Brandon J. Fisher

Hyperbaric Oxygen Therapy for Radiation-Induced Cystitis and Proctitis

PURPOSEnTo provide a retrospective analysis of the efficacy of hyperbaric oxygen therapy (HBOT) for treating hemorrhagic cystitis (HC) and proctitis secondary to pelvic- and prostate-only radiotherapy.nnnMETHODS AND MATERIALSnNineteen patients were treated with HBOT for radiation-induced HC and proctitis. The median age at treatment was 66 years (range, 15-84 years). The range of external-beam radiation delivered was 50.0-75.6 Gy. Bleeding must have been refractory to other therapies. Patients received 100% oxygen at 2.0 atmospheres absolute pressure for 90-120 min per treatment in a monoplace chamber. Symptoms were retrospectively scored according to the Late Effects of Normal Tissues-Subjective, Objective, Management, Analytic (LENT-SOMA) scale to evaluate short-term efficacy. Recurrence of hematuria/hematochezia was used to assess long-term efficacy.nnnRESULTSnFour of the 19 patients were lost to follow-up. Fifteen patients were evaluated and received a mean of 29.8 dives: 11 developed HC and 4 proctitis. All patients experienced a reduction in their LENT-SOMA score. After completion of HBOT, the mean LENT-SOMA score was reduced from 0.78 to 0.20 in patients with HC and from 0.66 to 0.26 in patients with proctitis. Median follow-up was 39 months (range, 7-70 months). No cases of hematuria were refractory to HBOT. Complete resolution of hematuria was seen in 81% (n = 9) and partial response in 18% (n = 2). Recurrence of hematuria occurred in 36% (n = 4) after a median of 10 months. Complete resolution of hematochezia was seen in 50% (n = 2), partial response in 25% (nxa0=xa01), and refractory bleeding in 25% (nxa0= 1).nnnCONCLUSIONSnHyperbaric oxygen therapy is appropriate for radiation-induced HC once less time-consuming therapies have failed to resolve the bleeding. In these conditions, HBOT is efficacious in the short and long term, with minimal side effects.

Cobalt, Linac, or Other: What Is the Best Solution for Radiation Therapy in Developing Countries?

The international growth of cancer and lack of available treatment is en route to become a global crisis. With >60% of cancer patients needing radiation therapy at some point during their treatment course, the lack of available facilities and treatment programs worldwide is extremely problematic. The number of deaths from treatable cancers is projected to increase to 11.5 million deaths in 2030 because the international population is aging and growing. In this review, we present how best to answer the need for radiation therapy facilities from a technical standpoint. Specifically, we examine whether cobalt teletherapy machines or megavoltage linear accelerator machines are best equipped to handle the multitudes in need of radiation therapy treatment in the developing world.

Implementation of a high-dose-rate brachytherapy program for carcinoma of the cervix in Senegal: a pragmatic model for the developing world.

West Africa has one of the highest incidence rates of carcinoma of the cervix in the world. The vast majority of women do not have access to screening or disease treatment, leading to presentation at advanced stages and to high mortality rates. Compounding this problem is the lack of radiation treatment facilities in Senegal and many other parts of the African continent. Senegal, a country of 13 million people, had a single (60)Co teletherapy unit before our involvement and no brachytherapy capabilities. Radiating Hope, a nonprofit organization whose mission is to provide radiation therapy equipment to countries in the developing world, provided a high-dose-rate afterloading unit to the cancer center for curative cervical cancer treatment. Here we describe the implementation of high-dose-rate brachytherapy in Senegal requiring a nonstandard fractionation schedule and a novel treatment planning approach as a possible blueprint to providing this technology to other developing countries.

Radiation oncology in Africa: improving access to cancer care on the African continent.

Radiation Oncology in Africa: Improving Access to Cancer Care on the African Continent Brandon J. Fisher, DO,* Larry C. Daugherty, MD,y John P. Einck, MD,{ Gita Suneja, MD,x Mira M. Shah, MD,k Luqman K. Dad, MD,{ Robert W. Mutter, MD, J. BenWilkinson, MD,** and Arno J. Mundt, MDz *Gamma West Cancer Services, Salt Lake City, Utah; yMayo Clinic, Jacksonville, Florida; zMoores Cancer Center, University of California San Diego, San Diego, California; xAbramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania; kHenry Ford Health System, Detroit, Michigan; {Anne Arundel Medical Center, Annapolis, Maryland; Mayo Clinic, Rochester, Minnesota; and **Willis-Knighton Health System/LSU Health Science Center, Shreveport, Louisiana

Why Target the Globe?: 4-year report (2009-2013) of the Association of Residents in Radiation Oncology Global Health Initiative

Departments of Radiation Oncology, *DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, Maryland, yHenry Ford Health Systems, Detroit, Michigan, zMayo Clinic, Rochester, Minnesota, xWashington University in St. Louis School of Medicine, St. Louis, Missouri, kKarmanos Cancer Center, Detroit Medical Center, Detroit, Michigan, {University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, **Gamma West Cancer Services, Ogden, Utah, yyMemorial Sloan-Kettering Cancer Center, New York, New York, and zzThe University of Texas, MD Anderson Cancer Center, Houston, Texas

Tumor bed-to-skin distance using accelerated partial-breast irradiation with the strut-adjusted volume implant device.

