Split-course chemoradiotherapy for locally advanced non-small cell lung cancer: a single-institution experience of 144 patients.

BACKGROUND: Concurrent chemoradiotherapy (CRT) is a standard of care in the treatment of unresectable locally advanced non-small cell lung cancer (NSCLC). At Rush University Medical Center, patients with locally advanced NSCLC are treated with split-course CRT in an attempt to maximize efficacy and tolerability. We reviewed our experience in advanced NSCLC since 1999. Subset analysis was performed on poor-risk patients. METHODS: All patients with a diagnosis of stage IIIA/IIIB NSCLC and treated with definitive split-course CRT between January 1999 and December 2008 were included in this retrospective study. The primary end point was overall survival. Poor-risk patients were defined in accordance with ongoing cooperative group trials. RESULTS: One hundred forty-four patients were identified, 35% stage IIIA and 65% stage IIIB. There were 52 poor-risk patients and 92 average-risk patients. Median survival for all patients was 20.4 months with an actuarial 32.1% 3-year overall survival rate. Poor-risk patients demonstrated a median survival of 22.1 months, statistically indistinguishable from the remainder of the cohort (p = 0.21). Acute esophagitis was mild, with a 3% rate of grade 3 esophagitis and no cases of grade 4 or 5. CONCLUSIONS: Split-course CRT appeared effective and was delivered with a favorable toxicity profile. Poor-risk patients experienced better than expected survival. Prospective evaluation of split-course CRT must be completed before it can be considered a standard treatment option in locally advanced NSCLC.

Weight gain in advanced non-small-cell lung cancer patients during treatment with split-course concurrent chemoradiotherapy is associated with superior survival.

BACKGROUND: Preoperative concurrent chemoradiotherapy (CRT) is an accepted treatment for potentially resectable, locally advanced, non-small-cell lung cancer (NSCLC). We reviewed a decade of single institution experience with preoperative split-course CRT followed by surgical resection to evaluate survival and identify factors that may be helpful in predicting outcome. METHODS AND MATERIALS: All patients treated with preoperative split-course CRT and resection at Rush University Medical Center (RUMC) between January 1999 and December 2008 were retrospectively analyzed. Endpoints included overall survival (OS), progression-free survival (PFS), local-regional progression-free survival (LRPFS), and distant metastasis-free survival (DMFS). Patient and treatment related variables were assessed for correlation with outcomes. RESULTS: A total of 54 patients were analyzed, 76% Stage IIIA, 18% Stage IIIB, and 6% oligometastatic. The pathologic complete response (pCR) rate was 31.5%, and the absence of nodal metastases (pN0) was 64.8%. Median OS and 3-year actuarial survival were 44.6 months and 50%, respectively. Univariate analysis revealed initial stage (p < 0.01) and percent weight change during CRT (p < 0.01) significantly correlated with PFS/OS. On multivariate analysis initial stage (HR, 2.4; 95% CI, 1.18-4.90; p = 0.02) and percent weight change (HR, 0.79; 95% CI, 0.67-0.93; p < 0.01) maintained significance with respect to OS. There were no cases of Grade 3+ esophagitis, and there was a single case of Grade 3 febrile neutropenia. CONCLUSIONS: The strong correlation between weight change during CRT and OS/PFS suggests that this clinical parameter may be useful as a complementary source of predictive information in addition to accepted factors such as pathological response.

Toxicity associated with bowel or bladder puncture during gynecologic interstitial brachytherapy.

PURPOSE: Interstitial brachytherapy for gynecologic malignancies is associated with significant toxicity. Some reports have correlated this toxicity with needle puncture of the visceral organs. This study examined our experience with interstitial brachytherapy and investigated the relationship between the visceral puncture and toxicity. METHODS AND MATERIALS: The outcomes of 36 patients treated with interstitial brachytherapy for gynecologic malignancies at a single institution between 2002 and 2007 were reviewed. Computed tomography was used to guide needle placement based solely on tumor coverage. No attempts were made to avoid visceral puncture; however, the source dwell times were minimized in these areas. RESULTS: At a median follow-up of 21 months, the crude locoregional control rate was 78%. Bowel puncture was noted in 26 patients and bladder puncture in 19. The mean operating time was 50 min, and 86% of patients were discharged in

Application of holographic display in radiotherapy treatment planning II: a multi-institutional study.

