Amr Aref

Bilateral Risk for Subsequent Breast Cancer After Lobular Carcinoma-In-Situ: Analysis of Surveillance, Epidemiology, and End Results Data

PURPOSE Noninvasive lesions involving the lobules of the breast are increasingly diagnosed as incidental microscopic findings at the time of lumpectomy or core-needle biopsy. We investigated the incidence rates of invasive breast cancer (IBC) after a diagnosis of lobular carcinoma-in-situ (LCIS) by using Surveillance, Epidemiology, and End Results (SEER) data. PATIENTS AND METHODS Patients (N = 4,853) having a diagnosis of primary LCIS in the time period of 1973 to 1998 were identified using the SEER Public Use CD-ROM data. The database was then searched for patients with subsequent primary IBC occurrences (n = 350). The clinical and pathologic characteristics of patients with subsequent primary IBCs were compared with the characteristics of patients with primary IBCs attained during the same time period (N = 255,114). RESULTS The incidence of IBC increased over time from diagnosis of LCIS, with 7.1% +/- 0.5% incidence of IBC at 10 years. IBCs detected after partial mastectomy occurred in either breast (46% ipsilateral and 54% contralateral); however, after mastectomy, most IBCs were contralateral (94.7%). IBCs occurring after LCIS more often represented invasive lobular histology (23.1%) compared with primary IBCs (6.5%). The standardized incidence ratio (the ratio of observed to expected cases) for developing IBC was 2.4 (95% CI, 2.1 to 2.6) adjusted for age and year of diagnosis. CONCLUSION LCIS is associated with increased risk of subsequent invasive disease, with equal predisposition in either breast. The minimum risk of developing IBC after LCIS is 7.1% at 10 years.

Sarcoma as a second malignancy after treatment for breast cancer

BACKGROUND Second malignant neoplasms may be a consequence of radiotherapy for the treatment of breast cancer. Prior studies evaluating sarcomas as second malignant neoplasms in breast cancer patients have been limited by the numbers of patients and relatively low incidence of sarcoma. Using data from the Surveillance, Epidemiology and End Results registries, we evaluated the influence of radiation therapy on the development of subsequent sarcomas in cases with primary breast cancer. METHODS Cases with primary invasive breast cancer (n = 274,572) were identified in the Surveillance, Epidemiology and End Results Cancer Incidence Public-Use Database (1973-1997). The database was then queried to determine the cases developing subsequent sarcomas (n = 263). Eighty-seven of these cases received radiation therapy, and 176 had no radiation therapy. The cumulative incidence of developing secondary sarcoma and the survival post developing secondary sarcoma were determined by the Kaplan-Meier method. RESULTS The occurrence of sarcoma was low, regardless of whether cases received or did not receive radiation therapy: 3.2 per 1,000 (SE [standard error] = 0.4) and 2.3 per 1,000 (SE = 0.2) cumulative incidence at 15 years post diagnosis, respectively (p = 0.001). Of the sarcomas occurring within the field of radiation, angiosarcoma accounted for 56.8%, compared to only 5.7% of angiosarcomas occurring in cases not receiving radiotherapy. The cumulative incidence of angiosarcoma at 15 years post diagnosis was 0.9 per 1,000 for cases receiving radiation (SE = 0.2) and 0.1 per 1,000 for cases not receiving radiation (SE < 0.1). Overall survival was poor for cases of sarcoma after breast cancer (27-35% at 5 years), but not significantly different between patients receiving or not receiving radiation therapy for their primary breast cancer. CONCLUSIONS Radiotherapy in the treatment of breast cancer is associated with an increased risk of subsequent sarcoma, but the magnitude of this risk is small. Angiosarcoma is significantly more prevalent in cases treated with radiotherapy, occurring especially in or adjacent to the radiation field. The small difference in risk of subsequent sarcoma for breast cancer patients receiving radiotherapy does not supersede the benefit of radiotherapy.

