Lindsay Burt

Stage Presentation, Care Patterns, and Treatment Outcomes for Squamous Cell Carcinoma of the Penis

PURPOSE Penile squamous cell carcinoma (SCC) is a rare entity, with few published series on outcomes. We evaluated the stage distributions and outcomes for surgery and radiation therapy in a U.S. population database. METHODS AND MATERIALS Subjects with SCC of the penis were identified using the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) Program database between 1988 and 2006. Descriptive statistics were performed, and cause-specific survival (CSS) was estimated using Kaplan-Meier analysis. Comparisons of treatment modalities were analyzed using multivariate Cox regression. Subjects were staged using American Joint Committee on Cancer, sixth edition, criteria. RESULTS There were 2458 subjects identified. The median age was 66.8 years (range, 17-102 years). Grade 2 disease was present in 94.5% of cases. T1, T2, T3, T4, and Tx disease was present in 64.8%, 17.1%, 9.5%, 2.1%, and 6.5% of cases, respectively. N0, N1, N2, N3, and Nx disease was noted in 61.6%, 6.9%, 4.0%, 3.7%, and 23.8% of cases, respectively. M1 disease was noted in 2.5% of subjects. Individuals of white ethnicity accounted for 85.1% of cases. Lymphadenectomy was performed in 16.7% of cases. The CSS for all patients at 5 and 10 years was 80.8% and 78.6%. By multivariable analysis grades 2 and 3 disease, T3 stage, and positive lymph nodes were adverse prognostic factors for CSS. CONCLUSION SCC of the penis often presents as early-stage T1, N0, M0, grade 1, or grade 2 disease. The majority of patients identified were treated with surgery, and only a small fraction of patients received radiation therapy alone or as adjuvant therapy.

Adjuvant radiotherapy for atypical meningiomas

OBJECTIVE The aim of this paper was to evaluate outcomes in patients with atypical meningiomas (AMs) treated with surgery alone compared with surgery and radiotherapy at initial diagnosis, or at the time of first recurrence. METHODS Patients with pathologically confirmed AMs treated at the University of Utah from 1991 to 2014 were retrospectively reviewed. Local control (LC), overall survival (OS), Karnofsky Performance Status (KPS), and toxicity were assessed. Outcomes for patients receiving adjuvant radiotherapy were compared with those for patients treated with surgery alone. Kaplan-Meier and the log-rank test for significance were used for LC and OS analyses. RESULTS Fifty-nine patients with 63 tumors were reviewed. Fifty-two patients were alive at the time of analysis with a median follow-up of 42 months. LC for all tumors was 57% with a median time to local failure (TTLF) of 48 months. The median TTLF following surgery and radiotherapy was 180 months, compared with 46 months following surgery alone (p = 0.02). Excluding Simpson Grade IV (subtotal) resections, there remained an LC benefit with the addition of radiotherapy for Simpson Grade I, II, and III resected tumors (median TTLF 180 months after surgery and radiotherapy compared with 46 months with surgery alone [p = 0.002]). Patients treated at first recurrence following any initial therapy (either surgery alone or surgery and adjuvant radiotherapy) had a median TTLF of 26 months compared with 48 months for tumors treated at first diagnosis (p = 0.007). There were 2 Grade 3 toxicities and 1 Grade 4 toxicity associated with radiotherapy. CONCLUSIONS Adjuvant radiotherapy improves LC for AMs. The addition of adjuvant radiotherapy following even a Simpson Grade I, II, or III resection was found to confer an LC benefit. Recurrent disease is difficult to control, underscoring the importance of aggressive initial treatment.

Use of proliferation rate, p53 staining and perforating elastic fibers in distinguishing keratoacanthoma from hypertrophic lichen planus: a pilot study

Background: Distinguishing keratoacanthoma (KA) and hypertrophic lichen planus (LP) histopathologically can be difficult, and the challenge is compounded by the tendency of KA to arise in association with hypertrophic LP.

