D.C. Shrieve

Stage Presentation, Care Patterns, and Treatment Outcomes for Squamous Cell Carcinoma of the Penis

PURPOSEnPenile squamous cell carcinoma (SCC) is a rare entity, with few published series on outcomes. We evaluated the stage distributions and outcomes for surgery and radiation therapy in a U.S. population database.nnnMETHODS AND MATERIALSnSubjects with SCC of the penis were identified using the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) Program database between 1988 and 2006. Descriptive statistics were performed, and cause-specific survival (CSS) was estimated using Kaplan-Meier analysis. Comparisons of treatment modalities were analyzed using multivariate Cox regression. Subjects were staged using American Joint Committee on Cancer, sixth edition, criteria.nnnRESULTSnThere were 2458 subjects identified. The median age was 66.8 years (range, 17-102 years). Grade 2 disease was present in 94.5% of cases. T1, T2, T3, T4, and Tx disease was present in 64.8%, 17.1%, 9.5%, 2.1%, and 6.5% of cases, respectively. N0, N1, N2, N3, and Nx disease was noted in 61.6%, 6.9%, 4.0%, 3.7%, and 23.8% of cases, respectively. M1 disease was noted in 2.5% of subjects. Individuals of white ethnicity accounted for 85.1% of cases. Lymphadenectomy was performed in 16.7% of cases. The CSS for all patients at 5 and 10 years was 80.8% and 78.6%. By multivariable analysis grades 2 and 3 disease, T3 stage, and positive lymph nodes were adverse prognostic factors for CSS.nnnCONCLUSIONnSCC of the penis often presents as early-stage T1, N0, M0, grade 1, or grade 2 disease. The majority of patients identified were treated with surgery, and only a small fraction of patients received radiation therapy alone or as adjuvant therapy.

Resident-Reported Brachytherapy Experience in ACGME-Accredited Radiation Oncology Training Programs

PURPOSEnTo describe resident-reported experience in brachytherapy in Accreditation Council of Graduate Medical Education-accredited radiation oncology training programs over the last 5 years.nnnMETHODS AND MATERIALSnArchived reports of Accreditation Council of Graduate Medical Education final resident case logs from the last 5 years were reviewed and summarized. Brachytherapy was categorized according to the dose rate (low dose rate vs. high dose rate), technique (interstitial vs. intracavitary), and primary tumor site. Linear regression was used to test for trends.nnnRESULTSnThe mean number of total brachytherapy procedures performed per resident in the last 5 years has decreased from 80.8 in 2006-2007 to 71.0 in 2010-2011, but the trend is not statistically significant. The average number of intracavitary procedures has remained steady. The average resident experience with interstitial brachytherapy has decreased in a statistically significant manner. The average number of interstitial procedures has decreased by 25%.nnnCONCLUSIONSnThe average number of interstitial procedures reported by residents has decreased by 25%. The community charged with training residents in interstitial brachytherapy should consider methods to ensure that residents obtain sufficient experience in the future.

Evaluation of alignment error due to a speed artifact in stereotactic ultrasound image guidance

Ultrasound (US) image guidance systems used in radiotherapy are typically calibrated for soft tissue applications, thus introducing errors in depth-from-transducer representation when used in media with a different speed of sound propagation (e.g. fat). This error is commonly referred to as the speed artifact. In this study we utilized a standard US phantom to demonstrate the existence of the speed artifact when using a commercial US image guidance system to image through layers of simulated body fat, and we compared the results with calculated/predicted values. A general purpose US phantom (speed of sound (SOS) = 1540 m s(-1)) was imaged on a multi-slice CT scanner at a 0.625 mm slice thickness and 0.5 mm x 0.5 mm axial pixel size. Target-simulating wires inside the phantom were contoured and later transferred to the US guidance system. Layers of various thickness (1-8 cm) of commercially manufactured fat-simulating material (SOS = 1435 m s(-1)) were placed on top of the phantom to study the depth-related alignment error. In order to demonstrate that the speed artifact is not caused by adding additional layers on top of the phantom, we repeated these measurements in an identical setup using commercially manufactured tissue-simulating material (SOS = 1540 m s(-1)) for the top layers. For the fat-simulating material used in this study, we observed the magnitude of the depth-related alignment errors resulting from the speed artifact to be 0.7 mm cm(-1) of fat imaged through. The measured alignment errors caused by the speed artifact agreed with the calculated values within one standard deviation for all of the different thicknesses of fat-simulating material studied here. We demonstrated the depth-related alignment error due to the speed artifact when using US image guidance for radiation treatment alignment and note that the presence of fat causes the target to be aliased to a depth greater than it actually is. For typical US guidance systems in use today, this will lead to delivery of the high dose region at a position slightly posterior to the intended region for a supine patient. When possible, care should be taken to avoid imaging through a thick layer of fat for larger patients in US alignments or, if unavoidable, the spatial inaccuracies introduced by the artifact should be considered by the physician during the formulation of the treatment plan.