Mastication and swallowing in patients with postirradiation xerostomia

PURPOSE Very little objective data has been reported on mastication and swallowing in xerostomic patients, which would substantiate presumed causal relationships between xerostomia and patient complaints. The purpose was to elucidate which components of mastication and swallowing were abnormal, and most directly related to xerostomia, and which appeared unaffected. METHODS AND MATERIALS A retrospective analysis of timing events in mastication and swallowing was done using videofluoroscopic data for 15 cancer patients with xerostomia, and 20 normal controls. Scintigraphy was also used to determine oropharyngeal residue after a water swallow. Cancer treatment modalities included radiation therapy or chemoradiation therapy. RESULTS For barium liquid and paste substances, timing measures were equivalent for controls and patients. Xerostomic patients took 46% longer to masticate a shortbread cookie, and timing for the initiation of swallowing was shorter, but duration of swallowing appeared unaffected. Oral and pharyngeal residues following the swallow were greater in the patient group. CONCLUSIONS Xerostomia primarily affected mastication and oral manipulation of a dry, absorbent food material. Increased oral and pharyngeal residues after a water swallow are ambiguously related to xerostomia. The initiation and duration of the pharyngeal swallow was not abnormal.

Objective evaluation of the quality of voice following radiation therapy for T1 glottic cancer

BACKGROUND Radiation therapy is commonly considered the treatment of choice for T1 glottic cancer. While it is generally believed that the quality of voice following irradiation is quite satisfactory, few studies have reported the results of objective assessment of voice after radiation therapy. PURPOSE To objectively evaluate the quality of voice following radiation therapy for T1 glottic cancer. MATERIALS AND METHODS The voices of 12 patients treated for T1 glottic cancer with radiation therapy were evaluated by acoustic analysis and speech aerodynamic studies. Eleven patients received between 6300 and 6665 cGy at a daily fraction size of 180-225 cGy. One patient received 7000 cGy at a daily fraction size of 200 cGy. Evaluation of the quality of voice was done 3 months to 7 years following completion of radiation therapy. RESULTS The number of patients who scored abnormal values for the measurements of fundamental frequency, jitter, shimmer and harmonic to noise ratio was 2, 10, 4 and 3, respectively. The number of patients who scored abnormal values for transglottic airflow rate, subglottal pressure and glottal resistance was 12, 8 and 9, respectively. None of the studied patients scored normal values in all given tests. CONCLUSION Although radiation therapy cures a high proportion of patients with T1 glottic cancer, the quality of voice does not return to normal following treatment.

American College of Radiology appropriateness criteria on multiple brain metastases.

EXPERT PANEL ON RADIATION ONCOLOGY–BRAIN METASTASES; GREGORY M. M. VIDETIC, M.D.,* LAURIE E. GASPAR, M.D., M.B.A.,y AMR M. AREF, M.D.,z ISABELLE M. GERMANO, M.D.,x BRIAN J. GOLDSMITH, M.D.,k JOSEPH P. IMPERATO, M.D.,{ KAREN J. MARCUS, M.D., MICHAEL W. MCDERMOTT, M.D.,** MARK W. MCDONALD, M.D.,yy ROY A. PATCHELL, M.D.,zz H. IAN ROBINS, M.D., PH.D.,xx C. LELAND ROGERS, M.D.,kk JOHN H. SUH, M.D.,* AARON H. WOLFSON, M.D.,{{ AND FRANZ J. WIPPOLD, II, M.D.

ACR Appropriateness Criteria®: Single Brain Metastasis

Single brain metastasis represents a common neurologic complication of cancer. Given the number of treatment options that are available for patients with brain metastasis and the strong opinions that are associated with each option, appropriate treatment for these patients has become controversial. Prognostic factors such as recursive partitioning analysis and graded prognostic assessment can help guide treatment decisions. Surgery, whole brain radiation therapy (WBRT), stereotactic radiosurgery or combination of these treatments can be considered based on a number of factors. Despite Class I evidence suggestive of best therapy, the treatment recommendation is quite varied among physicians as demonstrated by the American College of Radiologys Appropriateness Panel on single brain metastasis. Given the potential concerns of the neurocognitive effects of WBRT, the use of SRS alone or SRS to a resection cavity has gained support. Since aggressive local therapy is beneficial for survival, local control and quality of life, the use of these various treatment modalities needs to be carefully investigated given the growing number of long-term survivors. Enrollment of patients onto clinical trials is important to advance our understanding of brain metastasis.