PURPOSEnBecause of the risk of skin toxicity with single dwell position, single-lumen brachytherapy devices are sometimes contraindicated for tumor cavities 5-7mm from the skin surface. We discuss the use of multicatheter device to treat patients with tumor bed-to-skin distances <7mm.nnnMETHODS AND MATERIALSnWe treated 117 patients with accelerated partial-breast irradiation brachytherapy: 77 single-lumen and 40 multicatheter devices. A subset of 12 patients treated with SAVI(®) had bed-to-skin spacing <7mm. All patients had Tis-2N0 ductal carcinoma with negative margins. A total dose of 34.0Gy in 10 fractions was delivered twice daily. Planning target volume was created using computed tomography-based three-dimensional planning with a 1.0-cm expansion of the lumpectomy cavity. Skin dose was measured dosimetrically, with skin constraints <125% of the prescription. Toxicities were graded, and patients were assessed at various intervals.nnnRESULTSnOf the patients treated with the multicatheter device, 0% (0/12) had their device pulled. At 2 weeks after treatment, fewer than 50% of the patients had skin toxicities of Grades 1-2, all of which resolved by 6 months. The cosmetic outcome was good to excellent at followup.nnnCONCLUSIONSnMulticatheter devices permit well-tolerated accelerated partial-breast irradiation in patients with tumor cavities near the skin surface for which the single-lumen device may not be appropriate.

A framework for the implementation of new radiation therapy technologies and treatment techniques in low-income countries

We present a practical, generic, easy-to-use framework for the implementation of new radiation therapy technologies and treatment techniques in low-income countries. The framework is intended to standardize the implementation process, reduce the effort involved in generating an implementation strategy, and provide improved patient safety by reducing the likelihood that steps are missed during the implementation process. The 10 steps in the framework provide a practical approach to implementation. The steps are, 1) Site and resource assessment, 2) Evaluation of equipment and funding, 3) Establishing timelines, 4) Defining the treatment process, 5) Equipment commissioning, 6) Training and competency assessment, 7) Prospective risk analysis, 8) System testing, 9) External dosimetric audit and incident learning, and 10) Support and follow-up. For each step, practical advice for completing the step is provided, as well as links to helpful supplementary material. An associated checklist is provided that can be used to track progress through the steps in the framework. While the emphasis of this paper is on addressing the needs of low-income countries, the concepts also apply in high-income countries.

Radiation prophylaxis as primary prevention of heterotopic ossification of the knee: classification of disease and indications for treatment

ObjectiveHeterotopic ossification (HO) of the knee joint is seen in up to 42xa0% of patients following total knee arthroplasty (TKA). Despite this prevalence, there is a paucity of data to validate the efficacy and after effects of prophylactic radiotherapy (PRT) to the knee to prevent HO. We report retrospectively our institution’s experience with 12 patients treated with PRT of the knee joint. We also present a classification scheme and review the indications for PRT following TKA.MethodsBetween 1999 and 2010, 112 patients were treated at our institution with PRT for prevention of HO. Of these patients, 12 underwent PRT to the knee joint and were included in our analysis. All patients were treated with one fraction of PRT to a total dose of 700xa0cGy. Primary end points were joint range of motion (ROM) and HO formation. ROM was evaluated as “limited” or “full” by the patient’s surgeon or primary care provider at the most recent follow-up examination. The most recent radiograph was evaluated for presence of HO.ResultsWith a median follow-up time of 78xa0months (range, 1–132xa0months), 0/12 patients had evidence of HO on x-ray imaging. Full ROM was documented in 11/12 patients. One patient had limited ROM at the most recent follow-up due to severe osteoarthritis. No patient had impaired mobility or ROM directly attributed to fibrosis or late effects of PRT.ConclusionBased on our retrospective analysis, PRT appears to be a safe, effective treatment for prophylaxis of HO in the knee joint.

A phase II study of surgical excision, temozolomide, radiotherapy, and anti-EGFR radioimmunotherapy (EXTRA) as adjuvant therapy in high-grade gliomas

