Brendan Martin

Concurrent chemotherapy is associated with improved survival in elderly patients with bladder cancer undergoing radiotherapy

The current study was conducted to compare the overall survival (OS) of concurrent chemoradiotherapy (CCRT) versus radiotherapy (RT) alone in elderly patients (those aged ≥80 years) with muscle‐invasive bladder cancer (MIBC).

Adjuvant Radiotherapy Use by US Radiation Oncologists After Radical Cystectomy for Muscle-invasive Bladder Cancer

AIMS Historic trials suggested significant toxicity with adjuvant radiotherapy (ART) after radical cystectomy for muscle-invasive bladder cancer (MIBC). However, recent trials have found improved locoregional control and the 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ART consideration for select patients at high risk of local recurrence. ART practice patterns among US radiation oncologists are unknown and we carried out a survey to explore current trends. MATERIALS AND METHODS We conducted a survey of US radiation oncologists regarding the management of patients with cT2-3N0M0 transitional cell MIBC. Responses were reported using descriptive statistics. Chi-square and univariate logistic regression of clinical and demographic covariates were conducted, followed by multivariable logistic regression analysis to identify factors predicting for ART use. RESULTS In total, 277 radiation oncologists completed our survey. Nearly half (46%) have used ART for MIBC at least once in the past. In ART users, indications for ART include gross residual disease (93%), positive margins (92%), pathological nodal involvement (64%), pT3 or T4 disease (46%), lymphovascular invasion (16%) and high-grade disease (13%). On univariate logistic regression, ART use was associated with the number of years in practice (P=0.04), pre-cystectomy radiation oncology consultation (P=0.004), primarily treating MIBC patients fit for cystectomy (P=0.01) and intensity-modulated radiotherapy use (P=0.01). On multivariable logistic regression analysis, routine pre-cystectomy radiation oncology consultation (odds ratio 1.91, 95% confidence interval 1.04-3.51; P=0.04) and intensity-modulated radiotherapy use (odds ratio 2.77, 95% confidence interval 1.48-5.22; P=0.002) remained associated with ART use. CONCLUSIONS ART use is controversial in bladder cancer, yet unexpectedly has commonly been used among US radiation oncologists treating patients with MIBC after radical cystectomy. NRG-GU001 was a randomised trial in the US randomizing patients with high-risk pathological findings for observation or ART after cystectomy. However, due to poor accrual it recently closed and thus it will be up to other international trials to clarify the role of ART and identify patients benefiting form this adjuvant therapy.

Identification of Preoperative and Intraoperative Risk Factors for Complications in the Elderly Undergoing Elective Craniotomy

BACKGROUND Neurosurgical patients are aging as the general population is becoming older. METHODS A retrospective review of patients ≥65 years of age who underwent an elective craniotomy from 2007 to 2015 to identify risk factors for 30-day morbidity/mortality was conducted. Key preoperative variables included age, comorbidities, and functional status based on the Karnofsky Performance Status score and modified Rankin Scale score. Outcome variables included long-term care (LTC) complications, neurologic complications, systemic/infectious complications, length of stay, functional outcomes, and mortality. RESULTS A total of 286 patients ≥65 years underwent elective craniotomy at Loyola University Medical Center over 8 years. Seventy-two patients had a preoperative neurologic deficit and 95 had a systemic morbidity before surgery. Postoperative neurologic and systemic morbidity was 14% and 23%, respectively. 7% of patients experienced a LTC complication and 5 patients (1.7%) died. Worse preoperative scores on both the Karnofsky Performance Status and modified Rankin Scale predicted increased length of stay and mortality (P < 0.05). Univariable and multivariable analyses showed that patients with preoperative motor deficit, altered mental status, congestive heart failure, smoking history, and chronic steroid use were all more likely to have an LTC complication, and increased anesthesia time and estimated blood loss increased risk for LTC, neurologic, and systemic/infectious complications. CONCLUSIONS This study identifies factors that predict perioperative complications for elderly patients undergoing elective craniotomies, particularly congestive heart failure, smoking history, chronic steroid use, anesthesia time, and estimated blood loss. Age alone should not preclude elective craniotomy.

