J.A. Haas

CyberKnife boost for patients with cervical cancer unable to undergo brachytherapy

Standard radiation therapy for patients undergoing primary chemosensitized radiation for carcinomas of the cervix usually consists of external beam radiation followed by an intracavitary brachytherapy boost. On occasion, the brachytherapy boost cannot be performed due to unfavorable anatomy or because of coexisting medical conditions. We examined the safety and efficacy of using CyberKnife stereotactic body radiotherapy (SBRT) as a boost to the cervix after external beam radiation in those patients unable to have brachytherapy to give a more effective dose to the cervix than with conventional external beam radiation alone. Six consecutive patients with anatomic or medical conditions precluding a tandem and ovoid boost were treated with combined external beam radiation and CyberKnife boost to the cervix. Five patients received 45 Gy to the pelvis with serial intensity-modulated radiation therapy boost to the uterus and cervix to a dose of 61.2 Gy. These five patients received an SBRT boost to the cervix to a dose of 20 Gy in five fractions of 4 Gy each. One patient was treated to the pelvis to a dose of 45 Gy with an external beam boost to the uterus and cervix to a dose of 50.4 Gy. This patient received an SBRT boost to the cervix to a dose of 19.5 Gy in three fractions of 6.5 Gy. Five percent volumes of the bladder and rectum were kept to ≤75 Gy in all patients (i.e., V75 Gy ≤ 5%). All of the patients remain locally controlled with no evidence of disease following treatment. Grade 1 diarrhea occurred in 4/6 patients during the conventional external beam radiation. There has been no grade 3 or 4 rectal or bladder toxicity. There were no toxicities observed following SBRT boost. At a median follow-up of 14 months, CyberKnife radiosurgical boost is well tolerated and efficacious in providing a boost to patients with cervix cancer who are unable to undergo brachytherapy boost. Further follow-up is required to see if these results remain durable.

Cyberknife radiosurgery in treating trigeminal neuralgia

Purpose To assess the short term efficacy of Cyberknife stereotactic radiosurgical treatment of trigeminal neuralgia (TN). Methods 17 consecutive patients with medically or surgically refractory unilateral TN were treated with Cyberknife radiosurgery. Using superimposed CT cisternogram and MR images, the target segment of the trigeminal nerve was consistently defined as a 6 mm length of nerve approximately 2–3 mm distal to the dorsal root entry zone of the brainstem. A radiosurgical rhizotomy was performed with the Cyberknife utilizing a single collimator to deliver an average maximum dose of 73.06 Gy (range 72.91–73.73) to the target. Results Follow-up data were available for 16 of the 17 patients post-treatment (range 1–27 months, average 11.8 months). Overall, 14 of 16 (88%) patients responded favorably with either partial or complete relief of symptomatology. 11 of these patients were successfully free of all pain at some point in their post-treatment course, with seven patients pain free to the last follow-up visit (average 5.0 months, range 1–13 months). Symptoms recurred in four patients, taking place at 3, 7.75, 9 and 18 months after Cyberknife therapy. Only two patients reported side effects. One patient developed a bothersome feathery dysesthesia while the second patient reported a non-bothersome mild jaw hypoesthesia. There were no substantial complications related to stereotactic radiosurgery. Conclusion Cyberknife radiosurgery is a viable treatment alternative in patients with TN with competitive efficacy demonstrated in our group of patients while minimizing adverse effects.

Prostate-Specific Antigen Bounce Following Stereotactic Body Radiation Therapy for Prostate Cancer

