Curtis Miyamoto

Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy: Executive summary

In summary, SRS and SBRT require a team-based approach, staffed by appropriately trained and credentialed specialists. SRS and SBRT training should become a required part of radiation oncology residency training and of Accreditation of Medical Physics Educational Programs accredited clinical medical physics training. SRS and SBRT require significant resources in personnel, specialized technology, and implementation time. A thorough feasibility analysis of resources required to achieve the clinical and technical goals must be performed and discussed with all personnel, including medical center administration. Because various disease sites may have different clinical and technical requirements, feasibility and planning discussions are needed prior to undertaking new disease sites. Treatment of SRS/SBRT patients should adhere to established national guidelines. Acceptance and commissioning protocols and tests must be developed to explore in detail every aspect of the individual and integrated systems with the goal of ensuring safe and effective operation. A comprehensive quality assurance program, encompassing all clinical, technical, and patient-specific treatment aspects, must be developed to ensure SRS and SBRT are performed in a safe and effective manner. Patient safety in radiation therapy is everyones responsibility. Professional organizations, regulators, vendors, and end-users must demonstrate a clear commitment to working closely together to ensure the highest levels of safety and efficacy in stereotactic radiosurgery and stereotactic body radiation therapy.

Radioiodinated (I-125) monoclonal antibody 425 in the treatment of high grade glioma patients: ten-year synopsis of a novel treatment.

The present report is the follow-up of patients enrolled in a phase II clinical trial using 125I-MAb 425 as an adjuvant treatment for high grade gliomas. Patient median survivals support published data from an earlier preliminary report. From January 29, 1987 to January 25, 1997, 180 patients diagnosed with astrocytoma with anaplastic foci (AAF) and glioblastoma multiforme (GBM) were treated as outpatients with an average of three weekly intravenous or intraarterial injections of radiolabeled MAb 425. The mean dose was 140 mCi (5.2 GBq). Only one patient who received a single dose of more than 60 mCi (2.2 GBq) experienced acute toxicity. Patients received prior surgery and radiation therapy, with and without chemotherapy. Overall median survival for patients with GBM and AAF was 13.4 and 50.9 months, respectively, with Karnofsky Performance Status (KPS) ranging from 40 to 100 and age ranging from 11 to 75 years. Prognostic factors (KPS and age) correlated positively with increased survival, with KPS the most important determinant of median survival. Data analysis was performed on patients followed 5 years or longer. We conclude that the administration of 125I-MAb 425 with intensive medical management demonstrates a significant increase in median survival and should be considered a therapeutic regimen for the management of patients with high grade gliomas.

Ameloblastoma of the jaw. Treatment with radiation therapy and a case report.

Ameloblastoma of the jaw is an aggressive benign tumor of epithelial origin that has generally been treated surgically even for metastases. This article is a review of the literature and a report of a previously unpublished case. Despite earlier reports, it is suggested that the available data clearly indicate that it is a radiosensitive tumor. In this report, specific recommendations for radiation therapy are outlined, and guidelines for treatment planning, radiation dosage, and fractionation, expected outcome and follow-up are given.

Radiation therapy in the treatment of pituitary adenomas

Seventy-eight patients with pituitary adenomas were seen in the Department of Radiation Oncology at Hahnemann University between 1961 and 1986. Most were treated with megavoltage photons with or without prior surgery. In this group, 68 patients were followed: 39 were treated with radiation therapy (RT) alone, and 29 were treated with a combination of surgery and RT (S/RT). Patients were followed for 2 to 20 years. Of 68 patients, (97%) experienced complete response to treatment; 86% of the RT patients remained free of disease at 5 and 10 years. In the S/RT group, 100% and 94% remained free of disease at 5 and 10 years, respectively. Total disease-free survivals at 5 and 10 years were, respectively, 91% and 89%. The majority of the failures occurring in the RT group were with growth hormone-secreting tumors and Cushings disease. Of the 7 patients that failed or recurred (time to recurrence: 1–16 years posttreatment), 6 have been followed: 4 were treated with surgery, 1 with RT, and 1 with S/RT. All 6 have remained free of disease since salvage, with 2− to 14-year follow-up periods. Serious morbidity and mortality have been reported previously with bitemporal field radiation using kilovoltage and low megavoltage RT. However, there was no temporal lobe necrosis or death in any of the patients in this study.

Issues related to implementing a smoking cessation clinical trial for cancer patients.