Risk of Pseudoarthrosis After Spinal Fusion: Analysis From the Healthcare Cost and Utilization Project

BACKGROUND Pseudoarthrosis after spinal fusion is an important cause of pain, neurologic decline, and reoperation. METHODS The Healthcare Cost and Utilization Project State Inpatient Databases were queried in New York, California, Florida, and Washington for adult patients who had undergone new spinal fusion from 2009 to 2011. In accordance with the Healthcare Cost and Utilization Project methods series and analysis guidelines, generalized linear mixed effects models were used to estimate the odds of experiencing postoperative pseudoarthrosis as a function of multivariable patient characteristics, comorbidities, and surgical approach. RESULTS Of the 107,420 patients who had undergone cervical fusion, 1295 (1.2%) developed pseudoarthrosis requiring reoperation. On multivariable analysis, the risk factors included posterior (odds ratio [OR], 4.47; 95% confidence interval [CI], 3.92-5.10) and combined (OR, 1.77; 95% CI, 1.33-2.36) approaches, fusion of ≥9 vertebrae (OR, 2.54; 95% CI, 1.38-4.68), smoking (OR, 1.19; 95% CI, 1.05-1.34), and long-term steroid use (OR, 1.89; 95% CI, 1.18-3.00). Of the 148,081 patients who underwent thoracic or lumbar fusion, 2665 (1.8%) developed pseudoarthrosis. Posterior (OR, 0.58; 95% CI, 0.51-0.56) and combined (OR, 0.46; 95% CI, 0.40-0.54) approaches resulted in reduced rates. Fusion of 4-8 vertebrae (OR, 1.52; 95% CI, 1.39-1.67), ≥9 vertebrae (OR, 1.87; 95% CI, 1.49-2.34), hypertension (OR, 1.18; 95% CI, 1.09-1.28), sleep apnea (OR, 1.48; 95% CI, 1.26-1.72), smoking (OR, 1.22; 95% CI, 1.12-1.33), and long-term steroid use (OR, 1.53, 95% CI, 1.08-2.18) resulted in increased rates. CONCLUSIONS These findings strongly associate several diagnoses with the development of pseudoarthrosis. However, further prospective studies are warranted to establish causation.

Predictors of Distant Failure After Stereotactic Body Radiation Therapy for Stages I to IIA Non–Small-Cell Lung Cancer

Purpose: The use of stereotactic body radiation therapy (SBRT) has emerged as an effective treatment modality for patients with early‐stage non–small‐cell lung cancer (NSCLC), with excellent local control rates. Despite this, there is a predominant pattern of distant failure. We sought to identify factors that help predict which patients with stages I to IIA NSCLC treated with SBRT are at highest risk of distant failure, so that we may utilize these factors in the future to help determine which patients may benefit from the addition of systemic therapies. Patients and Methods: We retrospectively reviewed 292 patients treated with SBRT for early stage NSCLC from 2006 to 2016 at 2 institutions. Patients were classified by T stage, tumor size, location and histology, pretreatment positron emission tomography/computed tomography (PET/CT) standardized uptake value (SUV), smoking status, and age. The primary endpoint of the study was distant failure. We aimed to analyze if patient characteristics could be identified that predicted for distant failure through the use of competing risk analysis. Results: The median follow‐up was 21.9 months. The median dose of radiation and fractionation delivered was 50 Gy (range, 45‐65 Gy) in 5 fractions (range, 3‐13 fractions). The median patient age was 72.8 years (interquartile range, 65.4‐79.7 years). The 2‐year distant failure was 22.0%, and overall survival at 2 years was found to be 61.0%. For every 1‐year increase in patient age, the hazard of distant failure at any given time was 3% lower (hazard ratio, 0.97; 95% confidence interval, 0.94‐0.99; P = .04). None of the remaining characteristics emerged as significant risk factors for distant failure on univariable or multivariable analysis. Conclusions: Overall, our cohort had distant failure and survival rates comparable with what has been described in the literature. Although we were unable to identify factors outside of age that correlated to risk of distant failure, this topic warrants further investigation, as distant failure is the primary pattern of failure with SBRT when used as the primary management for early‐stage NSCLC. Additional molecular studies are needed to further inform on the role of systemic therapy in patients with early‐stage NSCLC to improve clinical outcomes.

What are the predictors that can help identify safe removal of drains following pancreatectomy

BACKGROUND The management of a drain after Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) remains a controversial issue. Our aim in this study was to identify a safe time for drain removal. STUDY DESIGN This is a retrospective study, of a prospective database, of patients who underwent a PD or DP at two tertiary care institutions. RESULTS A total of 180 patients underwent PD and DP during the observation period. Seventeen patients developed fistulas (9.4%), with 70.6% (n = 12) developing in soft pancreatic remnants vs. 29.4% (n = 5) in firm pancreatic remnants. Patients with amylase levels greater than 173 U/L on a postoperative day three were 11.46 times more likely to form a fistula compared to those with an amylase level at or below 173 U/L (p < .001). CONCLUSION Fistula formation is associated with pancreas texture, duct size, and drain amylase following PD or DP. Patients with firm pancreatic texture and large ducts are less likely to develop fistulas than those with soft pancreatic texture and small ducts.