Introduction: Prostate-specific antigen (PSA) bounce after brachytherapy has been well-documented. This phenomenon has also been identified in patients undergoing stereotactic body radiation therapy (SBRT). While the parameters that predict PSA bounce have been extensively studied in prostate brachytherapy patients, this study is the first to analyze the clinical and pathologic predictors of PSA bounce in prostate SBRT patients. Materials and Methods: Our institution has maintained a prospective database of patients undergoing SBRT for prostate cancer since 2006. Our study population includes patients between May 2006 and November 2011 who have at least 18 months of follow-up. All patients were treated using the CyberKnife treatment system. The prescription dose was 35–36.25 Gy in five fractions. Results: One hundred twenty patients were included in our study. Median PSA follow-up was 24 months (range 18–78 months). Thirty-four (28%) patients had a PSA bounce. The median time to PSA bounce was 9 months, and the median bounce size was 0.50 ng/mL. On univariate analysis, only younger age (p = 0.011) was shown to be associated with an increased incidence of PSA bounce. Other patient factors, including race, prostate size, prior treatment by hormones, and family history of prostate cancer, did not predict PSA bounces. None of the tumor characteristics studied, including Gleason score, pre-treatment PSA, T-stage, or risk classification by NCCN guidelines, were associated with increased incidence of PSA bounces. Younger age was the only statistically significant predictor of PSA bounce on multivariate analysis (OR = 0.937, p = 0.009). Conclusion: PSA bounce, which has been reported after prostate brachytherapy, is also seen in a significant percentage of patients after CyberKnife SBRT. Close observation rather than biopsy can be considered for these patients. Younger age was the only factor that predicted PSA bounce.

Coronary Calcium Scanning in Patients after Adjuvant Radiation for Early Breast Cancer and Ductal Carcinoma In situ.

Background and Objective: Radiation therapy (RT) is part of standard adjuvant treatment for breast cancer. Earlier studies demonstrated increased cardiac morbidity and mortality from this. Coronary Calcium scanning utilizing Multidetector Computed Tomography (MDCT) can detect early atherosclerosis in coronary arteries by identifying the amount of calcifications. In our study we employed these tools to detect occult atherosclerosis at least 5 years following breast RT. Methods: We evaluated 20 asymptomatic patients, <60 years old, treated with RT at least 5 years prior to enrollment. Nine received RT to the left and 11 to the right chest wall. The median interval between RT and calcium scan was 8 years. All patients were treated with external beam RT using tangential technique. All patients underwent MDCT to compute volumetric and Agatston calcium scores of the coronary arteries and the aorta. Results: Eleven patients had RT to the right chest wall, and eight had a calcium score of 0, while two had minimally elevated scores and one patient had a significantly elevated score. Meanwhile nine patients had RT to the left chest wall, and seven had a calcium score of 0. None had significantly elevated scores. In the aorta, 11 of 20 patients had a score of 0, while 8 of 20 had minimally elevated scores. Conclusion: In contrast to studies demonstrating increased cardiovascular morbidity, our pilot study did not detect significant occult atherosclerosis using MDCT of the coronaries and aorta of patients assessed five or more years following radiation for treatment of breast cancer.

A Retrospective Review of CyberKnife Stereotactic Body Radiotherapy for Adrenal Tumors (Primary and Metastatic): Winthrop University Hospital Experience

The adrenal gland is a common site of cancer metastasis. Surgery remains a mainstay of treatment for solitary adrenal metastasis. For patients who cannot undergo surgery, radiation is an alternative option. Stereotactic body radiotherapy (SBRT) is an ablative treatment option allowing larger doses to be delivered over a shorter period of time. In this study, we report on our experience with the use of SBRT to treat adrenal metastases using CyberKnife technology. We retrospectively reviewed the Winthrop University radiation oncology data base to identify 14 patients for whom SBRT was administered to treat malignant adrenal disease. Of the factors examined, the biological equivalent dose (BED) of radiation delivered was found to be the most important predictor of local adrenal tumor control. We conclude that CyberKnife-based SBRT is a safe, non-invasive modality that has broadened the therapeutic options for the treatment of isolated adrenal metastases.

Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer: A Small Academic Hospital Experience

Purpose/Objective(s): Stereotactic body radiation therapy (SBRT) has been shown to have increased local control and overall survival relative to conventional external beam radiation therapy in patients with medically inoperable stage I non-small cell lung cancer (NSCLC). Excellent rates of local control have been demonstrated both in clinical trials and in single-center studies at large academic institutions. However, there is limited data on the experiences of small academic hospitals with SBRT for stage I NSCLC. The purpose of this study is to report the local control and overall survival rates in patients treated with SBRT for stage I NSCLC at Winthrop-University Hospital (WUH), a small academic hospital. Materials/Methods: This is a retrospective review of 78 stage I central and peripheral NSCLC tumors treated between December 2006 and July 2012 with SBRT at WUH. Treatment was given utilizing fiducials and a respiratory tracking system. If the fiducials were not trackable, a spine tracking system was used for tumor localization. CT-based planning was performed using the ray trace algorithm. Treatment was delivered over consecutive days to a median dose of 4800 cGy delivered in four fractions. The Kaplan–Meier method was used to calculate local control and overall survival. Results: The median age was 78.5 years. Fifty-four percent of the patient population was female. Sixty seven percent of the tumors were stage IA, and 33% of the tumors were stage IB. Fifty-three percent of the tumors were adenocarcinomas and 29% were squamous cell carcinomas, with the remainder being of unknown histology or NSCLC, not otherwise specified The 2-year local control rate was 87%, and the 2-year overall survival was 68%. Conclusion: Our findings support that local control and overall survival at a small academic hospital are comparable to that of larger academic institutions’ published experiences with SBRT for stage I NSCLC.