Larynx motion associated with swallowing during radiation therapy

PURPOSE A basis is presented for predicting the reduction in radiation dose to the larynx attributable to swallowing during radiation therapy treatment. METHODS AND MATERIALS Laryngeal movement associated with swallowing can occur during radiation therapy even when the patients head is immobilized. Data on the extent and timing of laryngeal motions and the frequency of swallowing were used to predict the effect such motion would have on accuracy of radiation dose to the larynx. RESULTS In a nontracheostomized adult the larynx elevates approximately 2 cm during a swallow and moves anteriorly less than 1 cm. The normal frequency of swallowing in the supine position is once every 1-2 min. During therapy, the likelihood of a swallow occurring during an irradiation interval depended on the duration of the interval. For irradiation intervals less than 2 min long the ratio of number of swallows to number of intervals was 0.27. For irradiation intervals between 2-3 min long the ratio was 1.76. Based on conservative estimates of radiation field dimensions, larynx motion, and incidence of swallowing, the reduction in radiation dose attributable to swallowing during treatment would be approximately 0.5%. CONCLUSION With small fields the total dose is only decreased by 0.5% with swallowing, so the change in the total dose is insignificant.

Outcome of pyriform sinus cancer : a retrospective institutional review

Pyriform sinus cancer remains one of the most lethal of human diseases. Regardless of approach attempted significant enhancement of survival has not been realized. In this study a retrospective single institutional review of all patients diagnosed with pyriform sinus cancer during the 1980s was conducted. The results in 93 patients show an overall determinant 5‐year survival of 14.3%. Of patients undergoing surgery, median determinant survival was 37 months and 5‐year survival was 34.6%. In resectable patients treated with radiation with or without chemotherapy, median determinant survival was 13 months with 5‐year survival of 7.1% (P<.01). Surgical salvage was attempted in 8 patients without success.

Adequate irradiation of the internal jugular lymph node chain: Technical considerations

PURPOSE This research aimed to study the anatomic relationship between the internal jugular vein with the surrounding internal jugular lymph node chain and the underlying bony anatomical structures which are commonly used as landmarks for radiation therapy planning. METHODS AND MATERIALS Twelve patients with carcinoma of the head and neck region were studied prospectively. Using our three-dimensional planning system, a beams-eye view of the internal jugular vein was projected onto a lateral and anterior simulation film. Quantitative measurements were made in every case of the anatomic relationship between the internal jugular vein and the posterior border of the cervical vertebrae and sagittal midline. RESULTS The distance between the posterior border of the internal jugular vein and the posterior border of the cervical vertebrae ranged between 0 and 2.5 cm. The distances between the sagittal midline and the medial border of the internal jugular veins ranged between 2 and 4 cm. CONCLUSION To ensure adequate irradiation of the internal jugular lymph nodes, the posterior border of the lateral radiation therapy upper-neck fields should be placed at least 1 cm posterior to the posterior aspect of the cervical vertebrae. The midline block used in the lower neck anterior field should not exceed 2 cm in width.

Design considerations for a computer controlled multileaf collimator for the Harper Hospital fast neutron therapy facility

The d(48.5) + Be neutron beam from the Harper Hospital superconducting cyclotron is collimated using a unique multirod collimator (MRC). A computer controlled multileaf collimator (MLC) is being designed to improve efficiency and allow for the future development of intensity modulated radiation therapy with neutrons. For the current study the use of focused or unfocused collimator leaves has been studied. Since the engineering effort associated with the leaf design and materials choice impacts significantly on cost, it was desirable to determine the clinical impact of using unfocused leaves in the MLC design. The MRC is a useful tool for studying the effects of using focused versus unfocused beams on beam penumbra. The effects of the penumbra for the different leaf designs on tumor and normal tissue DVHs in two selected sites (prostate and head and neck) was investigated. The increase in the penumbra resulting from using unfocused beams was small (approximately 1.5 mm for a 5 x 5 cm2 field and approximately 7.6 mm for a 25 x 25 cm2 field at 10 cm depth) compared to the contribution of phantom scatter to the penumbra width (5.4 and 20 mm for the small and large fields at 10 cm depth, respectively). Comparison of DVHs for tumor and critical normal tissue in a prostate and head and neck case showed that the dosimetric disadvantages of using an unfocused rather than focused beam were minimal and only significant at shallow depths. For the rare cases, where optimum penumbra conditions are required, a MLC incorporating tapered leaves and, thus, providing focused collimation in one plane is necessary.