Given high rates of smoking among cancer patients, smoking cessation treatment is crucial; yet limited data exist to guide integration of such trials into the oncologic context. In order to determine the feasibility of conducting smoking cessation clinical trials with cancer patients, screening and baseline data from a large randomized placebo-controlled pharmacotherapy trial were analyzed. Descriptive statistics and regression analyses were used to compare enrollees to decliners, describe program enrollees, and assess correlates of confidence in quitting smoking. Out of 14,514 screened patients, 263 (<2%) were eligible; 43 (16%) refused enrollment. Among the eligible patients, 220 (84%) enrolled. Enrollment barriers included smoking rate, medical history/contraindicated medication, lack of interest, and language. Compared to enrollees, decliners were more likely to have advanced cancer. The trial enrolled a sample of 67 (>30%) African Americans; participants had extensive smoking histories; many were highly nicotine dependent; and participants consumed about seven alcoholic beverages/week on average. Head and neck and breast cancer were the most common tumors. About 52 (25%) reported depressive symptoms. A higher level of confidence to quit smoking was related to lower depression and lower tumor stage. Integrating a smoking cessation clinical trial into the oncologic setting is challenging, yet feasible. Recruitment strategies are needed for patients with advanced disease and specific cancers. Once enrolled, addressing participant’s depressive symptoms is critical for promoting cessation.

A study of middle ear function in the treatment of nasopharyngeal carcinoma with IMRT technique

PURPOSE This study evaluates the difference in damage to middle ear function with CRT and IMRT techniques in the treatment of nasopharyngeal carcinoma (NPC). We explore the isthmus of the Eustachian tube (ET) as the key anatomic site for the prevention of radiation-induced otitis media with effusion. METHODS AND MATERIALS Eighty-two patients with NPC were divided into two groups: 40 patients treated with CRT and 42 patients treated with IMRT. The difference between dosage over the middle ear cavity and the isthmus of the ET was evaluated in both CRT group and IMRT group. All patients underwent hearing tests including pure tone audiometry and impedance audiometry before and after RT. RESULTS The dosage difference to the middle ear cavity and isthmus between these two groups was statistically significant (p<0.05). The difference in hearing test results between these two groups was also statistically significant (p<0.05). If we limited the dose to the middle ear cavity under 34 Gy and the dose to the isthmus under 53 Gy with IMRT, we may decrease radiation-induced OME even with the larger 2.25 Gy fraction size. CONCLUSIONS IMRT may have better protected the middle ear function compared with the CRT technique, even with larger fraction sizes than for the conventional CRT technique.

Repeat stereotactic body radiation therapy for patients with pulmonary malignancies who had previously received SBRT to the same or an adjacent tumor site.

OBJECTIVES Retrospective analysis of patients with recurrences at or closely adjacent to the site of prior lung stereotactic body radiation therapy (SBRT) who received repeat SBRT. MATERIALS AND METHODS Nine patients with non-small cell lung cancer (n = 8) or oligometastatic colonic adenocarcinoma (n = 1) were treated with image-guided lung SBRT to a median of 60 Gy (range, 30-60) in a median of 3 fractions (3-5). Patients developed in-field relapse (n = 3) or recurrence adjacent (≤ 3.5 cm away) to the previous tumor location (n = 6) and received 2 nd lung SBRT to a median of 60 Gy. RESULTS Median follow-up after 2 nd SBRT was 22 months (4-40). All completed prescribed course of repeat SBRT and acute toxicity was limited. There was no grade >3 late toxicity. 3 (33.3%) patients developed Grade 3 late reactions: 2 pulmonary and 1 chest wall pain. Late pulmonary toxicity included 2 (22.2%) patients with Grade 3 and 3 (33.3%) with Grade 2. One patient (11.1%) had late Grade 3 and 1 (11.1%) Grade 2 chest wall pain. 1 (11.1%) developed Grade 2 late brachial plexopathy. No myelopathy was observed. Two patients developed progression of tumors treated by 2 nd SBRT. Local recurrence free survival and overall survival was 75% and 68.6%, respectively at 2 years. Relative volume of ipsilateral lung receiving 5 Gy (V5) and V10 were lower for 2 nd SBRT. CONCLUSION Repeat image-guided SBRT for patients with small peripheral recurrences was feasible and severe toxicity was not observed. Additional studies are needed to evaluate the safety and efficacy of lung reirradiation using 2 nd SBRT.

Predictors of smoking cessation among cancer patients enrolled in a smoking cessation program.