We hypothesized that use of a true 3D display providing easy visualization of patient anatomy and dose distribution would lead to the production of better quality radiation therapy treatment plans. We report on a randomized prospective multi-institutional study to evaluate a novel 3D display for treatment planning.The Perspecta Spatial 3D System produces 360 degrees holograms by projecting crosssectional images on a diffuser screen rotating at 900 rpm. Specially-developed software allows bi-directional transfer of image and dose data between Perspecta and the Pinnacle planning system.Thirty-three patients previously treated at three institutions were included in this IRB-approved study. Patient data were de-identified, randomized, and assigned to different planners. A physician at each institution reviewed the cases and established planning objectives. Two treatment plans were then produced for each patient, one based on the Pinnacle system alone and another in conjunction with Perspecta. Plan quality was then evaluated by the same physicians who established the planning objectives. All plans were viewable on both Perspecta and Pinnacle for review. Reviewing physicians were blinded to the planning device used. Data from a 13-patient pilot study were also included in the analysis.Perspecta plans were considered better in 28 patients (61%), Pinnacle in 14 patients (30%), and both were equivalent in 4 patients. The use of non-coplanar beams was more common with Perspecta plans (82% vs. 27%). The mean target dose differed by less than 2% between rival plans. Perspecta plans were somewhat more likely to have the hot spot located inside the target (43% vs. 33%). Conversely, 30% of the Pinnacle plans had the hot spot outside the target compared with 18% for Perspecta plans. About 57% of normal organs received less dose from Perspecta plans. No statistically significant association was found between plan preference and planning institution or planner.The study found that use of the holographic display leads to radiotherapy plans preferred in a majority of cases over those developed with 2D displays. These data indicate that continued development of this technology for clinical implementation is warranted.

Upright 3D treatment planning using a vertical CT.

In this report, we describe a novel technique used to plan and administer external beam radiation therapy to a patient in the upright position. A patient required reirradiation for thymic carcinoma but was unable to tolerate the supine position due to bilateral phrenic nerve injury and paralysis of the diaphragm. Computed tomography (CT) images in the upright position were acquired at the Northern Illinois University Institute for Neutron Therapy at Fermilab. The CT data were imported into a standard 3-dimensional (3D) treatment planning system. Treatment was designed to deliver 24 Gy to the target volume while respecting normal tissue tolerances. A custom chair that locked into the treatment table indexing system was constructed for immobilization, and port films verified the reproducibility of setup. Radiation was administered using mixed photon and electron AP fields.

Long term disease-free survival resulting from combined modality management of patients presenting with oligometastatic, non-small cell lung carcinoma (NSCLC).

We report outcomes on 23 patients with oligometastastic (1 or 2 sites) NSCLC treated with aggressive local, regional, and systemic treatment. The results suggest that this is a favorable subset of patients who may benefit from such an approach, with a 22% rate of long-term survival. This treatment strategy is a departure from the usual practice of palliative-only therapy for all NSCLC patients presenting with metastatic disease.

Vaginal lymphatic channel location and its implication for intracavitary brachytherapy radiation treatment.

PURPOSE: In vaginal intracavitary brachytherapy using cylindrical applicators, it is common to prescribe dose to a depth of 0.5 cm to cover the lymphatic channels. However, the actual depth of the lymphatics within the vaginal wall has never been determined. In this study, we examined the depth distribution of lymphatics lying beneath the mucosal surface of the vagina. METHODS AND MATERIALS: Between January 24, 1996 and October 27, 2003, 31 patients underwent full-thickness vaginal biopsy or partial resection for both benign and malignant disease. In addition, in February 2004, vaginal samples from two autopsy specimens were stretched and pinned for formalin fixation and slide production. Forty-five slides of both stretched and nonstretched vaginal tissue were stained with D2-40 monoclonal antibody lymphatic endothelium marker. The percentages of lymphatics located within 1, 1-2, 2-3, and 3-4mm were calculated for all slides. RESULTS: For the nonstretched samples, the percentages of lymphatics located within 1, 1-2, 2-3, and 3-4mm were 50.5%, 30.7%, 11.9%, and 6.9%, respectively. For the stretched samples, the percentages of lymphatics located within 1, 1-2, 2-3, and 3-4mm were 44.0%, 33.8%, 18.8%, and 3.4%, respectively. The differences of lymphatic percentages within and superficial to 1mm (p=0.60), 1-2mm (p=0.85), 2-3mm (p=0.89), and 3-4mm (p=0.99) were not statistically significant between the stretched and nonstretched states. CONCLUSIONS: Our results show that approximately 95% of vaginal lymphatic channels are located within a 3mm depth from the vaginal surface. This suggests that dose prescribed to a depth less than 0.5 cm may be adequate and could permit treatment with less normal tissue toxicity in certain clinical situations.