Joshua R. Niska

Stereotactic body radiotherapy for early-stage non-small cell lung cancer has low post-treatment mortality

Stereotactic body radiotherapy (SBRT) is increasingly used to treat stage I non-small cell lung cancer (NSCLC). In 2004, less than 0.5% of these cases were managed with SBRT. By 2011, SBRT accounted for 8.7% of cases (1).

Radiation and the heart: systematic review of dosimetry and cardiac endpoints

ABSTRACT Introduction: Recent trials in radiotherapy have associated heart dose and survival, inadequately explained by the existing literature for radiation-related late cardiac effects. Authors aimed to review the recent literature on cardiac dosimetry and survival/cardiac endpoints. Areas covered: Systematic review of the literature in the past 10 years (2008–2017) was performed to identify manuscripts reporting both cardiac dosimetry and survival/cardiac endpoints. Authors identified 64 manuscripts for inclusion, covering pediatrics, breast cancer, lung cancer, gastrointestinal diseases (primarily esophageal cancer), and adult lymphoma. Expert commentary: In the first years after radiotherapy, high doses (>40 Gy) to small volumes of the heart are associated with decreased survival from an unknown cause. In the long-term, mean heart dose is associated with a small increased absolute risk of cardiac death. For coronary disease, relative risk increases roughly 10% per Gy mean heart dose, augmented by age and cardiac risk factors. For valvular disease and heart failure, doses >15 Gy substantially increase risk, augmented by anthracyclines. Arrhythmias after radiotherapy are poorly described but may account for the association between upper heart dose and survival. Symptomatic pericardial effusion typically occurs with doses >40 Gy. Close follow-up and mitigation of cardiovascular risk factors are necessary after thoracic radiotherapy.

Fatal Radiation Pneumonitis in Patients With Subclinical Interstitial Lung Disease

Clinical Practice PointsWe report 2 cases of fatal radiation pneumonitis (RP) in lung cancer patients with asymptomatic interstitial lung disease (ILD) found incidentally on pretreatment imaging.Symptomatic ILD appears to be a risk factor for RP.Asymptomatic ILD found incidentally on imaging may be an underreported and underrecognized risk factor for RP.Additional research is needed in patients with any degree of ILD so that providers can better counsel patients and minimize the risks of thoracic radiotherapy.

Choosing wisely after publication of level I evidence in breast cancer radiotherapy

Background Recent trials in early-stage breast cancer support hypofractionated whole-breast radiotherapy (WBRT) as part of breast-conserving therapy (BCT). Evidence also suggests that radiotherapy (RT) omission may be reasonable for some patients over 70 years. Among radiation-delivery techniques, intensity-modulated RT (IMRT) is more expensive than 3-dimensional conformal RT (3DCRT). Based on this evidence, in 2013, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated schedules for women aged ≥50 years with early-stage breast cancer and avoiding routine use of IMRT for WBRT. To assess response to level I evidence and adherence to ASTRO recommendations, we evaluated the pattern of RT use for early-stage breast cancer at our National Comprehensive Cancer Network institution from 2006 to 2008 and 2011 to 2013 and compared the results with national trends. Methods Data from a prospective database were extracted to include patients treated with BCT, aged ≥50 years, with histologic findings of invasive ductal carcinoma, stage T1-T2N0M0, estrogen receptor-positive, and HER2 normal. We retrospectively reviewed the medical records and estimated costs based on 2016 Hospital Outpatient Prospective Payment System (technical fees) and Medicare Physician Fee Schedule (professional fees). Results Among 55 cases from 2006 to 2008, treatment regimens were 11% hypofractionated, 69% traditional schedule, and 20% RT omission (29% of patients were aged >70 years). Among 83 cases from 2011 to 2013, treatment regimens were 54% hypofractionated, 19% traditional schedule, and 27% RT omission (48% of patients were aged >70 years). 3DCRT was used for all WBRT treatments. Direct medical cost estimates were as follows: 15 fractions 3DCRT,

Initial toxicity, quality-of-life outcomes, and dosimetric impact in a randomized phase 3 trial of hypofractionated versus standard fractionated proton therapy for low-risk prostate cancer

7,197.87; 15 fractions IMRT,

First report of proton beam therapy for breast angiosarcoma from the prospective PCG registry

11,232.33; 25 fractions 3DCRT,

Tissue Expanders and Proton Beam Radiotherapy: What You Need to Know

9,731.39; and 25 fractions IMRT,

Impact of intravenous contrast enhancement phase on target definition for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC): Observations from patients enrolled on a prospective phase 2 trial

16,877.45. Conclusion Despite apparent resistance to shorter radiation schedules in the United States, we demonstrate that rapid practice change in response to level I evidence is feasible. Wider adoption of evidence-based guidelines in early-stage breast cancer may substantially lower health care costs and improve convenience for patients without sacrificing oncologic outcomes.

Electronic patient-reported outcomes and toxicities during radiotherapy for head-and-neck cancer

Purpose Randomized evidence for extreme hypofractionation in prostate cancer is lacking. We aimed to identify differences in toxicity and quality-of-life outcomes between standard fractionation and extreme hypofractionated radiation in a phase 3 randomized trial. Methods and materials We analyzed the results of the first 75 patients in our phase 3 trial, comparing 38 Gy relative biologic effectiveness (RBE) in 5 fractions (n = 46) versus 79.2 Gy RBE in 44 fractions (n = 29). Patients received proton radiation using fiducials and daily image guidance. We evaluated American Urological Association Symptom Index (AUASI), adverse events (AEs), and Expanded Prostate Index Composite (EPIC) domains. The primary endpoint of this interim analysis was the cumulative incidence of grade 2 (G2) or higher AEs. The randomized patient allocation scheme was a 2:1 ratio favoring the 38 Gy RBE arm. Results The median follow-up was 36 months; 30% of patients reached 48-month follow-up. AUASI scores differed <5 points (4.4 vs 8.6; P = .002) at 1 year, favoring the 79.2 Gy arm. Differences in AUASI were not significant at ≥18 months. EPIC urinary symptoms favored the 79.2 Gy arm at 1 year (92.3 vs 84.5; P = .009) and 18 months (92.3 vs 85.3; P = .03); bother scores were not significant at other time points. Cumulative ≥G2 genitourinary toxicity was similar between the 79.2 Gy and 38 Gy arms (34.5% vs 30.4%; P = .80). We found no differences in the EPIC domains of bowel symptoms, sexual symptoms, or bowel ≥G2 toxicities. Bladder V80 (79.2 Gy arm; P = .04) and V39 (38 Gy arm; P = .05) were predictive for cumulative G2 genitourinary AEs. Conclusions Low AE rates were seen in both study arms. Early temporary differences in genitourinary scores disappeared over time. Bladder constraints were associated with genitourinary AEs.

Azygous tumor thrombus extending into the heart

the cumulative number of chemotherapy cycles [1,2]. Even though nail and skin toxicity are not life threatening, effective management to ameliorate the symptoms is a necessity to allow patients to continue their chemotherapy regimen. In some cases, patients may require dose adjustment, as was the case in a series of three patients with PATEO syndrome described by Rodriguez-Lomba et al. [3] Despite development of PATEO syndrome, our patient was able to continue her chemotherapy regimen with use of a potent topical corticosteroid and cooling her hands in ice baths during subsequent paclitaxel infusions, an approach similar to Scott e et al’s [4,5] frozen glove therapy that was found to significantly reduce nail and skin toxicity associated with taxane-based chemotherapy. We present this case to heighten awareness of this unique manifestation of handfoot syndrome specific to taxane chemotherapy and share a successful approach towards management.