ObjectiveDespite evolution in surgical technique, radiotherapy technology, and targeted systemic therapies, prognosis for patients with high-grade gliomas remains poor. Standard treatment consisting of surgery, adjuvant chemoradiation, and chemotherapy has marginally improved survival in these patients. A recent novel approach has been the addition of adjuvant radioimmunotherapy with 125I-labeled anti-epidermal growth factor receptor monoclonal antibody 425 (125I-epidermal growth factor receptor (EGFR) monoclonal antibody (MAb) 425), which demonstrated safety and efficacy in patients with glioblastoma. Many institutions choose to treat grade 3 gliomas in an identical fashion to grade 4 tumors. In this phase II clinical trial, we tested the efficacy of adjuvant radioimmunotherapy in patients with pathologic diagnosis of high-grade glioma comprising either glioblastoma (GBM) or astrocytoma with anaplastic foci (AAF).MethodsPatients with newly diagnosed high-grade gliomas were eligible. Adjuvant radiotherapy was delivered with a median dose of 60xa0Gy after surgery. 125I-EGFR MAb 425 was given by three weekly intravenous injections of 1.85xa0GBq of radiolabeled 125I-EGFR MAb 425 following surgery and adjuvant radiation. When administered, temozolomide was given concominantly (75xa0mg/m2/day, 35–42xa0days) with radiotherapy followed by 6xa0cycles of adjuvant temozolomide (TMZ) (150–200xa0mg/m2/dayu2009×u20095xa0days, every 28xa0days q28d). Median survival was the primary endpoint. We compared survival in three treatment groups: patients who underwent surgery followed by radiation (CTL), patients who underwent surgery and radiation followed by radioimmunotherapy (RIT), and patients who underwent RIT with the additional of temozolomide (RIT + TMZ).ResultsBetween 1988 and 2008, a total of 390 patients with high-grade glioma underwent treatment at Hahnemann University Hospital with a median age of 48xa0years. Median survival in months was 7.3, 39.7, and 79.4 in the CTL, RIT, and RIT + TMZ arms, respectively. Multivariate analysis, which controlled for age and extent of surgery, demonstrated a persistent survival benefit of RIT. Combined results are reported as well as subgroup analysis of GBM and AAF patients.ConclusionAdjuvant 125I-EGFR MAb 425 radioimmunotherapy is a safe and effective treatment for patients with high-grade glioma and warrants further study with a randomized trial.

Clinical experience using accelerated partial breast irradiation for ductal carcinoma in situ.

To the Editor:Breast-conserving therapy (BCT) has becomestandard care as an alternative to mastectomy in thetreatment of most women with early stage 0, I, and IIbreast cancer (1). BCT includes tumor excision bymeans of lumpectomy followed by a course of dailyfractions of external beam radiation therapy to thewhole breast (45–50 Gy), which can be, and often is,followed by a boost to the tumor bed with an addi-tional 6–10 fractions, which achieves a total dose of60–64 Gy. These treatments typically span 5–7 weeks.Studies looking at the patterns of failure and localrecurrence for patients with breast cancer found thatthe majority (about 90%) of early breast local recur-rences occurred at the site of the original primarytumor (2). This observation and the desire to shortenthe treatment times led to the idea of using acceleratedpartial breast irradiation (APBI), which concentratesthe dose of radiation at the site of the lumpectomycavity and simultaneously limits the dose to otherstructures. This type of therapy is typically given over5 days, which not only reduces the toxicity of irradia-tion but also reduces the total treatment time.Results from trials studying the efficacy of APBIhave been encouraging, in that multiple techniqueshave been effective in maintaining excellent local con-trol and cosmetic outcomes with minimal toxicity(3–6). Several phase III randomized studies of APBIare under way; in addition, we are awaiting the resultsof the National Surgical Adjuvant Breast and BowelProject B 39/Radiation Therapy Oncology Group0413 protocol (B-39) large phase III trial that com-pares ABPI to whole breast irradiation (WBI) in earlystage breast cancer, which is finishing accrual in thenear future (7–10).Ductal carcinoma in situ (DCIS) comprises approxi-mately 25% of all cases of breast cancer diagnosedeach year (1). The National Comprehensive CancerNetwork (NCCN) guidelines continue to recommendBCT with standard adjuvant WBI as a category 1 rec-ommendation for DCIS (11). This recommendation isbased on the results of multiple randomized controlledtrials (12,13) demonstrating the efficacy of this com-bined modality approach. Specifically, these studiesreport an approximate 50% relative risk reduction inlocal control with the addition of adjuvant RT. Nosubgroup of patients with DCIS has proved not tobenefit from postoperative radiotherapy (14,15). In2002, DCIS was included as acceptable for APBI inthe American Society for Breast Surgeons (ASBS)guidelines. The APBI Consensus Statement Task Forceof the American Society for Radiation Oncology(ASTRO) classifies the subset of patients with pureDCIS as “cautionary,” with a recommended tumorcutoff size of 3 cm (16). Recent publications haveshown excellent 5-year follow-up results in patientswith DCIS treated with APBI (17–20).At our institutions we have noted low recurrencerates and excellent or good cosmesis outcomes in100% of the patients treated with APBI after breastconservation surgery (BCS) for patients with DCIS.This letter is in response to requests from brachythera-py specialists to publicize institution-specific dataregarding the use of APBI to treat breast cancer. Wehave now treated over 40 patients with stage 0 breastcancer treated with BCS and adjuvant APBI. Allpatients had biopsy-proven DCIS, and three patientsalso had an invasive component along with DCIS.With a median follow-up was 27 months (range,0–72 months, the overall and cause-specific survivalrates were 95% and 100%, respectively. The24-month actuarial ipsilateral breast tumor recurrence(IBTR) rate was 2.5%, with one patient having arecurrence. Another patient developed a contralateral