Albert Attia

Creation and Validation of the Singing Voice Handicap Index

Objectives: We developed and validated a disorder-specific health status instrument (Singing Voice Handicap Index; SVHI) for use in patients with singing problems. Methods: Prospective instrument validation was performed. Of 81 original items, those with poor statistical validity were eliminated, resulting in 36 items. The ability to discriminate dysphonic from normal singers, test-retest reliability, internal consistency, and construct validity were assessed. Results: We included 112 dysphonic and 129 normal singers, professional and nonprofessional, of classical, country, rock, choral, and gospel repertoire. Dysphonic singers had worse SVHI scores than normal singers (p ≤ .001, rank sum test). Test-retest reliability was high (Spearman correlation, 0.92; p ≤ .001). Internal consistency demonstrated a Cronbachs α of 97, and the correlation between the SVHI and self-rated singing voice impairment was .63 (p ≤ .001, Spearman correlation). Conclusions: The SVHI is a reliable and valid tool for assessing self-perceived handicap associated with singing problems.

Extended Survival and Prognostic Factors for Patients With ALK-Rearranged Non–Small-Cell Lung Cancer and Brain Metastasis

PURPOSE We performed a multi-institutional study to identify prognostic factors and determine outcomes for patients with ALK-rearranged non-small-cell lung cancer (NSCLC) and brain metastasis. PATIENTS AND METHODS A total of 90 patients with brain metastases from ALK-rearranged NSCLC were identified from six institutions; 84 of 90 patients received radiotherapy to the brain (stereotactic radiosurgery [SRS] or whole-brain radiotherapy [WBRT]), and 86 of 90 received tyrosine kinase inhibitor (TKI) therapy. Estimates for overall (OS) and intracranial progression-free survival were determined and clinical prognostic factors were identified by Cox proportional hazards modeling. RESULTS Median OS after development of brain metastases was 49.5 months (95% CI, 29.0 months to not reached), and median intracranial progression-free survival was 11.9 months (95% CI, 10.1 to 18.2 months). Forty-five percent of patients with follow-up had progressive brain metastases at death, and repeated interventions for brain metastases were common. Absence of extracranial metastases, Karnofsky performance score ≥ 90, and no history of TKIs before development of brain metastases were associated with improved survival (P = .003, < .001, and < .001, respectively), whereas a single brain metastasis or initial treatment with SRS versus WBRT were not (P = .633 and .666, respectively). Prognostic factors significant by multivariable analysis were used to describe four patient groups with 2-year OS estimates of 33%, 59%, 76%, and 100%, respectively (P < .001). CONCLUSION Patients with brain metastases from ALK-rearranged NSCLC treated with radiotherapy (SRS and/or WBRT) and TKIs have prolonged survival, suggesting that interventions to control intracranial disease are critical. The refinement of prognosis for this molecular subtype of NSCLC identifies a population of patients likely to benefit from first-line SRS, close CNS observation, and treatment of emergent CNS disease.

Human papillomavirus in early laryngeal carcinoma

To examine the role of HPV status in the etiology, prognosis, and treatment of head and neck squamous cell carcinoma in early larynx malignancies.

Management of Brain Metastases in Tyrosine Kinase Inhibitor–Naïve Epidermal Growth Factor Receptor–Mutant Non–Small-Cell Lung Cancer: A Retrospective Multi-Institutional Analysis

Purpose Stereotactic radiosurgery (SRS), whole-brain radiotherapy (WBRT), and epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) are treatment options for brain metastases in patients with EGFR-mutant non-small-cell lung cancer (NSCLC). This multi-institutional analysis sought to determine the optimal management of patients with EGFR-mutant NSCLC who develop brain metastases and have not received EGFR-TKI. Materials and Methods A total of 351 patients from six institutions with EGFR-mutant NSCLC developed brain metastases and met inclusion criteria for the study. Exclusion criteria included prior EGFR-TKI use, EGFR-TKI resistance mutation, failure to receive EGFR-TKI after WBRT/SRS, or insufficient follow-up. Patients were treated with SRS followed by EGFR-TKI, WBRT followed by EGFR-TKI, or EGFR-TKI followed by SRS or WBRT at intracranial progression. Overall survival (OS) and intracranial progression-free survival were measured from the date of brain metastases. Results The median OS for the SRS (n = 100), WBRT (n = 120), and EGFR-TKI (n = 131) cohorts was 46, 30, and 25 months, respectively ( P < .001). On multivariable analysis, SRS versus EGFR-TKI, WBRT versus EGFR-TKI, age, performance status, EGFR exon 19 mutation, and absence of extracranial metastases were associated with improved OS. Although the SRS and EGFR-TKI cohorts shared similar prognostic features, the WBRT cohort was more likely to have a less favorable prognosis ( P = .001). Conclusion This multi-institutional analysis demonstrated that the use of upfront EGFR-TKI, and deferral of radiotherapy, is associated with inferior OS in patients with EGFR-mutant NSCLC who develop brain metastases. SRS followed by EGFR-TKI resulted in the longest OS and allowed patients to avoid the potential neurocognitive sequelae of WBRT. A prospective, multi-institutional randomized trial of SRS followed by EGFR-TKI versus EGFR-TKI followed by SRS at intracranial progression is urgently needed.

