J. Yap

Multiple primary tumors in men with breast cancer diagnoses: a SEER database review.

Male breast cancer (MBC) comprises 1% of all breast cancers and less than 1% of cancer cases in men. After a diagnosis of MBC, men are at risk of developing a second primary cancer, particularly a second primary breast cancer. The objective of this study is to analyze the characteristics of the population of men diagnosed with a second malignancy, specifically a second MBC.

Association of Technetium99m MAG-3 renal scintigraphy with change in creatinine clearance following chemoradiation to the abdomen in patients with gastrointestinal malignancies

BACKGROUND Information on differential renal function following abdominal chemoradiation is limited. This study evaluated the association between renal function as measured by biochemical endpoints and scintigraphy and dose volume parameters in patients with gastrointestinal malignancies. MATERIALS AND METHODS Patients who received abdominal chemoradiation between 2002 and 2009 were identified for this study. Technetium(99m) MAG-3 scintigraphy and laboratory data were obtained prior to and after chemoradiation in 6 month intervals. Factors assessed included age, gender, hypertension, diabetes, and dose volume parameters. Renal function was assessed by biochemical endpoints and renal scintigraphy. RESULTS Significant reductions in relative renal function of the primarily irradiated kidney and creatinine clearance were seen. Split renal function decreased from 49.75% pre-radiation to 47.74% and 41.28% at 6-12 months and >12 months post-radiation (P=0.0184). Creatinine clearance declined from 90.67ml/min pre-radiation to 82.23ml/min and 74.54ml/min at 6-12 months and >12 months post-radiation (P<0.0001). Univariate analysis of patients who had at least one post-radiation renogram showed the percent volumes of the primarily irradiated kidney receiving ≥ 25 Gy (V(25)) and 40 Gy (V(40)) were significantly associated with ≥5% decrease in relative renal function (P=0.0387 and P=0.0438 respectively). CONCLUSION Decline in split renal function using Technetium(99m) MAG-3 scintigraphy correlates with decrease in creatinine clearance and radiation dose-volume parameters following abdominal chemoradiation. Change in split perfusion can be detected as early as 6 months post-radiation. Scintigraphy may provide early determination and quantification of subclinical renal injury prior to clinical evidence of nephropathy.

Intensity modulated radiation therapy in the treatment of esophageal cancer.

Chemoradiation plays a core role in the definitive and preoperative management of esophageal cancer. Remarkable advances in technology now allow for the implementation of intensity modulated radiation therapy (IMRT) to minimize normal organ damage and to maximize coverage of tumorous targets. While IMRT is commonly accepted in the treatment of prostate and head and neck cancers, there have been clinical and dosimetric studies supporting the use of IMRT in esophagus cancer. In addition, the IMRT technique was recently enhanced by the availability of volumetric intensity modulated arc therapy (VMAT). VMAT may allow for faster delivery of IMRT with the advantage of normal organ protection compared to the stop‐and‐shoot IMRT, with faster delivery time and reduced monitor units. This review summarizes the use of chemoradiation in esophageal cancer, discusses current dosimetric data and clinical outcomes with the use of IMRT, and reviews IMRT as part of multi‐modality treatment in esophageal cancer.

Giving oligometastases the best shot using stereotactic body radiosurgery with image guidance. How far is the cat out of the bag

