Alan T. Monroe

Angiosarcoma after breast-conserving therapy

Angiosarcoma arising in the irradiated breast after breast‐conserving therapy is being reported with increasing frequency. As more women undergo breast‐conserving therapy, the incidence can be expected to increase. Surgeons, medical oncologists, and radiation oncologists will be faced with difficult management decisions for this aggressive disease.

Radiation therapy for esthesioneuroblastoma: Rationale for elective neck irradiation†

Esthesioneuroblastoma is an uncommon malignancy of neural crest origin arising in the upper nasal cavity. We describe the University of Florida experience using radiation therapy (RT) in the treatment of this neoplasm, particularly the use of elective nodal irradiation.

Postoperative Proton Therapy in the Management of Stage III Thymoma

Journal of Thoracic Oncology • Volume 8, Number 5, May 2013 A 23-year-old woman with a Masaoka stage III type B2/ B3 thymoma was referred to our institution for adjuvant proton therapy after surgical resection. The patient initially presented with chest pain, shortness of breath, and a family history notable for her brother having died from metastatic thymoma at the age of 17 years. A chest computed tomography scan demonstrated a large anterior mediastinal mass. Surgical exploration and resection demonstrated a 16.5 × 8.5 × 3.7 cm mass invading the innominate vein, requiring graft reconstruction, and extending along the right paramediastinal/cardiac border to just above the right hemidiaphragm. Pathology revealed stage III type B2/B3 thymoma with no lymph node involvement, but microscopic positive margins. Because of stage and positive margins, recommendations were made for adjuvant radiation therapy (RT). An RT plan was developed to deliver 50.4 Gy to the postoperative Postoperative Proton Therapy in the Management of Stage III Thymoma

Dorsal Vagal Complex of the Brainstem: Conformal Avoidance to Reduce Nausea

PURPOSE To investigate the role of dose to the dorsal vagal complex (DVC) as an emetic stimulus in head-and-neck cancer patients treated with intensity modulated radiation therapy but without chemotherapy. METHODS AND MATERIALS Seventy consecutively treated patients were analyzed for factors associated with nausea. The DVC was contoured on treatment planning scans using a previously published template and mean dose to the structure was analyzed for dose response. RESULTS Nausea occurred in 26 of 70 patients (37%). Two patients (3%) experienced grade 2 nausea, with the remainder having grade 1 nausea. On univariate analysis, dose to the DVC, age, and T-stage were the only significant predictors of nausea. The highest quartile of dose to the DVC (>3000 cGy) was associated with an incidence of nausea of 67% compared with less than 30% in each of the other 3 quartiles (P = .0255). CONCLUSIONS Dose to the DVC of the brainstem appears to correlate with radiation-induced nausea and vomiting. Attentive treatment planning efforts can reduce dose to this critical structure and hopefully minimize the risk of nausea.

Clinical outcomes of image guided radiation therapy (IGRT) with gold fiducial vaginal cuff markers for high-risk endometrial cancer

Abstract Objective. To report two year clinical outcomes of image guided radiation therapy (IGRT) to the vaginal cuff and pelvic lymph nodes in a series of high-risk endometrial cancer patients. Methods. Twenty-six consecutive high-risk endometrial cancer patients requiring adjuvant radiation to the vaginal cuff and regional lymph nodes were treated with vaginal cuff fiducial-based IGRT. Seventeen (65%) received sequential chemotherapy, most commonly with a sandwich technique. Brachytherapy followed external radiation in 11 patients to a median dose of 18 Gy in 3 fractions. The median external beam dose delivered was 47.5 Gy in 25 fractions. Results. All 656 fractions were successfully imaged and treated. The median overall translational shift required for correction was 9.1 mm (standard deviation, 5.2 mm) relative to clinical set-up with skin tattoos. Shifts of 1 cm, 1.5 cm, and 2 cm or greater were performed in 43%, 14%, and 4% of patients, respectively. Acute grade 2 gastrointestinal (GI) toxicity occurred in eight patients (30%) and grade 3 toxicity occurred in one. At two years, there have been no local or regional failures and actuarial overall survival is 95%. Conclusion. Daily image guidance for high-risk endometrial cancer results in a low incidence of acute GI/genitourinary (GU) toxicity with uncompromised tumor control at two years. Vaginal cuff translations can be substantial and may possibly result in underdosing if not properly considered.

