Melissa Joyner

A comprehensive review of the treatment of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an uncommon but malignant cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastases, and subsequent distant metastases. The etiology of MCC remains unknown. It usually occurs in sun-exposed areas in elderly people, many of whom have a history of other synchronous or metachronous sun-associated skin lesions. The outcome for most patients with MCC is generally poor. Surgery is the mainstay of treatment. The role of adjuvant therapy has been debated. However, data from recent development support a multimodality approach, including surgical excision of primary tumor with adequate margins and sentinel lymph node dissection followed by postoperative radiotherapy in most cases, as current choice of practice with better locoregional control and disease-free survival. Patients with regional nodal involvement or advanced disease should undergo nodal dissection followed by adjuvant radiotherapy and, perhaps, systemic platinum-based chemotherapy in most cases.

Stereotactic body radiation therapy for centrally located lung lesions

Presentation of outcomes of patients treated by stereotactic body radiation therapy (SBRT) for lung lesions located within or touching a 2 cm zone around major airways. Serial tomotherapeutic SBRT has been planned and delivered at our institution since August 2001. Of 108 patients treated for primary and secondary lung tumors, nine harbored tumors (8 metastases, 1 recurrent NSCLC) located in close proximity to carina, right and left main bronchi, right and left upper lobe bronchi, intermedius, right middle lobe, lingular, or right and left lower lobe bronchi. SBRT was delivered to total doses of 36 Gy in 3 fractions (n = 8) or 6 fractions (n = 1), using a serial tomotherapy system (Nomos Peacock). We assessed local tumor control, clinical toxicity, normal tissue imaging changes, and overall survival. Median tumor volume was 26 cm3 (range 1.7 to 135 cm3). Tumor locations were hilar (n = 3), and parenchymal in six cases. Hilar lesions accounted for the three largest tumor volumes in the series. During a median follow-up of 10.6 months (range 2.5 to 41.5 months), all lesions treated were locally controlled as confirmed by CT or CT/PET imaging. Parenchymal imaging changes included focal lung fibrosis and major airway wall thickening. One occurrence of major airway occlusion (right lower lobe bronchus) was observed. This event was diagnosed by chest x-ray at 36 months, following treatment of the second largest hilar lesion in the present series. Based on the outcomes observed in this small sample series, SBRT for centrally located lung lesions appears feasible, was associated with low incidence of toxicities, and provided sustained local tumor control. However, long-term survival may be associated with major airway injury. As long-term follow-up in larger numbers of patients is lacking at this time, exclusion of patients with centrally located lesions may be considered when patients are treated in curative intent.

Accelerated partial breast irradiation: Past, present, and future

Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.

State of the art: Gastrointestinal malignancies in the human immunodeficiency virus (HIV) population

The gastrointestinal tract is one of the most common sites for the development of primary neoplasms arising in patients with pre-existing infection with the human immunodeficiency virus (HIV). Over the past decade, new information on the clinical manifestation, natural history, treatment options, and related toxicity have been reported, mostly notably the integration of highly active antiretroviral therapy (HAART). The following is a concise review summarizing the current state-of-the-art for GI tract malignancies in the HIV-positive patient and is designed to assist the clinical oncology team in developing a rationale plan when caring for these patients.

Malignant Phyllodes Tumor of the Breast: A Case Report

Phyllodes tumors of the breast have biphasic histological features with both epithelial and stromal components. Careful characterization of the stromal compartment is critical since it is the pathologic features of the stromal cells that determine its malignant potential. We present a case report of a woman with an aggressive malignant phyllodes tumor with sarcomatous differentiation, who succumbed to metastatic disease within 8 months of initial presentation.

Simultaneous Integrated Boost using Conformal Radiation Therapy for Treatment of Cervical Cancer

Purpose: Chemoradiation is the treatment of choice for locally advanced cervical cancer. At our institution, we have been using forward planned conformal radiation therapy to treat patients to the whole pelvis with asimultaneous integrated boost (SIB) to the uterus and parametria. Our aim is to report the local control, disease free survival, overall survival, and toxicities of definitive chemoradiation with SIB for treatment of cervical cancer. Methods: Medical records and treatment plans of patients with cervical cancer treated from 2009-2013 were reviewed using an IRB-approved database. The records of patients with cervical cancer treated with definitive chemoradiation and a three dimensional forward planned SIB were analyzed to determine local failure, distant failure, overall survival, and rate of toxicities. Results: Twenty one patients were treated with definitive chemoradiation with a SIB. Median follow up time was 18.1 months. The 2-year LC rate was 95.2%, the 2-year DFS was 80.9%, and there were no deaths, for an overall survival rate of 100%. One patient experienced Grade 3 or higher acute toxicity, and two patients experienced Grade 3 or higher late toxicities. Conclusions: This study demonstrates the feasibility and tolerability of SIB using forward planned conformal radiation therapy for the treatment of cervical cancer. This radiation technique can be used to deliver a higher dose to the area most at risk for recurrence in a shorter treatment time *Corresponding Author: Waqar Haque, MD, Deparment of Radiation Oncology, Greater Houston Physicians in Medicine, Association Houston, TX 77030, Tel: 832-367-1655/ Fax: 832-201-0602; E-mail: WAQARH786@gmail.com Received Date: February 02, 2016 Accepted Date: April 21, 2016 Published Date: April 27, 2016