Oligometastatic disease is hypothesized to be a state of limited metastases in which frank widespread metastasis has not yet evolved. Milano et al. reported on patients with oligometastases undergoing two or more curative-intent stereotactic body radiation treatment (SBRT). In these selected patients, the 4-year overall survival and progression-free survival rates were 33% and 28%, respectively (1). Oligometastases should be limited in number and extent while amendable to targeted local therapies for ablation with potential cure. For example, liver resection of oncologic lesions can be associated with long-term survival in selected patients (2). High dose and focal external beam radiation in the form of SBRT may be an alternative to invasive procedures in dealing with certain sites of disease. In this issue of Journal of GI Oncology, Perkins and colleagues focused on the treatment of oligometastases in patients with abdomino-pelvic recurrence or inoperable diseases. As the authors rightfully pointed out, these patients often have received heavy prior treatment of surgery, local radiotherapy, and chemotherapy, which precludes standard local treatment for the oligometastases (3). Perkins et al. review the application of SBRT and early gastrointestinal (GI) toxicities and radiographic responses based on computed tomography (CT) and positron emission tomography (PET). In this cohort of patients, a median SBRT dose of 18 Gy was used. Majority or 87% of patients received single-fraction SBRT, and authors reported a local control rate of 74% with a metabolic response rate of 85%. Of interest, 13% of sites showed a transient increase in the uptake of SUV which subsided in follow-up PET scanning, indicating a potential “flare” response to the SBRT (4). In addition to the encouraging results, the rates of early toxicity profiles at 1 month post-SBRT were limited to grade 1 and grade 2 effects at 61% combining both upper and lower GI sites. A Radiation Therapy Oncology Group (RTOG) – sponsored phase I trial of dose escalation of study of liver metastasis reached the dose level “IV” of 50 Gy given over 10 fractions, and the protocol was closed for accrual (5). The median dose of 18 Gy as reported here by Perkins et al. is biologically less intense, and there is potential for dose study for these GI sites in the future. This report of initial experience is limited to its retrospective nature and short follow-up. A minor portion of all sites, 13%, were treated in a fractionated fashion with the number of fractions limiting to 2 to 3 fractions. The rates of response and toxicity reporting may be affected in such a small cohort of patients. Image guidance was used in 78% of sites with placement of fiducials without significant adverse events according to the authors. Using PET scanning in pre- and post-treatment evaluation may add another dimension in gauging treatment response although the PET data were available only in 39% of the treated sites. The significance and meaning of SUV in PET imaging may be affected by the high dose nature of SBRT on tumor and surrounding normal tissues. In reference to experience of SBRT in lungs, post-treatment PET may have persistent and moderate SUV elevation for 1 to 2 years (6),(7). Therefore, interpretation of PET information in SBRT in GI sites will require further study and follow up. This report adds as building blocks for technical and clinical feasibility of targeted radiotherapy for these difficult-to-treat cases. Studies will be needed to identify patients with oligometastases who will benefit the most from targeted treatment. In the mean time, radiation oncologists will continue to fine tune techniques of delivering precise radiotherapy with cancer-controlling dose with great protection of normal organs. In a dosimetric study by MacDonald et al, proton beam-based targeted treatment produced comparable planning target volume dose with generally less dose to normal tissues than three-dimensional photon-based SBRT in lung cancer patients. The authors qualified that the clinical significance of their study remained to be determined (8). In patients with metastatic diseases, we often consider “the cat to be out of the bag.” With continuous progress in systemic treatments such as chemotherapy and biologics along with advancement in radiation techniques, it is hopeful that oncologists can differentiate subsets of patients with metastatic diseases and be able to restrain or even recapture the cat using multi-modality approaches.