Transitioning from a Low Dose Rate to a High Dose Rate Prostate Brachytherapy Program: Comparing Initial Dosimetry and Improving Workflow Efficiency through Targeted Interventions

Purpose We transitioned from a low-dose-rate (LDR) to a high-dose-rate (HDR) prostate brachytherapy program. The objective of this study was to describe our experience developing a prostate HDR program, compare the LDR and HDR dosimetry, and identify the impact of several targeted interventions in the HDR workflow to improve efficiency. Methods and Materials We performed a retrospective cohort study of patients treated with LDR or HDR prostate brachytherapy. We used iodine-125 seeds (145 Gy as monotherapy, and 110 Gy as a boost) and preoperative planning for LDR. For HDR, we used iridium-192 (13.5 Gy × 2 as monotherapy and 15 Gy × 1 as a boost) and computed tomography–based planning. Over the first 18 months, we implemented several targeted interventions into our HDR workflow to improve efficiency. To evaluate the progress of the HDR program, we used linear mixed-effects models to compare LDR and HDR dosimetry and identify changes in the implant procedure and treatment planning durations over time. Results The study cohort consisted of 122 patients (51 who received LDR and 71 HDR). The mean D90 was similar between patients who received LDR and HDR (P = .28). HDR mean V100 and V95 were higher (P < .0001), but mean V200 and V150 were lower (P < .0001). HDR rectum V100 and D1cc were lower (P < .0001). The HDR mean for the implant procedure duration was shorter (54 vs 60 minutes; P = .02). The HDR mean for the treatment planning duration dramatically improved with the implementation of targeted workflow interventions (3.7 hours for the first quartile to 2.0 hours for the final quartile; P < .0001). Conclusions We successfully developed a prostate HDR brachytherapy program at our institution with comparable dosimetry to our historic LDR patients. We identified several targeted interventions that improved the efficiency of treatment planning. Our experience and workflow interventions may help other institutions develop similar HDR programs.

Prognostic Indices for Predicting Facial Nerve Outcome following the Resection of Large Acoustic Neuromas

&NA; This study analyzes the simple ratio of anterior‐to‐posterior extension of large (>2.5 cm) acoustic neuromas relative to the internal auditory canal (ICA; anterior‐posterior [A/P] index) as a tool for predicting risk of facial nerve (FN) injury. In total, 105 patients who underwent microsurgical resection for large acoustic neuromas were analyzed retrospectively. House‐Brackmann (HB) scores were assessed immediately postoperatively, at 1 month, and at 1 year. Lateral‐medial, inferior‐superior, A/P, and maximum diameters were measured from preoperative magnetic resonance images. These measurements and the A/P index were analyzed using univariable and multivariable statistical models to assess relationship to FN outcomes. The retrosigmoid, translabyrinthine, and combined approaches were used, and the extent of resection was evaluated. For every 1 standard deviation increase in the A/P index, a patient was 3.87 times more likely have a higher postoperative HB score (p < 0.0001). Accordingly, for every 1‐mm increase anterior to the IAC, a patient was 16% more likely have a higher postoperative HB score (p < 0.001). After controlling for tumor size, a patient was still 3.82 times more likely have a higher postoperative HB score for every 1 standard deviation increase in the A/P index (p < 0.0001). While larger tumor size trended toward worse postoperative HB scores, it was not statistically significant. Our prognostic index may be useful to assess the risk of FN injury preoperatively for large acoustic neuromas, while also providing information about the tumor‐nerve relationship.

Improving the Accessibility of Patient Care Through Integration of the Hospital and Radiation Oncology Electronic Health Records

PURPOSE Radiation therapy (RT)-specific aspects of a patients cancer care commonly are documented and scheduled through a radiation oncology electronic health record (rEHR). However, patients who receive RT also receive multidisciplinary care from providers who use the hospital EHR (hEHR). We created an electronic interface to integrate our hEHR and rEHR to improve communication of the RT aspects of care between our department and the rest of the hospital. The objective of this study was to assess the impact of rEHR and hEHR integration on the accessibility of the RT-specific aspects of patient care to providers. METHODS AND MATERIALS We performed a preintegration and postintegration survey of 175 staff members at our academic cancer center. Respondents rated the importance and accessibility of several RT encounters and documents on a Likert scale. The Wilcoxon-Mann-Whitney, χ2, and Fishers exact tests were used to compare preintegration and postintegration responses. RESULTS There were 32 and 19 responses to the pre- and postintegration surveys, respectively. rEHR items most commonly reported to be at least moderately important were the dates of first treatment (n = 29 [91%]), last treatment (n = 29 [91%]), brachytherapy (n = 22 [69%]), radiosurgery (n = 22 [69%]), and computed tomography simulation (n = 21 [66%]). A drastic improvement was found in most items made visible in the hEHR through the interface. CONCLUSION By integrating our hEHR and rEHR, we improved the communication of patient care between the RT department and the multidisciplinary team. Institutions should pursue and support integration of the EHRs to improve the quality of care provided to patients with cancer.