Akkamma Ravi

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.

Influence of volumes of prostate, rectum, and bladder on treatment planning CT on interfraction prostate shifts during ultrasound image-guided IMRT

PURPOSE The purpose of this study was to analyze the relationship between prostate, bladder, and rectum volumes on treatment planning CT day and prostate shifts in theXYZ directions on treatment days. METHODS Prostate, seminal vesicles, bladder, and rectum were contoured on CT images obtained in supine position. Intensity modulated radiation therapy plans was prepared. Contours were exported to BAT-ultrasound imaging system. Patients were positioned on the couch using skin marks. An ultrasound probe was used to obtain ultrasound images of prostate, bladder, and rectum, which were aligned with CT images. Couch shifts in theXYZ directions as recommended by BAT system were made and recorded. 4698 couch shifts for 42 patients were analyzed to study the correlations between interfraction prostate shifts vs bladder, rectum, and prostate volumes on planning CT. RESULTS Mean and range of volumes (cc): Bladder: 179 (42-582), rectum: 108 (28-223), and prostate: 55 (21-154). Mean systematic prostate shifts were (cm, ±SD) right and left lateral:-0.047±0.16 (-0.361-0.251), anterior and posterior: 0.14±0.3 (-0.466-0.669), and superior and inferior: 0.19±0.26 (-0.342-0.633). Bladder volume was not correlated with lateral, anterior/posterior, and superior/inferior prostate shifts (P>0.2). Rectal volume was correlated with anterior/posterior (P<0.001) but not with lateral and superior/inferior prostate shifts (P>0.2). The smaller the rectal volume or cross sectional area, the larger was the prostate shift anteriorly and vice versa (P<0.001). Prostate volume was correlated with superior/inferior (P<0.05) but not with lateral and anterior/posterior prostate shifts (P>0.2). The smaller the prostate volume, the larger was prostate shift superiorly and vice versa (P<0.05). CONCLUSIONS Prostate and rectal volumes, but not bladder volumes, on treatment planning CT influenced prostate position on treatment fractions. Daily image-guided adoptive radiotherapy would be required for patients with distended or empty rectum on planning CT to reduce rectal toxicity in the case of empty rectum and to minimize geometric miss of prostate.

Breast Cancer in Men Prognostic Factors, Treatment Patterns, and Outcome

Purpose. The aim of this study was to review the clinical presentation and to evaluate prognostic factors, treatment modalities, outcome, and second malignancy in male breast cancer patients. A chart review was conducted of all men treated for breast cancer between January 1991 and December 2007. Cox proportional hazards regression model and Kaplan–Meier curve were used to determine prognostic factors and plot survival probabilities. Invasive carcinoma was diagnosed in 22 patients and ductal carcinoma in situ in 7 patients. With mortality as the endpoint, tumor size indicated hazard ratio (HR) of 1.5 for each 1-cm increase in tumor size (p = .03). Overall stage and increased age were associated with increased risk of mortality (HR = 2.1, p = .055; HR = 1.09 for a 1-year increase in age, p = .08, respectively). Adjuvant radiation therapy yielded an HR of 0.1 (p = .058), indicating a favorable association with the survival. Advanced age, higher stage, and increasing tumor size were unfavorable to survival in male breast carcinoma. The benefit of adjuvant radiation therapy should be addressed in future collaborative studies.

MammoSite multilumen catheter: dosimetry considerations.

PURPOSE To explore the dosimetric advantages of the new MammoSite multilumen (ML) balloon for breast brachytherapy treatment compared to conventional single lumen (SL) device plan. MATERIALS AND METHODS Patients deemed appropriate for accelerated partial breast irradiation (APBI) were implanted with the MammoSite ML balloon. Two plans were generated in each patient for the same target coverage (PTV_EVAL) and dose to normal structures were plotted. The first plan used only the central single lumen with single-dwell position (SL), and the second plan (ML) was generated using the other lumens of the device. Dose distributions of the SL and ML plans were compared. RESULTS For the same PTV_EVAL, the ML balloon improved dose coverage at the tip and base of the applicator compared to SL plan. The skin and rib doses were reduced using the ML plan versus SL plan for the same PTV_EVAL in-patient 2, where the skin-balloon distance was 7 mm and the rib-balloon distance was <1 cm. For patient 1, the skin and rib distances were greater than 1 cm and the ML plan did not further minimize the dose to normal structures. CONCLUSION In our initial experience, dosimetric goals can be better achieved using the ML MammoSite balloon when normal structures (skin and ribs) are close to PTV_EVAL with a distance of <7 mm and rib distance of <1 cm. The multiple lumen of ML balloon can optimize dose and reduce excessive dose to rib and skin and therefore minimize the long-term toxicities of rib discomfort, skin fibrosis and fat necrosis.

