Jared R. Robbins

Radiosurgery to the surgical cavity as adjuvant therapy for resected brain metastasis.

BACKGROUND The standard treatment of resected brain metastasis is whole-brain radiotherapy (WBRT). To avoid the potential toxicity of WBRT and to improve local control, we have used radiosurgery alone to the surgical cavity. OBJECTIVE To demonstrate the rates of local control, new intracranial metastasis, and overall survival using this treatment scheme without WBRT. METHODS Eighty-five consecutive patients with brain metastasis were treated with surgical resection of at least 1 lesion followed by radiosurgery alone to the surgical cavity and any unresected lesions from August 2000 to March 2011. Sixty-eight percent had gross total resections. After surgery, radiosurgery was delivered to the surgical cavity with a 2- to 3-mm margin. The median marginal radiosurgery dose was 16 Gy, and median target volume was 13.96 cm. Follow-up imaging and clinical examination were obtained every 2 to 3 months. RESULTS Median follow-up time was 11.2 months. Overall local control was 81.2%. The 6-month, 1-year, and 2-year rates of local control were 88.7%, 81.4%, and 75.7%, respectively. Forty-seven patients (55%) developed new intracranial metastases at a median time of 5.6 months. For the entire population, the rate of new metastases was 32.1%, 58.1%, and 62.9% at 6 months, 1 year, and 2 years, respectively. Median overall survival time was 12.1 months. From initial treatment until death or last follow-up, only 30 patients (35%) received WBRT as salvage treatment. CONCLUSION Radiosurgery to the surgical cavity without WBRT achieved excellent local control of resected brain metastasis. Close imaging follow-up allows early intervention for any new metastasis.

Radiosurgery of multiple brain metastases with single-isocenter dynamic conformal arcs (SIDCA)

PURPOSE To propose single-isocenter dynamic conformal arcs (SIDCA), a novel technique for radiosurgery of multiple brain metastases, and to compare SIDCA with volumetric modulated arc therapy (VMAT) and multiple-isocenter dynamic conformal arcs (MIDCA) for plan quality. METHODS AND MATERIALS SIDCA, MIDCA, and VMAT plans were created on 6 patients with 3-5 metastases. Plans were evaluated using Radiation Therapy Oncology Group conformity index (RCI), Paddick conformity index (PCI), gradient index (GI), volumes that received more than 100% (V(100%)), 50% (V(50%)), 25% (V(25%)) and 10% (V(10%)) of prescription dose, total monitor units (MUs), and delivery time (DT). RESULTS SIDCA achieved conformal plans (RCI = 1.38 ± 0.12, PCI = 0.72 ± 0.06) with steep dose fall-off (GI = 3.97 ± 0.51). MIDCA plans had comparable plan quality and MUs as SIDCA, but 52% longer DT. The VMAT plans had better conformity (RCI = 1.15 ± 0.09, p < 0.01 and PCI = 0.86 ± 0.06, p < 0.01) than SIDCA, worse GI (4.34 ± 0.46, p < 0.01), higher V(25%) (p = 0.05) and V(10%) (p = 0.02), 49% less MUs and 46% shorter DT. CONCLUSIONS All three techniques achieved conformal plans with steep dose fall-off from targets. SIDCA plans had similar plan quality as MIDCA but more efficient to delivery. SIDCA plans had lower peripheral dose spread than VMAT; VMAT plans had better conformity and faster delivery time than SIDCA.

ACR appropriateness criteria® follow-up and retreatment of brain metastases

Multiple options for retreatment are available, which include whole-brain radiation therapy, stereotactic radiosurgery, surgery, chemotherapy, and supportive care. Size, number, timing, location, histology, performance status, and extracranial disease status all need to be carefully considered when choosing a treatment modality. There are no randomized trials examining the retreatment of brain metastases. Repeat whole-brain radiation has been examined in a single-institution experience, showing the potential for clinical responses in selected patients. Local control rates as high as 91% using stereotactic radiosurgery for relapses after whole-brain radiation are reported. Surgery can be indicated in progressive and/or hemorrhagic lesions causing mass effect. The role of chemotherapy in the recurrent setting is limited but some agents may have activity on the basis of experiences on a smaller scale. Supportive care continues to be an important option, especially in those with a poor prognosis. Follow-up for brain metastases patients is discussed, examining the modality, frequency of imaging, and imaging options in differentiating treatment effect from recurrence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of the current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Adjuvant radiation therapy for patients with type II endometrial carcinoma: Impact on tumor recurrence and survival