Eltrombopag for radiation-induced thrombocytopenia in a glioblastoma patient

While growth factors exist to support patients with treatment-induced neutropenia and anemia, treatment-induced thrombocytopenia remains a problem and often causes treatment delays and dose reductions and requires platelet transfusions. Toxicities such as marrow fibrosis, thromboembolic events and rebound thrombocytopenia may further complicate the already complex management of cancer patients. We report the first use of eltrombopag for radiation-induced thrombocytopenia in a brain tumor patient. A 66 year old male with a history of chronic low back pain for years presented with increasing low back pain radiating down his right leg, paresthesias and increasing right lower extremity weakness for 4 months. Spine imaging revealed an enhancing L1-2 intramedullary lesion (Fig. 1a). He underwent a T12-L3 laminectomy and excision of this lesion. The pathological diagnosis revealed a glioblastoma. Subsequent imaging of the brain and spine revealed widely disseminated disease within the neuroaxis including a large splenial lesion (Fig. 1b) and drop metastases throughout cervical, thoracic and lumbosacral spine (Fig. 1c). We treated his craniospinal axis to a dose of 3600 cGy, 20 fractions of 180 cGy each, followed by a conedown field to T12 to L3 for an additional 900 cGy, total dose to T12-L3 was 4500 cGy, and a partial brain field to his bulky brain disease for an additional 2340 cGy, total dose 5940 cGy. However, due to concerns over myelosuppression, we decided to forego concurrent temozolomide. At the start of radiation, his pre-treatment baseline platelet count was 132,000 ll. During radiation, his platelets achieved nadir at 44,000 ll on day #19 and then stabilized between 57,000 and 73,000 ll for the remaining 5 weeks of radiation. Following completion of radiation, persistent moderate thrombocytopenia precluded our ability to start myelosuppressive chemotherapy. To date, there is no approved growth factor for support of patients with radiationor chemotherapy-induced thrombocytopenia. As part of our evaluation of our patient’s thrombocytopenia and prior to initiating treatment with eltrombopag (a nonpeptide thrombopoietin receptor agonist), we obtained a splenic ultrasound that ruled out splenomegaly, and a bone marrow biopsy revealed a hypocellular marrow with decreased megakaryocytes consistent with radiation effect (fields of CSI extended down to end of thecal sac & sacrum, laterally to sacroiliac joints). There was no evidence or suggestion of other drug reaction e.g. (heparin induced thrombocytopenia) or autoimmune phenomenon (e.g. ITP) to explain the findings. After registering through the Promacta Cares program (GlaxoSmithKline), he began treatment with eltrombopag at 50 mg po daily. Upon initiation of eltrombopag, his platelet count was 72,000 . After starting treatment with eltrombopag, his platelets reached 116,000 at 1 week, J. P. Duic (&) J. Grewal K. McConie Long Island Brain Tumor Center at Neurological Surgery, P.C. 600 Northern Blvd Suite 113, Great Neck, NY 11021, USA

Patient-reported quality of life progression in men with prostate cancer following primary cryotherapy, cyberknife, or active holistic surveillance