Supply and Demand for Radiation Oncology in the United States: A Resident Perspective

Supply and Demand for Radiation Oncology in the United States: A Resident Perspective Lindsay M. Burt, MD,* Daniel M. Trifiletti, MD,y Nima Nabavizadeh, MD,z Leah M. Katz, MD, MPH,x Zachary S. Morris, MD, PhD,k and Trevor J. Royce, MD, MS{ *Department of Radiation Oncology, University of Utah, Salt Lake City, Utah; yDepartment of Radiation Oncology, University of Virginia, Charlottesville, Virginia; zDepartment of Radiation Medicine, Oregon Health & Science University, Portland, Oregon; xDepartment of Radiation Oncology, New York University Langone Medical Center, New York, New York; kDepartment of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and {Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts

Tanning business practices in Salt Lake County, Utah

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Combined Hydroxyurea and Verapamil in the Clinical Treatment of Refractory Meningioma: Human and Orthotopic Xenograft Studies.

OBJECTIVE Previous in vitro and in vivo results suggested that hydroxyurea (HU) and verapamil could suppress meningioma growth individually and synergistically. We evaluated the clinical efficacy and safety of this approach for the treatment of refractory recurrent/progressive meningiomas and expanded our studies in a xenograft orthotopic mouse model. METHODS Six women and 1 man, aged 26-76 years (median, 56 years), with magnetic resonance imaging-proven progression of ≥ 25% in cross-sectional area of recurrent meningioma (2 World Health Organization grade I, 5 grade II) within the preceding 6 months received HU 1000 or 1500 mg/day (20 mg/kg/day, twice daily) as well as verapamil sustained-release tablets with dose escalation every 2 weeks (120-240 mg/day). They underwent magnetic resonance imaging every 3 months during therapy. To augment the clinical trial results, we performed mouse orthotopic xenograft experiments using similar dosing to test tumor growth, vascularity, and drug bioavailability. RESULTS After a mean of 8.1 cycles of treatment, the patients demonstrated no significant radiographic responses during mean follow-up of 14.5 ± 4.8 months. Median progression-free survival (PFS) was 8.0 months, and 6-month PFS was 85%. Side effects occurred in 6 (86%) patients. Xenograft studies showed no effect of individual or combined treatments on meningioma growth. Neither HU nor verapamil was detectable in mouse brain tumor tissue despite adequate serum levels within therapeutic ranges. CONCLUSIONS Our results showed no effect of HU or verapamil on tumor recurrence, PFS, and in vivo tumor burden reduction. Drug delivery to the tumor may be a major limitation.

Rural-metropolitan disparities in ovarian cancer survival: a statewide population-based study

PURPOSE To investigate rural-metropolitan disparities in ovarian cancer survival, we assessed ovarian cancer mortality and differences in prognostic factors by rural-metropolitan residence. METHODS The Utah Population Database was used to identify ovarian cancer cases diagnosed between 1997 and 2012. Residential location information at the time of cancer diagnosis was used to stratify rural-metropolitan residence. All-cause death and ovarian cancer death risks were estimated using Cox proportional hazard regression models. RESULTS Among 1661 patients diagnosed with ovarian cancer, 11.8% were living in rural counties of Utah. Although ovarian cancer patients residing in rural counties had different characteristics compared with metropolitan residents, we did not observe an association between rural residence and risk of all-cause nor ovarian cancer-specific death after adjusting for confounders. However, among rural residents, ovarian cancer mortality risk was very high in older age at diagnosis and for mucinous carcinoma, and low in overweight at baseline. CONCLUSIONS Rural residence was not significantly associated with the risk of ovarian cancer death. Nevertheless, patients residing in rural-metropolitan areas had different factors affecting the risk of all-cause mortality and cancer-specific death. Further research is needed to quantify how mortality risk can differ by residential location accounting for degree of health care access and lifestyle-related factors.