Accelerated fractionation head and neck intensity-modulated radiation therapy and concurrent chemotherapy in the community setting: Safety and efficacy considerations

This article reviews our community cancer centers experience treating head and neck cancer primarily with accelerated fractionation intensity‐modulated radiation therapy (IMRT), with or without concurrent chemotherapy, focusing on acute toxicity and efficacy.

Prevention of needle displacement in multifraction high-dose-rate prostate brachytherapy: A prospective volumetric analysis and technical considerations

PURPOSE We conducted a prospective study to evaluate needle displacements between prostate high-dose-rate (HDR) brachytherapy fractions and offer technical recommendations to help prevent displacements from the outset. METHODS AND MATERIALS Planning computed tomography and verification computed tomography scans were obtained at 1-mm slice thickness and prospectively assessed for interfraction needle movement for each fraction of a 2-fraction HDR prostate boost. For both the planning and verification CTs, distances from each needle tip to the centroid of 3 implanted prostate gold seeds were measured. We determined the mean and range of the displacement distances. RESULTS Thirty-three consecutive patients (66 fractions, 540 needle-pair positions for a total of 1080 needles) were evaluated for changes in the length between the needle tip and centroid displacement. Overall, only 0.2% of the needles had any change greater than 3.5 mm between the needle tip and centroid. The mean amount of displacement was 0.97 mm, with a standard deviation of 0.76 mm. Among the patients, no fraction had more than 1 needle with a variation greater than 3.0 mm. CONCLUSIONS Needle displacements in HDR prostate brachytherapy have been reported by numerous institutions using various techniques. We report the first study to demonstrate needle displacement of less than 1 mm on average, and we describe our process of care surrounding the implantation.

CyberKnife radiosurgery for trigeminal neuralgia: unanticipated iatrogenic effect following successful treatment

This case report of 74-year-old man with trigeminal neuralgia is presented to underscore the importance of evaluating the entire treatment plan, especially when delivering large doses where even a low percentage of the prescription dose can contribute a substantial dose to an unintended target. The patient was treated using the CyberKnife stereotactic radiosurgery system utilizing a nonisocentric beam treatment plan with a 5-mm fixed collimator generating 111 beams to deliver 6000 cGy to the 79% isodose line with a maximum dose of 7594 cGy to the target. Two weeks after treatment the patients trigeminal neuralgia symptoms resolved; however, the patient developed oral mucositis due to the treatment. This case report reviews the cause of mucositis and makes recommendations on how to prevent unintended targets from receiving treatment.

Truth or myth: Definitive chemoradiotherapy doesn't work for HPV/p16 negative oropharyngeal squamous cell carcinoma?

Article history: Received 1 November 2016 Received in revised form 23 November 2016 Accepted 3 December 2016 Available online xxxx

In Reply to Wang et al

To theEditor:Regarding the recent letter on our article,1,2 we appreciate the author’s comments and would agree that it is time to establish these critical brainstem regions as organs at risk for clinical trials within the cooperative group setting. We did not find the same correlation between dose to the dorsal vagal complex and oropharynx sites that the author mentions. I believe that themost significant factor in reducing dose to the dorsal vagal complex is to consider it important enough to contour, because any reasonable treatment planning effort in our clinic appears to achieve doses below 3000 cGy (or b 2000 cGy in patients undergoing concurrent chemotherapy, our current goal). The exceptions to thiswould be primary nasopharyngeal cases and the rare case with gross adenopathy at the skull base.