Primary lymphoma of the liver treated with extended left hepatic lobectomy

Primary lymphoma of the liver is an extremely rare entity; only five cases have been reported in the English language literature. Presented is a case report of a patient with primary hepatic lymphoma successfully treated by major liver resection. The current management trends are reviewed.

Treatment of Radiation-Induced Cognitive Decline

Opinion statementRadiation-induced cognitive decline in cancer survivors who have received brain radiotherapy is an insidious problem with worsening severity over time. Because of improved survival with modern therapies, an increasing number of long term survivors are affected with limited options for treatment once diagnosed. Recently there has been enthusiasm for evaluating new approaches to prevent the onset of radiation-induced cognitive decline. Clinical trials have assessed the role of pharmaceuticals such as memantine and donepezil in ameliorating the cognitive effects of brain irradiation. Radiosurgery, when clinically appropriate, allows for the avoidance or postponement of whole brain radiotherapy in some patients with brain metastases. Hippocampal-sparing intensity modulated radiotherapy has been proposed as a means of avoiding damage to regions of adult neurogenesis. Finally, cytoprotective agents are being investigated that target the molecular pathways that lead to brain injury and the resultant cognitive decline.

Multi-institutional experience of stereotactic body radiotherapy for large (≥5 centimeters) non-small cell lung tumors.

Stereotactic body radiotherapy (SBRT) is the standard of care for patients with nonoperative, early‐stage non–small cell lung cancer (NSCLC) measuring < 5 cm, but its use among patients with tumors measuring ≥5 cm is considerably less defined, with the existing literature limited to small, single‐institution reports. The current multi‐institutional study reported outcomes evaluating the largest such population reported to date.

Initial radiographic tumor control is similar following single or multi-fractionated stereotactic radiosurgery for jugular paragangliomas

OBJECTIVE To evaluate radiographic tumor control and treatment-related toxicity in glomus jugulare tumors treated with stereotactic radiosurgery (SRS). STUDY DESIGN Retrospective chart review. SETTING Tertiary academic referral center. PATIENTS Glomus jugulare tumors treated with SRS between 1998 and 2014 were identified. The data analysis only included patients with at least 18months of post-treatment follow up (FU). INTERVENTION Patients were treated with either single fraction or fractionated SRS. MAIN OUTCOME MEASURE Patient demographics and tumor characteristics were assessed. Radiographic control was determined by comparing pre and post treatment MRI, and was categorized as no change, regression, or progression. RESULTS Eighteen patients were treated with SRS, and 14 met inclusion criteria. Median age at treatment was 55years (range 35-79), and 71.4% of patients were female. 5 patients (35.7%) received single fraction SRS (dose range 15-18Gy), and 9 (64.3%) fractionated therapy (dose 3-7Gy×3-15 fractions). Median tumor volume was 3.78cm(3) (range 1.15-30.6). Median FU was 28.8months (range 18.6-56.1), with a mean of 31.7months. At their last recorded MRI, 7 patients (50%) had tumor stability, 6 (42.9%) had improvement, and 1 (7.1%) had progression. Disease improvement and progression rates in the single fraction group were 40% and 0%, and in the multiple-fraction group, 44.4% and 11.1%, respectively. There was no statistically significant difference in disease improvement (p=0.88) or progression (p=0.48) rates between groups (unpaired t-test). CONCLUSIONS At a median follow up of 28months, both single fraction and fractionated SRS appear to have comparable radiographic tumor control outcomes and toxicity profiles.

Short Course High Dose Radiotherapy in the Treatment of Anaplastic Thyroid Carcinoma

Purpose. Anaplastic thyroid carcinoma (ATC) is a rare but aggressive tumor with limited survival. To date, the ideal radiation treatment schedule, one that balances limited survival with treatment efficacy, remains undefined. In this retrospective series we investigate the effectiveness and tolerability of hypofractionated radiation therapy in the treatment of ATC. Methods. 17 patients with biopsy proven ATC treated between 2004 and 2012 were reviewed for outcomes and toxicity. All patients received short course radiation. Results. The most commonly prescribed dose was 54 Gy in 18 fractions. Median survival was 9.3 months. 47% of patients were metastatic at diagnosis and the majority of patients (88%) went on to develop metastasis. Death from local progression was seen in 3 patients (18%), 41% experienced grade 3 toxicity, and there were no grade 4 toxicities. Conclusions. Here we demonstrated the safety and feasibility of hypofractionated radiotherapy in the treatment of ATC. This approach offers shorter treatment courses (3-4 weeks) compared to traditional fractionation schedules (6-7 weeks), comparable toxicity, local control, and the ability to transition to palliative care sooner. Local control was dependent on the degree of surgical debulking, even in the metastatic setting.

CT-only planning for Gamma Knife radiosurgery in the treatment of trigeminal neuralgia: methodology and outcomes from a single institution.

Introduction: Gamma Knife radiosurgery (GKRS) has been established as a safe and effective treatment option for trigeminal neuralgia. Some patients have contraindications to magnetic resonance imaging (MRI), the standard stereotactic imaging used for GKRS treatment planning. Computerized tomography (CT) imaging may be used as an alternative in this scenario. We sought to evaluate the outcomes of our patients treated using this technique.