Factors influencing prostate cancer patterns of care: An analysis of treatment variation using the SEER database

Purpose The aim of this study is to describe the trends and factors that influence the initial treatment of men with localized prostate cancer (PC) in the United States between 2004 and 2014. Methods and materials The National Cancer Institutes Surveillance, Epidemiology and End Results database was used to identify patients with primary prostate adenocarcinoma between 2004 and 2014. Patients were staged in accordance with the American Joint Committee on Cancer 7th edition criteria and stratified according to the National Comprehensive Cancer Network guidelines risk group classification. Descriptive statistics describing treatment patterns by year of diagnosis, age, risk group, insurance status, and region were performed. Results A total of 460,311 male patients were identified with sufficient information to be categorized into National Comprehensive Cancer Network risk groups. Overall, 30.9% of patients had low-risk disease, 38.1% were intermediate risk, 20.2% were high risk, 4.4% were very high risk, 1.6% were node-positive, and 4.7% had metastatic disease. During the study period, there was a 60% decrease in brachytherapy monotherapy utilization for patients with PC, and no definitive treatment increased from 20.3% in 2004 to 26.3% in 2014. There were regional treatment variations and discrepancies in treatment by age. Radical prostatectomy was performed on a greater proportion of insured patients than patients with Medicaid or those who were uninsured, but radiation therapy and no definitive treatment was administered to a greater proportion of uninsured and Medicaid patients. Conclusions PC treatment shows declining trends in brachytherapy utilization, increases in conservative management, and stability of surgical procedures over time. There is wide variation by geographical region, age, and insurance status.

Comparison of treatment modalities for breast cancer arising in Hodgkin’s lymphoma survivors

ObjectivesBreast cancer (BC) in Hodgkin’s lymphoma (HL) survivors is traditionally treated with mastectomy, especially in those who received prior supradiaphragmatic radiation therapy (RT). Chest irradiation is a contraindication for breast-conserving therapy (BCT); however, retrospective studies have found that BCT is an acceptable treatment option for BCs that arise after prior RT. This study compares BC treatment modalities for female HL survivors.MethodsData was extracted from the Surveillance, Epidemiology, and End Results (SEER) from 1983 to 2009. All female HL survivors who subsequently developed BC and received surgical treatment were included. BC events were grouped by the type of surgical resection and RT utilization. All were staged using the American Joint Committee on Cancer (AJCC) seventh edition criteria. Multivariate analysis was performed to compare treatment groups.ResultsThere were 413 BC events arising in female HL survivors that received surgical management. Of these BC events, 371 were fully staged. Sixty-one received a bilateral mastectomy, 227 received a mastectomy, and 83 received a lumpectomy. A total of 65 BC events received RT, 19 after mastectomy and 46 after lumpectomy. On multivariate analysis for overall survival (OS) and cause-specific survival (CSS), there were no statistically significant favorable or adverse prognostic factors, including treatment modality.ConclusionBCT did not have an inferior CSS or OS compared to other treatment modalities for female HL survivors. BCT is an acceptable treatment option for a select group of female HL survivors who develop BC.

Impact of prone versus supine positioning on small bowel dose with pelvic intensity modulated radiation therapy

Purpose To report the results of a prospective study that compares small bowel doses during prone and supine pelvic intensity modulated radiation therapy. Methods and materials Ten patients receiving pelvic radiation therapy each had 2 intensity modulated radiation therapy plans generated: supine and prone on a belly board (PBB). Computed tomography on rails was performed weekly throughout treatment in both positions (10 scans per patient). After image fusion, doses to small bowel (SB) loops and clinical target volume were calculated for each scan. Changes between the planned and received doses were analyzed and compared between positions. The impact of bladder filling on SB dose was also assessed. Results Prone treatment was associated with significantly lower volumes of SB receiving ≥20 Gy. On average, prone on a belly board positioning reduced the volume of SB receiving a given dose of radiation by 28% compared with supine positioning. Target coverage throughout the treatment course was similar in both positions with an average minimum clinical target volume dose of 88% of the prescribed prone dose and 89% of the supine (P = .54). For supine treatment, SB dose was inversely correlated with bladder filling (P = .001-.013; P > .15 for prone). For 96% of treatments, the volume of SB that received a given dose deviated >10% from the plan. The deviation between the planned and delivered doses to SB did not differ significantly between the positions. Conclusions Prone positioning on a belly board during pelvic IMRT consistently reduces the volume of SB that receives a broad range of radiation doses. Prone IMRT is associated with interfraction dose variation to SB that is similar to that of supine positioning. These findings suggest that prone positioning with daily image guided radiation therapy is an effective method for maximizing SB sparing during pelvic IMRT.