outcomes in poorly-differentiated versus anaplastic thyroid cancers treated with radiation: a surveillance, epidemiology, and end results analysis.

PURPOSE: Poorly differentiated thyroid carcinoma (PDTC) and anaplastic thyroid carcinoma (ATC) are considered the most aggressive cancers of the head and neck. The aim of the study was to evaluate and compare survival outcomes in PDTC and ATC in a large population-based cohort. MATERIALS AND METHODS: Patients with PDTC and ATC diagnosed from 1973 to 2008 were obtained from Surveillance, Epidemiology, and End RESULTS database. Kaplan-Meier survival analysis and log-rank analyses were performed to evaluate (1) The effect of histology on cause-specific survival (CSS) and (2) the influence of factors such as treatment, treatment sequence, race, sex, and age on CSS. Multivariate analysis was performed to assess the independent effect of these factors on CSS. RESULTS: A total of 1352 patients with PDTC and ATC were identified. PDTC constituted 52.4% of patients versus 47.6% for ATC. Median CSS was similar in the two histology groups (P = 0.14). Both PDTC and ATC patients receiving radioisotopes showed a significantly better CSS compared to external beam radiation (P < 0.0001). PDTC and ATC Patients receiving radiation prior to surgery demonstrated a significantly lower CSS compared to patients receiving radiation postoperatively (P < 0.0001). Female gender and black/nonwhite race tended to improve CSS in PDTC and ATC patients (P = 0.29 and P = 0.03, for gender and race, respectively). However, multivariate analysis revealed only type of radiation treatment and age to be independently associated with CSS. CONCLUSION: This is the first large population-based study evaluating PDTC and ATC outcomes in patients who received radiation treatment. Radioisotope use and timing of radiotherapy (postoperative vs. preoperative) were associated with improved CSS in both histologies.

Phase I/II study of resection and intraoperative cesium-131 radioisotope brachytherapy in patients with newly diagnosed brain metastases.

OBJECT: Resected brain metastases have a high rate of local recurrence without adjuvant therapy. Adjuvant whole-brain radiotherapy (WBRT) remains the standard of care with a local control rate > 90%. However, WBRT is delivered over 10-15 days, which can delay other therapy and is associated with acute and long-term toxicities. Permanent cesium-131 ((131)Cs) implants can be used at the time of metastatic resection, thereby avoiding the need for any additional therapy. The authors evaluated the safety, feasibility, and efficacy of a novel therapeutic approach with permanent (131)Cs brachytherapy at the resection for brain metastases. METHODS: After institutional review board approval was obtained, 24 patients with a newly diagnosed metastasis to the brain were accrued to a prospective protocol between 2010 and 2012. There were 10 frontal, 7 parietal, 4 cerebellar, 2 occipital, and 1 temporal metastases. Histology included lung cancer (16), breast cancer (2), kidney cancer (2), melanoma (2), colon cancer (1), and cervical cancer (1). Stranded (131)Cs seeds were placed as permanent volume implants. The prescription dose was 80 Gy at a 5-mm depth from the resection cavity surface. Distant metastases were treated with stereotactic radiosurgery (SRS) or WBRT, depending on the number of lesions. The primary end point was local (resection cavity) freedom from progression (FFP). Secondary end points included regional FFP, distant FFP, median survival, overall survival (OS), and toxicity. RESULTS: The median follow-up was 19.3 months (range 12.89-29.57 months). The median age was 65 years (range 45-84 years). The median size of resected tumor was 2.7 cm (range 1.5-5.5 cm), and the median volume of resected tumor was 10.31 cm(3) (range 1.77-87.11 cm(3)). The median number of seeds used was 12 (range 4-35), with a median activity of 3.82 mCi per seed (range 3.31-4.83 mCi) and total activity of 46.91 mCi (range 15.31-130.70 mCi). Local FFP was 100%. There was 1 adjacent leptomeningeal recurrence, resulting in a 1-year regional FFP of 93.8% (95% CI 63.2%-99.1%). One-year distant FFP was 48.4% (95% CI 26.3%-67.4%). Median OS was 9.9 months (95% CI 4.8 months, upper limit not estimated) and 1-year OS was 50.0% (95% CI 29.1%-67.8%). Complications included CSF leak (1), seizure (1), and infection (1). There was no radiation necrosis. CONCLUSIONS: The use of postresection permanent (131)Cs brachytherapy implants resulted in no local recurrences and no radiation necrosis. This treatment was safe, well tolerated, and convenient for patients, resulting in a short radiation treatment course, high response rate, and minimal toxicity. These findings merit further study with a multicenter trial.

Role of radiation therapy for renal tumors.

Renal cell carcinoma (RCC) is an aggressive malignancy that carries a poor prognosis, especially in patients presenting with advanced stage. Primary treatment for localized RCC is surgical resection however, a significant number of patients still develop locoregional and distant metastasis after curative resection. In metastatic disease, radiation therapy (RT) has been used for palliation routinely for brain and other extracranial lesions with respectable response rates. However, RT for primary RCC has questionable benefit. In this article, the authors discuss the evidence with regards to the role of RT in primary RCC either as a primary treatment, adjuvant treatment, or preoperatively to improve resection outcomes. In addition, novel RT techniques such as stereotactic body radiation therapy and its use in RCC management are also addressed. Finally, the authors discuss the techniques and doses of RT for primary RCC.

Evidence supporting contemporary post-operative radiation therapy (PORT) using linear accelerators in N2 lung cancer.

PURPOSE: Post-operative radiotherapy (PORT) treatment for lung cancer declined since a meta-analysis failed to show benefit in patients with N2 disease. Because several included studies employed outmoded radiation planning and delivery techniques, we sought to determine whether PORT with modern technology benefits patients with N2 disease. METHODS: We conducted searches of the published literature. For inclusion, studies must have included patients with stage III-N2 lung cancer treated with PORT using only linear accelerators, used a control group that did not receive PORT, and reported outcome data for overall survival (OS). Prospective and retrospective analyses were included. Exclusion criteria were the use of cobalt devices or orthovoltage radiation. RESULTS: Data were evaluated with random-effects models. Three prospective and eight retrospective studies were included. The PORT and no-PORT groups included 1368 and 1360 patients, respectively. The PORT group had significantly improved OS over the no-PORT group (hazard ratio [HR] = 0.77, 95% confidence interval [CI] 0.62-0.96, P = 0.020). Locoregional recurrence-free survival (LRFS) in 10 studies for which data was available was also improved in the PORT group (HR = 0.51, CI 0.41-0.65, P < 0.001). CONCLUSIONS: PORT was associated with significantly lower risk of death and locoregional recurrence in patients with N2 lung cancer. Our study was limited by lack of access to individual patient data, which would have enabled more detailed analyses. Regardless, data thus far suggest PORT may be associated with a survival benefit. Given a lack of large-scale prospective data, clinical trials evaluating PORT with modern technology are warranted.