Anna Shapiro

PET Response-Guided Treatment of Hodgkin's Lymphoma: A Review of the Evidence and Active Clinical Trials

Risk-adaptive therapy for Hodgkins lymphoma focuses on treatment modifications based on assessment of response. [18F]Fluoro-deoxyglucose positron emission tomography (PET) performed during or after completion of chemotherapy is a strong prognostic factor for eventual treatment outcome. Conceptually, this strategy seeks to increase efficacy and minimize toxicity through the appropriate selection of patients for either therapy escalation (high-risk, PET positive) or de-escalation (low-risk, PET negative). Preliminary evidence with tailoring both chemotherapy (drug selection, number of cycles, and dose) and radiotherapy (omission or inclusion) is varied; however, numerous clinical trials seeking to validate this approach are ongoing. This paper summarizes the available evidence and active protocols involving PET response-adapted therapy for adult (early and advanced stages) Hodgkins lymphoma.

Dosimetric and Clinical Analysis of Retreatment of Vertebral Body Metastases Using Intensity Modulated Radiation Therapy

pancreatic tumors by mega-voltage cone beam CT (MV-CBCT) is frequently difficult and daily localization is often based on more easily seen adjacent bony anatomy. Fiducial markers implanted into pancreatic tumors serve as surrogates for daily tumor position and may more accurately represent absolute tumor position. The purpose of this study using MV-CBCT image-guided IMRT was to compare differences in daily shifts based on alignment to implanted fiducial markers vs. alignment to adjacent bony anatomy. Materials/Methods: Gold fiducial markers were placed into the primary pancreatic tumor under endoscopic ultrasound guidance in12 patients. Patients subsequently received image-guided intensity modulated radiation therapy (IG-IMRT) at Allegheny General Hospital (Pittsburgh, PA). The markers were visible on both planning CT and daily MVCBCT. MV-CBCT was performed prior to each fraction and shifts were calculated based on alignment to the fiducial markers. We retrospectively reviewed the archived MV-CBCT datasets and calculated shifts in lateral, longitudinal and vertical axes relative to the initial imaging plan based on alignment to adjacent bony anatomy for each fraction. These were compared to shifts based on alignment to fiducial markers. Results: 243 fractions were analyzed. Neither complications secondary to fiducial marker placement nor instances of fiducial migration were observed. The mean absolute difference in shifts between those based on fiducial markers and those from alignment to bony anatomy was 3 mm (range 0–13 mm), 6 mm (range 0–21 mm), and 3 mm (range 0–12 mm), in the lateral, longitudinal and vertical directions respectively. The mean 3-dimensional vector shift difference between markers vs. bony anatomy alignment was 8.6 mm. Sixty-four (26.3%) fractions had a shift difference of at least 1 cm in at least one axis and 96 (39.5%) had a 3dimensional vector shift of at least 1 cm. Conclusions: These data suggest that fiducial markers used in conjunction with MV-CBCT improve accuracy of daily target delineation compared to localization using adjacent bony anatomy. The magnitude of the shift differences we report are consistent withc those in other reports using gold markers implanted into pancreatic tumors in conjunction with portal imaging and to data using implanted electromagnetic transponders. The reasons for movement of pancreatic tumors relative to adjacent bony anatomy are unknown but may include daily variations in gastric distension or biliary drainage. Our series suggests that gold fiducial markers placed in pancreatic tumors under EUS-guidance are well-tolerated, easily visible on MV-CBCT and remain stably positioned in the tumor throughout the course of radiotherapy.

Intractable nausea in a patient with synchronous pancreatic cancer and a fourth-ventricular ependymoma

Symptoms of nausea and vomiting can present a diagnostic challenge for physicians. In this article, we report a patient who was found to have synchronous presentation of an ependymoma and pancreatic cancer. This case illustrates some of the diagnostic challenges in patients with constitutional symptoms. Furthermore, it illustrates the importance of surgical intervention as both a diagnostic as well as a therapeutic measure when managing patients with presumed metastatic disease to the brain.