Novalis intensity-modulated radiosurgery: methods for pretreatment planning.

OBJECTIVEThe Novalis stereotactic radiotherapy system (BrainLAB, Heimstetten, Germany) allows for precise treatment of cranial base tumors with single-fraction radiosurgery. In some cases, however, proximity of the optic nerve and chiasm is a concern. In these cases, intensity-modulated stereotactic radiosurgery (IMRS) can be used to limit the dose to these structures. IMRS planning can be labor intensive, which poses a problem when it is performed on the day of treatment. We describe our methods and results of preprocedure planning for IMRS for patients with lesions in the cavernous sinus or parasellar regions in whom the dose to the optic nerve or chiasm might exceed our acceptable tolerance dose (8 Gy). METHODSPatients whose lesions were more than 4 mm from the optic nerve and chiasm on standard magnetic resonance imaging scans but who were questionable candidates for radiosurgery because of concerns of dose to the optic nerve or chiasm were considered for IMRS. Preprocedure imaging (computed tomography and magnetic resonance imaging) was fused and analyzed using the BrainLAB BrainScan 5.3 treatment planning system. Dynamic conformal arc plans for stereotactic radiosurgery and IMRS were evaluated. Doses to the planning target volume and optic apparatus were assessed by dose-volume histograms and conformality index calculated to characterize the quality of the different plans. When IMRS was used, the preplan allowed for a rapid recalculation on the treatment day, minimizing the time patients were in the head frame before treatment. RESULTSWe describe three patients with recurrent pituitary tumors and three with meningiomas. Doses were 1500 to 2000 cGy prescribed to the 80 to 96% isodose line delivered by eight to 22 fields. Tumor volumes ranged from 2.70 to 8.82 cm3 (mean, 5.7 cm3). In five of the six patients, the dynamic conformal arc plan precluded delivery of therapeutic dose without exceeding optic nerve tolerance. On the basis of 95% coverage of target volume, maximum prescription doses of 7.7 to 20.64 Gy were possible with the dynamic conformal arc plans without exceeding 8 Gy to the optic apparatus. IMRS allowed maximum doses of 20 to 31 Gy using the same optic apparatus dose restriction. No complications have occurred, and all tumors have remained stable since treatment (mean follow-up period, 30 mo). CONCLUSIONWe believe this pretreatment technique streamlines the process for IMRS, allowing for better patient comfort and efficient physician time use.

Time Course and Accumulated Risk of Severe Urinary Adverse Events After High- Versus Low-Dose-Rate Prostate Brachytherapy With or Without External Beam Radiation Therapy