Total skin electron beam therapy in the management of cutaneous malignancies

In 1902, Scholtz1 first used ionizing radiation for the treatment of mycosis fungoides (MF); however, not until 1939 did Sommerville2 suggest an “X-Ray bath” for treatment of this T-cell lymphoma. Unfortunately, this technique was limited by such adverse side effects as bone marrow suppression. For the past fifty years, various techniques and dosage regimens have been employed in irradiating the entire skin surface with highenergy electrons.3,4 Total skin electron beam therapy (TSEBT) has been used for various primary or secondary cutaneous malignancies involving large segments of the body, such as MF,7–10,16 lymphoma cutis, cutaneous leukemia,5 Kaposi’s sarcoma,11 and inflammatory breast cancer. Lymphomas and leukemias may initially present as a primary manifestation in some extranodal sites such as the skin. In contrast to MF, primary cutaneous lymphomas are relatively rare, although the secondary cutaneous lymphomas and leukemias involving extensive areas of skin have been treated with TSEBT, mainly for palliation.5 MF is the most common type of cutaneous T-cell lymphoma (CTCL). Methods of treatment currently include systemic or topical steroids, chemotherapy with carmustine (BCNU) or mechlorethamine, PUVA (Psoralen and ultraviolet A), and radiation therapy. The duration of remission achieved by any of these methods is generally related to the stage of the disease and the predominant type of lesion at the time of treatment; i.e., plaque versus nodular lesion. PUVA is currently the most popular method for patch and early plaque lesions. When lesions evolve to tumor stage, however, the greater penetration of ionizing radiation provides a therapeutic advantage over PUVA. MF is radiosensitive and responds equally well to either X-rays or electrons. When extensive areas of the skin are involved, the treatment of choice should be TSEBT because of its physical characteristics. The most important advantage of electron beam treatment over conventional X-rays is its superficial penetrability, permitting very minimal radiation to the underlying normal tissue. The incident energy of the electron beam can be varied depending on the depth of the lesions. Various combinations with photon beam have been used to reduce the thickness of tumoral lesions and to treat locoregional lymph nodes. Classically, the prognosis is poor once MF extends beyond skin to lymph nodes, viscera, peripheral blood, or occasionally to the bone marrow. Patients with extracutaneous disease or with extensive tumoral stage usually prove refractory to therapy and treatment is aimed at palliation. Combined chemotherapy and TSEBT is also effective. Patients who received concurrent chemotherapy and 3,000 cGy of TSEBT incurred increased hematological toxicity but had a significantly higher complete response when compared with the topical mechlorethamine and TSEBT group.6 Unfortunately, the higher rate of complete response did not translate into improved disease-free survival or overall survival. Occasionally, a repeat course of TSEBT has been considered in patients who had recurrence following a long disease-free interval after the initial course of TSEBT and were refractory to other modalities. This second course of TSEBT is mainly for palliation. A median dose of approximately 12–20 Gy has been prescribed.22 A general guideline for treatment of MF is outlined in Table 1. TSEBT is a highly specialized treatment that requires the expertise of a medical physicist, a radiation dosimetrist, and an experienced radiation oncologist who has treated a significant number of patients. The treatment is delivered by a linear accelerator, usually at a treatment distance of approximately 3 meters. The patient stands upright in the path of dual fields, which cover the upper and lower segments of the body. Anterior, posterior, and left and right lateral positions are employed in a 4-field technique, with differential loading From the New York Presbyterian Hospital, Cornell Weill Medical Center, Stich Radiation Center, New York, New York, USA. Address correspondence to Akkamma Ravi, MD, New York Presbyterian Hospital, Cornell Weill Medical Center, Stich Radiation Center, Box. 575, 525 E. 68th Street, New York, NY 10021, USA.

Addressing connectivity issues: The Integrating the Healthcare Enterprise-Radiation Oncology (IHE-RO) initiative

In todays world, treating a patient successfully with radiation requires the integration of complex data from a variety of systems. In a typical radiation oncology clinic, data move from the treatment management system to treatment planning system to treatment delivery system. When there is a lack of interconnectivity between the systems, the potential for medical error is increased. Integrating the Healthcare Enterprise-Radiation Oncology (IHE-RO) is dedicated to the identification of connectivity problems encountered in the modern day radiation oncology clinic and the development of solutions to these problems. These solutions are then integrated and made available to the radiation oncology community. This article introduces the IHE-RO initiative, outlines the relevance of IHE-RO for the radiation oncology community, and provides a resource so that therapists, physicists, dosimetrists, administrators, and physicians alike can best understand which vendor equipment can effectively communicate between platforms because it has been deemed IHE-RO compliant through a series of connectivity tests.

