Dan Garwood

Neurobehavioral sequelae of cranial irradiation in adults: a review of radiation-induced encephalopathy.

PURPOSE To examine behavioral dimensions of treatment outcomes for patients receiving cranial irradiation. Radiation encephalopathy is one of these and refers to significant cognitive and emotional dysfunction following radiation therapy to the brain. Issues of definition, estimated incidence, pathophysiologic mechanisms, and recommended research designs are reviewed in relationship to functional neurobehavioral outcomes. PATIENTS AND METHODS Twenty-nine studies of adults receiving therapeutic cranial irradiation (TCI) involving 748 patients and 18 studies of prophylactic cranial irradiation (PCI) involving 368 patients are reviewed. Assessment of patient outcomes are summarized for research published since 1980, with specific attention to adverse changes in cognitive and emotional functioning. RESULTS Analyses revealed that 213 TCI patients and 100 PCI patients showed encephalopathy attributed to radiation. Manifestations of the late delayed effects of radiotherapy on brain function are related to patient age, total dose of irradiation, fraction sizes, and timing of chemotherapy. Radiation encephalopathy appears to be more common than the pathologic tissue injury of radiation necrosis. Accurate diagnosis of these neurobehavioral sequelae can require follow-up over a period of years with sensitive assessment procedures. CONCLUSIONS It is likely that the true incidence of treatment-related side effects of cranial irradiation in adults who survive more than 6 months without brain tumor growth or recurrence has been significantly underestimated. Research designs that include formal neuropsychologic assessment in conjunction with other neurodiagnostic tests can provide more comprehensive evaluation of long-term neurobehavioral outcomes.

Radiation practice patterns among United States radiation oncologists for postmastectomy breast reconstruction and oncoplastic breast reduction

BACKGROUND For patients requiring radiation therapy following mastectomy or breast reconstruction, there often exist much heterogeneity among practitioners with respect to radiation technique. METHODS AND MATERIALS A 14-question survey was sent nationwide to 1000 active email addresses from the American Society for Radiation Oncology member directory; 271 radiation oncologists completed the survey. RESULTS A total of 75.2% of respondents indicate that they do not routinely deflate the ipsilateral tissue expander (TE) prior to radiation, while 11.5% do routinely deflate (P ≤ .01); 52.2% indicate that they typically use bolus when treating their patients with TEs following mastectomy, 36.7% do not, and 11.1% on a case by case basis (P ≤ .01). Of respondents indicating bolus utilization, 32.8% use a bolus of 0.5 cm every other day; 31.4% indicate a bolus of 0.5 cm every day until tolerated; 20.4% use a bolus of 1 cm every other day; 5.8% indicate a bolus of 1 cm every day until tolerated; and 9.5% indicate a customized bolus approach (P ≤ .01). A total of 22.9% of respondents deliver boost to all patients with TE while 42.9% deliver boost only to select patients, and 33.5% indicate no utilization of boost (P ≤ .01). A total of 33.1% indicate that collaborating surgeons routinely place clips at the lumpectomy cavity at the time of breast reduction or complex tissue rearrangement, while 38.3% indicate that clips are occasionally placed, and 28.6% stated clips are not routinely placed (P = .15); 38.7% of respondents routinely deliver a boost for patients undergoing breast reduction only if clips have been placed in the tumor cavity, while 34.6% indicate that a boost is used regardless of clip placement. CONCLUSIONS Radiation treatments with tissue expanders have become common practice, but details of radiation treatment vary widely. Radiation oncologist and breast surgeons should continue to work to optimize radiation techniques and allow proper localization for radiation boost.

Ultrasound-Guided Placement of Gold Fiducial Markers for Stereotactic Partial-Breast Irradiation

OBJECTIVE A novel technique of placing gold fiducial markers in the breast using ultrasound guidance was developed and performed in 51 of 55 consecutive postlumpectomy patients enrolled in a phase I dose escalation trial of accelerated partial-breast irradiation (APBI) using robotic-based stereotactic body radiation therapy (SBRT). CONCLUSION All 51 postoperative patients underwent successful fiducial placement without complications. Our technique of placing gold fiducial markers in proximity to the seroma cavity is considered safe and effective for breast cancer patients being treated with APBI using robotic-based SBRT.

Clinical Principles and Applications of Chemoirradiation

The preceding discussion has been a brief overview of the varied ways in which chemotherapy and radiotherapy can be combined in treating patients with cancer. The practice of chemoirradiation is truly multidisciplinary and, as knowledge in the field expands, should play an increasing role in the control of neoplasms. As molecular biology brings us new targeted therapies, it is hoped that existing treatment regimens can be improved, in terms of both survival and ameliorating acute and late toxicity of therapy.