Purpose/Objective The optimal adjuvant treatment of type II endometrial carcinoma after hysterectomy remains controversial. The objective of this study was to determine the effect of adjuvant radiation therapy (RT) on recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival in patients with early-stage type II endometrial carcinoma. Materials and Methods In this institutional review board–approved study, our database of 1450 patients with endometrial cancer was reviewed. Seventy-nine surgically staged patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stages I and II serous and clear cell carcinoma were treated from 1991 to 2010. These patients were then divided into 2 groups; one group received adjuvant RT, and the other group included patients who did not receive adjuvant RT. Results The median age of the study cohort is 65 years, and the median follow-up is 47 months. Thirty-nine patients (49%) received adjuvant RT, and 40 patients did not. The 5-year RFS was significantly improved in patients who received RT (84% vs 58%; P = 0.002). Similarly, 5-year DSS was significantly improved in patients who received RT (87% vs 58%; P = 0.023) with a trend toward improved 5-year overall survival (74% vs 58%; P = 0.088). On multivariate analysis, lack of angiolymphatic invasion (P < 0.001 and P < 0.001), adjuvant RT (P < 0.001 and P = 0.004), and lack of lower uterine segment involvement (P = 0.007 and P = 0.009) were independent predictors of improved RFS and DSS, respectively. Conclusions In the current study of surgically staged patients with type II endometrial carcinoma International Federation of Gynecology and Obstetrics stages I and II, adjuvant radiation therapy with or without chemotherapy resulted in a significant improvement in recurrence-free and disease-specific survival.

ACR appropriateness criteria® pre-irradiation evaluation and management of brain metastases

Pretreatment evaluation is performed to determine the number, location, and size of the brain metastases and magnetic resonance imaging (MRI) is the recommended imaging technique, particularly in patients being considered for surgery or stereotactic radiosurgery. A contiguous thin-cut volumetric MRI with gadolinium with newer gadolinium-based agents can improve detection of small brain metastases. A systemic workup and medical evaluation are important, given that subsequent treatment for the brain metastases will also depend on the extent of the extracranial disease and on the age and performance status of the patient. Patients with hydrocephalus or impending brain herniation should be started on high doses of corticosteroids and evaluated for possible neurosurgical intervention. Patients with moderate symptoms should receive approximately 4-8 mg/d of dexamethasone in divided doses. The routine use of corticosteroids in patients without neurologic symptoms is not necessary. There is no proven benefit of anticonvulsants in patient without seizures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Vaginal Recurrence More than 17 Years after Hysterectomy and Adjuvant Treatment for Uterine Carcinoma with Successful Salvage Brachytherapy: A Case Report

Purpose: Although the majority of recurrences occur within the first 3 years of hysterectomy for endometrioid carcinoma, we report herein a successful salvage vaginal brachytherapy in a patient with endometrioid uterine carcinoma which recurred more than 17 years after initial treatment. Materials and Methods: A 61-year-old female was diagnosed with endometrioid adenocarcinoma of the uterus and treated with TAH-BSO, followed by adjuvant external beam radiation therapy (EBRT) to the whole pelvis. After remaining free of any recurrent or metastatic disease for more than 17 years, she was diagnosed with isolated vaginal cuff recurrence and successfully treated with a salvage high-dose-rate intracavitary vaginal brachytherapy. Results: The patient remained disease free until her death from unrelated causes 7 years later. Conclusion: To the best of our knowledge, this case represents the longest time to recurrence of endometrial cancer in someone who had been treated with TAH-BSO and adjuvant pelvic EBRT. This case highlights that even with adjuvant therapy, late recurrences may occur, and successful salvage brachytherapy is very effective.

Predictive Capacity of 3 Comorbidity Indices in Estimating Survival Endpoints in Women With Early-Stage Endometrial Carcinoma.