BackgroundTechnological advancements have led to the success of minimally invasive treatment modalities for prostate cancer such as CyberKnife and Cryotherapy. Here, we investigate patient-reported urinary function, bowel habits, and sexual function in patients following CyberKnife (CK) or Cryotherapy treatment, and compare them with active holistic surveillance (AHS) patients.MethodsAn IRB-approved institutional database was retrospectively reviewed for patients who underwent CK, Cryotherapy, or AHS. Quality of life (QoL) survey responses were collected every three months and the mean function scores were analyzed in yearly intervals over the 4 years post-treatment.Results279 patients (767 survey sets) were included in the study. There was no difference among groups in urinary function scores. The CyberKnife group had significantly lower bowel habit scores in the early years following treatment (year 2 mean difference: −5.4, P < 0.01) but returned to AHS level scores by year 4. Cryotherapy patients exhibited initially lower, but not statistically significant, bowel function scores, which then improved and approached those of AHS. Both CyberKnife (year 1 mean difference: −26.7, P < 0.001) and Cryotherapy groups (−35.4, P < 0.001) had early lower sexual function scores relative to AHS, but then gradually improved and were not significantly different from AHS by the third year post-treatment. A history of hormonal therapy was associated with a lower sexual function scores relative to those patients who did not receive hormones in both CyberKnife (−18.45, P < 0.01) and Cryotherapy patients (−14.6, P < 0.05).ConclusionsAfter initial lower bowel habits and sexual function scores, CyberKnife or Cryotherapy-treated patients had no significant difference in QoL relative to AHS patients. These results highlight the benefit of CyberKnife and Cryotherapy in the management of organ-confined prostate cancer.

MP05-18 PROSTATE FIDUCIAL MARKER PLACEMENT IN PATIENTS WHILE ON ANTICOAGULATION: FEASIBILITY PRIOR TO PROSTATE SBRT

Objectives: Fiducial marker placement is required in patients undergoing robotic-based Stereotactic Body Radiotherapy (SBRT) for prostate cancer in order to track the six degrees of prostate motion that occur intrafractionally, during treatment. Many patients take anticoagulant medication due to other comorbidities. Anticoagulation therapy can cause patients to bleed during procedures and, in general practice, are often temporarily discontinued prior to invasive medical procedures to reduce that risk. However, some patients may not be able to temporarily discontinue anticoagulation therapy due to an increased risk of a thromboembolic event from their comorbid medical conditions. We looked at a series of our patients who were unable to discontinue anticoagulation therapy prior to fiducial marker placement and report on their outcomes to assess whether they experienced bleeding complications from the procedure. Methods: From August, 2015 to January, 2016, 16 consecutive patients on chronic anticoagulation therapy and who were not cleared to stop these medications underwent fiducial marker placement into the prostate for treatment and planning purposes. The most common indications for uninterrupted anticoagulation therapy in this cohort included: recent stent placement (6=number); myocardial infarction (6=number); pulmonary embolus (2=number); and atrial fibrillation (2=number.) Anticoagulation therapy included Aspirin (7=number); Plavix (5=number); Coumadin (3=number); Lovenox (2=number); Eliquis (1=number); Brillinta (1=number); Pradaxa (1=number); and Effient (1=number). 6 patients were on more than one of these agents at the time of fiducial marker placement. All patients had Emla cream placed on the perineum and lidocaine gel placed into the rectum prior to the procedure for numbing purposes. A transrectal ultrasound was placed for visualization of the prostate and normal anatomy as well as to provide real time image guidance of marker placement during the procedure. 2 needles with 2 fiducial markers and a spacer in each were placed transperineally into the prostate under ultrasound guidance using a brachytherapy grid. The needles were then removed after the fiducial markers were placed and gentle pressure was applied to the perineum by the nursing staff. All patients were monitored for bleeding afterwards by a registered nurse. Results: All 16 consecutive patients who were on anticoagulation and underwent fiducial marker placement were discharged home the same day of the procedure. No patient experienced significant bleeding. Conclusions: Transperineal fiducial marker placement in patients who are unable to Open Access Abstract

Previous Cryotherapy and Older Age Predict for Faster Biochemical Response After Definitive SBRT for Prostate Cancer.

Conclusions: Table 1: Univariate Analysis, PSA Decline •Stereotactic Body Radiation Therapy (SBRT) remains an emerging treatment option for men with prostate adenocarcinoma with low or intermediate risk disease. •Despite a growing volume of investigation, there is a paucity of data that characterizes predictors of post-treatment PSA kinetics in the initial six-month window. •Cryosurgery is an evolving minimally invasive therapy for the treatment of focal prostate cancer. •The effect of previous cryosurgery on PSA kinetics following salvage SBRT has not been previously explored. •This study reports the effect of age and previous cryosurgery on initial PSA kinetics for patients that have undergone definitive SBRT for low or intermediate risk prostate cancer.