Abstract Many cancer patients continue to smoke postdiagnosis, which is associated with poorer clinical outcomes. Identifying prospective predictors of smoking cessation among patients currently receiving smoking cessation treatment can help guide the development and implementation of smoking cessation programs with this population. Material and methods. Data from 246 cancer patients participating in a randomized placebo-controlled smoking cessation clinical trial were used to examine baseline predictors of end-of-treatment and six-month postbaseline smoking cessation outcomes. Baseline demographic, smoking-related, disease-related, and psychological variables were examined as predictors of biochemically-confirmed point-prevalence abstinence. Results. Multivariate analysis indicated that, for end-of-treatment abstinence, patients were significantly more likely to have quit smoking if they were older (OR = 1.06, 95% CI: 1.03–1.10, p < 0.05) and were diagnosed with a non-tobacco related cancer (OR = 2.54, 95% CI: 1.24–5.20, p < 0.05). Likewise, for six-month abstinence, patients were significantly more likely to have quit smoking if they were older (OR = 1.04, 95% CI: 1.01–1.08, p < 0.05) and were significantly less likely to have quit smoking if they were female (OR = 0.47, 95% CI: 0.22–0.97, p < 0.05). Patients with tobacco-related cancers and female patients reported significantly higher levels of depression symptoms (p < 0.05), which proved predictive of smoking relapse. Conclusions. Patient age, gender, and cancer-type may be important factors to consider when developing and implementing smoking cessation interventions for cancer patients.

Use of image-guided stereotactic body radiation therapy in lieu of intracavitary brachytherapy for the treatment of inoperable endometrial neoplasia

PURPOSE Retrospective analysis of patients with invasive endometrial neoplasia who were treated with external beam radiation therapy followed by stereotactic body radiation therapy (SBRT) boost because of the inability to undergo surgery or brachytherapy. METHODS AND MATERIALS We identified 11 women with stage I-III endometrial cancer with a median age of 78 years that were not candidates for hysterectomy or intracavitary brachytherapy secondary to comorbidities (91%) or refusal (9%). Eight patients were American Joint Committee on Cancer (AJCC) stage I (3 stage IA, 5 stage IB), and 3 patients were AJCC stage III. Patients were treated to a median of 4500 cGy at 180 cGy per fraction followed by SBRT boost (600 cGy per fraction×5). RESULTS The most common side effect was acute grade 1 gastrointestinal toxicity in 73% of patients, with no late toxicities observed. With a median follow-up of 10 months since SBRT, 5 patients (45%) experienced locoregional disease progression, with 3 patients (27%) succumbing to their malignancy. At 12 and 18 months from SBRT, the overall freedom from progression was 68% and 41%, respectively. Overall freedom from progression (FFP) was 100% for all patients with AJCC stage IA endometrial carcinoma, whereas it was 33% for stage IB at 18 months. The overall FFP was 100% for International Federation of Obstetrics and Gynecology grade 1 disease. The estimated overall survival was 57% at 18 months from diagnosis. CONCLUSION In this study, SBRT boost to the intact uterus was feasible, with encouragingly low rates of acute and late toxicity, and favorable disease control in patients with early-stage disease. Additional studies are needed to provide better insight into the best management of these clinically challenging cases.

Development and Preliminary Testing of PROGRESS: A Web-based Education Program for Prostate Cancer Survivors Transitioning from Active Treatment

PurposeThis formative research study describes the development and preliminary evaluation of a theory-guided, online multimedia psycho-educational program (PROGRESS) designed to facilitate adaptive coping among prostate cancer patients transitioning from treatment into long-term survivorship.MethodsGuided by the Cognitive-Social Health Information Processing Model (C-SHIP) and using health communications best practices, we conducted a two-phase, qualitative formative research study with early stage prostate cancer patients (n = 29) to inform the Web program development. Phase 1 included individual (n = 5) and group (n = 12) interviews to help determine intervention content and interface. Phase 2 employed iterative user/usability testing (n = 12) to finalize the intervention. Interview data were independently coded and collectively analyzed to achieve consensus.ResultsSurvivors expressed interest in action-oriented content on (1) managing treatment side effects, (2) handling body image and comorbidities related to overweight/obesity, (3) coping with emotional and communication issues, (4) tips to reduce disruptions of daily living activities, and (5) health skills training tools. Patients also desired the use of realistic and diverse survivor images.ConclusionsIncorporation of an established theoretical framework, application of multimedia intervention development best practices, and an evidence-based approach to content and format resulted in a psycho-educational tool that comprehensively addresses survivors’ needs in a tailored fashion.Implications for Cancer SurvivorsThe results suggest that an interactive Web-based multimedia program is useful for survivors if it covers the key topics of symptom control, emotional well-being, and coping skills training; this tool has the potential to be disseminated and implemented as an adjunct to routine clinical care.