PURPOSEnSevere urinary adverse events (UAEs) include surgical treatment of urethral stricture, urinary incontinence, and radiation cystitis. We compared the incidence of grade 3 UAEs, according to the Common Terminology Criteria for Adverse Events, after low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy, as well as after LDR plus external beam radiation therapy (EBRT) and HDR plus EBRT.nnnMETHODS AND MATERIALSnMen aged >65xa0years with nonmetastatic prostate cancer were identified from the Surveillance, Epidemiology, and End Results-Medicare database who were treated with LDR (n=12,801), HDR (n=685), LDR plus EBRT (n=8518), or HDR plus EBRT (n=2392).xa0The populations were balanced by propensity weighting, and the Kaplan-Meier incidence of severe UAEs was compared. Propensity-weighted Cox proportional hazards models were used to compare the adjusted hazard of UAEs. These UAEs were compared with those in a cohort of men not treated for prostate cancer.nnnRESULTSnMedian follow-up was 4.3xa0years. At 8xa0years, the propensity-weighted cumulative UAE incidence was highest after HDR plus EBRT (26.6% [95% confidence interval, 23.8%-29.7%]) and lowest after LDR (15.7% [95% confidence interval, 14.8%-16.6%]). The absolute excess risk over nontreated controls at 8xa0years was 1.9%, 3.8%, 8.4%, and 12.9% for LDR, HDR, LDR plus EBRT, and HDR plus EBRT, respectively. These represent numbers needed to harm of 53, 26, 12, and 8 persons, respectively. The additional risk of development of a UAE related to treatment for LDR, LDR plus EBRT, and HDR plus EBRT was greatest within the 2xa0years after treatment and then continued to decline over time. Beyond 4xa0years, the risk of development of a new severe UAE matched the baseline risk of the control population for all treatments.nnnCONCLUSIONSnToxicity differences were observed between LDR and HDR, but the differences did not meet statistical significance. However, combination radiation therapy (either HDR plus EBRT or LDR plus EBRT) increases the risk of severe UAEs compared with HDR alone or LDR alone. The highest increased risk of urinary toxicity occurs within the 2xa0years after therapy and then declines to an approximately 1% increase in incidence per year.

Treatment of oropharyngeal squamous cell carcinoma with external beam radiation combined with interstitial brachytherapy.

We reviewed the outcomes of oropharyngeal squamous cell carcinoma treated with external beam radiation and interstitial brachytherapy.

Factors influencing prostate cancer patterns of care: An analysis of treatment variation using the SEER database

Purpose The aim of this study is to describe the trends and factors that influence the initial treatment of men with localized prostate cancer (PC) in the United States between 2004 and 2014. Methods and materials The National Cancer Institutes Surveillance, Epidemiology and End Results database was used to identify patients with primary prostate adenocarcinoma between 2004 and 2014. Patients were staged in accordance with the American Joint Committee on Cancer 7th edition criteria and stratified according to the National Comprehensive Cancer Network guidelines risk group classification. Descriptive statistics describing treatment patterns by year of diagnosis, age, risk group, insurance status, and region were performed. Results A total of 460,311 male patients were identified with sufficient information to be categorized into National Comprehensive Cancer Network risk groups. Overall, 30.9% of patients had low-risk disease, 38.1% were intermediate risk, 20.2% were high risk, 4.4% were very high risk, 1.6% were node-positive, and 4.7% had metastatic disease. During the study period, there was a 60% decrease in brachytherapy monotherapy utilization for patients with PC, and no definitive treatment increased from 20.3% in 2004 to 26.3% in 2014. There were regional treatment variations and discrepancies in treatment by age. Radical prostatectomy was performed on a greater proportion of insured patients than patients with Medicaid or those who were uninsured, but radiation therapy and no definitive treatment was administered to a greater proportion of uninsured and Medicaid patients. Conclusions PC treatment shows declining trends in brachytherapy utilization, increases in conservative management, and stability of surgical procedures over time. There is wide variation by geographical region, age, and insurance status.

American board of radiology maintenance of certification program: Evolution to better serve stakeholders

*21st Century Oncology, Inc, Fort Myers, Florida; yAmerican Board of Radiology, Tucson, Arizona; zHuntsman Cancer Institute, University of Utah, Salt Lake City, Utah; xVanderbilt University Medical Center, Nashville, Tennessee; jjYale School of Medicine, New Haven, Connecticut; {University of Texas M. D. Anderson Cancer Center, Houston, Texas; Memorial Sloan-Kettering Cancer Center, New York, New York; and **Baylor College of Medicine, Houston, Texas