Objective The negative impact of comorbidity on survival in women with endometrial carcinoma (EC) is well-known. Few validated comorbidity indices are available for clinical use, such as the Charlson Comorbidity Index (CCI), the Age-Adjusted CCI (AACCI), and the Adult Comorbidity Evaluation-27 (ACE-27). The aim of the study is to determine which index best correlates with survival endpoints in women with EC. Materials and Methods We identified 1132 women with early-stage EC treated at an academic center. Three scores were calculated for each patient using CCI, AACCI, and ACE-27 at the time of hysterectomy. Univariate and multivariable modeling was used to determine predictors of survival. Results For each of the studied comorbidity indices, the highest scores were significantly correlated with poorer overall survival. The hazard ratio of death from any cause was 3.92 for AACCI, 2.25 for CCI, and 1.57 for ACE-27. All 3 indices were independent predictors of overall survival with a P value of less than 0.001 on multivariate analysis. In addition, lymphovascular space invasion, lower uterine segment involvement, and tumor grade were predictors of overall survival. Lymphovascular space invasion, grade (P < 0.001), and high AACCI score were the only significant predictors of recurrence-free survival (RFS). Lymphovascular space invasion and tumor grade were the only 2 predictors of disease-specific survival. Conclusions Although all 3 studied comorbidity indices were significant predictors of overall survival in women with early-stage EC, AACCI showed a stronger association. It should be considered for evaluating comorbidity in women with early-stage EC.

Radiation Therapy for Chronic Hidradenitis Suppurativa

Background: Hidradenitis suppurativa is a chronic follicular occlusive disease in apocrine gland-bearing regions. Frequently refractory to conventional oral and topical treatments, it may require surgical intervention. Objective: To investigate the effectiveness of radiation therapy for refractory hidradenitis suppurativa. Methods and materials: Five patients with refractory Hurley stage II/III hidradenitis suppurativa were treated with radiation therapy to 13 affected sites. Electron beam radiation to a total dose of 7.5 gray was applied over 3 consecutive days. Results: The mean age of patients was 45 years; 80% had hidradenitis suppurativa for ≥ 6 years. Three patients had Hurley stage III; 2 had Hurley stage II. All had been treated previously with topical and oral antibiotics and other therapies, including surgery, radiation therapy, Nd:YAG laser therapy, and infliximab. No complete responses were observed, but 53% of the lesions had a partial response. Lesions in the axilla, gluteal, and inguinal areas had response rates of 100%, 67%, and 50%, respectively, compared to 0% for perineal lesions. Conclusions: Radiation therapy may be a promising treatment for refractory hidradenitis suppurativa. A prospective study is warranted to further evaluate response rates, define optimal dose fractionation schedules, and better understand the risk of long-term toxicity.

The impact of income on clinical outcomes in FIGO stages I to II endometrioid adenocarcinoma of the uterus.

Objective(s):To determine the influence of income on clinical outcomes in patients with surgical stages I to II endometrioid adenocarcinoma of the uterus. Methods:We retrospectively analyzed the records of 660 women initially treated from 1985 to 2009. On the basis of income data obtained from the 2000 US census, patients were separated into various income groups (halves, tertiles, and quartiles) based on median household income, with most focus on the half income groups. Results:Income groups were similar regarding treatments received and characteristics, with the exception of more African American (AA), unmarried patients, and a predilection for higher grade in the lower half income group (LHIG). Compared with the upper half income group (UHIG), the LHIG had lower disease-specific survival (DSS) (5 y: 93.9% vs. 97.0% and 10 y: 90.1% vs. 95.9%; P=0.023) and a trend toward lower overall survival (OS) (5 y: 83.4% vs. 86.5% and 10 y: 62.6% vs. 68.5%; P=0.067). In patients with higher-risk features, differences in outcomes between LHIG and UHIG were more pronounced; 10-year OS of 43.4% versus 60.2% (P=0.004) and 10-year DSS of 75.0% versus 93.0% (P=0.007), respectively. Regarding race, AA patients in the LHIG had lower OS than AA in the UHIG. On univariate analysis, income group and race were significant predictors for DSS, but on multivariate analysis, they were not statistically significant. Conclusions:Despite similar treatments and characteristics, a small decrease in DSS and a trend toward reduced OS was observed in LHIG patients, but income group was not statistically significant on multivariate analysis of outcome. These differences were more significant in patients with high-risk features.