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.

Is there a cause-specific survival benefit of postmastectomy radiation therapy in women younger than age 50 with T3N0 invasive breast cancer? A SEER database analysis: outcomes by receptor status/race/age: analysis using the NCI Surveillance, Epidemiology, and End Results (SEER) database.

Objective:Postmastectomy radiation therapy (PMRT) remains controversial for patients with pathologic stage T3N0 (pT3N0) breast cancer. A Surveillance, Epidemiology, and End Results (SEER) database analysis suggested that PMRT might benefit patients older than age 50. However, the relevance between estrogen receptor (ER), progesterone receptor (PR), race, and PMRT in patients younger than age 50 is unknown. Methods:The impact of PMRT treatment on cause-specific survival (CSS) and overall survival (OS) were analyzed for women in the SEER database from 1998 to 2007. Approximately half (47%) of the 1104 patients who met the study requirements received PMRT. We performed univariate analysis to compare CSS between the PMRT and no-PMRT groups for all patients and further stratified by age, race, tumor size, tumor grade, and ER/PR status. Results:No difference in CSS or OS was detected between women treated with or without PMRT. Black/other race, ER−, and PR−, all suggested a trend toward decreased CSS. In univariate analysis, PMRT seems to be beneficial in patients younger than age 40 (hazard ratio=0.65; P=0.25; a nonsignificant trend in favor of PMRT). Conclusions:This SEER database analysis of patients younger than age 50 and with pT3N0 breast cancer showed that PMRT did not significantly affect CSS at 5 years; however, it implied a trend of benefit for patients younger than 40. The findings that patients with African heritage and negative ER/PR status showing decreased CSS warrant further investigation to determine the role of personalized PMRT in these high-risk cohorts.

Adjuvant Radiation Therapy for T3N0 Breast Cancer Patients Older Than 75 Years After Mastectomy: A SEER Analysis

Introduction Breast cancer patients with tumors > 5 cm but without nodal disease who undergo mastectomy present a clinical challenge regarding the appropriate adjuvant treatment. Traditionally, postmastectomy radiation therapy (PMRT) was the standard of care. However, recent studies have suggested local failure rates without PMRT might be low enough to omit RT. This might be especially true in the elderly. Patients and Methods Women aged ≥ 75 years with a diagnosis of T3N0 breast cancer who had undergone mastectomy were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 database. The study period was limited to 2006 to 2009 for more modern sampling. Multivariable proportional hazards modeling was used to examine the association of treatment and mortality, adjusting for demographic and clinicopathologic factors. Results A total of 635 patients were identified. The median follow‐up period was 43 months. PMRT was given to 31.2% of the patients aged 75 to 79 years, 21.5% of those aged 80 to 84 years, and 11.7% of the patients aged ≥ 85 years (P < .001). The receipt of PMRT showed a trend toward improved overall survival on bivariable analysis (hazard ratio [HR], 0.58; P < .001) and multivariable analysis (HR, 0.78; P = .14). The 5‐year overall survival was 64.2% for those who had received PMRT and 44.8% for those who had not. A nonsignificant trend was seen toward improved breast cancer‐specific survival at 5 years on bivariable analysis (HR, 0.63; P = .09) but not on multivariable analysis. The interaction of age and PMRT receipt could have confounded the results. Patient age and tumor grade were significant indicators of the survival prognosis in these patients. Conclusion The results of the present analysis of the SEER database suggest that PMRT might still be beneficial in women aged > 75 years with T3N0 disease but also supports continuing efforts to confirm whether it could be safe to omit. It is likely that efforts to subdivide this population using other factors (eg, comorbidity) will be important. The search for refined inclusion and exclusion criteria for adjuvant RT remains an important field of research both clinically and economically. Micro‐Abstract Current trends seek to identify low‐risk breast cancer patients who can forego adjuvant radiation therapy (RT), including elderly patients with stage T3N0 who have undergone mastectomy. The present analysis of 635 such patients in the Surveillance, Epidemiology, and End Results database found decreasing use of postmastectomy RT (PMRT) with increasing age. We found a trend toward an overall survival benefit with adjuvant RT but no disease‐specific survival benefit. However, age could have been a major confounder. These data support continuing efforts to identify which subset of these patients, if any, will benefit from PMRT.

Znaczenie prognostyczne histologii guza i metody leczenia w przypadku raka płaskonabłonkowego, gruczolakoraka i raka gruczołowo-płaskonabłonkowego szyjki macicy w stadium IB1: badanie zapisów z rejestru SEER dotyczących lat 2004–2008

Objective: To determine the significance of histology and treatment modality on overall survival and cause-specific survival in stage IB1 cervical...