Gary D. Lewis

The role of adjuvant chemotherapy in locally advanced bladder cancer

Abstract Purpose: The standard of care for locally advanced bladder cancer (LABC) is neoadjuvant chemotherapy followed by cystectomy. However, the role of adjuvant therapy is unclear. The purpose of this study was to evaluate the outcomes of adjuvant chemotherapy for patients with LABC following neoadjuvant chemotherapy and cystectomy, and to determine whether select patients may benefit from adjuvant chemotherapy. Methods: The National Cancer Data Base (NCDB) was queried (2004–2013) for patients with newly diagnosed pT3-4N0-3M0 bladder cancer that received neoadjuvant chemotherapy and cystectomy. Patients were divided into two groups based on the adjuvant therapy they received: chemotherapy alone or observation. Statistics included multivariable logistic regression to determine factors predictive of receiving adjuvant chemotherapy, Kaplan–Meier analysis to evaluate overall survival (OS) and Cox proportional hazards modeling to determine variables associated with OS. Results: Altogether, 2592 patients met inclusion criteria; 901 (34.8%) patients received adjuvant chemotherapy, while 1691 (65.2%) were observed. Patients treated with adjuvant chemotherapy were more likely to have positive margins were younger and more likely to receive treatment at a nonacademic facility. There was no difference in median OS between patients treated with or without adjuvant chemotherapy (22.6 vs. 21.1 months; p = .267). However, a longer median OS was observed with the use of adjuvant chemotherapy was observed among patients with N2–3 disease (17.5 vs. 14.4 months; p = .005) and positive surgical margins (16.7 vs. 12.2 months; p = .025). On multivariate analysis, advancing age, pT4 stage, positive N stage, positive margins and lower socioeconomic status were associated with worse OS. Conclusions: In the largest study to date evaluating efficacy of adjuvant chemotherapy, while no difference in OS was observed for adjuvant chemotherapy in all patients, a longer OS was observed among patients with N2–3 disease or with positive surgical margins. Prospective studies are recommended to further evaluate these findings.

Early outcomes of uveal melanoma treated with intraoperative ultrasound guided brachytherapy using custom built plaques

PURPOSE To report early outcomes of patients with uveal melanoma treated with Eye Physics iodine-125 episcleral plaque therapy using modern biopsy techniques and intraoperative ultrasound guidance at our institution. METHODS AND MATERIALS A retrospective chart review was conducted for 48 consecutive patients with uveal melanoma who were treated with Eye Physics plaque brachytherapy performed by 1 ocular oncologist. All patients underwent intraoperative ultrasound for image guidance of plaque placement. A dose of 85 Gy was prescribed to the apical height of the tumor or 5 mm from the inner sclera, whichever was greater. Forty-five patients underwent biopsy. Visual acuity, complication data, and recurrence rates were recorded. RESULTS Median age at presentation was 63.0 years (range, 19-86 years). Median follow-up was 21.6 months. Median tumor apical height was 3.3 mm (range, 1.8-11.5 mm). Median dose at apex for tumor height >5 mm was 85.0 Gy and 142.5 Gy for tumor height ≤5 mm. Mean percent decrease in tumor height from baseline at 12, 24, and 36 months was 39.6%, 51.8%, and 53.8%, respectively. At 24 months, 19/23 (82.6%) patients maintained vision within 3 lines of baseline visual acuity. Twelve patients developed radiation retinopathy, 6 of whom were treated with anti-vascular endothelial growth factor therapy in the context of a clinical trial. No patients to date have local failure. Three patients are alive with confirmed hepatic metastases. CONCLUSIONS We reported 0% early local failure rate and steady reduction in tumor height in 48 patients with uveal melanoma, ranging from small to large size, who were treated with Eye Physics iodine-125 episcleral plaque therapy using intraoperative ultrasound guidance. This promising result emphasizes the importance of image guided brachytherapy with intraoperative ultrasound at the time of plaque placement.

Treatment Outcomes and Prognostic Factors in Male Patients With Stage IV Breast Cancer: A Population-based Study

Micro‐Abstract Male breast cancer is a rare disease, and limited data exists regarding metastatic male breast cancer. To better characterize this population, we used the Surveillance, Epidemiology, and End Results database to examine prognostic factors that affected survival outcomes. On multivariate analysis, patients with progesterone receptor‐positive disease, younger age (≤ 65 years), tumor size ≤ 2 cm, or who had undergone surgery of the primary tumor had better overall survival and cause‐specific survival. Purpose: Male breast cancer (MBC) represents < 1% of breast cancer patients, and limited data exists regarding metastatic MBC. To better characterize this patient subset, we performed a population‐based study examining prognostic factors among patients with stage IV MBC. Methods: Patients with stage IV MBC diagnosed between 1988 and 2012 were selected from the Surveillance, Epidemiology, and End Results database. Prognostic factors for overall survival (OS) and cause‐specific survival (CSS) were evaluated. Results: Overall, 394 patients had metastatic disease meeting inclusion criteria. The median follow‐up was 21 months. The 5‐year OS and CSS rates were 21.1% and 38.3%, respectively. Of those with known progesterone receptor (PR) status, 52% were PR‐positive, which was associated with better OS (P < .001) and CSS (P = .003). Overall, 197 patients (50%) received surgery for the primary tumor, and 197 (50%) did not. Patients undergoing surgery had longer median CSS than those who did not (36 vs. 21 months; P < .001). Additional factors that correlated with prolonged OS and CSS were smaller tumor size (≤ 2 cm; P < .05) and younger age (≤ 65 years; P < .05). In multivariate analysis, smaller tumor size, PR‐positivity, younger age, and resection of the primary tumor were associated with longer OS and CSS (P < .05). Conclusions: Although stage IV MBC has poor OS and CSS, patients with PR‐positive disease, younger age (≤ 65 years), tumor size ≤ 2 cm, or who undergo surgery of the primary tumor have better OS and CSS. This is the largest study of stage IV MBC to date, and these findings address some of the questions regarding this rare presentation of breast cancer.

GBM skin metastasis: a case report and review of the literature

Glioblastoma (GBM) is the most common type of malignant tumor found in the brain, and acts very aggressively by quickly and diffusely infiltrating the surrounding brain parenchyma. Despite its aggressive nature, GBM is rarely found to spread extracranially and develop distant metastases. The most common sites of these rare metastases are the lungs, pleura and cervical lymph nodes. There are also a few case reports of skin metastasis. We present the clinical, imaging and pathologic features of a case of a GBM with metastasis to the soft tissue scar and skin near the original craniotomy site. In addition, we discuss the details of this case in the context of the previously reported literature.

The utility of positron emission tomography/computed tomography in target delineation for stereotactic body radiotherapy for liver metastasis from primary gastric cancer: an illustrative case report and literature review

The liver is a common site for metastatic disease for many cancers. Radiation therapy is one means of treatment for liver metastases, especially for patients unable to undergo surgery or ineligible for systemic chemotherapy. In particular, stereotactic body radiotherapy (SBRT) has become an important option in the treatment of metastatic disease in the liver. SBRT delivers ablative doses of radiation in relatively few fractions. As such, precise and clear imaging plays an important role in maximizing disease control while minimizing normal tissue toxicity. We present a case that highlights the importance of using multiple imaging modalities for target volume delineation in stereotactic radiation treatment of liver metastases.