Pleomorphic Lobular Carcinoma of the Breast: A Review of 35 Cases at a Single Institution

Objectives: Pleomorphic lobular carcinoma (PL) is an aggressive subtype of invasive lobular carcinoma. There are few case series reporting on this aggressive form of breast cancer. This report features a descriptive and survivorship comparison of a large case series of PL reviewed by a single breast pathologist. Methods: From 1993-2010 we retrospectively reviewed 198 cases of invasive lobular carcinomas, 35 cases (34 patients with one patient presenting with 2 independent cancers) of PL and 163 cases of non-pleomorphic invasive lobular carcinoma (NPL). The pathology was reviewed by a single breast pathologist and classified as either PL or NPL according to WHO classification. Kaplan-Meier survivals were computed and compared with a log rank test using SPSS 18. Overall survival (OS) was computed from date of diagnosis. Progression free survival (PFS) until either local or metastatic failure was computed. Results: Median follow-up was 59.5 months and 73 months, for NPL and PL respectively. Median age of diagnosis was 55 and 58.67 for PL and NPL groups. Of the NPL group, 75.5% were post-menopausal opposed to 67.6% in PL group. PL cases were ER positive 87.1% vs. 90.1% of the NPL cases. Her-2/neu status was known in nearly 50% of cases with 17 positive NPL and 5 positive PL. Clinical stage at presentation was stage IIB or less in 67.6% of the PL and 80.1% of the NPL. Six presented (17.6%) with metastatic disease in the PL group and 12 (7.7%) in the NPL group. None of the descriptive comparisons were significantly different by c2 analyses. PFS at 5 years was 30% and 21% in PL and NPL, respectively (p=0.73). OS at 5 years was 68.5% for PL and 83.9% for NPL (p=0.031). Conclusions: PL patients showed a statistically significant decreased OS, but no significant difference in PFS, at 5 years from diagnosis.

MO‐EE‐A3‐06: Comparison of Pre‐ and Post‐Implant Prostate Volume Segmentation Using Trans‐Rectal Ultrasound and Computed Tomography

Purpose: To quantitatively evaluate differences in prostate volume measurements via transrectal ultrasound(TRUS) and computed tomography(CT) used for dosimetric planning in prostate brachytherapy.Method and Materials: Prostate volume measurements were made in 83 prostate brachytherapy patients. One to two weeks prior to implantation, patients were placed in the dorsal lithotomy position, and prostate volumes were measured via TRUS. Immediately afterward, patients were rescanned using CT to allow for comparison of CT and TRUS measurements. On treatment day, patients were rescanned via TRUS before and after implantation and were rescanned by CT within an hour after procedure completion. The prostate and urethra were delineated by the same physician on all scans, and prostate volumes were calculated. Results: Substantial correlation was found between pre‐/post‐ implant prostate US volumes (R2=0.7998), pre‐/post‐ implant CT volumes (R2=0.7872), and pre‐implant US and post‐implant CT volumes (R2=0.8352). However, it was found that the difference between pre‐ and post‐implant volume measurements varied with the combination of modalities compared. For pre‐ vs post‐implant TRUS, post‐implant prostate volumes averaged 26.1% larger than those measured prior to treatment. For pre‐ vs. post‐ implant CT, post‐implant measurements averaged 58.9% greater. Post‐implant CT measurements averaged 23.8% greater than post‐implant TRUS measurements. Conclusion: While it would be ideal to use the same method to measure pre‐ and post‐implant volumes, this is not generally practiced. Prostate volumes measured using TRUS and CT show a distinct relationship, but it is important to note that this does not mean that the modalities provide the same values for the same prostate. In addition, the relationship between pre‐implant TRUS and CT is not identical to that between post‐implant TRUS and CT. Therefore, it is not possible to state that accurate comparison of pre‐ and post‐implant dosimetric plans can be accomplished when different imaging modalities are used for each.

SU‐GG‐T‐22: Dosimetric Analysis of Real Time and Post Implantation Dosimetry for Prostate

Purpose: To quantify the changes in prostate volume and its effect on dosimetry for real time inverse planned low dose rate brachytherapy.Method and Materials:Ultrasoundimages of 30 consecutive patients in the lithotomy position were obtained one week before the implant procedure. The prostate and the urethra were contoured and then an optimized treatment plan was developed in order to obtain the number of Palladium‐103 seeds needed to deliver the prescribed dose of 120Gy to the target. At the day of the implant a new optimized plan was created based on the patients current prostate volume. Linked seeds were implanted according to the latter plan. A CT scan was performed after the seeds were implanted and the prostate and urethra were contoured. The post‐implant treatment plan was developed by locating the seeds on the CTimages and calculating the dose distribution. Results: By comparing the real time in the operating room and the post implant prostate volumes, it was found that there was an increase in volume ranging from 31% to 39%. According to the post implant plans the V100 ranged from 81% to 99%. A larger volume increase was observed for smaller size prostates. Furthermore, the smaller prostate volumes showed the lower values of V100. Conclusion: Prostate volume changes due to swelling after the implant appears to be associated with reduction of dose coverage as reflected in post implant dosimetry. Artifacts generated by the seeds, compromised the resolution of the CTimages and hence the accuracy of post implant prostate volumes. It appears that these factors effecttreatment planning which can ultimately determine the success in treating the cancer.