Pure Tubular Breast Carcinoma: A 34 year Study of Outcomes

To the Editor: Tubular carcinoma of the breast is a rare, well-differentiated variant of invasive ductal carcinoma which is thought to carry an excellent prognosis (1–3). The purpose of this study is to review the Roswell Park Cancer Institute experience with tubular breast cancers. Between September of 1971 and January 2004, 8,832 patients were treated for both invasive and noninvasive breast cancer, and 44 (0.5%) were coded as tubular carcinoma or invasive ductal carcinoma with tubular features. Tumors were considered tubular only if the pathology report specifically identified the histology as tubular carcinoma, and did not include a description of other histologic types. This process identified 27 of the 44 cases as tubular cancers, while 17 were considered of mixed tubular or other histology. Staging was according to the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 6th edition (4). Patient follow-up time was calculated using the potential follow-up method (5). The Kaplan–Meier method was used to derive survival probabilities (6). The mean patient age was 59.3 years and all patients were Caucasian. Seventy-eight percent (21 ⁄ 27) of patients had stage I disease, while 19% (5 ⁄ 27) had stage IIA disease, and 4% (1 ⁄ 27) was stage IIIA. Forty-one percent (11 ⁄ 27) of patients had a first-degree relative with breast or ovarian cancer. The initial detection of a breast tumor was made by mammogram in 52% (14 ⁄ 27) of cases, while a mass was palpated by the patient or a physician in 37% (10 ⁄ 27) of cases. Tumor characteristics are summarized in Table 1. The mean tumor diameter was 1.09 cm (range, 0.2–4.2 cm). The majority of patients, who had lymph nodes assessed by either axillary node dissection or a sentinel node biopsy, had no positive lymph nodes on presentation (84%), while 11% (2 ⁄ 19) had 1–3 positive nodes and 5% (1 ⁄ 19) had four positive axillary node metastases. Ductal carcinoma in situ was reported in 59% (16 ⁄ 27) of patients. All patients who had hormone receptor status assessed (16 ⁄ 16) were estrogen receptor (ER) positive, while the majority of patients (10 ⁄ 14) were also progesterone receptor positive. The upper outer quadrant was the site of occurrence in 67% (18 ⁄ 27) of patients and with 89% (24 ⁄ 27) of patients having unifocal disease and 11% (3 ⁄ 27) of patients having multifocal distribution. Seventy-four percent (20 ⁄ 27) of patients were treated with breast-conserving surgery, while 22% (6 ⁄ 27) underwent modified radical mastectomy (MRM), and one patient received no additional surgery after biopsy. In the post-operative setting, one third of patients (9 ⁄ 27) received no adjuvant treatment. Over half (15 ⁄ 27) of patients received post-operative radiation (XRT), 14 of which had undergone a previous breast conserving surgery, and one of which had a previous MRM. Thirty percent of patients (8 ⁄ 27) had XRT alone in the adjuvant setting, while 19% (5 ⁄ 27) receive a combination of XRT and hormonal therapy (HT), and 7% (2 ⁄ 27) received XRT and HT in combination with systemic chemotherapy. Eleven percent (3 ⁄ 27) of patients received HT alone in the adjuvant setting. With a median follow-up period was 5.3 years (range; <1–24 years), none of the patients had evidence of either local or systemic recurrence, and no patients had died of breast cancer. Seventy-eight percent (21 ⁄ 27) of patients were alive at the time of last follow-up and 22% (6 ⁄ 27) had died of other causes not related to breast cancer. Of patients with at least five-years of follow-up, overall survival at 5-years was 89% (16 ⁄ 18) while for those with at least 10-year follow-up, overall survival is 70% (7 ⁄ 10). Twenty-two percent of patients (6 ⁄ 27) were diagnosed with a second cancer, two of which developed infiltrating ductal carcinoma. Of those who developed a second malignancy, the only patient who received XRT, was a patient who developed infiltrating ductal carcinoma in the contralateral breast 7 years after completing XRT. Address correspondence and reprint requests to: Gary Y. Yang, MD, Department of Radiation Medicine, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY 14263, or e-mail: Gary.yang@roswellpark.org.

Adenocarcinoma of the proximal rectum and synchronous non-Hodgkin’s lymphoma

Colorectal cancer is one of the top 5 common cancers in the United States and the second cause of cancer death. In 2012, the American Cancer Society estimated 40,290 new cases of rectal cancer (1). With appropriate screening and treatment, the mortality from colorectal cancer can be reduced significantly across the United States (2). This article illustrates the need of proper staging and investigation of questionable findings, prior to developing a patient’s treatment plan.

Primary angiosarcoma of the breast: Pattern of presentation, surgery, radiation, and survival

21509 Background: Angiosarcoma of the female breast is most often associated with history of irradiation and/or lymphedema. Primary angiosarcoma of the breast is rare. The benefit of adjuvant radiation treatment (RT) is not known in this disease entity. Methods: A search of the SEER database (1973 to 2003) revealed 162 records of pathologically confirmed angiosarcoma. After exclusion of patients with multiple cancers, 99 patients with primary angiosarcoma were identified. Cox regression model was used in multivariate analysis. Kaplan-Meier estimates and Mantel-Cox modeling were used to calculate and compare survival rates. Results: Median age was 47 years (range 18–92). 66 patients presented with localized disease, 20 had regional involvement, 8 presented with metastatic disease, and 5 were unstaged. 58 patients had overlapping or extensive involvement, and 41 patients had disease in an isolated quadrant or was centrally located. Surgery comprised of partial mastectomy in 6 patients, total or subcutaneous...